General Anaesthesia (GA)

Dental treatment under general anaesthesia is a great solution for children with specific physical and psychological health requirements. Children requiring complex dental treatment and kids who are uncontrollable with sedation must be treated using general anaesthesia. With treatment using general anaesthesia no patient cooperation is necessary. This article is about dental treatment under general anaesthesia for children. For adult’s dental treatment under general anaesthesia including wisdom teeth extraction under GA see Pure Dentistry.

Regarding treatments specific to children, the following dental procedures can be undertaken while the child is under general anesthesia:

• Radiographs
• Examinations 
• Fissure sealants 
• Scale and Clean
• Fluoride Therapy
• Fillings
• Nerve and Pulp Treatment
• Stainless Steel Crown for Children
• Kids Composite Crowns
• Zirconia Crowns
• Space Maintainer
• Tooth Extractions

While treatment under GA is the most expensive form of dental treatment (as the cost of the hospital and an anaesthetist is also added to the cost of dentistry), the demand for this form of treatment is quite high because in some cases, treatment using GA is the most practical and effective treatment method for young children who require extensive dental treatment.

These days many young children are benefiting from the delivery of extensive dental care in a single GA session.

For some children, dental treatment under general anaesthesia is necessary. Dentistry using GA is the management technique of choice for the following patients:

• Children with disability or special needs
• Children for whom local anaesthesia cannot be used
• Extremely uncooperative children
• Very young and  uncooperative children requiring extensive dental treatment
• Children who require significant surgical procedures
• Children with extensive dental trauma 

GA is not the treatment of choice for children with minimal dental needs and when the child is a healthy and cooperative patient.

Dental treatment using general anaesthesia is not permitted when there is a medical contraindication to GA.

GA provides a safe and efficient method for the dental care of children who are unable to cooperate because of certain physical or mental conditions.

Kids requiring dental treatment under GA often have coexisting medical diagnosis. These conditions could be medical or psychological. 

Cerebral Palsy, severe Autism and ADHD, brain injuries are a few examples. Children with severe Autism do not usually fit in the so-called “normalised” dental service. When forced, they may show inappropriate behaviour, they may show uncontrolled movement or aggression during dental treatment. 

When a concern about a medical condition exists, an anaesthetic  consult is recommended. Dental Care using GA when Local Anaesthesia can’t be used

For some children local anaesthesia may not work. The child may require dental restoration or surgical procedure but local anaesthesia may be ineffective when there is an acute infection, anatomic variations or when the child is allergic to local anaesthesia.

For various reasons, a child may become extremely uncooperative, anxious, fearful or physically resistant during dental treatment. Dentistry under GA in such cases is appropriate when there is no expectation that the behaviour of the child will soon improve.

Usually the younger the child, the higher is the likelihood of the need for dental treatment under GA. The decision as to whether a child should be treated under GA depends on a combination of factors. The most important factors include:

• The age of the child
• The degree of the surgical trauma involved
• The level of perceived anxiety
• The history of the child responding to similar surgeries
• The complexity of the procedure
• The medical requirements of the child associated with anaesthesia
• The number of quadrants involved

Each child has to be assessed individually by the dentist because there are no fast rules. 

Other factors that are involved in the decision making process include:

• Allergies
• Physical status and developmental status
• Medications (current and previous medications)
• Specific surgical requirements
• Weight of the child
• Airway patency
• Psychological status of the child

GA is used only when other management techniques have failed or are not practical and inappropriate. This means that dental extraction under GA is employed only if it is an appropriate strategy. If the dentist determines that dental treatment under GA is appropriate, then a referral is required to the local GA service provider. Then additional dental and medical assessment will be carried out by the care providers.

In your consultation appointment, our dentist conducts a preoperative assessment of the teeth and the child. They also provide parents with information and parents sign an informed consent. It is recommended to discuss with one parent at the consultation appointment and also discuss with the other parent who is present on the treatment day.

The dentist provides a dental treatment plan. Treatment planning is necessary and helps with reducing the need for a repeat procedure during sedation. Where GA is employed for dental treatment in children, the emphasis should be on the procedure quality and outcome. Each procedure will be carefully planned by the dentist with consideration to the medical conditions that may be present in the mouth.

The dentist or the hospital will provide parents with fasting guidelines. Fasting instructions shall be followed. These instructions lead to the least distress for the child. Accepted practice for fasting before general anaesthesia is:

• 6 hours of fasting from solids and milk
• 4 hours from breast milk
• 2 hours from clear fluids

Each GA provide has different protocols. Always follow the fasting guidelines provided by your GA provider.

On the treatment day, the anaesthetist assesses the child to confirm the child’s fitness for the procedure. The dentist also discusses the treatment plan with the parents and assesses the child. The team checks the equipment and instruments to ensure equipment is operational prior to the dental procedures under general anaesthesia begins.

To minimize the child’s anxiety, a parent is allowed to stay with the child during induction. Induction may be intravenous or gaseous.The anaesthetist will decide which option is best for each child. Following the induction phase parents will be asked to leave the theater until the end of the procedure. They may prefer to stay in the hospital or go home until they are called at the end of the procedure.

Allowing the child to be with parents during induction can reduce the anxiety both in children and parents.  A child could become upset when in an unfamiliar environment. Treatment under general anaesthesia should be conducted in a comfortable atmosphere.

Parents of the children who require general anesthesia usually experience more stress than the child undergoing the GA. Sometimes providing a tour of the operation room prior to surgery can reduce the stress in parents. Also providing parents with the status of the child and letting them know that everything is alright can help reduce the stress. Children are great in sensing apprehension in their parents. Therefore, limiting the anxiety of parents can have a positive effect on the anxiety level in the children as well.

Following points can reduce the stress level in children:

• Involving the child in the tour of the facility
• Allowing the child to bring along a favorite toy, blanket, etc
• Providing preinduction sedation
• Providing a child-friendly environment
• Providing postprocedure sedation as required
• Allowing the child and parents to rejoin as early as possible

According to Cameron handbook of paediatric dentistry, morbidity in children arising from general anaesthesia is quite low and it can be estimated to be lower than 1:150,000. Dental treatment under GA requires experience and a lot of knowledge and skills to avoid treatment failure or repeat GA. Therefore, GA treatment for children should only be carried out by experienced kids dentists. Your dentist considers many factors when deciding to place a child under general anesthesia.

Before general anaesthesia, a review of the child’s medical history and examination by the anaesthetist is required. For children with complex medical requirements, a separate preoperative anaesthetic assessment may be required prior to the day of the surgery.

Your anaesthetist needs to be aware of:

• Any behavioural issues including autism, developmental delay
• Extreme anxiety or needle phobia
• Syndromes e.g. velocardiofacial or Down syndrome
• Cardiac disease or heart murmur
• Previous surgeries
• Any congenital defects e.g. cleft palate
• Any respiratory disease or airway problems e.g asthma, history of croup, micrognathia
• Sleep apnoea, known history of intubation difficulties, previous tracheostomy
• Neurological disease including epilepsy, or previous brain injuries, cerebral palsy
• Endocrine and metabolic disorders including diabetes or genetic metabolic disorders
• Any gastrointestinal issues including reflux, difficulty in feeding or swallowing
• Haematological e.g. haemophilia,haemoglobinopathies, thrombocytopenia
• Any Neuromuscular disorders, e.g. muscular dystrophy.

All medication will be documented and also all allergies e.g. allergy to latex.

Once the procedure is complete and the child is awake and in stable condition, parents should join the child in the recovery area. This helps reduce the anxiety for the child and parents. The dentist will discuss the outcome of the treatment on the same day and a post-GA follow-up appointment is arranged with the parents.