General Anaesthesia for Dental Treatment for Children

Question 1

GA definition

Answer 1

Any technique using equipment or drugs which produces a loss of consciousness in specific situations associated with medical or surgical interventions”.

• loss of consciousness or abolition of protective reflexes
  
  • Dept of Health “A Conscious Decision”

NO LONGER DONE IN GENEREAL PRACTICE

• Facilities must include access to PICU or rapid transfer

Question 2

physiology of GA

Answer 2

• Anaesthetic agents produces anaesthesia by depressing specific areas of the brain

Question 3

inhaled GA

Answer 3

enter through lungs

distributed to tissues by circulation

reach specific sites in the central nervous systm by crossing Blood Brain Barrier

• Magnitude of CNS depression is proportional to partial pressure as they reach the CNS.

Question 4

IV GA

Answer 4

given straight into circulation

distributed through bodoy

reach specific sites in CNS by crossing Blood Brain Barrier

Magnitude of CNS depression is proportional to partial pressure as they reach the CNS.

Question 5

anatomy impact respiratory physiology for child

large head, short neck, large tongue

Answer 5

low functional residual capacity (FRC)

Question 6

anatomy impact respiratory physiology for child

narrow nasal passages

are obligate nasal breathers at birth

Answer 6

closing volume is greater than FRC up to 5 years old,

leading to increased ventialtion/perfusion (V/Q) mismatch

Question 7

anatomy impact respiratory physiology for child

higher anterior larynx

larynx narrowest at cricoid cartilage

Answer 7

horizontal ribs, weak intercostal muscles leading to relatively fixed tidal volume (can’t increase unlike adults)

Question 8

anatomy impact respiratory physiology for child

large floppu epiglottis

Answer 8

oxygen consumption is high 6ml/kg/min

compared to 3ml/kg/min adults

Question 9

temperature regulation impact nervous system for child

high surface are to body weight ratio

Answer 9

increased incidence of periodic breathing and apnoea (sudden stops after rapid)

Question 10

temperature regulation impact nervous system for child

large head surface area and heat loss

Answer 10

ventilatory response to CO₂ is more readily depressed by opiates

Question 11

temperature regulation impact nervous system for child

require higher temperature for a thermoneutral environment

immature responses to hypothermia (poor shivering and vasoconstriction)

brown fat metabolism which increases oxygen consumption

Answer 11

immature neuromuscular junction leads to increased sensitivity to muscle relaxtants

Question 12

common inhaled GA

Answer 12

• nitrous oxide
• sevoflurane (agent of choice for induction)
• halothane
• isoflurane
• desflurane

Question 13

common IV agents

Answer 13

propofol (used for induction and in some situations for maintenance)

Question 14

drug decision for GA

Answer 14

anaesthetist will decide on what drugs they will use. Depends on the length and type of procedure, patient preferences for induction, medical history, previous GA experience, anaesthetists recommendations, equipment, staff and other resources.

Question 15

types of airway

Answer 15

• LMA (laryngeal mask airway)
• Nasal endotracheal intubation
• Oral endotracheal intubation

regardless a throat pack is needed

Question 16

concious levels/stages of anaesthesia

Answer 16

Historically observed with ether, modern anaesthetics are FAR more potent so induction and passage through stages is rapid!!!

• Stage 1: Induction
• Stage 2: Excitement
• Stage 3: Surgical Anaesthesia – want for working
• Stage 4: Respiratory Paralysis/ Overdose

Question 17

2 GA indications

Answer 17

• Child needs to be asleep for treatment because there is a belief that they are too young, too anxious, or too uncooperative to accept treatment any other way i.e the child needs to be fully anaesthetised

OR

• Dentist needs patient to be guaranteed to be completely still, operation is complex i.e. the surgeon needs the child to be fully anaesthetised (e.g. difficulty impacted canine)

Question 18

GA contraindication

Answer 18

• Risk of procedure do not outweigh benefits (anterior crowding, risks of orthodontic extraction with GA carries risk of death so outweighs straight teeth, unless psychological reasoning too)

Question 19

GA risks and complications

Answer 19

• Major Risks
  
  • Rare
    
    • Serious outcome/ major adverse event 1:400,0000, 3 in a million
  • Death, will not wake up again, brain damage

Parents must be warned even though very small risk. (if fit and well)

Dentists must be sensitive in how they broach this!!

• Minor risks
  
  • Common
  • Pain
  • Headache
  • Nausea, vomiting,
  • Sore throat
  • Sore nose/ nose bleed
  • Drowsiness
  • Upset
  • Increased anxiety about future dental treatment
  • Risks from treatment
    
    • Pain, bleeding , swelling, bruising, loss of space, visible restorations, restorations may be lost/ fail/wear through, stitches
• Damage to mouth/ oropharynx from intubation (all anaesthetics)
• Minor idiosyncratic/ allergic reactions- nausea and vomiting
• Malignant hyperpyrexia (rare! VERY important to ask re FH of this - specific care)
• Slow recovery from anaesthetic
• Prolonged apnoea after muscle relaxant (suxamethonium)
• “awareness”- paralysed but not effective anaesthesia
• Laryngospasm – scary, irritates airway and throw chest forward and arms back
• Coughing/moving during procedure- anaesthetic too light during stimulation eg extractions, do more complex first (e.g. leave sutures to last as less stimulating)
• Prolonged bleeding intra- operatively or bleeding post-op

Question 20

GA safety

Answer 20

GA has small risk of mortality so MUST be justified

• Airway is shared- dentist/anaesthetist
• Necessary to have space, facilities, equipment , appropriately trained personnel if emergency arises and resuscitation is required
• Agreed protocols to summon help and ensure timely transfer to specialist anaesthetic and medical care e.g. PICU or high dependency

Question 21

WHO surgical safety checklist

Answer 21

• Brief before list, debrief after (introduce team, go through each pt, discuss risks)
• For every patient every time:
  
  • Sign in
  • Time Out
  • Sign Out

Question 22

shared airway points

Answer 22

• Head and neck positioning so not over extended
• During dental treatment, esp extractions on lower arch mandible can easily fall or be pushed backwards and the chin onto the chest—obstructing airway
  
  • Dentist must be aware of this and lift mandible or anaesthetist/ assistant may help to hold mandible forward

Question 23

joint GA

Answer 23

GA has risks so minimise number of GAs (morality)

May be possible to do joint GA with other medical specialties e.g. ENT- tonsils, Haem/ Onco- lumbar punctures, Cardiac- TOE, Plastics- dressing/stitching, Maxfac- cleft surgery

Question 24

conditions to be careful of when thinking GA

Answer 24

• Sickle cell disease
• Down’s Syndrome
• Bleeding disorders
• Cardiac conditions
• Renal disease
• Diabetes
• Liver disease
• Cystic Fibrosis
• Severe asthma
• Epilepsy

Question 25

discharge criteria

Answer 25

• Fully conscious, able to maintain clear airway, exhibits protective reflexes
• Satisfactory oxygenation and respiration
  
  • 2-5yrs 24-30 breaths/min
  • 5-12yrs 20-24 breaths/min
• CVS stable- no unexplained cardiac irregularities, no persistent bleeding, pulse and BP acceptable, adequate peripheral perfusion (press fingertip, should blanch)
  
  • Heart rate 2-10yrs mean 80 beat/min
• BP for 1-10yrs= 90+ 2xage in yrs
• Pain, nausea and vomiting controlled
• Temperature in normal limits
• Eaten, drunk, been to toilet

Question 26

post-op instructions

Answer 26

• Pain control
• Travel home
• Rest / quiet play
• Monitoring
• What to look out for – pain, bleeding etc
• Next day off school/nursery – rest needed
• Extraction advice
• Soft diet
• Prevention
• Follow up
• Discharge letters

Question 27

consent for GA

Answer 27

active process

• Primary care dentist makes initial decision that GA may be necessary (although this may change at assessment visit)
• Explanation of risks and benefits of GA and all other alternative options
  
  • E.g. Prevention only, Biological caries management, LA +/- IS, IV, doing nothing
• Explanation of how different treatment modalities might affect the treatment plan- GA treatment plans more radical with reliable and clear prognostic outcomes
  
  • i.e. you should be confident the plan will last at least 5 years without child having pain

Advise that 1st appointment will be for treatment planning ONLY and that plan may change with a specialist opinion

Question 28

who can consent for child?

Answer 28

• Mother automatically
• Father if married to mother at time of child’s birth (Eng/ W/NI), conception (Scot) or subsequently
• Unmarried father if named on birth certificate (at reg or re-reg) after 15/04/2002 for NI, 1/12/2003 Eng+Wales, 04/05/2006 Scot
• Unmarried father whose child registered before these dates OR if not mentioned on birth certificate DOES NOT automatically have parental responsibility
  
  • May acquire by a court registered parental responsibility agreement with the mother or by obtaining a parental responsibility order or a residence order from the courts
• Adoptive parents (if legally adopted)
• Married step-parents and registered civil partners can acquire parental responsibility
  
  • by a court registered parental responsibility agreement with the mother or by obtaining a parental responsibility order or a residence order from the courts
• Legally appointed guardian
• Person with a residence order concerning the child
• Local authority that is designated to care for the child
• Local authority or person with an emergency protection order for the child
• If no legal guardian then social services will need to be involved

N.B: Foster parents and kinship carers DO NOT have automatic parental responsibility

Question 29

when should the first stage of GA consent be done

Answer 29

ideally be done on a separate day before the operation to give parents and child time to fully understand all the risks, benefits and alternatives and to give time to ask questions etc

• Pre-op information- pre-op preparation including fasting, proposed treatment, GA procedure, adult escort with no other children, post-op arrangements (travel, time off), post-op care and pain control
  
  • Booklets for anaesthetic dental for adult and child available

For GA MUST have written consent

Question 30

consent for GA

Answer 30

needs to be written

active process

Question 31

pre-op information to give to child and adult

Answer 31

pre-op preparation including fasting, proposed treatment, GA procedure, adult escort with no other children, post-op arrangements (travel, time off), post-op care and pain control

Booklets for anaesthetic dental for adult and child available

Question 32

referral letter for GA should state

Answer 32

• Patient name
• Patient address
• Patient/ Parent contact numbers- landline and mobile
• Patient medical history
• Patient GP details
• Parental responsibility
• Justification for GA
• Proposed treatment plan
• Previous treatment details

Must include

• Recent radiographs or if not available explanation of why (e.g. I have attempted to take bitewings/ periapicals but the patient is uncooperative)

Question 33

paedriatric pts include

Answer 33

• Neonates baby within 44 weeks of age from the date of conception
• Infants child up to 12 months of age
• Child 1-12 years
• Adolescent 13-16 years

Question 34

neonates

Answer 34

baby within 44 weeks of age from date of conception

Question 35

infants

Answer 35

child up to 12 months of age

Question 36

child

Answer 36

1-12 years

Question 37

adolescent

Answer 37

13-16 years

Question 38

differences between child and adult anaesthetic…..

Answer 38

reduce as pt increases in age

Question 39

bradycardia

Answer 39

SLOW HEART RATE

associated with reduced cardiac output.

associated with hypoxia should be treated with oxygen and ventilation initially.

• External cardiac compression will be required in the neonate with a heart rate of 60 beats per minute or less, or 60-80 beats per minute with adequate ventilation.

Question 40

arrhythmias in children

Answer 40

Sinus arrhythmia is common in children and all other irregular rhythms are abnormal

Question 41

arrhythmias

Answer 41

problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called tachycardia. When a heart beats too slowly, the condition is called bradycardia

Question 42

normal HR and systolic BP

Answer 42

Question 43

glucose metabolism in children

Answer 43

Hypoglycaemia common in the stressed neonate and glucose levels should be monitored regularly.

• Neurological damage may result from hypoglycaemia so an infusion of 10% glucose may be used to prevent this. Infants and older children maintain blood glucose better and rarely need glucose infusions.
• Glycogen stores are located in the liver and myocardium.

Hyperglycaemia is usually iatrogenic

Question 44

pre-op visit for anaesthetising children

Answer 44

• Use this time to develop rapport and trust with the child and parent. Address the child first and then include the parents in discussion. Address the queries and fears of the child as well as those of the parent. Explain the planned approach to induction so both parent and child know what to expect.
• It is important to take a medical and anaesthetic history.
  
  • Any previous problems with anaesthetics including family history
  • Allergies
  • Previous medical problems including congenital anomalies
  • Recent respiratory illness
  • Current medications
  • Recent immunisations
  • Fasting times
  • Presence of loose teeth.
• Conduct a physical examination as appropriate concentrating on the airway and cardiorespiratory systems.
• Children must be weighed. All drug doses relate to body weight. Weight (kg) can be estimated by: (age + 4) x 2. This is less accurate over 10 years.
• Investigations may occasionally be necessary:
  
  • Haemoglobin – large expected blood loss, premature infants, systemic disease, congenital heart disease
  • Electrolytes – renal or metabolic disease, intravenous fluids, dehydration
  • CXR – active respiratory disease, scoliosis, congenital heart disease
• Discuss post-operative pain management. If suppository medications are to be used, consent should be obtained from the parent and the child if they are able to understand

Question 45

pre-op fasting for anaesthesia in children

Answer 45

• 6 hours for solids and milk if greater than 12 months of age
• 4 hours for breast milk and formula feeds if less than 12 months of age
• 2 hours for unlimited clear fluids (as this decreases gastric acidity and volume)

There is an increased incidence of nausea and vomiting with long fasting periods.

Question 46

pre-op medication for anaesthesia in children

Answer 46

In our institution, sedative pre-medication is infrequently used. Psychological preparation and enlisting the help of the parents may decrease the need for sedative pre-medication.

Sedation has a significant failure rate, tastes bad, increases time spent in recovery and delays discharge for day stay procedures. However, an appropriately chosen drug, timed correctly can produce a calm or cooperative child.

We most commonly use analgesic pre-medication drugs such as paracetamol, ibuprofen or codeine phosphate given more than a half hour pre-operatively. EMLA or amethocaine cream is applied to identifiable veins on those children for whom an intravenous induction is planned. Allergy is possible to both these topical anaesthetic agents.

Following may be useful:

• Midazolam 0.5 mg/kg with a maximum of 15 mg given orally 15-30 minutes preoperatively. It has a variable result and can produce a very unpleasant excitatory phase. Timing is important for best effect. A sweetener may be necessary.
• Chloral hydrate 50 mg/kg orally to a maximum of 1g. This also can produce an unpleasant excitatory phase and has a bitter taste. It is also used for sedation.
• Ketamine 3-8 mg/kg orally 30-60 minutes pre-operatively.
• Temazepam 0.5-1 mg/kg orally for older children 1 hour pre-operatively.
• Clonidine 2-4mcg/kg orally. It may cause hypotension.

Beware narcotics in infancy because of apnoea.

Sedation should be used cautiously in those children with airway problems and should be avoided altogether in neurosurgical patients especially if they have raised intracranial pressure.

Question 47

preparation for anaesthesia in children

Answer 47

A parent may join their child at the time of induction. It is not compulsory but can be useful in many instances. There must be a member of staff available to accompany the parent from the anaesthetic room after induction. It must be remembered that being present at induction can be very stressful for the parent.

Warm the theatre and prepare any warming devices. Keeping children warm can be a simple thing to do to improve post-operative wellbeing and outcomes. Use bandages or cotton undercast padding to wrap the limbs and head. Plastic can also be useful to prevent radiant heat loss.

Prepare emergency drugs such as atropine and suxamethonium in a diluted concentration that you are familiar with to make dosing easy if an emergency should arise.

If you do not give anaesthetics to children regularly, calculate and write down the doses of the drugs you may use appropriate for the patient’s weight.

Have your equipment ready and checked.

• Oropharyngeal airway.
• Face masks
• Laryngeal mask
• Endotracheal tube
• Laryngoscope and blades
• Breathing circuit (T piece)
• Monitoring

Question 48

induction of anaesthesia

Answer 48

An inhalational induction can be an excellent technique for the child that fears needles or has difficult venous access. However, it is a two person technique. A skilled assistant will need to maintain the airway in the asleep child while intravenous access is obtained. If this help is unavailable, intravenous inductions should be carried out. A correctly sized oropharyngeal airway may be used. Choose one that is the same length as that from the corner of the mouth to the angle of the jaw.

• Halothane and sevoflurane are the agents of choice for gaseous induction.
  
  • Halothane has a slightly sweet smell and is well tolerated. Induction is moderately slow but the rate is increased with the addition of 50-65% nitrous oxide. Halothane has a slower offset and longer duration of action as it is more soluble. Arrhythmias are more likely to occur. Halothane production is gradually being discontinued in many places.
  • Sevoflurane is non-irritant and has a more rapid onset and offset of action as it is less soluble. A concentration of 8% can be used initially or it can be wound up gradually. Nitrous oxide use increases the rate and depth of anaesthesia obtained. It has improved haemodynamic stability. MAC values are 3.3 in infants, 2.5 in children and 1.7 in adults. Use is associated with emergence delirium.

Best sites for IV access:

• Back of hand
• Inner wrist
• Long saphenous vein \
• Other veins on the dorsum of foot
• Cubital fossa veins are difficult to find in infants and tissue easily at this site
• Elastoplast (non sterile) provides a secure means of fixation

Intravenous induction can be undertaken with propofol, thiopentone or ketamine. Preoxygenation for a rapid sequence induction can be difficult in small children and should be undertaken if able.

Question 49

best sites for IV access

Answer 49

• Back of hand
• Inner wrist
• Long saphenous vein \
• Other veins on the dorsum of foot
• Cubital fossa veins are difficult to find in infants and tissue easily at this site
• Elastoplast (non sterile) provides a secure means of fixation

Intravenous induction can be undertaken with propofol, thiopentone or ketamine. Preoxygenation for a rapid sequence induction can be difficult in small children and should be undertaken if able.

Question 50

intubation in children

Answer 50

• Straight Magill blades are useful in neonates and infants. A size 0 blade is best in babies less than 4 kg. A curved blade is usually easier once the child is 6-10 kg.
• Uncuffed tubes are used until 8-10 years of age.
• A small leak should be present. The leak is too large if it compromises ventilation.
• Tube size = age/4 + 4.5 is generally a better fit than age/4 + 4 up to 10 years ƒ Tube length in cm = age/2 +12 (or ID x 3 for an oral ETT and add 2cm for a nasal tube is easier to remember). This is only a guide and the tube length will always need to be checked clinically.
• 1 LMA up to 5 kg; 1.5 LMA 5-10 kg; 2 LMA 10-20 kg; LMA 2.5 20 – 30 kg; LMA 3 for over 30 kg
• Preformed RAE tubes may be too long.
• Secure the endotracheal tube with 1cm wide elastoplast, ensuring that the tape wraps about the tube and at least one tape is fixed to the less mobile maxilla. Re-check tube length at the time of taping

Question 51

maintenance of anaesthesia in children

Answer 51

• Add regional analgesia where necessary
• Beware intravenous narcotics in infancy especially ex-premature infants and neonates.
• Use intravenous fluids for cases with expected blood loss, intra-abdominal, or those taking longer than 30 minutes.
• Extubation laryngospasm tends to occur less frequently if the child is fully awake at the time of extubation.
• You may need to be with a child in recovery until fully awake if the recovery staff are inexperienced with children.

Question 52

ways of delivering safe and effective pain control in children and adolescents

Answer 52

A range of techniques are available, comprising four overlapping categories: behavioural techniques, local anaesthesia (LA), conscious sedation, and general anaesthesia (GA)

Question 53

only 2 indications for GA for dental Tx in children

Answer 53

• The child needs to be fully anaesthetised before dental treatment procedures can be attempted.
• The surgeon needs the child fully anaesthetised before dental treatment can be performed.

neither of these indications are absolute. Both require a degree of judgement on the part of the dental surgeon.

The decision to use GA is complicated by the knowledge that there is a small but real risk of death associated with GA.

The knowledge that the majority of operative care can be carried out using either LA or LA with conscious sedation, sets dentistry aside from other paediatric surgical specialties where GA is the norm

Question 54

when discussiong GA with carer and child consider

Answer 54

• The co-operative ability of the child.
• The perceived anxiety and how the child has responded to similar procedures.
• The degree of surgical trauma anticipated.
• The complexity of the operative procedure
• The medical status of the child

Question 55

example uses for GA

Answer 55

• Severe pulpitis requiring immediate relief.
• Acute soft tissue swelling requiring removal of the infected tooth/teeth.
• Surgical drainage of an acute infected swelling.
• Single or multiple extractions in a young child unsuitable for conscious sedation.
• Symptomatic teeth in more than one quadrant.
• Moderately traumatic or complex extractions e.g. ankylosed or infra-occluded primary molars, extraction of broken-down permanent molars.
• Teeth requiring surgical removal or exposure.
• biopsy of a hard or soft tissue lesion.
• Debridement and suturing of orofacial wounds.
• Established allergy to local anaesthesia.
• Post operative haemorrhage requiring packing and suturing.
• Examination under GA, including radiographs, for a special needs child where clinical evidence exists that there is a dental problem which warrants treatment under GA

Question 56

most common conditions for GA treatment

Answer 56

Severe pulpitis and acute infection

Question 57

Tx that rarely needs GA

Answer 57

• Carious, asymptomatic teeth with no clinical or radiographic signs of sepsis.
• Orthodontic extraction of sound permanent premolar teeth in a healthy child.
• Patient/carer preference, except where other techniques have already been tried

Except when

• Physical, emotional, learning impairment or a combination of two or more of these.
• Children who have attempted treatment using LA alone or LA combined with conscious sedation and been unable to co-operate.
• Medical problems which are better controlled with the use of GA.
  
  • Discuss with paediatrician – need written advice, severe conditions admit to ward

Question 58

GA risks

Answer 58

• Once decided to use GA explain to the parents that the anaesthetic is not administered by a dentist, but by an anaesthetic consultant who has undergone specialist training in paediatric anaesthesia (or by an anaesthetic specialist registrar under their direct supervision).
  
  • explained that the procedure will take place in an operating theatre, with a team trained in the care of children.
• The potentially serious nature of the procedure should be clearly explained to the parent(s) and, where appropriate, the patient.
  
  • Small but real risk of a catastrophe during GA.
    
    • Agreement should be reached between the dental and anaesthetic teams concerning how and when anaesthetic risk is explained and documented.
      
      • A key principle of the consent process is that a clinician cannot take informed consent for a procedure which they are not trained to perform themselves. However, the decision to use GA ultimately rests with the dentist, so some explanation of risk is required. Details of this process should be subject to local arrangements, but it is likely that clarification of a recommended procedure will come from a future guideline.

Question 59

GA Treatment plans need to aim to

Answer 59

Comprehensive planning aims to ensure all Tx is carried out under one GA

• The practice of extracting the most grossly carious and/or symptomatic teeth and leaving restorable teeth for future visits as an outpatient using LA with or without sedation is to be criticised

REMOVE ANY Q TEETH AS DON’T WANT ANOTHER GA AS RISK MORTALITY

Question 60

for GA care, special investigations required before are

Answer 60

• Radiographs

Question 61

restorations under GA

Answer 61

Most predictably successful restoration should be given

• Temporary/provisional restoration should be considered for certain circumstances e.g imminent exfoliation

Question 62

consent for GA

Answer 62

• Specific written consent should be obtained at the time of treatment planning and updated on the day of operation.
  
  • This provides a suitable period of reflection for the parents and/or child (18).
• Care should be taken to ensure that the parent understands whether primary teeth, permanent teeth or both are included in the treatment plan.
  
  • Even if the extraction of permanent teeth is following the prescription of an orthodontist, it is the operator’s duty to ensure that the parents fully understand that the teeth are not replaced naturally.
• It is good practice to obtain written consent from the child where it is thought that they have sufficient understanding and emotional maturity (18).
• Interpreting services must be used if it is thought that the parents may not understand the nature of the proposed treatment.
  
  • further reinforced by asking that the parent read the consent form carefully with an interpreter who is able to explain medical/dental terms in the parents’ own language.
  • It is not uncommon for a young child to have better English language skills than their parents. In these circumstances it is not acceptable to use the child as an interpreter.
• A blanket consent such as “restorations and extractions as necessary” is inadequate,
  
  • except where it is agreed that an examination under anaesthesia (EUA) is required before treatment planning can be completed.
    
    • It should be explained that the decision about the number of fillings and extractions can sometimes only be made when the child is anaesthetised and that this decision is left to the judgement of the operating clinician.
  • If agreement cannot be achieved, further referral to a colleague should be offered.

Question 63

pre-op assessment aims

Answer 63

• Ideally the diagnosis and treatment planning should be carried out on a separate day from that of the GA
  
  • several advantages, including:
    
    • Allowing the dentist sufficient time to fully explain the treatment required and assess the parents’ understanding.
    • Allowing the parent and child time to consider the proposed treatment, and ask further questions if necessary.
    • The pre-operative anaesthetic assessment may be carried out immediately prior to surgery unless the dentist is uncertain as to a patient’s suitability for day surgery - in which case they may ask for an anaesthetic review well in advance of surgery.

Question 64

dental GA in

Answer 64

hospital setting with adequate ‘critical care facilities’

Question 65

shared responsibility in dental GA

Answer 65

Airway management, pain control, underlying medical conditions, management/extent of blood loss and duration of the procedure are a shared responsibility.

• Effective communication with the anaesthetist is the key to providing optimal care for the child under GA.

Complete clinical records itemising each procedure carried out under GA are required, these should be easily distinguishable from out-patient records.

Details of the anaesthetic procedures are the responsibility of the anaesthetist

Question 66

clinical effectiveness of preformed metal crowns

Answer 66

most predictable and durable restorations for anything but the smallest of carious lesions in primary molars

Question 67

clinical effectiveness of pulp therapy in primary teeth

Answer 67

• should be provided with caution under GA, given the clinical failure rates of the medicaments available.
  
  • Exceptional circumstances (e.g. haemangioma/lymphangioma in supporting tissues) may be a contra-indication to extraction.

primary tooth restored under GA should be expected to exfoliate naturally without failure.

Question 68

resposibility for discharge of pt

Answer 68

shared between the dentist, the anaesthetist and the recovery nursing staff.

Question 69

general guidelines for discharge after GA

Answer 69

• Patients and parents should receive verbal and written post-operative instructions
• Advice should be given of any symptoms that might be experienced in the first 24 hours following discharge.
• Analgesics including paracetamol BNF should be recommended for use in the 24 to 48 hours following discharge.
• Specific instructions regarding mouth care after surgery should be given.
• The nature of any sutures placed should be described and an appointment made for post-operative assessment. It is wise to arrange such a follow up to ensure that healing is progressing normally and that any absorbable (dissolving) sutures have been lost spontaneously

in addition to following any local policies for discharge,

Question 70

why is it undesirable to have multiple dental GAs

Answer 70

• morbity
• behavioural/emotional effects
• cost

Question 71

DENTAL CARE UNDER GENERAL ANAESTHESIA - DISCHARGE ADVICE FOR PARENTS

Answer 71

We hope the following information will be of help to you:

You will be able to take your child home when you and the nurses feel confident that s/he

• can walk steadily around the ward
• is reasonably comfortable
• is not feeling sick
• is drinking water/juice and able to hold it down

Eating and Drinking:

Your child needs to have a soft, smooth diet and nothing which is too warm or too cold, to avoid discomfort and further bleeding.

Oral Hygiene:

It is important to maintain good oral hygiene as this will promote healing.

• ON THE DAY OF EXTRACTIONS: avoid rinsing their mouth as this may start bleeding.
• THE FOLLOWING TWO DAYS AFTER THE OPERATION:
  
  • You may try salt water mouthwashes and gently introduce tooth brushing as and when comfortable. Young children may not be able to rinse.
    
    • Boil water and pour it into a tumbler. Dissolve a level teaspoon of common salt. Allow to cool until it can be used without burning

Problems to look for:

• Pain: Some discomfort is inevitable. Aim is for your child to be as comfortable as possible after their operation. They may be discharged with pain relieving medication - follow the advice from the nursing staff on how to take this medication. If you do not have medication at home please buy paracetamol or ibuprofen syrup from a pharmacy.
• Swelling: Facial swelling is common and will disappear within a few days. You may find it helpful to wrap something cool (e.g. frozen peas) in a towel and rest it on the swollen area for a few minutes, but not for extended time periods
• Bleeding: Do not be alarmed if there is a small amount of blood from the extraction sockets. Roll up a clean handkerchief or gauze, moisten with warm water, place over the socket and have your child bite firmly for at least 10 minutes. If this fails to control the bleeding after about 30 minutes, seek professional help.
• Stitches: Any dissolving stitches should be gone in a week. Non-dissolving stitches need to be removed and you should receive an appointment for this.

Now that your child is going home, we wish to remind you that after a general anaesthetic there is a period in which his/her judgement, performance and reaction time are affected by the anaesthetic, even though the child may feel quite normal again. It is therefore very important in the 24 hours after the operation that your child:

• is not allowed to do anything potentially dangerous to her/himself or others, such as playing in an adventure playground, riding a bicycle, climbing trees, swimming, or going out by themselves.
• remains in the immediate care of a responsible adult.
• is given painkillers if necessary or as directed by the dentist.

For urgent enquiries please contact………………

Question 72

A biological mother always has parental responsibility unless it has been removed from her by a court.?

Answer 72

true

Question 73

A child is living with their maternal grandmother, there is no fathers name on their birth certificate and grandmother tells you that the child lives with her because mum has a chaotic life.

In this case the grandmother can consent to all dental treatment?

Answer 73

FALSE - she can only consent in emergency situations as mother retains parental responsibility

Question 74

Step parents automatically gain parental responsibility when they marry a child’s biological parent.?

Answer 74

FALSE - they do not obtain parental responsibility but they can apply to the courts for it

Question 75

Adoptive parents have parental responsibility following completion of the adoption process?

Answer 75

TRUE

Question 76

When parents divorce parental responsibility is given to the parent that the child lives with the majority of the time.?

Answer 76

FALSE - it stays with both parents unless given up or removed by a court