Hospital Dentistry Using General Anesthesia

Welcome to the University of Michigan Dentistry
Podcast Series promoting oral health care worldwide. [Continuous beeping sound] [Type writing typing out letters] [Beeping sound] When severe handicapping conditions, unmanageable
behavior, medical or other problems are present among patients with severe dental diseases
management techniques become limited for the delivery of dental treatment. The indications for the use of general anesthesia
are the very young, immature patient with rampant caries, mental retardation which prevents
communication with the patient. Physical, handicapping conditions could significantly
limit positioning of the patient or which interfere with access to the oral cavity.
Emotional disturbances which produce inordinately high levels of anxiety or fear and patients
for whom the routine methods of treatment and behavior management have failed. When
general anesthesia has been selected as the method of choice to treat the patient’s dental
problems, hospitalization will be required either on an in-patient or out-patient basis.
Medical consultations will be required to evaluate the stasis of the patient’s physical
health and to determine if any significant anesthetic risks are present. Preservation
of a hospital bed and scheduling of operating room time must be coordinated with the hospital
admission’s department and the operating room. Hospitals with live-in facilities for parents
have the advantage of keeping a familiar person close to the child. When a date and time have been agreed upon,
the patient is escorted to the hospital and the following procedures are accomplished
either before admission or at the time of admission. Physical examination, including dental history,
medical history and systems review. Consultations with other medical or dental
specialists as indicated. Initiation of laboratory studies. Hemoglobin, hematocrit, white blood cell count,
urinalysis, chest X-ray, and dental X-rays when possible. Admission orders including medications, diet,
oral care, and activity on the ward. Consent for the dental procedures and the
use of general anesthesia. Anesthesia evaluation which includes a chart
review, instructions to the patient and parent, and orders to prepare the patient for general
anesthesia. Upon arrival at the operating room, the dental
team should be prepared to receive the patient and assist with patient transfer to the operating
table. [People talking] The induction phase will begin with the patient
on the ward cart. This 12 year old boy with Down syndrome is bought to the operating room
for a general anesthetic for dental treatment. General anesthesia was indicated due to mental
retardation and severe obstructive behavior previously demonstrated in the dental office.
This patient received pre-operative sedative medication one hour before entering the operating
room. An intramuscular injection, 80 milligrams
of seconal, was given for sedation. In addition, three milligrams of morphine sulfate was given
IM for relaxation, post-operative analgesia, and to potentiate the sedative effect of seconal.
These drugs and dosages were chosen based upon the patient’s health history and body
weight. Anesthetist: Oh what a good boy. What a good
boy. You are such a good boy. Such a good boy. Uh-oh. No Eddie, no Eddie. Narrator: Notice that despite careful pre-medication
this patient requires some physical restraint by those assisting the anesthetist. Anesthetist: That’s okay. Good boy. One more.
Good boy. Oh yes. Such a good boy. Such a good boy. Narrator: Inhalation of a gaseous mixture
of an anesthetic agent, in this case, fluothane with nitrous-oxide and oxygen will render
the patient into a state of light anesthesia. This method of induction was chosen because
it requires a minimum of patient cooperation and can be accomplished very atramatically.
As anesthetic induction begins the patient’s eyelids close and the torso relaxes but the
anesthetic mask is held firmly in place over the mouth and nose. The patient is then transferred to the operating
table in the supine position by several assistants. A blanket is used to cover the torso and extremities
to minimize heat loss from the body during the general anesthesia procedure. Initially, ECG leads are placed on the upper
torso to monitor heart rate and rhythm. A plastic airway is placed to assist breathing. [People talking; heart monitor beeping] A stethoscope is utilized to listen to both
heart beat and respirations. A towel is used to wrap the head protecting
the patient’s hair. [Heart rate monitor beeping] IV puncture has begun in preparation for the
administration of pharmacological agents necessary to accomplish nasal and endotracheal intubation
and for the purpose of fluid replacement during the course of treatment. Intravenous fluid
replacement and maintenance is required because the patient receives nothing by mouth for
eight hours prior to the administration of general anesthesia. Additionally fluid maintenance
helps prevent a decrease in blood pressure caused by nasal dilating effects of anesthetic
agent. Finally the fluid facilitates the administration of intravenous drugs. The IV fluid is a normal saline solution with
5% dextrose in water. This provides the patient with calories and fluid volume compatible
with the blood. Once the needle and tubing have been stabilized
with tape, arm board is taped to the patient’s forearm and hand. This prevents accidental
dislodgement of the IV needle during the procedure or the recovery period. A blood pressure cup is applied to monitor
blood pressure throughout the procedure. At this point the first injection is administered.
Robinul, 0.2 milligrams, is given IV to dry secretions and block nasal responses stimulated
by intubation. Uncontrolled these responses could produce hypoxia and subsequent bradycardia. A topical application of 4% cocaine solution
will be used to anesthetize the nasal-mucus membranes and produce nasal constriction and
to minimize epistaxis. A powerful muscle relaxant, 30 milligrams
of succinylcholoine, will be administered IV just prior to intubation to relax the vocal
cords allowing a tube to pass easily into the trachea. Cotton tip applicators are used to swab the
nasal passages with the cocaine solution. The nasal endotracheal tube has been selected
and placed on the patient’s chest in a sterile gauze containing lubricant. The patient is
profused with 100% oxygen just prior to attempting intubation because succinylcholoine paralyzes
the patient for approximately 90 seconds. The cocaine swabs are removed and the left
nostril is selected for the initial attempt at nasal intubation. [People talking, heart monitor beeping in
background] Once the tube has passed through the nose
and into the pharynx, its proximal end must be directed between the vocal cords. The lighted tip of a laryngoscope can illuminate
the back of the throat allowing the anesthetist to visualize the cords. The curved blade of
a laryngoscope is used to retract the mandible down and forward with the tongue held against
the floor of the mouth. The Magill forceps is used to grasp the proximal
end of the tube and position it over the opening between the cords. Downward pressure is provided by anesthetist’s
assistant pushing on the distal end of the tube forcing it into the trachea. Quickly
the lung fields are checked to be sure that both lungs are being inflated. If the lungs
are not being inflated, then the tube has mostly likely passed into the esophagus and
must be repositioned. If only one lung is being inflated, then the tube itself is blocking
one of the main bronchi and must be retracted slightly to allow inflation of both lungs.
When adequate respiration is confirmed, all other vital signs including blood pressure,
heart rate and rhythm, and temperature are checked to be sure the patient’s condition
remains stable. Eyelids are taped closed to keep the eyes
moist and to protect them from debris that might land on the face during the course of
dental treatment. Tape is applied to the nasal tube and securely
placed over the skin of the cheeks previously prepared with tincture of benzoin. This helps
prevent accidental repositioning or dislodgement of the endo-trachael tube. The air way and entire head drape are secured
in place with two lined strips of one inch adhesive tape. Notice the head turban previously
placed to protect the hair and ears. Careful protection and stabilization of the head and
airway will allow the operator greater access to the oral cavity and the operating team
a greater margin of safety. To minimize exposure to radiation, the anesthetist,
operator, and assistants are protected with lead aprons while dental films are exposed.
In addition, the operator will use lead-lined gloves to protect his hands from direct exposure
since the patient’s jaws must be held shut for him. The green light on the side of this portable
X-ray unit indicates when the machine is operative. A full-mouth radiographic survey is often
required in the operating room because of the poor level of cooperation obtained from
these patients in the office. The severe obstructive behavior which serves as one indication for
general anesthesia frequently precludes the acquisition of an acceptable radiographic
survey in the office setting. The initial maxillary anterior occlusal radiograph is
taken with the airway disconnected for approximately 10 seconds. A team of three can operate most
efficiently to take radiographs. A typical series of eight films including two anterior
occlusal views, two bite wings, and four periapicals should not take longer than 6-8 minutes. Disconnecting the airway for 10 seconds is
quite safe. If the patient is breathing on his own, then a 10 second interruption in
anesthetic gas will not interfere with the state of anesthesia. Similarly, if the breathing
is supported then a 10 second interruption in breathing will have not dilatory affect
whatsoever as this is much too short a period of time for the patient to experience any
oxygen debt. Notice that the orange light on the head of
the X-ray unit flashes on during the exposure time to ensure the operating team that the
films are being exposed. The operating team consisting of the dentist
and his chair-side assistant will be seated at the head of the table. The instrument tray
will be positioned within easy reach using a Mayo stand to support the tray over the
patent’s torso. The chair-side assistant’s primary function is to maintain a clear, dry
field for the operator and assist with the retraction of soft tissues when necessary. Notice the anesthetist recording vital information
on the anesthesial record concerning the patient’s condition and drugs administered. The dentist and his assistants will wash their
hands using clean technique. Gloves and safety glasses are used to prevent cross-contamination
and accidental injury to the eyes. At this point the patient is draped and instruments
and equipment are prepared for the dental operation. A second assistant will oversee
the operation of all mobile equipment and prepare all instruments, handpieces, and materials
to be utilized in the course of treatment. The throat pack will be placed prior to any
intra-oral procedures. Initially, scaling, oral prophylaxis, examination, and a treatment
plan will be accomplished. All indicative restorative procedures will be completed next
followed by a topical fluoride treatment. Oral surgery procedures, usually simple extractions,
will complete the dental operation. At the conclusion of treatment the throat pack will
be removed, extubation accomplished and the patient transferred to the recovery room.
In recovery, the patient will continue to have all vital signs monitored closely for
30 to 60 minutes while supportive therapy assures the patient’s rapid recovery from
general anesthesia. A molt mouth prop is used to facilitate the
placement of a throat pack. A single strip of one inch gauze soaked in sterile saline
solution to prevent abrasion and irritation of the soft tissue structures in the posterior
pharynx is placed initially with a Kelly forcep. In this position, the pack would prevent the
accidental ingestion or aspiration of foreign materials that might otherwise lodge in the
back of the throat during operative procedures. Dentist: I need a little suction before I
go any farther okay? Assistant: A little suction, Doctor. Suction is employed throughout the packing
procedure to remove all fluid from the throat. Final placement of the pack after it has been
cut should be done with the fore finger to prevent laceration or bruising of the soft
tissues and to determine by palpation adequacy of the packing. The pack fits snugly between
the right and left faucial pillars and behind the soft palate. Once the throat has been packed effectively,
dental treatment may safely begin. The molt mouth prop remains in place to hold the mouth
open for all intra-oral procedures. Scaling of the teeth to remove hard deposits
initiates the dental treatment. Notice the sequence of events designed to minimize wasted
time and effort. Scaling is completed in both the maxillary and mandibular arches on the
right side of the mouth before proceeding to the left. When scaling is completed on the left side,
the polishing procedure begins on the left and again is completed in both arches before
switching to the right side. [Buzzing sound] When switching the molt mouth prop from side-to-side,
the tongue which tends to protrude abnormally due to displacement by the throat pack and
the lips must be carefully protected to avoid pinching them on the occlusal surfaces on
the teeth. The oral examination will proceed in a pattern
similar to scaling and oral prophylaxis. This method reduces the mouth props to a minimum
and allows the most efficient use of time possible. Any reduction in the overall anesthesia
time will increase the safety factor and hasten the patient’s recovery from general anesthesia.
Due to the nature of the patient’s behavior, this may the first time that a complete and
thorough oral examination could be accomplished. Examination and charting are completed on
one side of the mouth before proceeding to the other side. Radiographs are examined and a treatment plan
may now be formulated. The operative phase of dental treatment begins
with isolation of the teeth using a rubber dam. Rubber dam isolation provides the operator
with maximum access and visibility to the operating field. Rubber dam isolation effectively
retracts soft tissues and provides a reservoir for fluid and debris to collect. This added
protection of the patient’s airway is greatly appreciated by the anesthesia team. Conventional quadrant isolation can be employed.
However it may be more efficient to isolate an entire arch. Another alternative rubber dam isolation technique
is utilized here to isolate first permanent molars in opposite arches with the same rubber
dam. Here we see an alternative method of ligating
the anterior teeth providing maximum control of the retraction of the soft tissues. Note
that these alternative methods of isolation may be uncomfortable or difficult for the
patient to tolerate if awake and should therefore be used mainly for patients under general
anesthesia. The equipment which the dental team brings to the operating room should be
very mobile. The mobile unit containing high and slow speed handpieces and air/water syringe
is powered by either a self-contained electric motor which produces sufficient air pressure
or a nitrogen tank to provide direct gas pressure for the air driven handpieces. The suction
equipment is contained in a mobile cart and a vacuum is created by an electric motor. Notice the operator informs the anesthetist
about the local anesthetic to be used for infiltration. Dentist: Hold that for a second. H and J. Assistant: H and J. The administration of a local anesthetic is
done for simple extractions primarily to control hemorrhage. It is important to achieve adequate
hemostasis in a short period for a patient under general anesthesia. For this patient,
approximately two milliliters of 0.5% xylocaine with 1-200,000 epinephrine is used for infiltration.
A lower concentration of epinephrine was chosen because a patient receiving fluothane is sensitized
to cardiac arrhythmias from the administration of epinephrine. Therefore, the lower concentration
allows a greater margin of safety and the dentist may anesthetize more teeth. A local
anesthetic is administered eight to 10 minutes before the planned extractions. The nasal
constriction is better after a wait of this length. Having completed the necessary restorations
on the right side of the mouth and the administration of local anesthetic for extractions, the rubber
dam is applied to the left side again with a double clamp. Efficiency is important in providing dental
treatment under a general anesthetic. The efficient use of time is imperative to minimize
anesthesia time. Consequently it is important that the operator develop the ability to think
several steps ahead in his procedures. By allowing the assistants to prepare equipment
and materials in advance, the dentist will not have to wait unnecessarily. The dentistry
may proceed at a rapid pace without rushing or hurried confusion. Notice the assistant
in the lower left hand corner mixing Dycal will the field is being prepared for the application
of this medicament. Likewise varnish is prepared and applied while
the restorative material is being mixed. This series of procedures from Dycal to final
carving and burnishing should flow continuously without any stoppage of action in the operating
field. Notice that the isolation of teeth in the opposite arches with a double clamp
rubber dam has provided a clear, dry operating field throughout the procedure. Excellent
retraction of soft tissues by this isolation has provided the operating team with an additional
margin of safety and allowed the maximum use of time. A 1.23% acidulated phosphate fluoride is applied
topically to all teeth prior to extraction procedures in order to have the mouth as clean
and as dry as possible. The effectiveness of a topical fluoride treatment at this point
is enhanced by the fact that the patient’s secretions have been dried the robinul. At this point the extractions will be accomplished
beginning on the side of the mouth where the fluoride treatment was completed. Teeth in
both arches are curetted and then delivered with forceps. Extractions, similar to the examination restorative
and preventative procedures, are accomplished with no wasted motion. All instruments are
used until their function is no longer required and never used twice in the same sequence.
Repetition of instrument exchange is to be avoided if possible to save time and effort. As the extractions are completed, gauze pressure
packs are prepared to control hemorrhage prior to excavation. The operating team must check
to be sure that the oral cavity is free and clear of fluid and debris. Dentist: Let me have that large pack with
the string on it. We’re all set. He’s ready to wake up. Next the throat pack is carefully removed
with a Kelly forcep. Notice the condition of this single strip of gauze. The distal
end is stained with blood and small particles of debris. The proximal end is clean indicating
that the pack was effective in preventing the aspiration or ingestion of any blood or
debris. A pair of 4×4 gauzes folded and tied with dental floss to allow easy and quick
removal are placed as mechanical pressure packs to control hemorrhage from the extraction
sites. Immediately following removal of the throat
pack, the anesthetist will examine the throat using the laryngoscope. She will suction the
throat free of any debris from the operation which may have lodged behind the pack. At this point the patient is recovering from
anesthesia. All anesthetic gases have been stopped and the patient is breathing 100%
oxygen. Extubation is accomplished when the throat
is clear of debris and secretions, and the patient has adequate spontaneous respirations.
Extubation is done at the moment when the patient’s lungs are inflated so that the first
breathe after the removal of the tube will be an expiration help cough up debris and
secretion from the lungs. Notice the anesthetist’s hand position on the mandible, elevating the
jaw and preventing the tongue from falling backward into the throat occluding the airway.
The anesthetist will occasionally assist shallow breathing with positive pressure on the bag.
Vital signs are checked to be sure that the patient’s condition remains stable following
removal of tube, especially adequate ventilation of the lungs. The ward cart is positioned
alongside the operating table. The table is brought up to the level of the bed prior to
transfer. The patient is transferred to the ward cart
in preparation for transport to the recovery room. Notice that the IV is maintained until the
patient can take clear liquids by mouth and in case additional drugs should be required
during recovery. The patient is positioned on his side to prevent the inspiration of
secretions or vomit. Blankets are again used to cover the patient for warmth. The acronym P-A-R-U stands for pulse-anesthetic-recovery-unit.
This recovery room is designed for patients who are expected to have either minor or no
complications recovering from their general anesthetic. The patient will remain under
observation in the recovery room for 30 to 60 minutes before returning to the hospital
ward. Initially, a cold steam mask is attached to
the patient’s face to help remoisten the lungs which tend to become dry from breathing an
anesthetic gas such as fluothane. A blood pressure cup is applied and all vital
statistics concerning physical condition in the recovery room are recorded on the patient’s
chart. Post-operative orders must be written before
the patient returns to the hospital ward or is sent home. These orders include medications,
diet, and oral care instructions plus any other instructions suggested by medical consultants. If the patient is to remain overnight for
observation, the dental service will check the patient on rounds and write discharge
orders the following day. If the patient is managed on an out-patient basis, the anesthesiology
service discharges the patient when all vital signs are stable. In this event two adults
are required to assist the patient in leaving the hospital. At the time of discharge, the parent is given
written instructions and prescriptions which pertain to the patient’s home care. A recall
appointment is usually scheduled two to four weeks post-operatively to check healing and
the condition of our restorations. Polishing of the restorations and repetition of the
topical fluoride treatment may be attempted as some of these patients become more cooperative
after hospitalization and relief of pain. Finally two documents are added to the patient’s
record. An operation report is dictated which describes in detail what was done for the
patient in the operating room. The final document is a narrative summary which reviews the entire
hospitalization from admission to discharge. The student may refer to a hospital dentistry
text or manual for the details of this and other documents found in the patient’s chart. In summary, we have seen general anesthesia
administered to a 12 year old boy with Down syndrome for the purpose of completing all
dental treatment at one time. The actual operating time was approximately one hour. All patients are scheduled for a recall on
an out-patient basis. To avoid future hospitalizations, attempts are initiated to maintain the health
of the oral structures in the routine clinical setting. Dentist: No tooth count? Okay, I’ll tell you
what he’s got. He’s uhů on the right side, the only tooth that he has, the only primary
tooth that he has is Tů You have been listening to a presentation
from the University of Michigan’s School of Dentistry which is dedicated to supporting
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