Tip:
Highlight text to annotate it
X
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% *** 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 *** 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 *** 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 4x4 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 open learning and open educational resources.
This recording is licensed under the creative comments. It may be reused and redistributed
for nonprofit use. Please attribute materials to the University of Michigan's School of
Dentistry and redistribute under this same license. For more information on how this
and other University of Michigan School of Dentistry recordings may be used visit www.dent.umich.edu/license.