In-Office Anesthesia for Pediatric Dentistry
John A. Yagiela, DDS, PhD
Christine L. Quinn, DDS, MS
Advances in anesthesia techniques have made it possible to provide safe, reliable, and economical anesthesia services for children in the dental office. The following is a description of patients who might benefit from sedation or anesthesia, the types of anesthetic services provided in the dental office, the risks and costs of such services, and important instructions for the parent.
Children below the age of 5 are often unable to cooperate with needed dental care, especially if the treatment is extensive and time consuming. Children with previous bad experiences in the dental office or who have become frightened by scary stories told by siblings or other individuals also have difficulty receiving necessary care. A third group providing a distinct challenge to the dentist includes children with special medical or behavioral needs. In years past, options for treating such patients were limited. The child could be placed in a hospital and receive general anesthesia—an expensive, inconvenient, and time-consuming option. Alternatively, the patient could be treated by the dentist using physical restraints or sedative drugs to control behavior. Limitations to this approach include compromises in dental care, patient comfort, and either the effectiveness or safety of the sedation. Lastly, for the very young, treatment could be deferred until the patient is old enough to tolerate regular care. Problems with this approach include increased cavities and pain, and heightened risk of infection, premature loss of teeth, and malocclusion. In-office anesthesia provided by an independent dentist anesthesiologist offers a highly effective and safe solution to the child, parent, and dentist.
The dentist anesthesiologist is fully trained in outpatient anesthesia for the dental patient. He or she will evaluate the needs of the child—medical, dental, and psychological—and determine the most appropriate type of anesthesia service to provide. The dentist anesthesiologist will provide the necessary preoperative evaluation, intraoperative management, and postoperative care for the safe and effective treatment of the child. Additional responsibilities include ensuring that all necessary drugs, supplies, equipment, and facilities are immediately available and that the patient is continuously monitored throughout the case. The range of in-office anesthesia services available include specialized local anesthetic techniques, conscious sedation (in which the patient is relaxed but responsive to verbal command), deep sedation (in which the patient may not be responsive to verbal command), and light general anesthesia. Intubation general anesthesia can also be performed but requires additional drugs, supplies, and equipment.
The safety record of in-office anesthesia administered by an independent dentist anesthesiologist is unsurpassed by any other system of anesthesia delivery. Nevertheless, there are some potential complications that need mentioning. Nausea and vomiting, though uncommon with the forms of anesthesia delivered in the dental office, can occur. Generally, vomiting is most likely after the child wakes up and begins to move about. Venous irritation from the insertion of the intravenous catheter or from the drugs administered is another unlikely and minor potential complication. Because children vary in their response to medications, recovery may be delayed, especially after prolonged procedures. Laryngospasm, a condition in which the vocal cords close in response to a stimulus such as liquid dripping into the back of the throat, occasionally occurs and requires for its treatment suctioning of the mouth, delivery of oxygen under gentle pressure, and rarely the administration of a muscle relaxant. Respiratory depression, a possible side effect of all sedative agents, is easily managed by ensuring a patent airway and providing ventilation assistance. Allergic reactions, extremely rare with the drugs used in anesthesia for dentistry, are managed by the use of emergency drugs to reverse the signs and symptoms of the reaction. A final complication of anesthesia care in the child is urination during or after a prolonged procedure. A diaper or training pants is especially helpful in the young child, and bringing a change of clothes is advisable for all pediatric patients. A blanket is also useful in helping to ensure the patient is comfortable during and after treatment.
The following pre- and postoperative instructions are general in nature and may be modified by the dentist anesthesiologist to meet specific needs.
- Fasting: No solid food or milk for 8 hours before anesthesia. Children who are breast feeding may do so up to 4 hours before treatment. No clear liquids (e.g., water, apple juice) for 2 hours before anesthesia. Clear jello and popsicles are considered clear liquids.
- Medications: Take medications with a small sip of water.
- Clothing: The child should wear a short-sleeved shirt or blouse and nonrestrictive clothing. Small children should have on a diaper or training pants.
- Parents: A parent or guardian should be with the child and be able to give the child undivided attention (e.g., no small siblings with a single parent).
- Feeding: A clear liquid should be first offered to the child in small volumes. Soft foods (jello, ice cream, warm but not hot soup) may then be tried. Chewing should be avoided until all local anesthesia has dissipated.
- Temperature: A small elevation in temperature (under 101 °F) may occur the first day after anesthesia. It may be treated with children’s pain reliever. Avoid overdressing the child, especially on a warm day. If the child appears flushed, wet the skin with cool water.
- Sleeping: It is normal for a child to be sleepy after anesthesia. The child should be placed on a firm mattress without a large pillow.
- Call the dentist or dentist anesthesiologist if there is persistent vomiting (beyond 4 hours), if the temperature rises above 101 °F, or if there is any other concern.
UCLA Dental Anesthesia Service
Drs. John A. Yagiela and Christine L. Quinn are full-time faculty members of the UCLA School of Dentistry who provide in-office anesthesia services as a part of their faculty responsibilities. They are often accompanied by their second-year anesthesia resident to provide team care for the patient.
Dr. Yagiela received his DDS degree in 1971 from the UCLA School of Dentistry and his PhD in pharmacology in 1975 from the University of Utah. He received his anesthesia training at the UCLA Center for the Health Sciences and has a joint appointment as Professor of Anesthesiology in the School of Medicine, in addition to his primary appointment as Professor and Coordinator of Anesthesia and Pain Control at the School of Dentistry and Chair of the Division of Diagnostic and Surgical Sciences. A Diplomate of the American Dental Board of Anesthesiology, Dr. Yagiela has been providing in-office anesthesia services since 1984.
Dr. Quinn graduated with the DDS degree from the USC School of Dentistry in 1987 and obtained her MS degree and certificate in dental anesthesia in 1989 from The Ohio State University College of Dentistry. She is a Clinical Professor of Anesthesia in the School of Dentistry. A Diplomate of the American Dental Board of Anesthesiology, Dr. Quinn spends half her time in teaching and patient-care activities at UCLA and the remainder in delivering out-patient anesthesia services in dental offices.
(reprinted with permission)