Anesthesiology

Dental Surgery

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What the Anesthesiologist Should Know before the Operative Procedure

Carious teeth and gum disease interfere with overall health and may be a sign of systemic illness. The majority of dental procedures are done on an outpatient basis under local anesthesia, with or without sedation. Frequently, patients with physical, emotional, and/or behavioral limitations will require general anesthesia for their dental procedure.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

The large majority of dental surgery is elective.

Emergent: Dental surgery is rarely emergent. However, a dental abscess has the potential to cause significant soft tissue swelling that may interfere with breathing. In the event of airway compromise from a dental abscess, an emergent tracheostomy under local anesthesia may be necessary. Ludwig angina is a septic cellulitis of the submandibular region that can present as above. In the setting of airway compromise, delay for additional preoperative information is inappropriate.

Urgent: Dental surgery is rarely urgent. However, a dental abscess had the potential to cause a systemic inflammatory response. Patients may present with fever, chills, and even hypotension. In the setting of systemic symptoms, urgent surgery to treat the source of the infection may be necessary and should be performed as soon as appropriate.

Elective: The large majority of dental surgery is elective.

2. Preoperative evaluation

The following patient populations frequently require general anesthesia for their dental procedures:

  • Patients who are physically or mentally handicapped from cerebral palsy, profound mental retardation, or autistic behavior.

  • Patients who are too young to cooperate with dental care.

  • Patients who are fearful, unmanageable, or psychologically challenged.

  • Patients who are medically compromised secondary to craniofacial abnormalities, congenital heart disease, epidermolysis bullosa, oncologic disease, or some other chronic illness.

Medically unstable conditions warranting further evaluation: Because dental procedures under general anesthesia are typically elective in nature, it is relatively uncommon that a patient would present with an unstable condition that would require further evaluation. Patients with congenital heart disease with an abnormal heart rhythm or symptoms of heart failure should be evaluated by a pediatric cardiologist prior to receiving a general anesthetic.

Delaying surgery: Delaying surgery may be indicated if the patient has an active upper respiratory tract infection (URI) or has had a URI in the previous 4 weeks. There is no consensus regarding the optimal anesthetic management of patients with URIs. It has been demonstrated that patients with a URI or recent history of a URI are at greater risk for perioperative respiratory events. Perioperative respiratory events are more common in the patient with an ongoing or recent URI who has an ETT for their procedure, a history of reactive airway disease, a history of tobacco smoke exposure, a history of being born prematurely (<37 weeks), or copious amounts of secretions or nasal congestion. These respiratory events, however, cause very little residual morbidity.

Patients who do not have significant comorbidities and have a mild uncomplicated URI can be safely anesthetized for their dental procedure. Patients with significant comorbidities and/or a complicated URI should generally have their procedure delayed for at least 4 weeks.

3. What are the implications of co-existing disease on perioperative care?

The large majority of patients who present for dental surgery under general anesthesia are otherwise healthy children who are either too young or too fearful to participate with dental care. Three other patient populations deserve mention, patients with cerebral palsy, congenital heart disease, and epidermolysis bullosa.

Cerebral palsy

Perioperative evaluation

Cerebral palsy (CP) is a term used to describe a collection of motor system disorders that originate from a nonprogressive neurologic injury sustained perinatally or before two years of age. CP often results in spasticity and hypertonicity. Many patients with CP have abnormalities of speech, vision, and intellect while others function at a high educational and vocational level.

Respiratory: CP patients frequently have a history of recurrent pneumonias from chronic aspiration and a lack of an effective cough. Reactive airway disease is also prevalent.

Gastrointestinal:Reflux is common and many patients with CP require a Nissen fundoplication to control their disease. These patients often have an impaired ability to handle their pharyngeal secretions and may be on an antisialogogue, such as glycopyrrolate.

Neurological:CP patients may have a history of serious behavioral disturbances that may be exacerbated by a new, strange environment. Roughly 30% of patients with CP have a seizure disorder and are on anticonvulsants. Also, these patients often are unable to regulate their temperature, especially in the perioperative period. Cool and vasoconstricted extremities make IV access sometimes difficult.

Perioperative risk reduction strategies

Surgery should be delayed if the patient has an ongoing or a recent history (4 weeks) of an aspiration pneumonia. Pulmonary medications, including inhaled beta agonists, inhaled steroids, and antisialogogues, should be continued perioperatively. Suctioning of the oropharynx after induction and trachea after intubation, may be required in the event of excessive secretions. Anticholinergics can be given IV perioperatively to minimize secretions (i.e., glycopyrrolate 5 to 10 mcg/kg IV).

Oppositional behavior and poor venous access often make a rapid sequence induction to prevent aspiration impossible. Anti-reflux medications should be continued perioperatively and the airway should be secured expeditiously. Aggressive behavior may necessitate premedication prior to induction of anesthesia (i.e., ketamine 3 to 5 mg/kg IM or midazolam 0.5 to 1 mg/kg PO). Intranasal administration of midazolam, clonidine, or dexmedetomidine has also been described with success.

The literature has neither confirmed nor refuted that patients with CP have an exaggerated hyperkalemic response to succinylcholine. Succinylcholine has been used safely in this patient population and can be used with caution when indicated.

Patients with CP often require greater than expected doses of non-depolarizing muscle relaxants.

Mean alveolar concentrations (MAC) are lower in patients with CP. Similarly, anesthetic agents lead to a greater hypotonic state in these patients.

Narcotics appear to have greater potency in patients with CP and dosing should be reduced accordingly to avoid postoperative respiratory depression.

Epidermolysis bullosa

Perioperative evaluation

The term epidermolysis bullosa (EB) encompasses a heterogeneous group of congenital, hereditary blistering disorders. Three major types of EB are recognized: epidermolysis bullosa simplex (with intraepidermal blistering), junctional epidermolysis bullosa (separation at the level of the lamina lucida), and dystrophic epidermolysis bullosa (dermal blistering just beneath the lamina densa). All forms of the disease result in varying degrees of skin fragility and blister formation that occurs after minor trauma or friction. Multiple caries and overcrowding of the teeth are a frequent finding in patients with EB. Treatment is supportive in nature with the focus being on maintenance of skin and mucosal membrane integrity, good nutrition, and the prompt identification and treatment of infection.

Airway:Mouth opening may be limited. In conjunction with the prominent overbite commonly observed in this patient population, direct laryngoscopy and intubation may be impossible. Choanal and nasal stenosis secondary to skin and mucosal scarring is common. Glottic stenosis may also occur from prior airway manipulations. Ankyloglossia, improper positioning of tongue tissue in the mouth, can be pronounced. Fortunately, the restricted position of the tongue often facilitates easy mask ventilation. Previous anesthetic records should be reviewed with particular focus paid to previous intubation attempts.

Cardiac:A dilated cardiomyopathy, likely secondary to nutritional deficiencies, may be present. A preoperative echocardiogram may be indicated, especially in older patients with severe forms of disease.

Skin: Preoperative evaluation should include a close assessment for obvious skin lesions and joint contractures. This may alert the anesthesiologist to specific areas that require further padding and care in positioning. Skin lesions and contractures may limit sites for IV cannulation.

Gastrointestinal: Gastroesophageal reflux disease and esophageal strictures are common in patients with EB. Proton pump inhibitors and H2 blockers should be continued perioperatively.

Perioperative risk reduction strategies

Key to perioperative care of patients with EB is to avoid any shearing forces to the patient’s skin. The operating room should be warmed prior to induction of anesthesia. The OR table should be padded with “egg crate”, sheep skin, and/or lubricated plastic drapes. Consideration should be given to positioning the patient (with parental assistance) on padding prior to transport to the OR and simply transferring the patient with the padding to the OR table.

Adhesive should be removed from ECG leads and pulse oximeter probes. Gauze can be used to facilitate placement of ECG leads and pulse oximeters. A layer of gauze or cotton padding should be placed under the BP cuff. The BP cuff inflation interval may be extended.

Water-based lubricant should be available. The mask and laryngoscope blade(s) should be copiously lubricated. Numerous anesthetic regimens have been used successfully for patients with EB. The basic principle is to induce anesthesia without causing agitation that can lead to excessive movement and skin damage. Gentle positioning of the face mask is crucial to mask inductions.

Intravenous catheters should be secured with silicone-based dressings/tape (Mepilex or Mepitac) or gauze. Tourniquets should only be applied if absolutely necessary and should be done so with gauze protecting the skin from direct contact with the tourniquet.

Patients with EB often have difficulty closing their eyes and are at increased risk for corneal abrasions. Preservative free ophthalmologic gel should be used to protect the eyes.

Intubation becomes more difficult with advancement of age and disease. ETTs may need to be at least 0.5 mm smaller than expected for age. In addition to the blades, ETTs should be lubricated. Fiberoptic intubation may be required secondary microstomia. Video laryngoscopy has been used successfully.

Nasal intubation is not contraindicated as long as the tube is lubricated, warmed, and placed atraumatically. Laryngeal mask airways (LMA) have been used successfully in patients with EB. LMAs, however, may be prohibitive to dental surgery.

Emergence agitation should be avoided in order to prevent excessive movement and skin damage upon emergence from anesthesia. IV clonidine, dexmedetomidine, propofol, and fentanyl have all been described for both prevention and treatment of emergence agitation.

Congenital heart disease

Perioperative evaluation

Nearly 40,000 children are born each year in the United States with some form of congenital heart disease (CHD). Medical and surgical advancements in the care of patients with CHD have resulted in the survival of patients into adulthood. The vast majority of patients are diagnosed with CHD before age 5. Chromosomal abnormalities occur in approximately 10% of patients, with trisomy 21 being the most commonly noted chromosomal defect.

CHD can be classified as acyanotic or cyanotic. Acyanotic CHD refers to that group of lesions that result in the shunting of blood from the left side of the heart to the right side of the heart and the pulmonary circulation. Examples of acyanotic CHD include atrial septal defects (ASDs), ventricular septal defects (VSDs), and atrioventricular canal defects. The ultimate result in acyanotic CHD if left untreated is pulmonary hypertension, right ventricular hypertrophy, and eventually congestive heart failure.

Cyanotic CHD refers to that group of lesions that result in the shunting of unsaturated blood from the right side of the heart to the left side of the heart. Examples of cyanotic CHD include tetralogy of Fallot, complete transposition of the great arteries, and left hypoplastic heart syndrome. Survival in the presence of a right to left intracardiac shunt requires communication between the systemic and pulmonary circulations. Most children with cyanotic CHD do not survive to adulthood without surgical intervention.

Most patients with CHD that present for dental surgery have either had a complete or palliative repair of their defect.

Cardiovascular:Patients with complex CHD despite palliative repair may have a right-to-left shunt and be hypoxemic at baseline. Children who are chronically hypoxemic may be polycythemic and have symptoms of hyperviscosity syndrome. Arrhythmias and heart failure are two common issues in complex CHD. Patients may be on antiarrhythmics, digoxin, beta-blockers, or diuretics preoperatively. Preoperative assessment should focus on the presence of residual defects, right to left shunting, symptoms of heart failure, and/or arrhythmias. Recent echocardiograms, ECGs, and CXRs should be reviewed. Preoperative evaluation of hemoglobin, coagulation studies, and electrolytes should be considered. A pediatric cardiologist should be consulted and/or immediately available prior to delivering an anesthetic to any child with complex CHD.

Respiratory: Anatomic abnormalities of the tracheobronchial tree are not infrequent findings in patients with CHD. These anomalies can be congenital in origin or a result of compression by abnormal adjacent cardiac structures. Pulmonary hypertension is common as is coexistent intrinsic pulmonary disease such as pneumonia and chronic obstructive pulmonary disease.

Neurological: Neurologic dysfunction is common in patients with CHD. Prolonged hypoxemia, thrombotic events from hyperviscosity, and embolic events from a paradoxical emboli can all contribute to observed neurologic damage. A brain abscess is a major risk to patients with cyanotic CHD, especially in the setting of poor dentition.

Hemostasis:In patients with cyanotic CHD, prothrombin time (PT) and partial thromboplastin time (PTT) may be prolonged. Perioperative bleeding can also occur in the absence of a prolonged PT and/or PTT.

Perioperative risk reduction strategies

Patients with complex CHD, especially cyanotic CHD, should have their dental surgery in an institution with pediatric anesthesiology and pediatric cardiology immediately available.

Surgery should be delayed if the patient has an ongoing or a recent history (4 weeks) of URI. Surgery should be delayed if the patient has signs and symptoms of heart failure and his/her condition is not medically optimized. In patients with significant polycythemia, consideration can be given to elective preoperative hematocrit reduction.

All cardiac medications with few exceptions should be continued in the perioperative period. Discontinuation of digoxin must be balanced with the risk of worsening heart failure.

In those patients with increased pulmonary blood flow and left to right shunting, measures to avoid pulmonary overcirculation and subsequent decreased systemic blood flow should be employed including (1) avoiding an increased systemic vascular resistance (2) avoiding the pulmonary vasodilation that may occur with supplemental oxygen or hypocarbia.

In those patients with limited pulmonary blood flow and right-to-left shunting, measures to avoid worsening of the right-to-left shunt and subsequent hypoxemia should be employed including (1) avoiding crying and agitation, (2) avoiding relative hypoxemia, (3) avoiding hypercarbia, (4) avoiding hypotension, and (5) avoiding hypovolemia and decreased venous return.

Every precaution should be taken to prevent gas bubbles from entering intravascular catheters. In the absence of overt heart failure or a significant arrhythmia, invasive monitoring should not be necessary for an elective dental procedure in this patient population. Numerous anesthetic regimens have been used for pediatric patients with CHD. The anesthesiologist should employ those anesthetic agents that will maintain the patient’s preload, pulmonary and systemic vascular resistances, heart rate, and contractility within his/her normal range.

The American Heart Association lists the following cardiac conditions for which endocarditis prophylaxis with dental procedures is reasonable: (1) prosthetic cardiac valve or prosthetic material used for cardiac valve repair. (2) previous history of infective endocarditis, (3) unrepaired cyanotic CHD, including palliative shunts and conduits, (4) completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure, and (5) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (6) cardiac transplantation recipients who develop cardiac valvulopathy. Amoxicillin, ampicillin, cefazolin, or cetriaxone are all acceptable antibiotics for prophylaxis. Azithromycin, clarithromycin, or clindamycin are acceptable in the penicillin allergic population.

b. Cardiovascular system:

N/A

c. Pulmonary:

N/A

d. Renal-GI:

N/A

e. Neurologic:

N/A

f. Endocrine:

N/A

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

The large majority of patients who present for dental surgery under general anesthesia are otherwise healthy children who are either too young or too fearful to participate with dental care. This patient population is often not on any medications perioperatively.

If a patient is on chronic medications, perioperative continuation is recommended. All anti-seizure medications should be taken as prescribed preoperatively with a small amount of water and resumed as soon as possible postoperatively. In addition, all medications prescribed for the control of reactive airway disease should be taken as prescribed and consideration should be given to the perioperative administration of inhaled beta agonists in patients with significant disease.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

N/A

i. What should be recommended with regard to continuation of medications taken chronically?

N/A

j. How to modify care for patients with known allergies

N/A

k. Latex allergy - If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

l. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics

N/A

m. Does the patient have a history of allergy to anesthesia?

N/A

5. What laboratory tests should be obtained and has everything been reviewed?

Preoperative laboratory tests are rarely indicated prior to dental surgery. Patients with CHD, especially complex and/or cyanotic CHD, should have a complete blood count (CBC) and coagulation panel preoperatively. Patients on chronic diuretic therapy should have an electrolyte panel preoperatively.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

The large majority of patients who present for dental surgery under general anesthesia are not candidates for moderate sedation because of psychological or medical factors. General anesthesia is indicated.

General anesthesia

Benefits: General anesthesia provides the dentist a still, anesthetized patient for whom dental rehabilitation can be provided. It also minimizes the psychological trauma that a patient with chronic disease associates with medical procedures.

Drawbacks: General anesthesia is not without risk especially in patients with chronic illnesses. However, the benefits in most circumstances outweigh the risks.

Airway concerns: Patients with epidermolysis bullosa or craniofacial abnormalities may be difficult to intubate via traditional means. Fortunately, the large majority of patients with the above mentioned conditions are easy to mask ventilate. Airway adjuncts, like a fiberoptic bronchoscope or video laryngoscope, should be available if the potential for a difficult intubation exists. Appropriately sized LMAs should also be readily available.

6. What is the author's preferred method of anesthesia technique and why?

Premedication

A significant number of patients who present for dental surgery under general anesthesia have physical, emotional, and/or behavioral limitations. These limitations often lend to preoperative anxiety or interfere with the patient’s ability to cooperate with anesthetic care. Preoperative anxiolysis is most commonly and reliably achieved with oral midazolam. Premedication options in the anxious, uncooperative, or combative child include:

  • midazolam 0.5 to 1 mg/kg PO (time to anxiolysis 10 to 15 minutes)

  • midazolam 0.3 mg/kg IN (patients frequent complain of nasal burning)

  • ketamine 4 to 6 mg/kg PO (time to anxiolysis 10 to 15 minutes)

  • ketamine 2 to 3 mg/kg IM (consider also administering glycopyrrolate or atropine IM to decrease secretions)

  • clonidine 4 mcg/kg PO or IN (time to anxiolysis unpredictable, at least 30 minutes)

Induction

The preferred induction technique for the majority of patients is inhalational. After coating the anesthesia mask with a fruit-scented lip balm, sevoflurane, nitrous oxide, and oxygen are administered using high flows and concentrations. Diversion techniques, such as telling jokes, will often facilitate patient cooperation with a mask induction. Preinduction application of standard ASA monitors is not always possible or necessary in the uncooperative patient. Early application of a pulse oximeter is prudent. Patients often require gentle application of continuous positive airway pressure to manage the pharyngeal excitement and hypotonia that occurs during a mask induction. After induction and application of standard ASA monitors, a peripheral IV is placed. Maintenance of anesthesia in the period of time prior to intubation is achieved with sevoflurane via a mask.

Nasotracheal is preferred over orotracheal intubation in this patient population. To facilitate intubation, propofol (1 to 2 mg/kg IV) +/- a non-depolarizing muscle blocker is administered. The nares are then inspected for patency and/or foreign bodies. A nasal decongestant, such as oxymetazoline, should be applied to vasoconstrict the nasal mucosa and minimize bleeding. In addition, lubricant and a topical anesthetic applied to the nares may minimize nasal trauma and patient response to nasal intubation. The nares can also be dilated with similar sized nasal trumpets to that of the ETT prior to intubation attempt(s).

Nasal RAE ETTs are favored and the size of the ETT (uncuffed or cuffed) should be the same size that is required for oral intubation. The nasal RAE ETT should be gently inserted through the nare into the pharynx. The laryngoscope is then passed orally to visualize the tube and glottis. Next, the ETT is passed through the vocal cords. Frequently, Magill forceps are needed to direct the ETT through the glottic opening. The nasal RAE ETT should then be taped in a manner that does not put pressure on the nostril or forehead.

Maintenance and emergence

Maintenance of anesthesia is typically achieved with volatile anesthetic with or without nitrous oxide. Analgesia may be provided with fentanyl (1 to 3 mcg/kg IV) or morphine (0.1 mg/kg IV). Ketorolac (0.5 mg/kg IV) may also be used in those procedures that do not involve extensive dental extractions. Acetaminophen (30 to 40 mg/kg rectal) can too be administered prior to the completion of surgery for postoperative pain control.

Antibiotics are typically only indicated in patients with certain cardiac lesions. (See above.)

A throat pack is frequently placed intraoperatively to minimize blood and secretions entering the stomach. The OR team should be vigilant in documenting both the placement and removal of the throat pack.

Most would advocate the patient be awake for extubation secondary to the risk of oral secretions prompting laryngospasm during emergence from anesthesia.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

N/A

c. Postoperative management

What analgesic modalities can I implement?

Dental procedures are often not associated with significant postoperative pain. Moderate postoperative pain can be treated with fentanyl (1 to 3 mcg/kg IV), morphine (0.1 mg/kg IV), or oxycodone (0.1 mg/kg PO). Mild postoperative pain can be treated with acetaminophen (15 mg/kg PO) if the patient did not receive a dose PO preoperatively or rectal intraoperatively.

What level bed acuity is appropriate?

Patients rarely require admission postoperatively. Occasionally, patients with significant comorbidities require admission for monitoring.

What are common postoperative complications, and ways to prevent and treat them?

Postoperative nausea and vomiting (PONV) can be a significant postoperative problem after a dental procedure, likely secondary to swallowed blood. Ondansetron (0.1 mg/kg IV) and dexamethasone (0.1 to 0.2 mg/kg, up to 10 mg IV) can be given intraoperatively as prophylaxis. Ondansetron can also be used for rescue in the PACU, along with diphenhydramine (0.75 to 1 mg/kg IV) or promethazine (0.25 to 0.5 mg/kg IV) in patients over 2 years of age. Significant PONV may necessitate postoperative admission.

Emergence delirium is a common postoperative phenomenon in the pediatric population. While self-limited, it can be dangerous and frightening for the patient, medical caregivers, and family members. Successful prophylaxis has been described with fentanyl, clonidine, and dexmedetomidine. Successful rescue has also been described with all of the above as well as with propofol. Dosing recommendations vary across the literature.

Postoperative hyperpyrexia is common and usually self-limited in this patient population. It is important to consider, however, that malignant hyperthermia can present late in the PACU.

Postoperative croup, especially in the setting of a traumatic intubation, may require treatment in the PACU with dexamethasone (0.4 mg/kg, up to 10 mg IV) or racemic epinephrine (0.5 mL of 2.5% solution in NS). It is recommended that patients who are given racemic epinephrine be observed for rebound swelling for up to 4 to 6 hours after administration.

What's the Evidence?

Theroux, MC, Akins, RE. "Surgery and anesthesia for children who have cerebral palsy". Anesthesiol Clin N Am . vol. 23. 2005. pp. 733-43.

(Description of perioperative care for children with cerebral palsy.)

Goldschneider, K, Lucky, AW, Mellerio, JE, Palisson, F, Miranda, M, Azizkhan, RG. "Perioperative care of patients with epidermolysis bullosa. Proceedings of the 5th international symposium on epidermolysis bullosa, Santiago, Chile, December 4-6, 2008". Pediatr Anesth . vol. 20. 2010. pp. 797-804.

(A review by a multinational, interdisciplinary panel of experts assembled in Santiagio, Chile, on the best practices for perioperative care of patients with EB.)

Tait, AR, Shoba, M. "Anesthesia for the child with an upper respiratory tract infection: still a dilemma". Anesth Analg . vol. 100. 2005. pp. 59-65.

(Suggested algorithm for the assessment and anesthetic management of the child with an upper respiratory infection.)

Wilson. "Prevention of infective endocarditis: guidelines from the American Heart Association". Circulation . vol. 116. 2007. pp. 1736-54.

(Guidelines from the AHA for prevention of infective endocarditis.)

Yumul, R, Emdadi, A, Moradi, N. "Anesthesia for noncardiac surgery in children with congenital heart disease". Semin Cardiothorac Vasc Anesth. vol. 7. 2003. pp. 153-65.

(This review covers the classification of congenital heart diseases, and the preoperative assessment, monitoring, anesthetic considerations, and management in the pediatric population with congenital heart disease.)
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