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Indian Journal of Anaesthesia 2008;52:Suppl (5):725-737

General Anaesthesia for Dentistry


Naveen Malhotra
Summary
The first general anaesthetics administered were for dental extractions. General anaesthesia for dentistry is not
without risk and should not be undertaken as a first-line means of anxiety control. Considerations should always be
given to the possibility of local anaesthetic techniques with or without conscious sedation. Patients requiring general
anaesthesia for dental work are frequently children or individuals with learning difficulties. The standards of general
anaesthesia for dentistry should be the same as those in any other setting.

General anaesthesia in dentistry covers three main types of surgical procedures: Dental chair anaesthesia, Day
care anaesthesia and In-patient anaesthesia. All standard equipments, gadgets, monitors and drugs for anaesthesia
and resuscitation should be available and checked before administering anaesthesia. Each individual must have had
appropriate experience of, and training in dental anaesthesia. Sevoflurane has largely replaced halothane as agent of
choice for inhalation induction of anaesthesia and propofol is agent of choice for intravenous induction. The transpar-
ent neonatal mask for nasal ventilation offers significant advantages. Laryngeal mask airway is being used for all but
the simplest extractions. The most commonly used operating position is semi-supine. In recovery, airway obstruction
is common in patients undergoing dental procedures and they should be closely supervised by an experienced nurse.
Routes of tracheal intubation in maxillo-facial surgical procedures are: oro-tracheal intubation, nasal intubation, retro-
molar intubation and submento-tracheal intubation. A team of vigilant and experienced anaesthesiologist and dental
surgeon is able to prevent and manage the complications associated with dental procedures under general anaesthe-
sia.

Keywords Surgery: Dental; Anaesthesia: General.

Introduction work routinely in operation theatres.4 Majority of the


dental procedures can be performed under local ana-
There is a long historical association between esthesia which is inherently safe. Most dentists are skilled
Anaesthesia and Dentistry. Some of the initial in techniques of local anaesthetics and nerve blocks.5
anaesthetics given were for dental extractions.1, 2 The General anaesthesia should not be used as a method of
first general anaesthetic administered for a dental ex- anxiety control but for pain control, because more spe-
traction is credited to Horace Wells. Wells, on 11th cific methods (local anaesthesia with or without con-
December 1844, underwent extraction of one of his scious sedation and behaviour management techniques6)
own wisdom teeth by a colleague whilst under the in- are available to manage anxiety. All general anaesthetics
fluence of nitrous oxide. In 1846, William Morton, a are associated with some risk and modern dentistry is
pupil of Wells, successfully demonstrated the proper- based on the principle that all potentially painful treat-
ties of ether to facilitate dental extraction in Massachu- ment should be performed under local anaesthesia, if
setts.3 at all possible. General anaesthesia should be strictly
limited to those patients and clinical situations in which
Dentistry, in its surgical and restorative aspect, is local anaesthesia (with or without sedation) is not an
in majority based on office practice. Limited dentists option. 7-13

Associate Professor, Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Sciences (PGIMS),
Rohtak-124001 (Haryana) Correspondence to: Naveen Malhotra, 128/19, Naveen Niketan, Civil Hospital Road, Rohtak-124001
(Haryana), E-mail: naveen_m2000@yahoo.com

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Indian Journal of Anaesthesia, October 2008(P.G.Issue)

In 1970s and 1980s there were numerous deaths, who may not tolerate dental surgery under local anaes-
often in healthy children undergoing simple dental pro- thesia or some may be failures of attempts using local
cedures under general anaesthesia. The reasons were anaesthesia. It is recommended that only specialist pae-
multifactorial, including administration of anaesthesia in diatric anaesthetists should administer general anaes-
conditions with substandard monitoring, assistance and thesia to very young children.
resuscitation equipments. Also, patients were poorly
prepared for anaesthesia and surgery.3 However, cur- 3. Mentally challenged patients: Such patients,
rently there is a world wide trend that increasing num- because of problems related to physical/mental disabil-
ber of children are receiving dental treatment under ity, are unlikely to allow safe completion of treatment
general anaesthesia.14-16. under local anaesthesia.

General anaesthesia in dentistry covers three main 4. Dental phobia: Patients in whom long-term
types of surgical procedures: 3 dental phobia will be induced or prolonged are admin-
istered general anaesthesia in first sitting. The long term
1. Dental chair anaesthesia: It is outpatient aim in such patients should be the graduated introduc-
anaesthesia, mainly for simple extraction of teeth espe- tion of treatment under local anaesthesia using, if nec-
cially in children. essary, conscious sedation and behaviour management
techniques.
2. Day care anaesthesia: It is for minor oral
surgery. 5. Allergy to local anaesthetics: It is rare and
is due to amide group of local anaesthetics. The pre-
3. In patient anaesthesia: It is for complicated servative methylparaben can also cause allergic reac-
extractions, oral surgical procedures and maxillofacial tions. However, allergic reaction should be differenti-
surgical procedures. ated from vasovagal attacks, palpitation and flushing
occurring as a result of absorption of adrenaline present
Indications of general anaesthesia in den-
in local anaesthetic solution.
tistry 3, 7, 8, 12
6. Extensive dentistry & facio-maxillary sur-
Decisions about general anaesthesia can only be
gery: Local anaesthesia is unsuitable in an awake pa-
made on an individual patient basis, but its use in den-
tient when the dentistry is likely to be extensive.
tistry should be limited to:

1. Acute infection: In such clinical situations it General principles


would be impossible to achieve adequate local anaes-
thesia and so complete treatment without pain, e.g. Patient assessment
management of acute dento-alveolar abscess and se-
vere pulpitis. In these conditions, drug therapy or drain- The initial screening of patients for general anaes-
age procedures with other methods of pain relief are thesia should be performed as for any other anaesthetic.
inappropriate or unsuccessful. The local anaesthetic may The anaesthesiologists should always be ready to dis-
not be effective in such conditions because of local cuss with dental colleagues policies for general anaes-
change in pH and there is a risk of spreading infection thesia, and their implications for an individual patient,
also. to allow efficient patient management. 3, 12

2. Children: Majority of out-patient general ana- The Clinical setting


esthesia in dentistry is administered to small children
Defining the setting in which a general anaesthetic

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Naveen Malhotra. General anaesthesia for dentistry

is administered must take into account the worst case all the equipment before use and there should be im-
scenario because the uneventful anaesthetic is not the mediate access to spare apparatus in the event of fail-
problem. Complications of modern anaesthesia are rare, ure. Maintenance must be in accordance with the
but skilled team work is required to prevent permanent manufacturers instructions. Facilities for the supply and
harm to the patient. The further away from the support storage of medical gases must meet the relevant regu-
of other clinical services that an anaesthetic is adminis- lations.8
tered, the greater is the risk of death should a compli-
cation occur. Ideally, all general anaesthetics for den- Staffing standards
tistry should be administered within the administrative
aegis of the range of services typically provided by. Each individual must have had appropriate expe-
The location of any such facility must allow easy ac- rience of, and training in, dental anaesthesia. The
cess for emergency services.8 anaesthesiologist must have a dedicated assistant (op-
erating department assistant or practitioner, nurse or
Equipments, monitors and drugs dental nurse) with recognised training in this role and
no other contemporaneous responsibilities. Because the
All standard equipments, gadgets, monitors and dentist also requires assistance, a minimum of four
drugs for anaesthesia and resuscitation should be avail- people are required for any procedure under general
able and checked before administering anaesthesia. This anaesthesia. Until consciousness returns, a patient re-
includes (not exclusive) anaesthesia machine, vaporiz- covering from general anaesthesia must be appropri-
ers, oxygen, nitrous oxide, breathing circuits (adult and ately protected and monitored continuously in adequate
paediatric), nasal and facial masks, oral and nasal air- recovery facilities. Such monitoring should be under-
ways, different laryngoscopes with all sizes of blades, taken by the anaesthesiologist or a dedicated individual
all range of nasal and oral tracheal tubes, independent who is appropriately trained, and directly responsible
suction apparatus, etc. SAFE agents (Short acting fast to the anaesthesiologist. 8
emergence) have particular place in day care anaes-
thesia.3, 7 Aftercare
Minimum monitoring standards during anaesthe- The brief nature of most dental procedures means
sia should be followed. Peripheral arterial oxygen satu- that the majority of patients may be managed on an
ration, ECG, non-invasive blood pressure and ambulatory basis. Modern anaesthetic drugs permit
capnography (when tracheal intubation is performed) rapid recovery of consciousness and early discharge,
should always be done. A precordial stethoscope can but it should be recognised that it may take more than
be very helpful. The anaesthesiologist should be clini- 24 hours for all traces of the agents to be eliminated.
cally vigilant and continuously monitor colour of lips Thus when, in the opinion of the anaesthesiologist, pa-
and mucosa, and movements of chest and reservoir tients are ready for discharge they must be accompa-
bag. The alarms of monitors should never be switched nied by a responsible, legally competent adult who has
off.10, 11 been given clear instructions regarding the implications
of anaesthetic hangover effects. All patients must be
All resuscitation drugs and equipments, including assessed specifically for fitness for discharge by the
defibrillator should be immediately available. Moreover, anaesthesiologist. The administration of general
the whole staff should be adequately trained in resusci- anaesthetics for longer periods of time demands a level
tation (adult and paediatric). The dental chair should of recovery facility that can only be provided in a mod-
be capable of head-down tilt and should be movable in ern day-surgery unit, and standard criteria for the du-
the event of power failure. The anaesthetist must check

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Indian Journal of Anaesthesia, October 2008(P.G.Issue)

ration of day-stay procedures apply. 7-9 Pre-anaesthetic preparation

Types of dental surgery The patient is explained about the anaesthetic


and dental procedure and clear fluids are allowed up
Dental surgery comprises exodontia, which is re- to 4 hours preoperatively. A proper consent should al-
moval of teeth, and conservation, which is filling them, ways be taken. The patient must be accompanied be-
crowning them and other restorative measures. fore and after the surgery and supervised by an adult
for 24 hours.
Exodontia : Removal of teeth, it is usually a short
procedure. Premedication
Conservation: Conservation operations take longer This is not usual, but may be used in children with
and often involve using a drill, which squirts water, so a especially challenging behaviour. Chloral hydrate (50-
pharyngeal pack is necessary to prevent aspiration even 100mg.kg-1), trimeprazine (2mg.kg-1) or midazolam
with a cuffed endotracheal tube.11 (0.50.75 mg.kg-1) may be given orally mixed with a
small quantity of juice to disguise the taste, or intrana-
Consent sally (midazolam 0.20.3 mg.kg-1). The patients are in-
structed to empty their bladder and bowels before sur-
Written and informed consent by the patient or
gery.10, 11
parent/ guardian if the patient is minor or mentally chal-
lenged.
Induction of anaesthesia
Dental chair anaesthesia In small children, gaseous induction using
sevoflurane (with parental presence) is often easiest.
The common indications are:
Since its introduction, sevoflurane has largely replaced
1. Children: Majority of patients are children be- halothane as agent of choice because inhalation is quick
tween ages 4 and 10 years requiring extraction of tooth/ and smooth and there are limited cardiovascular and
teeth. Such patients frequently have upper respiratory respiratory effects.19 Sevoflurane supplementation of
tract infection. 66% nitrous oxide in oxygen is used. Sevoflurane may
either be introduced in 2% increments every 2 to 3
2. Adult patients with acute infection. breaths to a maximum of 8%, with maintenance of ana-
esthesia at or around 4%, or it may be introduced at
3. Mentally challenged patients. the maximum concentration of 8%, with maintenance
at 4%. Induction using 8% sevoflurane does not ap-
Only ASA physical status class I & II patients
pear to cause any adverse effects.20 However, if
should be administered Dental Chair Anaesthesia or
sevoflurane is not available halothane is preferred over
Office-Based anaesthesia care. Patients with compro-
isoflurane that is irritant and can lead on to coughing
mised airway requiring advanced airway management
and laryngospasm.21 Desflurane offers the advantage
devices, haemodynamic instability requiring invasive
of reduction in recovery time.22 A pulse oximeter and
monitoring and those who require prolonged post-op-
ECG should be placed before the child goes to sleep.
erative care should be operated in an in-patient setting.
A cannula must be inserted once the child is asleep for
Congenital cardiac anomalies and syndromes (predis-
all but the briefest general anaesthetic, for example ex-
posing to difficult airway, unstable spine, etc) should
traction of one tooth that takes a couple of seconds.
be specifically looked for in paediatric patients. 3, 7, 11, 17,
18

728
Naveen Malhotra. General anaesthesia for dentistry

Older children may be offered a choice of gas- mask may indicate breathing. Still, constant vigilance is
eous or intravenous induction, and letting them decide needed as the bag on the breathing circuit may not move
is a good way of enlisting cooperation because the child even with adequate ventilation, and no CO2 trace will
feels less threatened. Propofol is agent of choice for be obtained.3, 11 Adenotonsillar hypertrophy can com-
intravenous induction and it ensures clear headed re- promise the nasal airway and nasopharyngeal airways
covery and good anti-emesis, however thiopentone can have been shown to significantly improve airway pa-
also be used. Ketamine has delayed recovery charac- tency and reduce episodes of airway obstruction.23
teristics and induces dysphoria. Application of local
anaesthetic cream (EMLA) to the skin will ensure that Laryngeal mask airway (LMA) is being used for
insertion of the cannula is painless. However, it has to all but the simplest extractions. It provides some bar-
be applied one hour prior to procedure which can be rier to aspiration when compared to mask. The
difficult in out-patient setting.3, 11 armoured variety is more suitable as its tube is nar-
rower and takes up less room in the mouth and its flex-
Airway for exodontia ibility makes it easier to keep out of the dentists way.
It is important to hold the LMA firmly in place during
The type of airway chosen depends on the sur- the surgery because it has a tendency to move. Down-
gery, and it is vital to liaise with the surgeon. Extraction ward pressure on the jaw during extractions may ob-
of a few easy baby teeth is done using a transparent struct it.24-25
neonatal mask over the nares. The surgeon inserts a
gauze pack from one buccal sulcus to the other in or- The airway is shared by the anaesthesiologist and
der to prevent too much mouth breathing and aspira- dentist. Too large mouth gag should not be used be-
tion of tooth fragments. A gag or bite-block is posi- cause it can make airway maintenance difficult. The oral
tioned on the side opposite the extractions to open the pack should not be placed too far posteriorly in the
mouth. However, the nasal mask is still used by some mouth, otherwise it can compromise nasal airway. The
dental anaesthetists (Fig. 1). The transparent neonatal anaesthetist must hold the patients head both to pre-
mask has significant advantages: the external nares can vent excessive movement of the neck, which can cause
be seen with a transparent mask so that it is possible to pain postoperatively, and to provide support to the jaw
check that they are not obstructed, and misting of the and counter pressure to the dentists pushing and pull-
ing.

Operating position
The operating position is controversial. Tradition-
ally, patients sat upright in the dental chair but it can
cause postural hypotension. The sitting position has
gradually become less common for dental surgery un-
der general anaesthetic. In the supine position, the inci-
dence of airway obstruction is high due to falling back
of tongue and there is greater risk of pharyngeal soiling
due to blood. Overall, maintaining airway with nasal
mask is difficult in supine position. The most commonly
used position is semi-supine. In this position, erect head
and neck helps in maintenance of airway, besides car-
Fig.1 Mask for nasal ventilation diovascular and respiratory advantages of semi-reclin-

729
Indian Journal of Anaesthesia, October 2008(P.G.Issue)

ing position and elevated legs.3, 7, 11 supervised by an experienced nurse. Oxygen supple-
mentation ameliorates the severity of desaturation but
Airway for conservation does not prevent it. 28 The patients are monitored in the
recovery area for at least 30 minutes before returning
Operations for dental conservation and periodon- to dental clinic. No oral fluids are given for 2-3 hours
tal procedures tend to take longer and to involve quan- to avoid vomiting and aspiration.
tities of water being squirted into the mouth. They should
therefore be performed with an endotracheal tube and Postoperative analgesia
pharyngeal pack in place to prevent aspiration, which
can otherwise occur even with a cuffed tube. It is usual Extraction of baby teeth is not especially painful.
to intubate nasally. An LMA makes the surgery difficult The main problem is the psychological trauma of wak-
because it leaves little space for the dental drill and suc- ing up uncomfortable in a strange place. It is important
tion.11 that the parents are present, and the administration of
paracetamol 10-15 mg.kg-1 is usually all that is needed.
Maintenance Analgesia may be given rectally (paracetamol or
diclofenac suppositories) during the operation, but for
For short operations it is often easier to use a tech- short operations this is of no major advantage.
nique involving spontaneous respiration of inhalational Ibuprofen or paracetamol may be given orally in liquid
agent, nitrous oxide and oxygen, which gives flexibility form in recovery.
and rapid recovery. Using 50% inspired oxygen con-
centration is beneficial and has been shown to decrease The extraction of adult teeth is undoubtedly pain-
the incidence and severity of hypoxaemic episodes. ful. Non-steroidal analgesics are effective, and it has
Incremental doses/continuous/ target controlled infu- been shown that oral diclofenac given on admission is
sion of propofol can be used for maintenance of ana- as effective as rectal diclofenac given peroperatively.11
esthesia. For extensive and complicated restorations,
it is better to paralyse and ventilate the patient. Fitness for discharge

Recovery Patients should be clinically observed to be alert,


oriented, able to stand and walk unassisted, and
The tooth sockets continue to bleed after dental haemodynamically stable. There should be no obvious
extraction, especially in the presence of infection. Ini- surgical complications. Simple scoring systems, like
tially, patients are best nursed in left lateral position with Aldrete post anaesthetic recovery score (uses colour,
a degree of head-down tilt to encourage drainage of respiration, circulation, consciousness and activity as
any blood and secretions away from the larynx and criteria) can be applied.7
administered 100% oxygen. Thorough but gentle oro-
pharyngeal suctioning is done. The LMA or endotra- Day care anaesthesia
cheal tube should not be removed until the cough reflex
has returned. Removal of the LMA while the child is In day care facility, patient undergoes formal ad-
still deeply anaesthetized has been associated with lower mission to the hospital but is discharged home later in
oxygen saturations in dental patients.26 A study of deaths the day. The procedures which are usually done are
related to dental anaesthesia found that more than half minor oral surgical procedures including laser treatment
occurred in recovery.27 Significant desaturation is com- and limited extractions. The surgical procedure usually
mon after brief dental anaesthesia and the principal lasts not longer than one hour and there are no antici-
cause is airway obstruction, these patients should be pated post operative complications. The patients are

730
Naveen Malhotra. General anaesthesia for dentistry

usually adults belonging to ASA physical status class I ever, it is pertinent to note that these patients can have
or II. They are accompanied by a responsible adult swelling of face, missing or loose teeth, pain and tris-
and home circumstances should be suitable for con- mus limiting the mouth opening or a maxillo-mandibu-
tinuing post-operative care. lar fixation may be in situ. Thorough airway evaluation
should be done and necessary radiographs evaluated,
Patients are assessed formally by the especially the antero-posterior and lateral views of neck.
anaesthesiologist and investigated. Usually for patients The nasal patency should be done to facilitate nasal
below 40 years complete blood examination and urine intubation. Such patients may have polytrauma and
complete examination is done. For patients aged 40 complete evaluation is necessary, including complete
years or more an ECG is done. Adequate preopera- haemogram. Neurological evaluation is necessary in
tive fasting is necessary, usually six hours for adults and patients with co-existing head injury. The electrolyte
four hours for children. If patient is anxious, premedi- status must be assessed because such patients have a
cation is advised in form of oral alprazolam or limited oral intake (usually liquids). 3, 7
midazolam, but it can delay recovery. A proper con-
sent is taken. Intravenous induction with propofol is Principles of airway management7, 29
done in adults and older children. Neuromuscular block-
ade is achieved with atracurium or vecuronium. The 1. Patients with complex maxillo-facial injuries are
use of depolarizing neuromuscular blocking agent suc- potential difficult airway patients. Difficult airway trol-
cinylcholine is best avoided in such predominantly am- ley should be checked and immediately available.
bulatory patients because of muscle pains. Naso-tra-
cheal intubation is commonly done but oro-tracheal in- 2. Do not administer neuromuscular blocking
tubation can be done if only one side of the mouth is to agent until it is possible to do mask ventilation.
be operated. Pharynx is properly packed. Anaesthesia
is maintained with administration of halothane / 3. Maxillo-Mandibular Fixation:
sevoflurane and nitrous oxide in oxygen. Diclofenac and It is important to understand that in patients with
dexamethasone are administered to reduce pain and panfacial trauma, surgical reconstruction often involves
swelling. Local anaesthetic may be infiltrated into the intraoperative maxillo-mandibular fixation to restore
sockets by the surgeon, or a block is performed if sur- dental occlusion and it is the important aspect of surgi-
gery is limited to one or two quadrants. For more ex- cal procedure. The fixation is done with high tensile
tensive procedures, short acting opioid like fentanyl is strength elastic bands (common) or classical wires.
administered. Long acting opioid, like morphine is Discuss with the surgeon, the possibility of removing
avoided in day care surgery.3, 11 maxillo-mandibular fixation just before induction of ana-
esthesia. Removal of bands/wires can make airway
In- patient anaesthesia management quite easier. It can be redone intra-op-
eratively after securing the airway. If possible, subse-
It is for complicated extractions, oral surgical pro-
quent removal at the end of surgery makes tracheal
cedures and maxillofacial surgical procedures (fixation
extubation and recovery simple. The maxillo-mandibular
of maxillary, mandibular and nasal fractures, mandibu-
fixation can be finally put in situ in the ward once pa-
lar set back, maxillary advancement, osteotomies and
tient is fully conscious and airway oedema subsided.
removal of tumours.
4. Throat pack is put to prevent ingestion of blood
Pre-anaesthetic evaluation into the stomach or its settling above the cuff of tra-
cheal tube.
It is same as for any other major operation. How-

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Indian Journal of Anaesthesia, October 2008(P.G.Issue)

5. A reinforced or flexo-metallic tube is most com- nasotracheal tube. Further, the presence of nasotracheal
monly used for tracheal intubation. tube can interfere with the surgical reconstruction of
naso-orbital - ethmoid (NOE) complex.31-33
6. Such patients commonly receive steroids
perioperatively to reduce airway oedema. C) Retromolar intubation 34, 35
7. A tongue suture is applied if there is gross air- When orotracheal intubation is not feasible and
way oedema and mouth is open. nasotracheal intubation contraindicated, retromolar in-
tubation is indicated to secure the airway perioperatively.
8. Displacement of tracheal tube can occur be-
cause the tracheal tube is quite close to the surgical In this technique, oral endotracheal intubation is done
with a flexometallic tracheal tube which is then placed
field. Proper fixation of tracheal tube should be done
in the retromolar region. The retromolar space is the
and anaesthesiologist should be vigilant to promptly
space behind the last erupted upper and lower molar
detect it.
teeth. The retromolar tube is stabilized in position by
9. Routes of tracheal intubation fixation to first or second molar tooth in figure of eight
fashion. (Fig. 2) It allows intraoperative maxillo-man-
A) Oral tracheal intubation: dibular fixation, thus restoring dental occlusion, which
is the important step for successful facio-maxillary sur-
It can be done under direct laryngoscopic view, gery.
fiberoptic bronchoscope guided, by using lighted stylet,
through LMA (guided by fiberoptic bronchoscope) or
intubating LMA. Oro-tracheal intubation is not feasible
if intraoperative maxillo-mandibular fixation is to be
done.30

B)Nasal intubation:
It is the most common route of tracheal intuba-
tion. It can be laryngoscope guided, fiberoptic bron-
choscope guided or blind. Depending upon the clinical
Fig 2 Retromolar Intubation
circumstances the patient may be anaesthetized and
breathing spontaneously or paralyzed, or may be The adequacy of retromolar space can be deter-
awake. Nasal passage is well prepared with a vaso- mined by introducing the index finger in the patients
constrictor and a topical anaesthetic. mouth and asking him or her to close the mouth. If there
is no compression on finger, the retromolar space is
However, nasotracheal intubation is not possible
adequate. Success of retromolar intubation can also
in some patients (10-15%) due to associated skull base
be increased by selecting one size smaller tracheal tube
fractures, cerebrospinal fluid rhinorrhoea (any attempt
which has a corresponding smaller outer diameter.
towards nasotracheal intubation may lead to passage
of tracheal tube into cranium, meningitis, sepsis and Advantage: This technique avoids the need of
epistaxis), fractures of nasal skeleton and anatomical any surgical technique i.e. tracheostomy and submento-
obstruction of nasal airway (deviated nasal septum, tracheal intubation for securing airway perioperatively.
nasal spur, and hypertrophied nasal turbinates). These
conditions cause physical obstruction to the passage of Disadvantages: These are minor and avoidable-

732
Naveen Malhotra. General anaesthesia for dentistry

1. The tracheal tube can interfere with the main endotracheal tube at the submental skin exit point is
surgical field and positioning and application of dental noted. It is usually 2 cm more than the oral fixation.
fixation devices. This helps in checking the tube position intraoperatively.
The tube is fixed in position with suture (as chest tube
2. Too jealous fixation of flexometallic tracheal drain). (Fig. 3)
tube with wire ligature should not be done because it
can deform the tube.

D) Submento-tracheal intubation 29, 36-39


Submento- tracheal intubation is an alternate
technique of airway management in patients with cranio
- faciomaxillary trauma when retromolar intubation is
not possible. It is an alternative to short-term tracheo-
stomy.
Fig 3 Submento-Tracheal Intubation
Technique
Intraorally, the tracheal tube lies in the sublin-
Orotracheal intubation with reinforced gual sulcus between the tongue and mandible. It is away
(flexometallic) endotracheal tube is done using stan- from the surgical field and allows intraoperative maxillo-
dard general anaesthesia technique. At the start of pro- mandibular fixation. The total procedure is usually com-
cedure, nitrous oxide in switched off and patient is ad- pleted within 5-10 minutes and the blood loss is mini-
ministered 100% oxygen. A 1.5-2 cm incision is made mal (<10ml). At the end of surgical procedure,
in the submental region parallel and medial to the infe- submento- tracheal intubation is converted back to
rior border of the mandible. The incision is lateral to orotracheal intubation. The reinforced tube can be pulled
the anterior belly of digastric muscle. When ever pos- out through the submental tunnel also. The submental
sible, the right side is preferred because it allows better incision is closed not so tightly with interrupted skin
visualization of the intraoral position of tracheal tube sutures. The intraoral incision heals secondarily.
with direct laryngoscopy. The incision is extended
intraorally by blunt dissection with artery forceps through Perioperative care
the subcutaneous layers, mylohyoid muscle, submucosa
Antibiotic cover is provided, same as for
and mucosa. The intraoral opening is lateral to the sub-
trauma patients, as per institutional protocol. Oral hy-
mandibular and sublingual ducts. Thus, a submental
giene is maintained with 0.2% chlorhexidiene glauconate
tunnel is created.
mouthwash 4-6 times per day. The submental incision
The tracheal tube is briefly disconnected from is not closed so tightly to allow certain degree of drain-
the breathing circuit and the tube connector is removed age and helps in preventing infectious complications.
from the tube. The pilot balloon followed by the tra- Antiseptic dressing is done. Stitches are removed on
cheal tube is gently pulled out through the submental sixth postoperative day. The scar is almost invisible af-
tunnel. During this step, the endotracheal tube is stabi- ter two months.
lized intraorally manually or by Maggils forceps. The
The submental endotracheal tube has been left
tube connector is reattached and endotracheal tube is
in situ for up to three days. Mechanical ventilation can
connected to the anaesthesia breathing circuit. Bilat-
be instituted through it in the intensive care unit. Tra-
eral air entry is checked. The distance marking on the
cheal suction with a lubricated catheter can be easily

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Indian Journal of Anaesthesia, October 2008(P.G.Issue)

done through the submentally placed tube. The avail- simple, easy and non invasive technique of tracheal in-
ability of reinforced tracheal tubes made of polyvinyl tubation when oral intubation is not feasible and
chloride has the advantage of a low pressure, high vol- nasotracheal intubation is contraindicated. When ret-
ume tracheal tube cuff. However, when submental en- romolar intubation is not possible, submento-oral intu-
dotracheal tube is not removed, it is mandatory that bation is a relatively harmless alternative to tracheo-
immediate access to oral airway is ensured at all times. stomy for securing the airway perioperatively.
Maxillo-mandibular fixation should be deferred till ex-
tubation and confirmation of secure airway. If maxillo- Complications of dental anaesthesia
mandibular fixation is necessary then cutter should be
immediately available. If reinforced tube is removed 1. Hypoxaemia:
outside the operating room, then after extubation clo-
During dental chair anaesthesia, there is high po-
sure of submental incision is done under local anaes-
tential for airway obstruction resulting in hypoxaemia.
thesia.
This can result from inhalation of teeth, crowns, por-
Damaged submento tracheal tube (leaking cuff, tions of filling, etc. A sudden decrease in arterial oxy-
loose universal connector) can be replaced success- gen saturation by up to 10% can occur under general
fully with the use of tracheal tube exchanger, while the anaesthesia due to upper airway obstruction at the time
tracheal tube is placed submentally. The apparent steep of insertion of the dental prop and pack and during
angle of insertion in the submental approach can be extractions. This obstruction is accentuated by coex-
negotiated successfully. isting rhinitis and hypertrophied adenoids and tonsils in
young children. Further, in such patients airway clo-
Advantages sure occurs at lung volumes well above functional re-
sidual capacity (FRC), producing a large intrapulmo-
This technique provides a secure airway, un- nary shunt. During general anaesthesia, there is further
obstructed intraoral surgical field, allows intraopera- reduction in FRC and intrapulmonary shunt is exacer-
tive maxillo-mandibular fixation and avoids complica- bated and together with propensity for upper airway
tions of tracheostomy. It is a simple, safe and useful obstruction, there is greater tendency to hypoxia.28, 40,
41
technique with very low morbidity.

Disadvantages Increasing fractional inspired oxygen concentra-


tion to 0.3 reduces the incidence and severity of
It can cause trauma to submandibular duct, peroperative desaturation. However, increasing the
sublingual gland or duct and facial nerve or lingual nerve. FiO2 further to 0.5 has not been shown to result in
Superficial infection of the submental wound can occur more improvement in oxygen saturation.42, 43 Applica-
which if not treated properly can result in oro-cutane- tion of 5cm H2O continuous positive airway pressure
ous fistula. Incidence of hypertrophic scarring is low. (CPAP) can result in significant reduction in incidence
and severity of peroperative arterial desaturation by
E) Retrograde intubation and tracheostomy: very increasing FRC and overcoming partial airway obstruc-
rarely required. tion.44
Airway management in patients with cranio- 2. Arrhythmias:
facio-maxillary trauma is a challenge for both
anaesthesiologists and surgeons. It requires close in- There is high incidence of cardiac arrhythmias,
teraction between them. Retromolar intubation is a especially with the use of halothane. They are usually

734
Naveen Malhotra. General anaesthesia for dentistry

attributed to light anaesthesia, elevated levels of cat- Definition: It is a minimally depressed level of
echolamines and trigeminal nerve stimulation. They are consciousness that retains the patients ability to inde-
increased in the presence of hypercarbia or hypoxia. pendently and continuously maintain an airway and re-
The arrhythmias usually occur during extraction of teeth spond appropriately to physical stimulation and verbal
but are transient, seldom require treatment and respond command. It is produced by a pharmacological or non-
to cessation of pull on the tooth.45 pharmacological method or a combination thereof. In
dentistry, it is used to reinforce positive suggestion and
3. Subcutaneous emphysema: reassurance in a way which allows dental treatment to
be performed with minimal physiological and psycho-
Subcutaneous emphysema of face and cervical
logical stress, and enhanced physical comfort. The tech-
areas, although rare but can occur due to the use of air
nique must carry a margin of safety wide enough to
driven, ultra-high speed dental instruments. The air en-
render loss of consciousness highly unlikely.13
ters along the mandibular periosteum at the operative
site. Nitrous oxide is discontinued on detection of em- Conscious sedation may be induced by any one
physema and respiratory parameters closely moni- of the following modalities:
tored.46
1. Oral administration of a single sedative drug
4. Dislocation of temporo-mandibular joint: It (midazolam, diazepam, alprazolam, lorazepam,
occurs not infrequently in children if mouth is opened zolpidem, promethazine, chloral hydrate).
widely. It can predispose to airway obstruction due to
alteration in position of tongue. It can be easily reduced 2. Nitrous oxide and oxygen
at the end of surgery.
3. Combination of oral sedative drugs or nitrous
5. Operating room pollution: Dental surgeries oxide and oxygen with an oral sedative drug
are areas of high contamination with anaesthetic gases.
Efficient ventilation (12-15 room changes of air per hour) 4. Parenteral administration of sedative drugs (in-
and scavenging are required. travenous- midazolam, propofol; intramuscular; sub-
cutaneous; submucosal or intranasal-midazolam).
6. Hyperthermia: Tissue destruction, environ-
mental temperature during surgery, administration of Relative analgesia
certain drugs, dehydration and bacteraemia have all
been implicated in temperature rise after anaesthesia. It is an inhalation sedation technique consisting of
Procedures provoking bacteraemia (extractions) can three elements: First, administration of low to moder-
be managed by routine administration of antibiotics.6, 47 ate concentration of nitrous oxide in oxygen (0-70%);
Second, as nitrous oxide begins to exert its pharmaco-
7. Non-compliance of post-operative instruc- logical effects, the patient is subjected to reassuring and
tions: Patients undergoing day surgical procedures are semi-hypnotic suggestions; and thirdly the use of fail-
given instructions not to drink alcohol, drive vehicles or safe equipment with a range of safety features, espe-
make important decisions for 24 hours. Some patients cially preventing accidental administration of 100% ni-
do not comply with these instructions. Compliance can trous oxide.50 Sevoflurane 0.1-0.3% and 40% nitrous
be improved by physician reinforcement of instructions oxide in oxygen has been used for inhalational con-
and patient education.48 scious sedation in children undergoing dental treat-
ment.51
Conscious sedation
To conclude, provision of treatment under gen-

735
Indian Journal of Anaesthesia, October 2008(P.G.Issue)

eral anaesthesia in selected children is justified and such 12. American Academy of Pediatric Dentistry. Guidelines
services should be provided safely, effectively and effi- for the elective use of conscious sedation, deep seda-
tion and general anaesthesia in pediatric patients. Ped
ciently in the appropriate environment. Dental treatment Dentistry 1985; 7:334-7.
under general anaesthesia can be carried out in a day
13. Royal College of Dental Surgeons of Ontario. Guide-
care facility with a high level of patient and parent sat- lines for use of sedation and general anaesthesia in den-
isfaction. Anaesthetic management by a qualified and tal practice. Canada: Royal College of Dental Surgeons
experienced person and dental treatment by a qualified of Ontario, 2005.
operator allow the procedure to be carried out with 14. Alcaino E, Kilpatrick NM, Smith EDK. Utilization of day
minimal morbidity. stay general anaesthesia for the provision of dental treat-
ment to children in New South Wales, Australia. Int J
If the otherwise well-trained anaesthesiologist fails Paed Dentistry 2000; 10: 206-12.
to meet the challenge of office dentistry, the field is left 15. Jamieson LM, Thomson KFR. Dental general anaesthetic
by default to either the poorly trained physician, or the trends among Australian children. BMC Oral Health
2006, 6:16-22.
dentist who may be tempted to essay surgery and ana-
16. Jamieson LM, Thomson KFR. Dental general anaesthetic
esthesia simultaneously. In either case, the patient is
receipt among Australians aged 15+ years, 19981999
poorly served, and anaesthesia slips backward, not to 20042005. BMC Oral Health 2008, 8:10-7.
forward.49 17. UK National Clinical Guidelines in Paediatric Dentistry.
Guidelines for the use of general anaesthesia (GA) in
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