Republic of Iraq

Ministry of Higher Education

and Scientific Research
University of Baghdad
College of Dentistry

Hospital Dental Services for Children and The

Use of General Anesthesia

A Project Submitted to
The College of Dentistry, University of Baghdad,
Department of Pedodontics and Preventive dentistry in
Partial Fulfillment for the Bachelor of dentistry

By

Haider Raed Aziz

Fifth grade

Supervised by

[Link] N. Yasin

B.D.S, [Link]. Pediatric Dent.

2023A.D.
1444.H
Certification of the Supervisor
I certify that this project entitled "Hospital Dental Services for Children and the
Use of General Anesthesia" was prepared by the fifth-year student Haider Raed Aziz
under my supervision at the College of Dentistry/University of Baghdad in partial
fulfilment of the graduation requirements for the bachelor’s degree in Dentistry.

supervisor’s name.

Lect. Heba N. Yassin

Date:

II
DEDICATION

I'd like to dedicate this project to my beloved father and my beloved

mother without both I would never make it to this point.

To all my friends, thank you for being always there for me with all your
love and support.

III
Acknowledgement
I would like to Express my grateful thanks to dean of college of dentistry,
University of Baghdad Prof. Dr. Raghad A. Al-Hashimi.
My deep thanks to scientific assistant Dean Prof. Dr. Ali Al-bustani,
Grateful thanks are expressed to Asist prof. Aseel Haider Mohammed, Head of the
department of Pedodontics and Preventive Dentistry for her scientific support and
advice.
To my supervisor [Link] N. yassin, I would like to express.
gratitude to scientific care and to the spirit of high morality that encourage and advise
me always to right way throughout this research. Ask Allah to reward her the best
reward.
Great thanks to all members of Pedodontics and Preventive dentistry department
for high ethics and for standing help.

IV
 List of contents

Subject Page
No.

Certification of the supervisor II

Dedication III
Acknowledgment IV

List of contents V

List of tables VI
List of figures VI
List of abbreviations VII
Introduction 1
Aim of the study 2
Review of Literature 3
1. Obtaining hospital staff privileges 3
2. Indications for general anesthesia in the treatment of children 3
3. Psychological effects of hospitalization on children 5
4. Medical history and physical examination 7
5. Inhaled general anesthesia and conduct of anesthesia 9
6. Toxicity of inhaled general anesthesia 11
7. Anesthetic preparation of the child 12
8. Perioral Cleaning, Draping, and Placement of pharyngeal throat 15
pack
9. Restorative dentistry in the operating room 17
10. Completion of the procedure 19
Conclusion 20
References 21

V
 List of Tables
Table Table Title Page
No. No.

1. American society of anesthesiologists’ physical status 8

classification system

LIST OF FIGURES

Figure Figure title Page

No. No.
1. (A) Patient is in a stable anesthetic condition and ready for the dental 14
procedure. Notice the position of the precordial stethoscope, blood pressure
cuff, and orotracheal tube. (B) This shows the position of the orotracheal
tube taped to the far right side of the mouth. Note the tape is solely on the
maxilla to not impede mouth opening. (C) This shows the intraoral portion
of the orotracheal tube. Note the tube is positioned buccal to the maxillary
second primary molar to allow access to most of the oral cavity. If work in
that quadrant is impaired by the tube, it can be moved and taped to the other
side
2. A special eye guard protects the patient’s eyes during the procedure 15
3. Obtaining diagnostic radiographs. Notice the use of protective lead gloves, 16
thyroid collar, gown, and lead aprons. The blue plastic bag lying over the
patient contains a protective lead apron that will be replaced by a surgical
patient drape at the conclusion of obtaining x-rays and before initiating the
surgical procedure
4. Special care must be taken during perioral cleaning to prevent materials 17
from entering the oral cavity.
5. Placement of the surgical sheet and triangular draping of the oral cavity 17
area. The nasotracheal tube is exposed to allow for easy monitoring of its
connections

VI
 LIST OF ABBREVIATIONS

DGA Dental General Anesthesia

ECC Early childhood caries

GA General Anesthesia

IV Intra venous

MH Malignant hyperthermia

PALS pediatric advanced life support

PONV Post operative nausea and vomiting

SHCN Special health care need

VII
Introduction
General anesthesia (GA) is a state of a controlled loss of consciousness using both
intravenous drugs and gas inhalation (Torpy et al.,2011).
Under the influence of anesthetic medications, patients lose the ability to feel any
stimulus no matter how painful it is, and the body’s natural reflexes are lost as well
(Revision,2018).
Dental general anesthesia (DGA) is a widely used technique in pediatric dentistry.
It facilitates the delivery of proper treatment to children with severe dental decay who
cannot cope with treatment in the conventional dental setting due to anxiety or limited
cooperation ability (Karim et al.,2008).
There are several indications for DGA in children, but caries is generally the most
common cause. Occasionally some healthy and Special health care need (SHCN)
patients require treatment under (GA) due to congenital disorders or traumatic
accidents Even though some risks are associated with DGA, it remains a safe procedure
overall (Martins-Junior et al.,2013).
DGA comes with a high cost and requires unique equipment; nonetheless, both
dentists and parents find it an acceptable way of treating children (Ramazani,2016).
A study that assessed the mortality of dental GA by a review included 20 studies
from 1955 to 2017 concerned with deaths associated with dental GA. They found 218
deaths out of 71,435,282 patients (3 deaths per 1,000,000 persons) with a mortality rate
of 1:327,684 (Mortazavi et al., 2017).
multiple researchers have proven that single, brief exposure to these drugs presents
a minimal risk for neural growth and development (Dimaggio et al.,2011).
Dental pain was the most common postoperative dental morbidity during the first
3 days after dental GA. Therefore, The Royal College of Anesthetists guidelines
recommends using sedation instead of dental GA whenever suitable (Hulin ,2015).

1
Aim of the study

Aim of study to review all aspects of treatment for children in the hospital and under
General anesthesia.

2
Review of the literature
1. Obtaining Hospital Staff Privileges
Requirements for obtaining hospital staff privileges vary among institutions.
The dentist must fulfill the following three basic requirements to become a hospital
staff member:( American Academy of Pediatric Dentistry,2022)
1. The applicant must have graduated from an accredited dental school.
2. The applicant must be licensed to practice dentistry in the state in which the facility
is located.
3. The applicant must have high moral and ethical standards.
Additional requirements may have to be met to obtain staff privileges. In a
children’s hospital, dentists might be required to have adequate advanced training to
treat and manage children in the hospital. The requirements may include a dental
residency of 1–4 years in a teaching hospital in which the dentist (1) gains experience
in recording and evaluating the medical history and current medical status of
children.(2) receives instruction in physical examination techniques and in recognition
of conditions that may influence dental treatment decisions; (3) learns to initiate
appropriate medical consultations when a problem arises during(4) learns the
procedure for admitting, monitoring, and discharging children; and (5) develops
proficiency in operating room protocol. A rotation in which the dental resident was
actively involved in administering general anesthesia to children is highly desirable.
Current certification in basic cardiopulmonary resuscitation should be maintained by
all members of the hospital’s professional staff, including dentists. It is highly desirable
to have participated in a pediatric advanced life support (PALS) course as well
(Jeffrey,2011).
2. Indications for General Anesthesia in the Treatment of Children
The use of general anesthesia (GA) for dental care in children is sometimes
necessary for safe, efficient, and effective care (Jeffrey,2011)

3
 Children with special needs are defined by having any physical, developmental,
mental, sensory, behavioral, cognitive, or emotional disabilities that require
differentiated medical treatment, special medical intervention, and/or use of
specialized services or programs. This definition can be applied in dental care, when
due to the above characteristics these children require the use of appropriate behavioral
guidance techniques, conscious sedation, or general anesthesia (Newacheck et
al.,1998).
GA is an efficient and safe resource for patients whose special characteristics
make it impossible for treatment to be performed under local anesthesia or conscious
sedation. Health services and treatment policies with respect to the General Assembly
vary from country to country (Robertson et al; 2012., Cantekin et al.,2014).
The use of GA is increasing in patient profile, as preschoolers under the age of
six and/or with mental disabilities lack the psychological maturity needed to tolerate
dental treatment. Particular attention should therefore be paid to oral health promotion
and education, as well as early prevention in pregnant women and to risk groups such
as disabled patients (Foley et al.,2001; Ibricevic et al.,2001)
Similarly, despite an overall decrease in the prevalence of tooth decay and
advances in preventive dentistry, restorative treatment and dental extractions are on the
rise in this group of patients with special needs compared to healthy subjects of similar
age, especially in the group of the mentally disabled. If we want to offer better quality
of care, it is necessary to have adequate dental treatment under GA to improve the
efficacy and safety of treatment and establish best clinical practices. This requires
careful analysis of clinical evidence in order to provide adequate support for these
children, taking great care to avoid further withdrawal as much as possible (López-
Velasco et al.,2021).
If the benefits of the procedure outweigh the risk of anesthesia, there are few if
any contraindications to general anesthesia. However, when a concern about the
medical condition exists, consultation with an anesthesiologist would be desirable.
Patients for whom general anesthesia is usually contraindicated include those with a

4
medical contraindication to general anesthesia and healthy and cooperative patients
with minimal dental needs (Jeffrey,2011).
[Link] Effects of Hospitalization on Children
Hospitalization is a frequent source of anxiety for children.20%–50% of children
demonstrate some degree of behavioral change after hospitalization. Separation of the
child from the parent appears to be a significant factor in post hospitalization anxiety,
although other causes are also documented. Allowing the parent to stay with the child
during the hospitalization, and especially to be present when the child leaves for and
returns from surgery, can reduce anxiety for the child and parent alike (king and
Nielson,1976).
According to Camm et al. (1987) postoperative behavioral changes reported by
mothers of a limited sample of children who received dental treatment with general
anesthesia in a hospital were like those observed in children who received treatment
under conscious sedation in a dental clinic. Mothers of children receiving dental
treatment with general anesthesia in a hospital setting were found to experience more
stress during the procedure. Ways to decrease these stresses include providing a prior
tour of the operating room facility, informing the parents of the status of the child
during the procedure, and letting them know that “everything is all right.
About 75% of the children receiving general anesthesia exhibited some type of
behavioral [Link] changes included less fuss about eating, fewer temper
tantrums, and better appetite. Negative changes included biting the fingernails,
becoming upset when left alone, being more cautious or avoiding new things, staying
with the parent more, needing more attention, and being afraid of the dark. Ways to
minimize negative changes include: (1) involving the child in the operating room tour;
(2) allowing the child to bring along a favorite doll or toy;(3) giving pre-induction
sedation;(4) providing a nonthreatening environment;(5) giving post-procedural
sedation as needed; and (6) allowing parents to rejoin their children as early as possible
in the recovery area. Some centers allow parents to be present at the induction of
anesthesia. This decision is at the discretion of the anesthesiologist(Jeffry,2011).

5
 Usually, anesthesia is induced when the child breathes anesthetic gases such as
sevoflurane and/or nitrous oxide through a face mask. As the child becomes
anesthetized, the parent is encouraged to provide calm, loving reassurance until the
child is unaware of the parent’s presence. For this technique to be effectively utilized,
it is mandatory that the operating room team be comfortable with the parent’s presence
and prepared to care for the parent if he/she were to become distressed. It is also critical
that the parent be educated as to what to expect as the child is anesthetized, including
the possibility that the child may not readily accept the mask, that the child’s breathing
may become obstructed or “snory,” or that the child’s eyes may display abnormal
movements as he/she enters the excitement stage of anesthesia. Parental presence can
be especially helpful with the child with autism spectrum disorder or with a child who
refuses or is resistant to oral sedation such as midazolam (Camm et al.,1987).
Another similar technique utilizes certified child life therapists skilled in the
application of distraction techniques and play therapy. These personnel must also be
educated as to their responsibilities during the induction of anesthesia. Utilization of
parental presence or child life therapists can markedly reduce the requirement for oral
sedation and thus enhance facility throughput by avoiding any delays in medication
administration, emergence from anesthesia, or postoperative observation time required
to meet discharge criteria. To limit the severity and duration of psychological
disturbances, the dentist should strive to reduce parental apprehension concerning the
operative procedure. Because children often sense apprehension in their parents,
effectively reducing the parents ’anxiety will put the child more at ease. Thoroughly
explaining the procedure, describing the normal post-anesthetic side effects, and
familiarizing the child and parents with the hospital can reduce postoperative
anxiety(Jeffry,2011).
children treated for early childhood caries (ECC) under general anesthesia or
under conscious sedation at a very young age behaved similarly or better in a follow-
up examination approximately 14 months after treatment than at their pretreatment
visit, as measured by the Frankl scale and by the sitting pattern (Peretz et al.,2000).

6
 children were more likely to exhibit positive behavior at their 6-month recall
appointment following dental treatment for childhood caries under general anesthesia
compared with those treated under oral conscious sedation (Fuhrer et al.,2009).
[Link] History and Physical Examination
The primary steps in preoperative preparation are to determine whether the child
is in the best possible state of health, given the child’s underlying medical condition,
and to manage any concurrent acute interceding illness. The key concept is that the
patient’s medical condition should be “optimized” when he or she presents to the
operating room (OR). The American Society of Anesthesiologists has an established
risk-stratification system as seen in table (1)(Kenneth et al. ,2014).

Table (1): American society of anesthesiologist’s physical status classification

system (Kenneth et al;2014).

ASA physical status 1: A normal healthy patient

ASA physical status 2: A patient with mild systemic disease

ASA physical status 3: A patient with severe systemic disease

ASA physical status 4: A patient with severe systemic disease that is a constant threat to life

ASA physical status 5: A moribund patient who is not expected to survive without the
operation
ASA physical status 6: A declared brain-dead patient whose organs are being removed for
donor purposes

The details of the patient’s medical history are not always apparent to the
perioperative care team; therefore, the pediatrician’s detailed knowledge of the patient’s
medical history is an especially important area in which he or she can improve overall
care for a patient. For example, pediatrician input has been shown to frequently modify
the perioperative plan in children undergoing dental procedures (Auvergne et al.,2011).

7
 Planning for anesthesia benefits from communication about neurologic
development and function, airway anomalies (e.g., difficult intubations, history of
airway surgery), cardiac and pulmonary function (including sleep apnea as well as lung
disease), coagulation history, endocrine and renal diseases, and history of exposure to
chronic opioids, anesthetics, and sedatives. Motion sickness is a risk factor in adults
for postoperative nausea and vomiting (PONV) and is very likely a predictor in
children as well. This history should be noted, as should a history of PONV with
previous surgeries (Gan et al.,2007).
General psychosocial history can guide perioperative management. Conditions
such as severe anxiety or posttraumatic stress disorder or conditions that impair the
child’s ability to process information (e.g., attention-deficit disorder) or interact with
strangers under stressful conditions (e.g., oppositional defiant disorder, autism
spectrum disorders) should be conveyed to the anesthesia care team. Before elective
procedures, consultation with a psychologist to aid in preparing the family and child
with these severe cognitive and emotional disorders may be helpful as well (Auvergne
et al.,2011).
The medical history should include the following information according to Jeffry,
(2011)
1. Allergies and previous allergic or adverse drug reactions.
2. Current medications, including dosage, time, route, and site of administration for
prescription, over the counter, herbal, or illicit drugs. Many drugs, including herbal
agents (e.g., St. John’s wort, echinacea, kava, valerian), may alter drug
pharmacokinetics, prolonging the effects of sedative agents.
3. Diseases or abnormalities in the patient, including pregnancy status of adolescents
and neurologic impairment that might increase the potential for airway obstruction,
such as a history of snoring or obstructive sleep apnea.
4. Previous hospitalizations, including the date, purpose, and hospital course.
5. History of general anesthesia or sedation and any associated complication.
6. Family history of diseases and sedation or anesthetic complications.

8
7. Review of body systems.
8. Age (in years and months) and weight.
9. Name, address, and contact information of the child’s medical home.

According to Jeffry, (2011) the physical evaluation should include the following:
1. Height and weight.
2. Vital signs, including heart and respiratory rates, blood pressure, and temperature. If
determination of baseline vital signs is prevented by the patient’s physical resistance or
emotional condition, the reason(s) should be documented.
3. Evaluation of airway patency to include tonsillar size and anatomic abnormalities
that may increase the risk of airway obstruction (e.g., mandibular hypoplasia, large,
short neck, limited mandibular range of motion).
4. Physical abnormalities or conditions that may affect routine intraoperative
monitoring (e.g., recent orthopedic injuries to arms or legs, active skin rashes).
[Link] General Anesthesia and Conduct of Anesthesia
Inhalation anesthetics (nitrous oxide, halothane, isoflurane, desflurane,
sevoflurane, most used agents in practice today) are used for induction and
maintenance of general anesthesia in the operating room. The volatile anesthetics
(halothane, isoflurane, desflurane, and sevoflurane) are liquids at room temperature
and require the use of vaporizers for inhalational administration. Nitrous Oxide is
already under normal conditions of temperature and pressure. All inhalational
anesthetics provide amnesia and immobility, except for nitrous oxide, which also
provides analgesia. Inhaled anesthetics are commonly used in combination with IV
anesthetic agents (Amanda et al.,2022).
The most used anesthetic gases are halothane, nitrous oxide, isoflurane,
sevoflurane, and desflurane. The primary mode of administration is by inhalation
through a face mask, laryngeal mask airway, or a tracheal tube. They can be useful for
preoperative sedation in addition to intravenous (IV) anesthetic agents such as

9
midazolam and propofol in the perioperative and intraoperative setting (Brown et
al.,2018).
The gold standard to measure potency is the minimum alveolar concentration
(MAC), defined as the minimum alveolar concentration of inhaled anesthetic, at which
50% of people do not move in response to a noxious stimulus (Aranake et al.,2013).
The most common adverse effect of inhaled anesthetic agents is postoperative
nausea and vomiting (PONV). There has been some evidence showing that intravenous
anesthesia instead of inhaled agents reduces the risk of PONV (Scheiermann et
al.,2018).
Independent of the source, usually anti-emetic agents such as ondansetron,
metoclopramide, and/or dexamethasone are administered both prophylactically and
symptomatically to reduce the incidence of nausea and vomiting (Brown et al.,2018)
Malignant hyperthermia (MH) is also an adverse effect that can occur with the
administration of inhaled anesthetics, most seen with the inhaled gas halothane.
Patients susceptible to this adverse effect have heritable alterations between their
proteins and muscular cytosolic concentrations of Ca2+(Hopkins et al.,2018).
When exposed to anesthetic gases, there is an excessive release of Ca2+ in the
skeletal muscle causing the patient to exhibit symptoms such as hyperthermia,
tachycardia, muscle rigidity, hyperkalemia, and metabolic imbalances. Reversal is
achievable by administering dantrolene and restoration of normal body temperature,
and correction of metabolic imbalances (Rosenberg et al.,2015).
Patients with a known history or family history of MH should avoid volatile
inhalation agents and other precipitating agents such as succinylcholine. Typically, the
volatile agent vaporizers are completely removed from the anesthesia machine, and it
is flushed with high flow air or oxygen for an hour before being used with a susceptible
patient. A few inhalation agents are known to irritate the airways of patients with severe
asthma and induce bronchospasm due to the pungent smell on induction, primarily with
desflurane and isoflurane. Other agents like sevoflurane can be used in asthmatic
patients to help relax the airways on induction as they do not have such pungent smells.

10
Isoflurane, sevoflurane, desflurane will decrease systemic vascular resistance leading
to a drop in systemic blood pressure. These changes are more profound in hypovolemic
patients. Nitrous oxide can cause diffusion hypoxia quickly following discontinuation
of the agent. It is recommended that 100% FiO2 be used to counteract the rapid dilution
of O2 in the alveoli (Amanda et al.,2022).
[Link] of inhaled General Anesthesia
It is worth mentioning that there is no pharmacological intervention for an overdose
of inhaled anesthetics. In an overdose incident, the primary treatment method is
supportive, with optimal ventilator settings and alveolar clearance. Several rare acute
and chronic toxicities can occur with inhaled agents. Acute toxicities include carbon
monoxide poisoning (CO2), nephrotoxicity, and hepatotoxicity. Chronic toxicities
include hematotoxicity, teratogenic effects, and carcinogenic toxicities (Amanda et al.
,2022)
The dose of Nitrous Oxide necessary used in a routine anesthetic can cause
diffusion hypoxia. As gas exits the bloodstream into the lungs, the nitrous oxide
displaces air and oxygen from the alveoli. This can be ameliorated by using
supplemental oxygen to displace and dilute the nitrous oxide (Amanda et al.,2022).
Nephrotoxicity occurs most commonly with sevoflurane as its metabolism occurs
at a much faster rate than other gases. This faster rate of absorption causes high levels
of inorganic fluoride, which correlates with renal impairment. While this observation
has largely occurred in research studies, the clinical recommendation remains to avoid
sevoflurane in patients who have known renal dysfunction (Dayan,2016; Ong Sio et
al.,2017).
The possibility that anesthetic agents might cause neurotoxicity and resultant
learning deficits in young children has become an important topic over the past few
years. Pediatric anesthesiologists and dentists have been asked by parents and
caregivers about toxic effects and long-term cognitive and behavioral outcomes. This
issue was first recognized in animal studies in the early 2000s(Jeffry,2011).

11
[Link] Preparation of the Child
After donning operating room attire, the dentist should report to the surgical suite
and inform the anesthesiologist of any special requests concerning the procedure before
the induction of anesthesia. When the patient enters the operating room, the mandatory
“time-out protocol,” usually initiated by the circulating nurse, identifies the patient,
allergies, planned medications, and proposed treatment to the dentist and
anesthesiologist before induction for the child’s safety (Jeffry,2011).
Nasotracheal intubation is preferred to ensure good access to the oral cavity.
However, a history of epistaxis or certain medical comorbidities may make
nasotracheal intubation relatively contraindicated. One technique for nasal
endotracheal intubation utilizes a latex-free red rubber catheter to serve as an
atraumatic dilation device to prevent the passage of the hollow-pointed endotracheal
tube through the nasopharyngeal tissues (Ray and Tobias,2003).
Orotracheal intubation is not contraindicated, however, and can be used in a
dental case with minimal restorative needs. In this event, the anesthesiologist will
typically place the endotracheal tube to the least affected side of the oral cavity first
and then move it to the other side after treatment of disease not obscured by the tube is
completed one must recognize that complications related to the administration of
general anesthesia (i.e., laryngospasm, tooth avulsion or aspiration, traumatic
intubation, compromised airway, and malignant hyperthermia) are possible and may
require expert management by the anesthesiologist(Jeffry,2011).
The anesthesiologist is responsible for starting intravenous fluids, securing the
necessary monitoring equipment, performing the intubation, and stabilizing the
endotracheal tube. The anesthesiologist will select the type of intravenous fluid,
calculate the estimated fluid replacement and fluid deficit volumes, and perform a
physical assessment of dehydration. The monitoring equipment should include (1) an
automatic sphygmomanometer;(2) electrocardiographic leads;(3) a temperature
monitoring device;(4) a pulse oximeter;and (5) a capnography device. The
anesthesiologist must confirm that the child is in stable condition prior to the onset of

12
the dental operation. If orotracheal intubation is used, special attention is focused on
optimal tube placement as in Figure (1) (Jeffry,2011).

Figure(1):(A) Patient is in a stable anesthetic condition and ready for the dental procedure. Notice
the position of the precordial stethoscope, blood pressure cuff, and orotracheal tube. (B) This shows
the position of the orotracheal tube taped to the far-right side of the mouth. Note the tape is solely on
the maxilla to not impede mouth opening. (C) This shows the intraoral portion of the orotracheal tube.
Note the tube is positioned buccal to the maxillary second primary molar to allow access to most of
the oral cavity. If work in that quadrant is impaired by the tube, it can be moved and taped to the other
side (Jeffry,2011).

Special care is taken to protect the child’s eyes as in Figure (2). In addition, a
shoulder roll is placed, padding is added to the patient’s pressure points, the
endotracheal tube and head are stabilized, heating or cooling blankets are used as
needed, and the safety belt is secured. The dentist has the table positioned to conduct
dental procedures, and the anesthesiologist administers any preoperative intravenous
medications requested (Jeffry,2011).

13
 Figure (2): A special eye guard protects the patient’s eyes during the procedure
(Jeffry,2011).

Before scrubbing, the dentist should obtain any necessary preoperative radiographic
studies. All persons involved in the radiologic procedure should wear protective lead
apparel. Radiographs of excellent quality can be made while a patient is under general
anesthesia without exposing the patient or staff to unnecessary radiation as in
Figure(3). Digital radiographs are advantageous because radiation exposure is
decreased, and image feedback is immediate (Jeffry,2011).

14
Figure (3): Obtaining diagnostic radiographs. Notice the use of protective lead gloves,
thyroid collar, gown, and lead aprons. The blue plastic bag lying over the patient
contains a protective lead apron that will be replaced by a surgical patient draped at the
conclusion of obtaining x-rays and before initiating the surgical procedure
(Jeffry,2011).

[Link] Cleaning, Draping, and Placement of pharyngeal Throat

Pack
Before the dental procedure is begun, the perioral area is cleansed with sterile 4 ×
4-inch gauze pads. The first gauze pad is saturated with a bacteriostatic cleaning agent
and the second gauze pad with sterile water. Alcohol is not used in the operating room
because it is a potential fire hazard. This procedure is intended not to sterilize the area
but only to remove gross debris as in (Figure 4) (Jeffry,2011).

15
Figure (4) Special care must be taken during perioral cleaning to prevent materials from entering the
oral cavity.

A surgical sheet is then positioned over the remainder of the child's body. This helps
maintain body temperature and provides a clean field during the procedure. The head
is draped with three towels arranged to form a triangular access space for the mouth.
The towels are secured in place with towel clamps or hemostats. The mouth should be
fully exposed as in Figure (5) (Jeffry,2011).

Figure (5): Placement of the surgical sheet and triangular draping of the oral cavity area. The nasotracheal
tube is exposed to allow for easy monitoring of its connections.

16
 The anesthesiologist may request that part of the nasotracheal tube remain exposed
so that all connections can be easily monitored. The assistants then place all supporting
carts and stand around the table in positions that the dentist finds comfortable and
efficient. The example set-up of the surgical suite provided is only a suggestion; the
final positioning of equipment and individuals is at the discretion of the surgeon and
surgical staff. The patient’s mouth is opened with the aid of a Molt mouth prop. Care
should be taken not to impinge on the lips or tongue with the prop. The mouth is
thoroughly aspirated. The pharyngoplasties’ area is sealed off with a strip of moist 3-
inch sterile gauze approximately 12–18 inches long. Written documentation of throat
pack placement and removal is required on the physical history form of the medical
chart. This packing reduces the escape of anesthetic agents and prevents any material
from entering the pharynx. The gauze should be tightly packed around the tube so that
a good seal is ensured. Once the pack is in place, a thorough intraoral examination is
performed, followed by dental prophylaxis. The dentist should then evaluate any new
radiographic studies that have been obtained and formulate a final treatment plan
(Jeffry2011).

[Link] Dentistry in the Operating Room

Instruments used for restorative dental procedures in the operating room are the
same as those used for procedures in the dental operatory. Local anesthesia may be
used to minimize pain and bleeding. The use of local anesthesia can decrease the
anesthetic requirements or need for postoperative opiate analgesia and thus decrease
postoperative side effects such as nausea(jeffry,2011).
According to Spiro and Burns (1980) found that they were able to treat seven teeth
per hour in children under general anesthesia compared with only three teeth per hour
in children of similar age in a clinic setting.
The use of quadrant isolation with a rubber dam is preferred. After the completion
of all dental procedures, a topical fluoride varnish should be applied before the throat

17
pack is removed. Documentation of dental procedures, extracted teeth, sutures, blood
loss, and hydration in the medical chart is required(jeffry,2011).
Eidelman et al., (2000) reported that the quality of restorative treatment per-
formed was better under general anesthesia than under conscious sedation.
Restorative dental care under general anesthesia allows for excellent patient
compliance and the easy achievement of a well-lighted field, and therefore increases
the quality and quantity of dental care while decreasing the anxiety level for the
clinician and patient during dental treatment(jeffry,2011).
The dentist should place restorations that will provide the greatest longevity with
the least amount of maintenance, for example, full-coverage stainless-steel crowns
rather than large amalgam restorations on posterior primary teeth. In a 3-year study of
comprehensive dental cases treated under general anesthesia (Eidelman et al.,2000).
Stainless-steel crowns to be significantly more successful (3% failure rate) than
amalgam composite restorations 29% failure rate (O’Sullivan and Curzon,1991).
A 6-month retrospective study by Tate et al. (2002), to assess the failure rates of
dental restorative procedures performed under general anesthesia by pediatric dental
residents found stainless-steel crowns to be best (8%), followed by amalgam (21%)
and composite (30%); composite strip crowns (51%) had the lowest successful
restorative treatment rate.
In a 6- to 27-month postoperative period following general anesthesia. Al-Eheideb
and Herman (2003), reported similar values, with stainless-steel crowns (95.5%) being
more successful than amalgams or composite restorations (50%). Pulpotomies had an
extremely high success rate (97.1%), whereas sealants were retained only 68.3% of the
time. In a 30-month longevity study of over 1000 composite restorations completed in
the operating room.
Bücher et al. (2013), noted a high success rate (81.5%). In another study of
composite strip crowns, Kupietzky et al. (2003), found them to be aesthetic and
durable, with an 88% overall retention rate after 6 months.

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 In the sample of pediatric dental patients treated under general anesthesia in a
postgraduate dental hospital in Dubai Mohammad (2016) concluded the following:
1- Pre-formed Stainless-Steel Crown were the predominant modality of restorative
treatment over composite restorations and zirconia crowns.
2-ECC and pre-cooperative stage were the main reasons leading to Dental General
Anesthesia.
3-Comprehensive treatment plans, which consisted mainly of dental extractions and
fewer pulp therapies, were found to have been conducted in those Special Health Care
Needs children, accompanied by a notable increase in preventive interventions when
compared to healthy patients.
4-Different treatment approaches were observed between Special Health Care Needs
and healthy children.
5-A major finding was that many children were not brought-in following dental general
anesthesia and had frequently missed recall appointments. This increased the
likelihood of developing new carious lesions and consequently increased the need for
further dental treatment.
[Link] of the Procedure
The anesthesiologist should be notified 10 minutes before the completion of the
procedure so that the child can begin to be aroused and preparations can be extubation.
The recovery room personnel are notified that the child will soon be arriving so that
they can begin preparations. On completion of the dental procedure, the oral cavity is
thoroughly debrided, and the throat pack is removed carefully to prevent aspiration of
any materials that might be lodged against it. The “end time-out protocol” is called by
the circulating nurse to identify any patient safety concerns. The dentist verbalizes a
needle and sponge count and removal of the throat pack to the nurse. The
anesthesiologist then brings the patient through emergence, and the trachea is
extubated. The dentist should remain in the operating room during the extubation
process to assist the anesthesiologist if necessary. When the child is transported to the

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recovery room, the dentist should accompany the anesthesiologist and provide
assistance during transportation (Jeffry,2011).

Conclusion
The dental treatment under GA for children is one of solutions for certain cases. It
Requires special Privileges for hospital stuff. It requires postoperative care and follow
up.

20
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