A multi-disciplinary approach is required when evaluating the risk versus benefit of proceeding with GA for delivery of dental treatment for the patients with special dental needs.
It is valid to consider specific factors that are particularly addressed for this group of patients such as: capacity assessment and valid consent, and assessment of the individual’s medical, social and behavioural issues.
Patients who may may require GA:
- Patients with severe learning difficulties
- Patients with severe anxiety and dental phobia when other methods (LA alone, IHS/IV, oral sedation) would not be possible
- Patients with severe mental health disorders
- Patients with physical disability and movement disorders, eg. spine problems restricting from dental treatment on dental chair
- Patients with significant co-morbidity, such as those with congenital disorders, in whom sedation may not be safe and perioperative monitoring is required
- Uncooperative children with multiple carious cavities with the presence of acute dental infections
- patient with drugs/alcohol misuse as they may not tolerate routine treatment or any other form of sedation
The best interests of the patient must remain at the forefront of decision-making processes. The special care dentist responsible for the patient’s oral heath must make a balanced decision on the treatment best suiting the patient, taking into account their behavioural capabilities, cognitive function and medical condidtions. Decision should be made in partnership with the patient and the next of kin or guardian of the patient. The dentist should be able to convey an estimation of the extent of anticipated treatment and its chances of success.
In case when a patient lacks capacity and does not have a next of kin, a formal local procedures must be followed. In the UK, an independent mental care advocate (IMCA) must be appointed in accordance with the Mental Health Act.
When general anaesthesia is planned in patient with special needs, dentist, medical professional (GP) or consultant and sometimes anaesthetist may be involved in the consent process to determine the risks and benefits of treatment.
GA check list must be completed
Children – Consent form 2 for GA ! (UK)
Adults – Consent form 1 for GA ! (UK)
Patient with lacking capacity to consent – Consent form 4 ! (UK)
Pre – and postoperative GA instructions in writing
Attached radiographs, if available
Written and verbal information is imperative as the patient may have a varied number of carers who may need to refer to this information. Instructions for patients and carers (both verbal and written) should include the following:
Preoperative fasting advice !
- Advice on which routine medications should be taken/omitted on the day of surgery
- Arrival times in designated areas, transport/escort, parking facilities
- Overnight bag with clothing and medication in the event of unplanned overnight stay
- Advice on postoperative recovery, analgesia and establishment of routine diet and medications
- Contact numbers for surgical and anaesthesia related-questions and management of complications.
Consent for General Anaesthetic (example, internal protocol)
- Make sure accompanying adult has parental responsibility for any child seen. If the child was born prior 2003 to unmarried parents the father cannot sign consent without a Court Order (UK). If the child was born after 2003 to unmarried parents, the father may sign consent.
- Full dental charting completed. Where appropriate radiographs taken to check for interproximal decay.
- Number and location of teeth for extraction explained to parent / legal guardian / patient.
- Medical history re-checked with parent / legal guardian / patient and filled in on computer record. They should be specifically asked about family history with GA and any issues followed up. Allergies checked including soy and egg. Custom screen form filled in and teeth for treatment charted again on this form using FDI notation.
- Child / patient weighed and height measured and pulseoximeter reading taken. If adult blood pressure taken.
- Instructions for day of procedure explained including pre-operative pain relief, starvation regime, appropriate escort, transportation. If the child / patient is to be a planned admittance to a hospital ward, inform them / their carers that they will be at the hospital all day.
- Pos-operative outcomes discussed. Both short term (eg. uncomfortable mouth) and long term consequences to having teeth out mentioned (eg. dental crowding).
- Written consent completed on proper form. Tooth notation used again and also ‘layman’s’ description of teeth to come out (for example: three baby teeth). If local anaesthesia to be used it is noted. In written consent under ‘serious or frequently occurring risks’ general anaesthetic risk and pain / bleeding / bruising / swelling / infection and possible crowding in adult teeth to be written and explained to parent / legal guardian / patient. Finally form is signed by parent / legal guardian / patient.
- D6 form given to parents / legal guardian / patient and also a copy of the signed consent form.
- Parent / legal guardian / patient told where to seek urgent treatment while on the waiting list.
- Approximate waiting time given and inform patient that they will be contacted by telephone with appointment.
- Get daytime telephone number / mobile number / work number of / parent / legal guardian / patient.
For children < 16 yers – use of NHS Consent Form 2: ” Parental Agreement to Investigation or Treatment for a Child or Young Person”
Information about what treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed is crucial for children and their parents when making up their minds about treatment. The courts have stated that patients should be told about ‘significant risks which would affect the judgement of a reasonable patient’.
Things to remember:
- GA should be considered as a last resort following behavioural management+ LA, CBT+LA and conscious sedation + LA
- dental treatment under GA limited to only predictable and long term successful outcomes and one-stage procedures; ie. restorative treatment of teeth with poor long term prognosis should not be carried out (BSDH guidelines)
- common dental procedures done under GA: scaling, FMD, extractions, fillings, stainless steel crowns; rarely: impressions for immediate dentures,
- one-stage root canal treatment in single-rooted teeth, particularly important from aesthetic point of view (upper incisors) possible but needs a proper clinical justification and prediction of tooth longevity, apex locator must be used to determine working length, ideally hand-held x-ray machine use if available and following a risk assessment
- ASA individual assessment (I, II, II for conscious sedation and mandatory for GA)
- air ways assessment (PSA scale 1-4) considering use of LMA or intubation
- BMI score for each patient !
- consult difficult cases with anaesthetist who will be involved in GA, send a letter prior to GA arrangement whatever patient is suitable for a day anaesthesia
- balance if necessary to extract deciduous D’s and C’s to prevent from central line shift
- check carefully BMI score for obese patients
- ‘Deep sedation’ is a part of GA !
- proper hand hygiene regime and protocol to follow in the theater
- all necessary equipment to be ready: all sort of instruments, surgical motor in case of difficult extraction, electro cauter in case of bleeding or need to carry out operculectomy, loupes
- Currently attempts of a new DGA approach, particulary for Paediatric DGA – “Sit and Wait” approach in certain ‘busy’ areas (eg. London, Manchester) in order to make the service more efficient, reduce DNA’a and provide an immediate help avoiding long waiting time (more than 4o weeks in some areas). Indications: child in severe pain but no associated large swelling/spreading infection, generally fit and well, also cases of acute dental trauma.
- check the numer of throat packs before and after procedure
- check the patient age, for some “quick GA list” only children above 3 years old can be accepted; to discuss with anaesthetist each individual case below 3 years old
- patient with cervical spine injury C4-C5: anaesthetist needs to check if it is possible to tilt the patient neck for intubation procedure
- consider to combine eg. extractions under GA and other invasive procedures within oral mouth if required, eg. incision of operculum, grommets; tonsilectomy + xga’s not advisable.
- almost full clearance due to rampant caries in eg. 4 yeears old child may happen, including extractions of all A’s, B’s, D’s and E’s (C’s usually more resistance to demineralization and caries)
- to check cross food allergy: egg, soya, peanuts as patients allergic to above mentioned usually receive GA induction with the use of propofol (constraindicated in patients with egg and soya allergy)
- to check if patient is allergic to topical anaesthetic gel (eg. EMLA, previous experience at hospital) used for cannulation (IV sedation or GA)
- to check if patient is allergic to some ‘plasters’ , eg. millipore used to attach cannula
- to check if patient is allergic to latex ! ‘old fashion’ McKesson props for mouth rest may contain latex
- re-check soft tissues (particularly buccal mucosa) after procedure as case reports of contact allergic reaction (soft tissue lesion), ulcerations, irritation or trauma caused by mouth props or cheeks retractors
- good practice if to provide analgesics prior DGA sessions, apart from post-op, in order to make patient more comfortable and pain free afterwards
- tongue and cheeks retractor are essential!
- second operator role absolutely important: suction control, keeping soft tissues and tongue away from operation field, stabilizing patient’s head and supporting proper diagnosis (better view from one side), holding mouth prop, pressing first knot while suturing, cutting sutures, providing a second opinion about clinical decision, complex tx plan, alteration in original planning (eg. additional extraction(s)).
- there are patients who require repeated GA periodically due to new cavities as GA is the only option for them
- GA for thorough dental assessment in patients with special needs can be jutified if any symptoms of odontogenic problem: pain/swelling/significant mood change/agitation/fingers biting, etc.
- patient may not be able to indicate dental problem, typically express it by eg. pointing with finger, holding hand, biting objects, refusing eating, avoiding (cold), grinding, clenching, etc.
- some more complex dental procedures can be also performed during GA. eg. Hall technique (SS crowns on deciduous teeth), immediate denture fit, impressions, single stage RCT of the front tooth
- GA for dental patients can be combined with eg. grommet operation, PEG tube placement/replacement but is not recommended with tonsillectomy
- occasionally for a prolonged procedures patient may require special measures to maintain a stable temperature (eg. warming plastic cover + warm air delivery)
- cooperation with second operator/dentist vitaly important; procedures sharing advisable, eg. one side of the mouth/dental arch per one dentist, another side/dental arch – another dentist to avoid posture stress and physical overload
- close cooperation with anaesthetist; team meeting before GA, discussion about MH, obstacles, risks, patient weight, previous GA’s, allergic reactions, use of appropriate air ways support (LMA, intubation, etc) suitable for individual case.
- supraglottic air way control (LMA) does not require muscle relaxants!
- to assist anaesthetist regarding eg: pressing arm during cannulation, clinical holding, etc.
- throat pack can be marked with impregnated radiopaque marker (‘black line’) to visualize and locate it using x-rays in case of lost during GA procedure (GA incident)
- necessary paperwork consented and signed by patient: NHS consent form 2 for children, 1 for adults, 4 for patient when lack of capacity to consent (special needs, dementia, etc.), check list, copies of radiographs, R4 treatment plan/FP17 signed, pre- and postoperative instructions.
- team work crucial, including hospital staff, anaesthetic team, recovery staff, ward nurses, etc.
- a team meeting before procedure under GA involving dental team, anaesthetist team
- a short discussion in ward/preparation room with patient/parents/carers re: all aspects of planned procedure
- once patient is anaesthetised – initial check: dental chart confirmation, up-date (might not be possible beforehand due to patient condition), prop to block dental arches from closing
- anaesthetist assistant checks patients details, often ‘bar code bracelet’ is used in order to identify the patient
- remember: there is no time to hesitate during GA, all clinical decisions must be taken promptly, eg. to extract or to try restore teeth
- laryngeal mask – a possible compression and paraesthesia of linguo -pharyngeal nerve if used more than 1 hour
- risk of intubation: wrong pathway, vocal cord damage due to pressure, not sealed baloon, laryngospasm
- intubation tube with metal wire reinforcement to prevent tube bending/obturation (very flexible, needs guide, leader)
- Combitube – universal measure, easy to use without laryngoscope
Exodontia during GA – questions:
- which cases are suitable/not-suitable for xga ?
- are surgical extractions a viable option during GA?
- are surgical skills necessary for being a dentist performing xga’s ?
- are deeply impacted third molars contraindicated for xga ?
- what it the safe ‘time margin’ to complete difficult extraction(s) under GA ?
- is radiograph compulsory prior xga(s) ?
- how to manage a patients in case of he/she could not tolerate radiographs due to disability but requires xga(s) ?
- how to carry out xga(s) efficiently during time-limited GA session ?
- how to cope with fractured tooth/root ?
- is a radical approach the only option for xga’s?
- extract or treat eg. asymptomatic, sound upper canine, sinus tract within attached alveolar mucosa, with a pus discharge?, no evidence of caries or perio involvement, slight attrition, no access to radiographs (special needs patient). Could sinus tract be associated with potentially impacted lateral incisor (missing, gap closed, hypodontia)?
- can we leave separated apex and fractured root end? are they evidence-based criteria to make a decision to leave or to remove deeply buried root(s) ?
- non-standard armamentarium and special surgical instruments are very useful during exodontia under GA: molar roots separators, special purpose forceps, desmotoms, easy-to-use needle holder, etc.
- root(s) portion elevator
- ultra-thin and extra-long root fragment forceps
- adhesive pad or sponge for clinical sharps (needles) can be useful while performing dental procedures under GA
After multiple XGA’s or ‘full mouth clearance’ due to advanced dental problems, the continuous mattress suture is highly recommended. It does save the time, it is relatively easy and allows an uniform post-op healing
- due to different expectations/points of view, parents unable to agree together for dental treatment under GA for their child, eg. dad happy to consent for GA but Mum still reluctant to it
- uncertain parental responsibility, shared parental responsibility
- parents happy to consent for certain treatment/procedure, eg. fillings under GA but refused extractions under GA
- parents happy to consent for certain treatment/ (eg. single extraction of one affected and symptomatic tooth) but very apprehensive to consent for full treatment plan (eg. at least 10 teeth need to be removed)
- consent ‘borderline’ cases, eg. patient with additional needs, mild, high functioning autism, who may not be fully aware of all potential long term consequences of radical exodontia
- long waiting list to get treatment carried out under GA
- limited time to complete eg. RCT under GA, possible for single-rooted tooth, aces to apex locator and x-ray machine
- young, needle phobic patient in pain awaiting for second orthodontic opinion regarding extractions of hypoplastic 6’s – to prioritize GA referrals if patient is in pain
- bariatric patients, BMI above 35
- extractions under GA for purely orthodontic reason, dental/needle phobia – are they justified ?
- a need for multiple extractions of deciduous teeth under GA – but parents reluctant to consent for it
- “allergy to GA” – family history of prolonged reaction to muscle relaxants (mepivacurium, pancuronium, etc.), genetic predisposition
- single deciduous tooth extraction under GA – chronic periodontitis/abscess – is it justified ? other alternatives ?
- constantly monitor the position of LMA – attached with adhesive strips to patient chin within middle line – to monitor carefully re: potential dislodgement, do not move tube from center line, eg. during assessment of lower incisors
- clinical holding may be necessary during cannulation in young patients or patients with special needs
- young patient who recently had GA for any medical conditions
- be careful re: potential risk of malignant hyperthermia – a congenital condition, patient has to be tested for it, special caution in case of Duchenne Muscular Dystrophy
- needle phobic patient,
- mild infection on the day of GA, postpone DGA if patient suffers from chest infection or in AB course for upper/lower respiratory tracts infections)