Dental General Anaesthesia

Question 1

What were the trends in GA provided to the public in England and Wales from 1973 to 1985?

Answer 1

• There was a decrease in levels from 1973 to 1985 due to reduction in caries and introduction of F.
• It was predicted that the need for GA would reduce but since 2000’s there has been a steady increase in GA need due to dental caries.

Question 2

What is the main reason for GA hospital admission for children in dentistry?

Answer 2

Dental caries is the leading cause for children in England to be admitted to hospital for:
- Simple Xla of tooth
- Surgical removal of tooth

Question 3

What is a significant risk of GA?

Answer 3

Can result in death – but risk is relative: 1 in 300 000 – 500 000

Question 4

What is the relative risk of sedation vs LA?

Answer 4

Sedation: 1 in 2 – 3 million.
LA: 1 in 7 million

Question 5

What were the outcomes of ‘A conscious Decision 2000’?

Answer 5

• DGA only undertaken if absolutely necessary
• Only takes place in hospital setting with trained staff, where they have critical care facilities on same site

Question 6

What are the adv of DGA?

Answer 6

 Eliminates need for behaviour management during treatment (anxiety & poor cooperation)
 Completion of extensive treatment at single visit
 Control of complications (e.g. difficult xla, bleeding risks)

Question 7

What are the disadv of DGA?

Answer 7

 Risk to patient - mortality
 Range of Work limited e.g. extirpation & SSC would be considered at a later date rather than at time of GA.
 Limited access – long waiting lists
 Cost (more expensive for GA referral compared to tx in general practice)
 Can be a traumatic experience – often treating mostly anxious pts. Children often don’t learn from GA. Aim of DGA – compliance. GA may cause dental fear in some children leading to adult dental anxiety.

Question 8

What are the post op risks of GA?

Answer 8

o Pain
o Nausea and Vomiting
o Sore throat / cough due to intubation
o Headache
o Airway
o Cardiac
o Damage to ST or adjacent teeth
o Post operative admission

Question 9

True or false: Children with behavioural problems treated conventionally were less anxious five years on than children treated under DGA.

Answer 9

True- GA can result in dental anxiety in childhood and also lead into adult dental anxiety.

Question 10

What factors influence case selection for GA?

Answer 10

 Cooperation – pre-cooperative (<3 yrs old), disability/special needs, language difficulties, phobic
 Medical History, psychological disorder such as severe anxiety/phobia.
 Type and Extent of Treatment

Question 11

What other factors may influence the decision to refer pt for GA?

Answer 11

• the use of local anaesthesia is either contraindicated, or inappropriate due to the presence of acute orofacial infection;
• there has been previous failure of local anaesthesia or sedation;

Question 12

What does it mean if a child is pre-cooperative?

Answer 12

Too young to understand enough to cooperate. <3 yrs old.

Question 13

How can pts MH influence GA referral?

Answer 13

 Pre op tests and information
 Risk to patient
 Inpatient vs Day Case
 Specialist Management (Possible multidisciplinary)
 Special Precautions - anatomical or functional abnormalities of the airway, congenital syndromes such as epidermolysis bullosa, or conditions associated with increased anaesthetic risk, such as the mucopolysaccharidose
 e.g. sickle cell anaemia, cystic fibrosis – GA avoided in these pts. But if a child needs multiple teeth extracted and is cooperative -> may consider GA because only need to cover them in one visit.

Question 14

The presence of facial swelling, due to either dentofacial infection or trauma, is of particular significance as this may limit ________ during GA.

Answer 14

Mouth-opening

Question 15

Why might a child require in-pt care with GA referral?

Answer 15

e.g. due to existing MH – cardiac disease or coagulation disorders.

Question 16

What factors are considered in GA tx planning?

Answer 16

• The tx: any restoration placed on a primary tooth must last the natural life time of the tooth
• Create an environment which reduces the potential for further treatment to a minimum e.g. self cleansing areas, SSC (protects the whole tooth vs restoration which leaves some areas of a tooth exposed)
• Tooth - consider the most valuable teeth to restore e.g. second molars.
• Parent expectations - carious primary teeth need XLA. – tx under GA often different to tx under LA e.g. more Xla.
• Is GA required? – can different tx methods/strategies be used? Can we wait and monitor tooth until exfoliation?

Question 17

What are the restorative tx options available under GA?

Answer 17

1. Occlusal / PRR’s
2. SSC – high survival rate, complete coverage
3. Vital pulpotomy

Question 18

Why are class 2 restorations, pulpectomy & pulp capping avoided in DGA?

Answer 18

• Significant failure rates associated with class II restorations in the primary dentition (60% amalgam restorations failed after 3 yrs)

*Poor success rates of pulp capping & pulpectomy procedures

*Treatment indicated for non-vital primary teeth is generally extraction

Question 19

What is the benefit of Hall crowns as prophylactic tx?
-GA tx planning

Answer 19

In a high risk pt, who may need to come back in a few years for GA again – HC may be useful as preventative procedure to minimise risk to child and future GA referral.

Question 20

Which teeth are most likely to be prioritised for keeping in place with GA?

Answer 20

Second molars – E’s. Early loss leads to significant mesial drift of 6’s with reduction in dental arch perimeter. No centre line shift

Question 21

What is the impact of early loss of first molars (D’s) ?

Answer 21

• GA - Less inclined to hold on to D’
• Can balance -> helps prevent a centre line shift.
• No reduction of arch perimeter
• Possible centre line shift (mesial drift of E’s and subsequently the 6’s)

Question 22

Where D’s are removed, what benefit does this pose for high caries risk pts?

Answer 22

By freeing M surface of E and freeing D surface of C -> can help create an environment of self-cleansing and reducing caries risk going forward = reduces need for further GA.

Question 23

What is the impact of early loss of primary canines ?
- GA

Answer 23

 Unilateral loss leads to significant centre line shift
 Have to lose C on other side if losing a canine
 Can cause problems in occlusion and problems with eruption of permanent canines.

Question 24

What exception is there to the removal of primary canines?

Answer 24

May be desirable to prevent ectopic eruption of permanent canines

Question 25

What is the impact of early loss of primary anteriors?

Answer 25

• No space loss but may affect speech initially (but effect is transient)
• Psychological effects to child/ parent – poor aesthetics.
  *Difficult to restore anterior teeth due to early failure.

Question 26

What are the factors influencing the option to restore primary teeth under GA vs exodontia only?

Answer 26

o Pre School (3-4 yrs old) - Pre cooperative, Early loss has most impact (e.g. 6’s drift forward)

o Parents – depends on motivation & cooperation. High caries risk child, and will remain high caries risk.

o Caries Risk and Compliance with Prevention

o Extent of Disease

o Special Needs – may be more likely to get comprehensive care. Need more time in terms of GA.

Question 27

What are the responsibilities of a GDP when referring for GA?

Answer 27

1. Need a clear justification for use of GA in referral letter
2. Consent – inform parents why GA necessary, alternatives to GA, risks, idea of tx and limitations – warn pts tx plan may change leading to more xla under GA. Warn of possible long waiting times. Emergency tx can be provided at GDP whilst on waiting list.

Question 28

When planning a general anaesthetic, why do we measure children’s weight and height?

Answer 28

> Dose of GA meds often based on weight of child (greater weight = increased dose)

> Airways – smaller airways in children. Height can be measured to determine size of laryngeal mask / endotracheal tube to use for intubation.

> Positioning of child during GA can be planned once height and weight measured.