GOOD MORNING

Seminar presented to,

The Department of Pedodontics

Seminar prepared by,

Sachin Sunny Otta

Final year Part II

2011 KUHS

Reg no. 110021192

Dental Services for

Children & the use of General

Anaesthesia

Indroduction Dentist provide essential service to patient by

consultative and emergency procedure . Joint

Commission on Accreditation of Health care

Organisation [JCAHO] issue standard for

hospital governance for all hospital service. In

order to consider staff privileges many

hospitals have incorporated general dental

services along with dental speciality to serve

the community

OBTAINING HOSPITAL STAFF

PREVILAGESBasic requirements to become hospital staff member

applicant must have graduated from an accredited dental school

Applicant must be licensed to practice dentistry in the country in which facility is located

Applicant must have high moral & ethical status

Additional requirements

To sign ‘Delineation of Privileges form indicating the procedure that staff member are qualified to perform

Show proof of professional liability insurance and membership in ADA

Requirements for in a children’s hospital: Dental residency

of one to four years in hospital to ….

Gain experience in evaluating medical history and

current medical status

Receive instruction in physical examination techniques

and in recognition of condition that may influence dental

treatment decision

Learn to initiate appropriate medical consultation when a

problem arise during treatment

Learns the procedure for admitting monitoring and

discharging children

Develop proficiency in operating room protocol

PSYCHOLOGICAL EFFECTS

OF HOSPITALIZATION ON

CHILDREN Separation of child from parent is significant factor

for post hospitalization anxiety

Ways to decrease stress :

1.Prior tour to operating room

facility

2.Informing parents of status

of the child during procedure

3.Letting the parents know that “everything is allright”

CHANGES EXHIBITED BY CHILDREN:

POSITIVE

a) Less fuss about eating

b) Fewer temper tantrums

c) Better appetite

NEGATIVE

a) Biting the nail finger

b) Becoming upset when left alone

c) Being more cautious & avoiding

new things

a) Staying with parents & needing

more attention

a) Afraid of dark

WAYS TO MINIMIZE NEGATIVE CHANGES:

1. Involve child in operating room tour

2. Allow child to bring favourite toy/doll

3. Pre induction sedation

4. Provide non threatening environment

5. Allow parent to rejoin their children as early as possible

in the recovery area.

OUTPATIENT VERSUS

INPATIENT SURGERYOUT PATIENT/AMBULATORY METHOD

HIGHLIGHTS…

Common method

Advances in anaesthetic medication & changes in

preoperative & postoperative management

Better tolerated by family & hospital team

Less traumatic for patients

Same-day-surgery centres & freestanding

ambulatory care have cut health care costs

INDICATED FOR…

Young patients with ASA class I or II

Patients with well controlled chronic systemic diseases(

asthma,diabetes,CHD)

TO NOTE…

Child to be brought by the parent to the hospital one &

half hours before the dental surgery

Comprehensive medical history & physical examination,

anaesthesia assessment &limited hematological

evaluation done

Post operative instructions & follow ups scheduled

INPATIENT METHOD

Increasing cost –disadvantage

INDICATED FOR…

Child with existing medical conditions & require close

follow ups

If child lives outside general area of hospital

Medically/developmentally disabled patients with multiple

problems.

GENERAL ANESTHESIA“A drug-induced loss of consciousness

during which patients are not arousable,

even by painful

stimulation. The ability to independently maintain ventilatory

function is often impaired. Patients often require assistance

in maintaining a patent airway, and positive-pressure

ventilation may be required because of depressed spontaneous

ventilation or drug-induced depression of neuromuscular

function. Cardiovascular function may be impaired.”

(AAPD)

GENERAL ANESTHESIA IN THE

TREATMENT OF CHILDREN To provide safe efficient and effective care

Oral hygiene and preventive care must be done at onset of treatment with parents or guardian

Depending on patient treatment is done either in ambulatory care setting or inpatient hospital setting it is recommended that at least one or two attempts be made using conventional behaviour management techniques or conscious sedation before GA is considered

Parental or guardian written consent to be obtain before use of GA

Documentation regarding dental treatment needs ,unmanageability in dental sitting ,contributory medical problem must be included in patient hospital records

Indication for GA

Patient unable to cooperate with certain physical ,mental

or medically compromising disability

Patients with dental restorative or surgical needs for

whom LA is ineffective because of acute infection,

anatomic variation or allergy

Extremely uncooperative ,fearful anxious,physically

resistant or uncommunicative child or adolescent with

substantial dental need for whom there is no expectation

Patients who sustained excessive orofacial or dental

trauma

Patients for whom the use of GA may protect the

developing psyche or reduce medical risk

PROCEDURES1. MEDICAL AND DENTAL HISTORY

2. PRE OPERATIVE DENTAL EXMINAITION.

3. PARENTAL CONSULTATION

4. PEDIATRIC CONSULTATION

5. PRE OPERATIVE ANESTHESIA EXAMINATION

6. ONE WEEK BEFORE APPOINTMENT (CONSENTFORM)

7. PREOPERATIVE ORDERS

8. PATIENT ADMISSION

9. EQUIPMENT PREPARATION

10. OPERATING ROOM PROTOCOL

11. INDUCTION OF ANAESTHESIA

12. PERIORAL CLEANING & THROAT PACK

13. RESTORATIVE PROCEDURE

14. COMPLETION OF PROCEDURE

15. POST ANESTHETIC CARE

16. POST OPERATIVE ORDERS

17. OPERATION REPORT

18. DISCHARGE AND FOLLOW UP CARE

1.MEDICAL & DENTAL

HISTORY

Medical and dental history

Family and social history

Chief complaint

Request the needed

laboratory investigation

CBC,PT,INR,BT,CT

ASA Level

Thyroid function tests

2.PRE – OPERATIVE DENTAL

EXAMNATION

2-Pre- operative dental examination

Clinical examination

Extra- oral

(head and neck physical examination)

Intra- oral

Soft tissue Hard tissue

Radiographic

Examination

3.PARENTAL

CONSULTATION

Discuss the reason/need for G.A

Risks/benefits with G.A.

Anticipated post-operative behavior.

Need for a physical examination

Need for laboratory tests.

Need for medical consultation (if indicated).

Admission process to the hospital/ one day surgery.

Pre-surgical and post-surgical dietary precautions.

4.PEDIATRIC CONSULTATION

PEDIATRIC CONSULTATION

PEDIATRIC Evaluation

Medical historyReview of body

systemASA

classification

Request the needed laboratory investigations

Pediatric Review of the

laboratory result

5.Pre operative anesthesia

examination

Tonsillar size assessment

The anesthetic recommendation:

• Cleared for the operation after the pediatric

clearance.

• Fasting from the midnight the day before the

surgery

• Preoperative medication (Midazolam)

ASA Physical Status Classification System

ASA I

A normal healthy patient ASA II

A patient with MILD systemic disease ASA III

A patient with SEVERE systemic disease ASA IV

A patient with SEVERE systemic disease that is a constant threat to life ASA V

A moribund patient who is not expected to survive without the operation ASA VI

A declared brain-dead patient whose organs are being removed for donor purposes

Mallampati classification

Class 1: Full visibility of tonsils, uvula and soft palate

Class 2: Visibility of hard and soft palate, upper portion

of tonsils and uvula

Class 3: Soft and hard palate and base of the uvula are

visible

Class 4:Only Hard Palate visible

6.ONE WEEK BEFORE

APPOINTMENT LEGAL CONSENT IS SIGNED

consent form for blood transfusion in case of

emergency is signed

The date of the operation.

7.PREOPERATIVE ORDERS

Diet description and restrictions

Laboratory studies needed for anesthesia and

surgery clearance

Preoperative Medication

Consultations requests as needed

Oncall for operating rooms

Dietary precautions

NPO guidelines:

Ingested Material

Minimum Fasting period(h) Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee

2 Breast milk

4

Infant formula

6 Nonhuman milk: because nonhuman milk is similar to solids in

gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period

6 Light meal:

6

1.No milk or solids for 6-8 hours .

2.Clear liquids up to 3hours before the procedure.

Reasons for diet instructions

Prevent emesis during or immediately after a sedative

procedure.

Uptake is maximized when the stomach is empty.

8.ADMISSION TO THE HOSPITAL Child come to the hospital on the day of surgery & stays

postoperatively until next morning.

Childs admission order to be written by dentist regarding

preliminary information

Nursing staff explain the standard hospital procedure to

the parents

Child will be visited by anaesthesiologist who assess

childs present state of health and review the past &

present hospital record prior to exposure to GA

Anaesthesiologist explains the procedure and answers

any questions by child or parents.

Dentist & staff should be present in the operating room

30min before the dental procedure.

9.EQUIPMENT

PREPARATION

10.OPERATING ROOM

PROTOCOL

All persons in the operating room must follow occupational safety & Health Administration (OSHA) guidelines:

Wear appropriate attire to prevent contamination of surgical suit , hallway and recovery room

1. Shirt , pant or skirt and coverings for face head and feet

2. Hood is used to cover unshaven facial hair

3. Eye glasses ,googles ,face shield are used

4. Mask to cover moth and nose

Operating room positions of the staff while

performing the necessary dental

procedures

11.INDUCTION OF ANAESTHESIA Magnitude of depression is directly proportional to

partial pressure of inhalational agent reaching

specific site in CNS

Induction of anaesthesia is quick and passage

through stages of anaesthesia is rapid

Technique of inhalational anaesthesia vary with :

a) Equipment used

b) Chemical absorption of expired co2

c) Rebreathing of expired gases

Techniques are :

1. Open or non breathing system

2. Semi open system

3. Semi closed system

4. Closed system

Advantages : exhaled gas mingled with fresh gas and are rebreathed after all co2 is removed by chemical absorber. Inhaled gases are humidified and reservoir bag or ventilation allows assisted respiration . Reduced loss of body heat and water vapour and decreased environmental contamination are advantages of low flow semi closed system

Anaesthethic potency express as Minimum Alveolar

Concentration {MAC}: It is the concentration of agent

required inhibit response to standard surgical

stimulus . It is additive when different agents are

used in combination

Commonly used inhaled anaesthetic : nitrous oxide

isoflurane, desflurane, sevoflurane

Mode of application: face mask (pleasent odour)

Common among the list: sevoflurane (lower blood/

gas partition coefficient; hence procedure rapid

induction and emergence produce less myocardial

depression and fewer less significant respiratory

problem).

Anesthetic preparation of the

child:Time out protocol

1. Preperation of operating room attire

2. Dentist should inform anaesthesiologist of any

special request concerning the procedure

3. Once patient enters the operating

room,circulating nurse identifies the

patient,planned medication & proposed

treatment to the dentist & anaesthesiologist.

4. Nasotracheal intubation/Oral tracheal intubation

is done to ensure good access to oral cavity

Monitoring equipments:

a) Automatic sphygmomanometer

b) ECG leads

c) Temperature monitoring device

d) Pulse oximeter

e) Capnography device

Eye guards for eye protection

Shoulder roll & safety belts are secured.

12.PERIORAL CLEANING,DRAPPING &

PLACEMENT OF PHARYNGEAL THROAT

PACK1. Perioral area cleansed with 3 sterile 4X4 inch gauze

pads

First gauze pad saturated with bacteriostatic cleaning agent

Second gauze:sterile water

Third gauze:alcohol

2. Surgical sheet positioned over remainder of childs body to maintain body temperature & provide clean field during procedure

3. Head is draped with three towels arranged to form a triangular access space for the mouth

4.Assistants place all supporting carts & strands around table in position

5. Mouth is opened using mouth prop & aspirated

6. Written documentation of throat pack placement & removal is required

7. Oral prophylaxis

8.Evaluate radiographic evidences & formulate treatment plan

THROAT PACK

Technique Seal the pharngoplataine area by moist sterile

gauze ( 12 to 18 inch long )

Documentation Written documentation for time of placement

Written documentation for time of removal

Function Reduce the escape of anesthetic agent. Prevent any material from entering the pharynx

Requirement The gauze must be tightly packed around the tube Ensure good seal

Throat pack

13.RESTORATIVE DENTISTRY

IN OPERATING FIELD

Allows excellent patient compliance & easy achievement of well lighted field

Restoration should be of longest longevity & least amount of maintenance

Most acceptable: full coverage s.s crowns

L.A may be used

Quadrant isolation with rubber dam

Topical fluoride treatment after completion of procedure

14.COMPLETION OF

PROCEDURE

END TIME OUT PROTOCOL:

1. Notify the anaesthesiologist 10 min before the

completion of procedure

2. Recovery room personnel is notified about childs

arrival

3. On completion of procedure,oral cavity is

thoroughly debrided & throat pack is removed

carefully

4. End time out protocol is called by circulating

nurse to identify patient safety concern

5. Dentist verbalise the nurse to remove throat

pack

15.POST ANAESTHETIC CARE

UNIT Dentist should inform the nurse of procedure done &

of special request or instructions

If extraction of tooth done: nurse instructed how &

where to apply gauze pack for hemostasis

Confirm that airway is patent,vital signs are

stable,child recovery id good

Dentist should meet the parents to provide brief

report of childs conditions & review of treatment

Prescription may be written for pain control-

Acetaminophen with codeine,Antibiotics –

Amoxicillin,clindamycin, Antiemetics-

Prochlorperazine,ondansetron

16.Post operative order

outpatient order

Inpatient order

Operative report

Post instructions to the parents

OUT patient

orders

Monitor vital signs until stable.

Disconnect IV when release from recovery.

Start clear liquids in day surgery.

Recall appointment.

Analgesic prescription.

Discharge from day surgery when meet discharge criteria.

IN patient orders

IV solution (e.g. ;5 % dextrose with ½ normal saline) at rate (e.g. 40 ml/hr)

Monitor vital signs for 15 minutes until stable .

Elevate head 30 degree.

Apply ice packs ( swelling)

Apply pressure pack ( homeostasis)

Start clear liquids as patient tolerated.

Medications.

17.Operative report Type of dental procedure.

Type of intubation.

Teeth restored.

Teeth extracted.

Dental prophylaxis and topical fluoride

application.

Summary (length of the procedure, blood

loss, complications)

Prognosis.

Dentist name and signature.

Post operative complication

Fever Nausea Vomiting

Hypoxia Bleeding

BIBLIOGRAPHY

Dentistry for the Child &

Adolescent- Mcdonald & Averys

(9th edition)

Always laugh when you can. It

is cheap medicine

-Lord Byron

THANKYOU..