Anesthesia for Pediatric Dentistry Chapter

Andrew Herlich, Brian P. Martin, Lisa Vecchione, and Franklyn P. Cladis

CONTENTS
Human Dentition  1023
l Dental Development  1023
l Dental Identification  1025
l Dental Anatomy and Physiology  1025
32
Dentist’s Needs and Techniques  1030
l Clinical Settings for Pediatric Dentists  1031
Sedation and Anesthesia for Dental Procedures  1033
l Procedural Sedation  1033

Dental Pathophysiology  1027 l General Anesthesia  1034

l Orthodontic Pathology  1028 Postoperative Problems  1037
l Facial Cellulitis  1030 l Dental Complications of Anesthesia  1038

Patient Spectrum  1030 Summary  1040

I n light of the advances in health care, dental disease is

still among the most prevalent of diseases, accord-
ing to the Centers for Disease Control and Prevention (CDC).
Although dental caries (tooth decay) is largely preventable, it
remains the most common chronic disease of children aged
6 to 11 years, and of adolescents aged 12 to 19 years. Tooth
decay is more common than many other common chronic dis-
eases of childhood including asthma. It is four times more com-
mon than asthma among adolescents aged 14 to 17 years (CDC
Division of Oral Health). Maternal nutritional and behavioral
influences are very strong factors that propagate transmission
of caries from the mother to her infant (American Academy of
Pediatrics, 2003). The impact of caries is pervasive; poor nutri-
tion may cause them or be the result of them. However, fluori-
dation of community water supplies, use of children’s vitamins
containing fluoride, and increased awareness of dental hygiene
have produced a significant reduction in dental caries in the
general population.
Despite advances in preventive dentistry, some conditions
still require more than local anesthesia to facilitate dental
treatment. General anesthesia may be required to treat chil-
dren with severe systemic disease or disabling congenital
anomalies, as well as infants and toddlers with milk-bottle car-
ies who require partial or complete oral rehabilitation. General
anesthesia may also be required for children and adolescents
with severe developmental delay who require a safe and effec-
tive environment to render the necessary dental treatment. In
addition, the fearful or combative child may require procedural
sedation when behavior modification techniques have not suc-
ceeded. Proper care for these populations necessitates a care
team approach, consisting of properly trained anesthesia and
dental providers. A glossary of commonly used dental terms is
shown in Table 32-1.
HUMAN DENTITION
Dental Development
Initial calcification of the primary tooth buds may be seen in the
fourth month of prenatal life. In general, by the end of the sixth
prenatal month, all of the primary teeth have begun to develop.
The newborn infant is edentulous, with the rare exception of a
mandibular central incisor. This natal or neonatal tooth tends
to be quite mobile, and in the past it was thought to require
immediate extraction. Recent data suggest that by the end of
the neonatal period, this mobile tooth becomes quite stable and
capable of normal masticatory function. This is indeed fortu-
nate for the infant, because these neonatal teeth are frequently
the only primary teeth that develop in that position (King and
Lee, 1989; Cunha et al., 2001).
The sequence of eruption of human teeth may critically
affect infant feeding, behavioral, and masticatory skills. Major
changes in the appearance of the dentition in the oral cavity
probably alter important aspects of neurobehavioral develop-
ment (Wright, 2000). As an example of eruption sequence alter-
ations, premature infants and neonates requiring prolonged
orotracheal intubation have significant defects in both oral and
dental structures that may persist past age 5 years, even after
removal of the orotracheal tube (Fadavi et al., 1992).
The order of appearance of the teeth in the oral cavity tends to
follow generalized patterns (Table 32-2). Usually the teeth erupt
in pairs. A mandibular right central incisor erupts at approxi-
mately the same time as the mandibular left central incisor, at
approximately 6 to 7 months of age. The mandibular teeth usu-
ally precede their maxillary counterparts; the maxillary incisors
erupt approximately 1 month later than the mandi­bular inci-
sors. The eruption sequence continues and is usually complete

1023
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TABLE 32-1. Glossary of Common Dental Terms TABLE 32–2. Eruption Sequence of the Human Dentition

Proper Name Common Name or Definition Approximate Age Approximate Age

Eruption Begins Eruption Is Completed
Abutment Tooth or teeth on either side of an
edentulous area supporting a bridge Primary Dentition
Amalgam Silver-coated restoration Maxillary
Bicuspid Premolar tooth (older term) Central incisor 7½ mo 1½ yr
Bitewing Dental radiograph that views several Lateral incisor 9 mo 2 yr
adjacent maxillary and mandibular teeth
simultaneously; especially useful in Cuspid 18 mo 3¼ yr
evaluating dental caries First molar 14 mo 2½ yr
Bruxism Involuntary tooth grinding Second molar 24 mo 3 yr
Burr Drill bit used to prepare a tooth for caries Mandibular
restoration
Central incisor 6 mo 1½ yr
Caries Dental cavity or cavities
Lateral incisor 7 mo 1½ yr
Composite Tooth-colored restoration
Cuspid 16 mo 3¼ yr
Crown Portion of the tooth seen in the mouth above
the gum line; also, term used for the dental First molar 12 mo 2¼ yr
restoration of the same anatomic region;
Second molar 20 mo 3 yr
popularly known as a cap
Cuspid Canine tooth (older term) Permanent Dentition

Diastemata Separations between the teeth; commonly Maxillary

seen between the maxillary central Central incisor 7–8 yr 10 yr
incisors
Lateral incisor 8–9 yr 11 yr
Dry socket Nonhealing extraction site
Cuspid 11–12 yr 13–15 yr
Endodontic therapy Root canal therapy
First bicuspid 10–11 yr 12–13 yr
Exfoliation Spontaneous loss of a tooth
Second bicuspid 10–12 yr 12–14 yr
Exodontia Dental extraction
First molar 6–7 yr 9–10 yr
Eye tooth Canine tooth (familiar term)
Second molar 12–13 yr 14–16 yr
Gingivitis Inflammation of superficial aspects of the
peridontium Mandibular
Handpiece Dental drill Central incisor 6–7 yr 9 yr
Ludwig’s angina Dental infection of the floor of the mouth Lateral incisor 7–8 yr 10 yr
involving the submandibular, submaxillary, Cuspid 9–10 yr 12–14 yr
and submental spaces bilaterally
First bicuspid 10–12 yr 12–13 yr
Milk tooth Primary or baby tooth
Second bicuspid 11–12 yr 13–14 yr
Occlusion Patient’s “bite”
First molar 6–7 yr 9–10 yr
Oral prophylaxis Dental cleaning
Second molar 11–13 yr 14–15 yr
Overbite Degree of vertical overlap of the maxillary
teeth over the mandibular teeth From Schour I, Massler M: The development of the human dentition, JADA
Overjet Degree of horizontal projection of the 28:1153, 1941. Reprinted by permission of ADA Publishing.
maxillary teeth beyond the mandibular
teeth
Periapical Area surrounding the apex of the root; a
periapical dental radiograph also includes
the clinical crown of the tooth by age 2 to 2½ years. The last tooth to erupt is the deciduous
Periodontium Soft and hard tissues surrounding and second molar, called the 2-year molar because of its appearance
supporting teeth at age 2 years.
Pulpotomy Therapeutic removal of the coronal portion
When completed, the primary dentition totals 20 teeth
of the dental pulp (Wright, 2000). As the toddler’s growth continues, the man-
dible and maxilla enlarge, causing separations, also known as
Pyorrhea Common name for periodontal
inflammation, or gum disease; except for diastemata, between the primary teeth (Zwemer, 1993). The
gingivitis, periodontal disease is rare in diastemata increase as the primary teeth are beginning to exfo-
children liate and the permanent or succedaneous teeth begin to erupt.
Rubber dam Square latex or vinyl sheet used to isolate The separations also permit sufficient room for the proper
the teeth from the oral cavity during dental alignment of the permanent dentition.
treatments The maintenance of the health and hygiene of the pri-
mary teeth is essential to avoid premature tooth loss. When

primary teeth are prematurely lost as a result of decay or
trauma, the space needed for the permanent tooth erup-
tion is also lost because the natural tendency of the tooth
is to tip mesially (toward the midline) in the oral cavity.
Subsequently, dental malocclusions tend to occur. Finally,
the primary teeth may also function as the permanent teeth
if the permanent analogous tooth fails to develop (Wright,
2000).
The transition period between exfoliation of the primary
teeth and eruption of the permanent teeth is called the mixed-
dentition phase. This phase continues until the last primary
tooth is normally exfoliated or extracted. Unlike the primary
teeth, the permanent teeth normally erupt so that there is
tooth-to-tooth contact.
Development of the secondary, or permanent, dentition
begins at birth with calcification of the buds of the permanent
first molars. The permanent dentition begins its eruption pat-
tern with the permanent first molar, usually at approximately
6 years of age. Like their primary counterparts, the mandibular
teeth usually precede the maxillary teeth, with the permanent
mandibular incisors beginning to appear at approximately age
6 to 7 years. Unlike the primary dentition, where there is usu-
ally a variability of several months in the timing of eruption, the
permanent teeth may vary as much as 1 to 2 years in eruption
sequence. After eruption of the permanent first molars, eruption
of the remaining permanent teeth then occurs in this sequence:
mandibular central incisors, maxillary central ­incisors, man-
dibular lateral incisors, maxillary lateral incisors, mandibular
cuspids, maxillary and mandibular first premolars, maxillary
and mandibular second premolars, maxillary cuspids, and man-
dibular and maxillary second molars (see Table 32-2). At the
completion of the eruption sequence, the permanent dentition
consists of 32 teeth (Wright, 2000).
The third molars, commonly known as wisdom teeth, have
the least predictable eruption sequence of any of the human
dentition. They may erupt as early as age 15 to 16 years, as late
as age 25 years, or not at all. Quite commonly, the third molars
fail to erupt because of dental germinal pattern alterations or
impactions in the soft or hard tissues. Impactions usually occur
because of insufficient bony growth of the maxilla or mandible
in proportion to the individual’s full dental complement.
In addition to the frequently absent third molars, two other
permanent tooth forms are sometimes congenitally absent. The
mandibular premolars and the maxillary lateral incisors may be
congenitally absent, either singly or in symmetric pairs (Neville
et al., 2002). Occasionally, a tooth that is thought to be congeni-
tally absent is actually impacted in the soft tissues or alveolar
bone.
Just as there are congenitally absent teeth, there are super-
numerary or accessory teeth. The most common supernumer-
ary tooth is the mesiodens, a conically shaped tooth consistently
located in the midline between the maxillary central incisors.
Other supernumerary teeth are the third premolars and fourth
maxillary molars (Neville et al., 2002).
Identification of mobile primary versus transitional, or
mixed, dentition can be of importance to anesthesia personnel.
It is often recommended that mobile primary teeth be removed
prior to airway instrumentation, as they may be at risk for dis-
lodgment and airway obstruction. Likewise, it is important to
note that newly erupted permanent teeth are often slightly
mobile, with incomplete root formation. For this reason,
extra care should be taken during laryngoscopy, oral airway
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1025
p­ lacement, or other jaw manipulation, as immature permanent
teeth may be predisposed to luxation or avulsion trauma if too
great a force is placed on them.
Dental Identification
There are two principal universal dental identification systems.
In both systems, the primary teeth are designated by letters,
and the permanent teeth are designated by numbers. These
systems differ in the way that the dental arches (mandible and
maxilla) are divided. The first system uses a sequential means
for identification, with the primary maxillary right second
molar designated as tooth A and followed sequentially around
the contralateral side of the maxilla to the left second molar,
which is tooth J. The primary mandibular left second molar is
tooth K, and the sequence is completed on reaching the man-
dibular right second molar, tooth T. Similarly, the numbering
system for the permanent dentition starts with the maxillary
right third molar as tooth 1 and continues to the maxillary left
third molar, tooth 16. The sequence continues with the man-
dibular left third molar, tooth 17, and is completed with the
mandibular right third molar, tooth 32 (Herlich, 1990). Both
pediatric and general dentists commonly use this system of
tooth identification.
The second designation system divides the dental arch into
quadrants. All primary central incisors are tooth A and follow
distally or posteriorly, so that all primary second molars are
tooth E. To make the designation more specific, the quadrant
is also named. For example, the primary maxillary right lateral
incisor is designated maxillary right B. Similarly, the perma-
nent dentition is divided into quadrants. All central incisors are
tooth 1 and continue posteriorly, so that all third molars are
tooth 8. This system is most commonly used by orthodontists
(Fig. 32-1).
Dental Anatomy and Physiology
The tooth is composed of a crown, which is usually visible for
clinical examination, and a root, which is not seen during rou-
tine clinical examination. They are separated by the cemento­
enamel junction or cervical region of the tooth (Fig. 32-2). The
cementoenamel junctions are seen more commonly in adult
dentition if gingival (“gum”) recession occurs. The crown is
responsible for the slicing, ripping, and grinding of foodstuffs
(incisors, canines, and molars, respectively). The root structure
imparts stability to the tooth in its surrounding tissues. The
anterior teeth, the incisors and the canines, are single rooted
with a conical shape. The posterior teeth, the premolars and
molars, are multirooted and impart most of their stability by
both the number of roots and the subtly divergent directions in
which the roots may grow.
Surrounding the root structure of the tooth is the periodon-
tium, which is composed of three structures as follows:
l The most external portion is a combination of the gingival
and alveolar mucosa, which constitute the soft tissue cover-
ing for the remainder of the periodontal structures.
l The periodontal ligament attaches the external surface of
the root to the alveolar bone, acting as a shock absorber and
anchor during masticatory function.
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MAXILLARY
Central incisor (first incisor)
Lateral incisor (second incisor)
Canine (cuspid)
First molar
Second molar
RIGHT

LEFT

Second molar
First molar
Canine
Lateral incisor (second incisor)
MANDIBULAR Central incisor (first incisor)
MAXILLARY

Central incisor (first incisor)

Lateral incisor (second incisor)
Canine (cuspid)
First premolar (first bicuspid)
Second premolar (second bicuspid)
First molar
Second molar
Third molar
RIGHT

LEFT

Third molar
Second molar
First molar
Second premolar (bicuspid)
First premolar (bicuspid)
Canine (cuspid)
Lateral incisor (second incisor)
Central incisor (first incisor)
B MANDIBULAR
n  FIGURE 32-1. A, Tooth identification and sequence. B, Cast models of the primary dentition (upper) and permanent dentition (lower).
(A, From Herlich A: Dental complications of anesthesia, Prog Anesthesiol 11:250, 1990. B, From Ash MM Jr, editor: Wheeler’s dental anatomy,
physiology, and occlusion, ed 7, Philadelphia, 1993, Saunders, p 2.)

Maxillary sinus
Alveolar bone
Periodontal
ligament
Cementum
Root
Root canal
Pulp chamber
Dentin
Enamel
Buccal Palatal Mesial
l The bony component is called the alveolar bone or tooth
socket. Beneath the alveolar bone rests the supporting basal
or skeletal bone. Basal bone, the part seen in edentulous
patients, forms the skeletal support for full or partial den-
tures. When the tooth structure is lost, alveolar bone is also
lost and is not naturally regenerated.
The individual teeth are composed of enamel, dentin, dental
pulp, and cementum (Wright, 2000) (see Fig. 32-2). The enamel
covers the external surface of the dental crown. It is the hardest
substance in the human body and, unlike bone, has no living
cells. When intact, enamel functions as a thermal insulator and
an impervious barrier to chemicals and microorganisms.
On the internal surface of the enamel lies the dentin. It is
composed of microtubules and has living cells in the dentinal
structure. When tooth decay is advanced, noxious stimuli are
readily transmitted via the dentinal tubules to the underlying
dental pulp. The neurovascular supply of the individual teeth is
contained in the dental pulp. Pain is easily elicited by many dif-
ferent stimuli—thermal, tactile, or liquid. The pain is transmit-
ted from the dental pulp through the root apices to the alveolar
bone and subsequently to the body’s pain receptors.
The final portion of the tooth structure is the dental cemen-
tum, which covers the external surface of the roots. Because
it is not nearly as hard and impervious to the surroundings
as is enamel, noxious stimuli are perceived when the cemen-
tum is exposed. The cementum is similar to the dentin of the
tooth. Patients who enjoy good dental health usually do not
have exposed cementum. However, with gingival and alveolar
recession, root structure and its investing cementum may be
exposed to the external environment.
Some morphologic differences exist between deciduous and
succedaneous teeth. The most obvious difference exists in the
size of the teeth in general. The deciduous teeth are signifi-
cantly smaller than their permanent counterparts. With respect
to the molars, the buccal-lingual dimensions are proportion-
ately narrower. In contrast, the mesial-distal dimensions are
proportionately larger.
Another difference between the sets of dentition rests in the
color of the enamel. The primary teeth are milky white, or opal-
escent; hence, the name milk teeth. The permanent teeth, on
the other hand, are significantly less “milky” because pigment
absorption has occurred during their development or has been
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1027
n  FIGURE 32-2. Schematic (left) and
radiographic (right) views of a right
maxillary molar. (Modified with permission
from Ash MM Jr, editor: Wheeler’s dental
anatomy, physiology, and occlusion, ed 7,
Philadelphia, 1993, Saunders, p 6.)
Distal
acquired during the intraoral lifetime of the tooth (Wright,
2000). Two examples are tetracycline staining (developmental)
and caffeine staining (acquired).
The pulp chambers of the primary teeth are larger than the
permanent teeth because of the relative thinness of the decidu-
ous enamel and dentin (Wright, 2000). Less than meticulous
dental restorations or large carious lesions may predispose the
primary teeth to pulpal or endodontic therapy earlier than their
permanent counterparts.
The root structures of the primary molars are more saber
shaped and extend laterally beyond the crown width. This
unique root structure allows adequate room for the permanent
tooth bud to develop and mature until the exfoliative process is
completed for the primary tooth (Wright, 2000).
DENTAL PATHOPHYSIOLOGY
Despite declines in the overall caries rate of the general pop-
ulation, dental caries remains a common chronic disease of
childhood. The high incidence is related to several risk factors,
including consumption of fermentable carbohydrates (sugar-
containing beverages), lack of adequate oral hygiene practices
and fluoride exposure, and socioeconomic status. Early child-
hood caries specifically refers to severe caries involving mul-
tiple teeth in the preschool age group.
In the presence of fermentable carbohydrate, the metabolic
by-products of microorganisms (particularly Streptococcus
mutans) result in the acidic demineralization of enamel of the
teeth. If the body’s capacity for remineralization of the affected
tooth is is overwhelmed, a microscopic cavity will form in the
surface of the enamel. Topical fluoride exposure in toothpaste
is an important resource for remineralization of these initial
lesions. If remineralization capacity is inadequate, the cari-
ous lesion will progress through the enamel into the dentin,
or the inner layer of tooth structure. Further progression will
involve the neurovascular bundle or pulp in the tooth. Bacterial
contamination of the pulp will result in pulpal inflammation
(toothache) or outright necrosis. An acute or chronic dental
abscess may then develop. Localized signs of dental abscess
include gingival edema, and pain during mastication or palpa-
tion. Treatment of dental abscess is accomplished with either
endodontic therapy (root canal) or extraction of the tooth.
1028   P a r t  III    Clinical Management of Specialized Surgical Problems
Class I Class II
Treatment of dental caries is surgical. Using a burr, the car-
ious portion of the tooth structure is removed. The tooth is
then restored to form and function using an appropriate dental
restorative material, such as amalgam (traditional silver filling
material), composite resin (mixture of plastic and silicate par-
ticles), or stainless steel (for crowns).
Orthodontic Pathology
Teeth erupt into the alveolar processes of the maxilla and man-
dible and are held into bone by the periodontal membrane and
gingival fibers. Together, the teeth and the jaws provide struc-
ture to the lower third of the face. In a normal bite, the maxilla
and maxillary teeth are larger, which allows the maxillary arch
to overlap the mandibular arch. Occlusion describes how max-
illary and mandibular teeth fit together during chewing or at
rest.
Malocclusion is the improper alignment of the teeth and jaws
or bad bite. A skeletal malocclusion describes a malalignment
between the jaws. A dental malocclusion describes the inter-
arch relationship between the upper and lower teeth. A maloc-
clusion may be caused by both hereditary and environmental
factors. Crowding, spacing, supernumerary teeth, hypo­dontia,
and asymmetric jaw growth are determined mostly by inheri-
tance. Environmental factors such as thumb sucking, dental
caries, premature loss of primary teeth, and trauma also can
contribute to malocclusion (Mossey, 1999). An untreated mal-
occlusion can lead to tooth decay, periodontal disease, abnor-
mal wear of teeth, difficulty in chewing and speaking, and poor
self-image.
Edward H. Angle, who is regarded as the father of ortho-
dontics, developed a classification system for malocclusion
based on the sagittal (anteroposterior) relationship of the
teeth and jaws (Angle, 1899). Angle believed the upper first
molars were critical to occlusion, and that the upper and
lower molars should meet so that the mesiobuccal cusp of
the upper molar contacts in the buccal groove of the lower
molar. If this molar relationship existed and the teeth were
arranged on a smoothly curving line of occlusion, then
n  FIGURE 32-3. Angle classification system for
malocclusion.
Class III
­ ormal occlusion would result (Fig. 32-3). Angle’s classifica-
n
tion system is as follows:
Class I: Malocclusion, in which jaws are aligned well, but
teeth are crowded, rotated, or missing.
Class II: Overbite, in which the maxilla may be too large and
protrude, or the lower jaw may be too small and retruded.
The maxillary molar is anterior to the mandibular molar.
Class III: Underbite, in which the upper jaw is too small or
the lower jaw is too large and protrudes. The maxillary
molar is posterior to the mandibular molar.
Discrepancies in the vertical or transverse dimension can
also contribute to a malocclusion. An openbite or deepbite
describe how teeth fit together in the vertical dimension.
Whether orthodontic treatment should occur in one or
two phases of treatment is a source of controversy. Phase I,
or early orthodontic treatment, may correct a problem when
the patient still has primary teeth or has a combination of pri-
mary and permanent teeth. Some practitioners believe it may
keep more serious problems from developing, and it may make
treatment at a later age shorter or less complicated. Typically,
early treatment involves the use of materials and techniques to
guide or modify growth as adult teeth are erupting (Kluemper
et al., 2000)
Appliances used in early treatment may be removable or
fixed (cemented). They may be made of metal, ceramic, or
acrylic. Examples of appliances used to address transverse dis-
crepancies include palatal expanders, quad helixes, and trans-
palatal arches (Fig. 32-4). Headgear therapy may be used to
treat anteroposterior discrepancies (class II or class III maloc-
clusions) and are composed of a removable and fixed compo-
nent. A lower lingual holding arch is a banded appliance used
to maintain space for the eruption of permanent teeth in the
mandibular arch (Fig. 32-5). Functional appliances change
the position of the lower jaw to produce movement of teeth
and modification of growth. Examples of functional appli-
ances include the Twin block, Herbst appliance (Fig. 32-6), and
Bionator.
Phase II or active treatment involves placement of fixed
appliances (braces) or Invisalign in the permanent ­dentition

n  FIGURE 32-4. Appliances used to address transverse discrepancies
include bonded palatal expander (A), banded palatal expander (B),
quad helix (C), and transpalatal arch (D).
n  FIGURE 32-5. A lower lingual holding arch.
n  FIGURE 32-6. Herbst appliance, used to change the position
of the lower jaw.
(Boyd, 2008). Treatment times vary with several factors,
including the severity of the problem being corrected, patient
response to treatment, and patient compliance. Temporary
anchorage devices (Fig. 32-7) are implants used to provide abso-
lute anchorage and help move teeth (Cope, 2005). Patients use
retainers to keep teeth in their new positions after treatment.
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1029
n  FIGURE 32-7. Temporary orthodontic anchorage devices.
n  FIGURE 32-8. Nasoalveolar molding.
Combined surgical orthodontic treatment is used to treat
patients with severe malocclusions or craniofacial anomalies.
Presurgical orthodontic treatment is used to prepare patients
for surgery by removing dental compensations and upright
teeth over basal bone (Proffit and Miguel, 1995). In a traditional
orthognathic procedure, a surgical splint may be fabricated and
wired to the patient’s teeth. This splint may help the surgeon
determine the final position of the jaws.
Nasoalveolar molding (NAM) is a presurgical orthopedic
technique used to reduce the severity of the cleft deformity in
infant patients with complete unilateral or bilateral cleft lip and
palate (Grayson et al., 1999). The appliance is composed of a
removable acrylic plate fabricated from an intraoral impression,
and a nasal stent (Fig. 32-8). The amount of acrylic is sequen-
tially reduced to decrease the separation between the greater
and lesser alveolar segments. Once the gap between the alveo-
lar segments is 5 mm or less, the nasal stent is added to mold
the nasal cartilage. Lip or nasal repair occurs at 4 to 6 months
of age. Patients with NAM can present for cleft lip surgery or
ear, nose, and throat procedures such as myringotomy and
tubes. The NAM appliance can be left in place during inhalation
induction and mask ventilation, or it can be removed before the
1030   P a r t  III    Clinical Management of Specialized Surgical Problems
beginning of induction. The device should be removed before
airway instrumentation for a laryngeal mask airway (LMA) or
endotracheal tube.
Facial Cellulitis
Bacterial abscess can spread from the apex of the root of the pri-
mary or permanent tooth into the surrounding alveolar bone
and periosteum into deep tissue planes of the face or neck,
resulting in an odontogenic facial cellulitis. Fever, dysphagia,
leukocytosis, trismus, and dehydration are common physical
findings. The lateral pharyngeal, retropharyngeal, masticator,
buccal, submandibular, and submental spaces may be involved.
Appropriate antibiotic therapy and prompt surgical drainage and
extraction of the infected tooth are critical components of care.
Careful preoperative airway evaluation is critical in patients
with facial cellulitis. Involvement of the masticator space or
other anatomic spaces of the neck may threaten the airway.
Ludwig’s angina, with bilateral involvement of the subman-
dibular space and with associated superior displacement of the
tongue base can cause airway compromise.
PATIENT SPECTRUM
The population base of the pediatric dentist or pedodontist is
generally composed of healthy children who are able to com-
prehend and follow simple directions by the pedodontists and
their staff. However, pediatric dentists are trained (2 years or
longer) to treat the following patient groups:
l Physically handicapped adolescents and adults
l Neonates, young infants, and toddlers too young to coop-
erate with routine dental care
l Fearful, unmanageable, or psychologically challenged
children
l The entire spectrum of medically compromised children
l Children with dental problems in a hospital critical care
unit
l Children with orofacial trauma
l Children requiring interceptive or minor orthodontic care
The physically handicapped patient most likely to appear for
pedodontal treatment has athetoid cerebral palsy, postencepha-
litis syndrome, profound mental retardation, or autistic behav-
ior (Dougherty et al., 2001; Shenkin et al., 2001; Waldman and
Perlman, 2001). For example, patients with cerebral palsy may
be wheelchair bound and have significant difficulty in control-
ling athetoid motion. The use of nitrous oxide, which depresses
involuntary movement, may ensure a higher success rate in
dental treatments for patients with cerebral palsy (Kaufman
et al., 1991). The pedodontist is specially trained to deal with
these problems in the kindest and most expedient methods
available regardless of the clinical setting (Rosenstein, 1978;
Pope and Curzon, 1991).
The pedodontist may be called on to fabricate a presurgical
appliance for cleft lip and cleft palate in newborn infants. These
presurgical appliances facilitate surgical closure of the palate.
They also improve sucking and feeding in the cleft lip and palate
patient. Toddlers who have circumoral burns from child abuse
or domestic accidents may need an acrylic prosthesis to protect
their circumoral tissues from shrinkage.
Emotionally impaired children or those who are too fear-
ful to undergo routine treatment by a general dentist are fre-
quently referred to the pediatric dentist who is both familiar
with and comfortable in the treatment of such patients.
The pediatric dentist is routinely called on to treat the medi-
cally compromised child or adolescent when the general prac-
titioner is reluctant to get involved in treatment. For example,
the pediatric dentist primarily treats the child with congenital
heart disease, the insulin-dependent diabetic, the patient with
craniofacial anomalies, or the child with oncologic diseases in
conjunction with the pediatrician or primary care physician.
Both fear and lack of training may cause the general dentist
to feel quite uncomfortable in treating the compromised child
or adolescent. In addition, the general dental practitioner fre-
quently lacks the physical resources, such as specialized equip-
ment, to care for these patients. The pediatric dentist is usually
quite comfortable in recommending and prescribing antibi-
otic prophylaxis for subacute bacterial endocarditis (SBE), for
example, and keeps current with appropriate timing in dosage,
effectiveness, and relative risks (Wahl, 1994; Hayes and Fasules,
2001; American Academy of Pediatric Dentistry, 2002e).
A few unfortunate children develop such severe illnesses or
injuries that they require prolonged admissions in critical care
units. These children also need dental care, which takes place
at the bedside. For example, the child who has sustained sig-
nificant head injuries may develop neuropathic chewing, which
damages dental tissues (wearing down of teeth via grinding
action) or soft tissues (tongue or cheek maceration). The pedo-
dontist can fabricate an intraoral acrylic appliance to prevent
further damage to oral tissues.
Finally, the pediatric dentist may be called to the emergency
department of a hospital to treat orofacial trauma. This situ-
ation is more common in pediatric hospitals, where pediatric
dental house officers are on 24-hour call with attending super-
vision. In general, in hospitals without specific pediatric dental
services, the oral and maxillofacial surgeon handles pediatric
dental trauma.
DENTIST’s NEEDS AND TECHNIQUES
The pediatric dental patient requiring anesthesiology services
usually needs many dental procedures during a single anes-
thetic administration. The quality of dental restorations is
probably improved under general anesthesia (Tate et al., 2002;
Al-Eheideb and Herman, 2003). In addition, the parents of
children who have had general anesthesia for pediatric den-
tal care have greater satisfaction than parents of children who
did not have general anesthesia (Acs et al., 2001). After induc-
tion of general anesthesia and protection of the airway, the
anesthesiologist, the anesthesia machine, and the anesthesia
equipment cart are positioned at either the patient’s head or
side.
The dentist’s first step is to obtain necessary intraoral
­radiographs of the teeth (periapical, bitewing, and occlusal
radiographs). The dentist then performs a clinical examination.
After placement of a pharyngeal pack (which should be noted on
the anesthesia record), dental impressions may be taken if future
orthodontic treatment is anticipated. Also, the dentist usually
places a rubber dam around the dental arch to be treated. Despite
its name, the rubber dam is not usually latex. Nevertheless, if
the patient is latex sensitive, care must be taken to ensure that

nonlatex products are being used. The rubber dam is held in
place by a metal clamp that grasps the dental crown. A substan-
tial length of dental floss or umbilical tape is tied around the
clamp before its placement, to prevent inadvertent loss in the
aerodigestive tract. Except for extractions and oral prophylaxis,
the remainder of the treatment is performed with the rubber
dam in place. Caries removal and tooth restoration take place
with silver amalgam, tooth-colored composite, or preformed
crowns. The rubber dam affords the dentist a dry environment
in which the dental materials can cure optimally and achieve
their greatest compressive and tensile strength. The rubber dam
is also a barrier to protect the patient from iatrogenic dental
trauma, including the accidental loss of dental materials or bro-
ken instruments and their possible entrance into the aerodiges-
tive tract. The application of topical fluorides takes place after
all of the restorative dentistry is completed with the rubber dam
still in place (Mathewson and Primosch, 1995).
When severe malocclusion, facial skeleton dysmorphism,
or tooth loss prevents rubber dam placement, the dentist
still needs to maintain a dry intraoral environment. Injection
of ­glycopyrrolate (0.005 to 0.01 mg/kg) or atropine (0.01 to
0.02 mg/kg) immediately after the placement of the intravenous
cannula affords satisfactory intraoral conditions. The pedodon-
tist places cotton rolls along the buccal and lingual or facial
and palatal margins of the adjacent soft tissues to assist in the
achievement of a dry oral cavity.
Pediatric dentistry may also encompass the need for oral and
maxillofacial surgery. Oral and maxillofacial surgeons frequently
perform these procedures after extensive training. Many oral
and maxillofacial surgeons have dual dental and medical train-
ing, as well as fellowship training in head and neck surgery or
plastic and reconstructive surgery. Because children may have
craniofacial anomalies, including orofacial clefts, orthognathic
problems, tumors, and blunt or penetrating trauma, such sur-
gical management requires the ability to combine cosmesis,
restoration of normal occlusion, and the promotion of normal
growth and development of the entire facial skeleton (Kaban,
1993; Vig and Fields, 2000; Ord et al., 2002; Oza et al., 2002;
Zeltser et al., 2003).
Clinical Settings for Pediatric Dentists
Most pediatric dental treatment occurs in the dental office
without the need for psychological or pharmacologic interven-
tion to address the child’s fear and anxiety. The hallmark of
dental pain management is a kind practitioner and staff and
the responsible use of adequate local or topical anesthesia, or
both. For some patients, simple behavior modification tech-
niques improve the level of cooperation in the dental chair.
These techniques include the tell-show-do method and voice
control for the fearful, hostile, or disruptive child. The tell-
show-do technique involves explaining before the procedure,
demonstrating the procedure outside of the child’s mouth, and
then actually performing the procedure on the patient. This
technique removes the fear of the unknown from the proce-
dure (Lenchner and Wright, 1975). Voice control involves
modulation of both the volume and tone of the dentist’s voice
to achieve positive behavioral results (Wilson, 1994; American
Academy of Pediatric Dentistry, 2008). When behavior modi-
fication is deemed necessary for a preschool child, it should
be scheduled during the morning, because the child’s longest
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1031
attention span and optimal level of cooperation are early in the
day. Additional techniques include positive reinforcement, dis-
traction, and parental presence (American Academy of Pediatric
Dentistry, 2008). Additional behavior modification techniques
have been used by the dentist to physically restrain fright-
ened children. This protective stabilization is the restriction
of the patients’ freedom of movement, with or without their
permission, to decrease the risk of injury and to allow the safe
completion of the treatment. Included in these techniques are
passive physical restraint with a rigid board (papoose board),
and active physical restraint by dental personnel. These tech-
niques are controversial because of their potential psychologi-
cal trauma and legal implications (Nathan, 1989; Wilson, 1994;
Wright, 1994). Continuous monitoring of the patient is essen-
tial during protective stabilization.
Most analgesia for pediatric dental procedures is achieved
by local anesthetic block. Most blocks are local infiltration in
the maxillary region, or mandibular nerve blocks in the man-
dible. Adverse reactions to local anesthetics seldom occur when
they are administered alone. Most commonly, they are related
to a relative overdose or lapse in technique. However, even a
low dosage, inappropriately injected, can cause palpitations,
diaphoresis, or even dizziness (Kaufman et al., 2000). Rarely
does vasomotor collapse occur. True allergic reactions, includ-
ing allergy to metabisulfite or other preservatives of local anes-
thetics (e.g., paraaminobenzoic acid), are probably the smallest
proportion of untoward reactions (Campbell et al., 2001).
Behavior modification may include such novel approaches
as hypnosis or music therapy. Highly motivated, intelligent,
attentive, or anxious children may have a good emotional and
analgesic response to hypnosis when other forms of behavior
modification, including pharmacologic forms, are precluded
(Kleinhauz and Eli, 1993). Children as young as 3 to 4 years
may be successfully hypnotized in the dental office (Lampshire,
1975). Music did not diminish pain, anxiety, or disruptive
behavior in a recent study (Aitken et al., 2002), despite anec-
dotal beliefs of pediatric dentists and parents. Nevertheless, in
this study, the patients enjoyed listening to the music and chose
to listen to music in subsequent visits.
Electroanesthesia (transcutaneous electronic nerve stimu-
lation [TENS]) has been used successfully for children in the
dental office setting. TENS is reported to be effective based
on several interrelated theories. These pain control theories
include gate control, endorphin release, and serotonin release.
For dental procedures, disposable electrode pads are placed
bilaterally in the treated dental arch after drying the buccal
mucosa. Using a dentally specific TENS device, a pulse rate of
110 Hz, and a pulse width of 225 microseconds in the normal
mode, amplitude is slowly increased until the desired response
is obtained. Twitching of the lower lip is the amplitude end point
in the mandibular arch, and twitching of the orbicularis oculi
is the amplitude end point in the maxillary arch. Children are
instructed to raise a hand if the amplitude is too uncomfortable,
and it is then diminished (te Duits et al., 1993). This technique
works best in the area of restorative dentistry in the teeth that
have relatively shallow lesions with respect to the dentoenamel
junction (Quarnstrom, 1992; te Duits et al., 1993).
The spectrum of use of sedation is illustrated by the fact that
medication, including nitrous oxide, is being used less than in
previous years and studies. A study by Houpt (2002) suggests
that, although more sedation is being used, it is being used
by fewer ­practitioners on more patients in the United States.
1032   P a r t  III    Clinical Management of Specialized Surgical Problems
A ­retrospective review of pediatric sedation management
suggests that at one U.S. dental school pediatric dental clinic,
nonpharmacologic behavioral management is favored more
frequently because of its greater success (Eid, 2002). One
British study estimated that more than 300,000 general anes-
thesias are still being administered for dentistry each year in
Great Britain, mostly for children. The authors suggest that
fewer general anesthetics are available for dentistry now than
in the 1970s (Blayney et al., 1999). It is implied that most gen-
eral anesthesias in Great Britain, however, as opposed to in the
United States, are provided in a hospital setting.
Most pediatric dentists and those treating handicapped
patients are experienced in the use of nitrous oxide and oral
premedication when necessary in the dental office. The reported
advantages of nitrous oxide delivered via a Goldman nasal mask
include analgesia and sedation (Nathan et al., 1988). The inci-
dence of diffusion hypoxia is minimal after the use of nitrous
oxide and oxygen alone, as opposed to nitrous oxide supplemen-
tation to parenteral or oral sedatives (Quarnstrom et al., 1991;
Dunn-Russell et al., 1993). Hypoxemia may occur when 30% to
50% nitrous oxide is added to chloral hydrate sedation (Litman
et al., 1998b). In a recent study, nasal midazolam and nitrous oxide
resulted in satisfactory sedation in 96% of the pediatric patients
without any clinically relevant oxygen desaturation (Wood, 2010).
However, in children with enlarged tonsils, oral midazolam
(0.5 mg/kg) and 50% nitrous oxide resulted in significant upper
airway obstruction and implied hypoxia (Litman et al., 1998a).
Patients classified by the American Society of Anesthesiologists
(ASA) as having physical status I or II are appropriate candidates
for treatment with pharmacologic adjuncts in the dental office
setting. If a child’s physical status is III or beyond, the hospital
setting is probably a wiser choice. It must be emphasized that the
pediatric dentist should use local anesthesia to optimize analge-
sia and anesthesia for the patient. Local anesthesia may add to the
potential complications of polypharmacy if attention is not paid
to dosages that are age and weight appropriate. This is especially
true in the pediatric age group. The pediatric dentist rarely uses
intramuscular or intravenous sedation while serving as both
the operator and the practitioner administering the sedation.
The reports of severe adverse outcomes include hypoxic brain
damage and occasional deaths, with the use of nitrous oxide,
local anesthesia, and other premedicants. Anesthesiologists
should have an active role in the training of pediatric dentists
in techniques of anxiolysis and moderate sedation. Adverse
outcomes will likely be diminished under these circumstances
(Herlich, 2010; Costa et al, 2010). Invariably, these adverse
outcomes result from relative or absolute overdosage of one
or a combination of nitrous oxide, local anesthetic, and par-
enteral medication (Goodson and Moore, 1983; Doyle and
Goepferd, 1989; Coté et al., 2000a). Because of the widely pub-
licized adverse outcomes of dental office sedation and general
anesthesia, the trend in this type of care has been to move away
from the dental office unless guidelines for deep sedation and
anesthesia by the American Academy of Pediatric Dentistry
are followed. These guidelines were promulgated in 1985 and
restated in 2006 to promote and ensure that the public is aware
and the pediatric patient is protected. The guidelines describe
that the anesthesia care provider must be a separate individual
with appropriate licensing, credentialing, and training to per-
form deep sedation and general anesthesia.
In the United Kingdom, a group of investigators performed
several retrospective analyses during the 1970s and 1980s.
Retrospective data obtained from a national data bank ­indicated
that dental office deaths were infrequent, and the number
decreased substantially in the second survey. The decreases
in deaths probably result from two factors. First, fewer gen-
eral anesthesias were being administered in the dental office.
Second, the practice of the single individual being both dental
practitioner and anesthetist is becoming less frequent because
of warnings and suggestions from the General Dental Council
of Great Britain. The anesthetist and dental practitioner are
more commonly two individuals, each of whose attention is
directed toward a single task. Also, the British survey indicated
that the person providing anesthesia is more commonly a phy-
sician (Coplans and Curson, 1982, 1993). In the United States,
closed claims morbidity and mortality involving oral surgeons
show that during the period of 1988 to 1999, there were 22
deaths in the office and 136 anesthesia-related claims in total. It
was calculated that the death rate was 1 in every 747,732 (0.013
in 10,000) administrations of anesthesia in the dental office
(Deegan, 2001). D’Eramo and colleagues (2008) in a survey of
oral maxillofacial surgeons in Massachusetts found the adult
death rate to be 1 in 1,733,055 from office-based anesthesia.
Data from the Pediatric Sedation Research Consortium indi-
cated no mortality in over 49,000 propofol sedations, of which
307 were for dental procedures (Cravero et al., 2009).
In the United States, opposing forces create difficulties for
the pediatric dental patient. Economic issues tend to restrict
hospital-based procedures, including payment for the dental
service only, without payment for the anesthesia service; pay-
ment for the anesthesia service only, without payment for the
dental service; and frequently no payment or only partial pay-
ment for the hospital service. Frequently, the patient’s family is
faced with a significant out-of-pocket expense, which many can-
not afford. On the other hand, the litigious nature of our society
has prevented the rational expansion of anesthesia services in
the office environment beyond sedation. Mandated equipment
and monitors and the cost of liability insurance may be prohibi-
tive for the office practitioner.
Another issue with significant economic ramifications is the
cost of multiple treatments in the dental office with procedural
sedation as opposed to a single session in the operating room
of the hospital under general anesthesia. In studying healthy
patients aged 24 to 60 months, Lee and colleagues (2001) found
that a patient who required more than three treatment visits
with procedural sedation had more cost-effective treatment
when all of the treatments were provided in a single visit under
general anesthesia.
A reasonable compromise may be a well-equipped hospital or
surgicenter dental clinic with standard monitoring devices and
resuscitation equipment. Pediatric patients with ASA status I or
II may be suitable candidates. With the use of proper equipment
and appropriately trained personnel, a large diversity of patients
may be safely and satisfactorily treated on an outpatient basis.
If the clinic is rationally designed, including recovery areas
equipped with oxygen, suction apparatus, and essential moni-
toring devices, the anesthesiologist can safely administer the
anesthetic outside of the traditional operating room setting. It
allows more efficient use of time and space as well as reduced
cost. From the perspective of the parent and child, outpatient
treatment permits a more rapid return to familiar surround-
ings and activities of daily living (Zuckerberg, 1994). Only the
patients with disease or physical conditions that preclude off-
site clinical practice need to be treated in the operating room in

today’s environment. Some examples of the patients who may
need the traditional operating room setting include those with
difficult airways, those with coagulopathies, and those with
complex anomalies or cardiovascular disease for whom more
than standard monitoring is necessary.
SEDATION AND ANESTHESIA FOR DENTAL
PROCEDURES
The key to success in anesthetic management is a good patient
history and physical examination. The parent or caregiver of
the child should be able to relate relevant data such as previous
anesthetic successes and failures. These anesthetic experiences
should also be related for any family members. Birth history,
growth, and development, including psychological issues and
the child’s emotional status, may be helpful in conducting a
safe and pleasant dental experience. If the child has significant
fears or behavioral problems that warrant premedication, the
historical background permits the anesthesiologist to select an
appropriate premedication agent.
The physical examination of the child must include the air-
way. Despite plans for nasotracheal intubation, the oral cavity
must also be examined, because nasotracheal intubation may
not be successful. Loose teeth, enlarged tonsils and adenoids, or
herpes labialis all affect the anesthesiologist’s management of
the airway. Issues of nasal obstruction or sinus disease also have
a great impact on the decision-making process for airway man-
agement. Cardiac murmurs should be investigated as to their
relative seriousness. Most cardiac murmurs are in fact innocent
flow murmurs; however, reasonable percentages are pathologic
conditions and warrant prophylaxis for endocarditis. Other fac-
tors, such as coagulation status, neurologic history, and recent
viral syndromes, may also affect the anesthesiologist’s decision-
making process.
Procedural Sedation
In 1985, The American Academy of Pediatric Dentistry estab-
lished goals for sedation of the pediatric dental patient. These
goals were updated in 2006 and are as follows:
1. To guard the patient’s safety and welfare
2. To minimize physical discomfort and pain
3. To control anxiety, minimize psychological trauma, and
maximize the potential for amnesia
4. To control behavior and/or movement so as to allow the safe
completion of the procedure
5. To return the patient to a state in which safe discharge from
medical supervision, as determined by recognized criteria, is
possible
With these goals in mind, procedural sedation of the pedi-
atric dental patient may be considered. The foundations of
pharmacologic sedation for the pediatric dental patient are
monitoring standards to which all practitioners should adhere
(Wilson, 2000). Minimum or moderate procedural sedation
intended in the sensitive patient may become deep sedation or
general anesthesia if vigilance is not applied. These standards
have been promulgated by several organizations, including
the ASA (2002), The American Academy of Pediatric Dentistry
and American Academy of Pediatrics (McGuire, 2007), and the
American Academy of Pediatric Dentistry (2002d) (Consensus
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1033
Conference, National Institutes of Health, 1985; Rosenberg
and Campbell, 1991; Council on Scientific Affairs, AMA, 1993).
The American Academy of Pediatric Dentistry guidelines sug-
gest that children who are status ASA III or IV should have
treatment that necessitates sedation performed in a hospital
environment.
The use of precordial/pulse oximetry for nitrous patients
is not supported for nitrous oxide alone in the 2009 American
Academy of Pediatric Dentistry Guidelines (American Academy of
Pediatrics and American Academy of Pediatric Dentistry, 2006).
Additionally, a full E-cylinder of oxygen and a self-inflating bag
and mask capable of delivering 15 L/min of oxygen must be avail-
able in the care facility. An important monitor is a trained indi-
vidual whose sole duty is to pay attention to the electronic and
mechanical monitors in place and who is prepared to act on
untoward events. As mentioned, the treating dentist should not
be the person administering the anesthetic.
Before any sedation is administered, including nitrous oxide
with oxygen, appropriate fasting guidelines must be given to the
parents or guardians of the patient. Data suggest that prolonged
fasts meant to reduce the likelihood of vomiting and aspiration
are somewhat deleterious to patient outcome. Guidelines for
fasting from solid foods, milk, and milk products remain at a
minimum of 8 hours. However, clear liquids, including pulp-
less juices, plain gelatin, and ice popsicles, are encouraged and
acceptable until 2 hours before the anticipated arrival in the
care facility. The pediatric patient is more cooperative and the
parents are more satisfied as a result of these suggested guide-
lines (Schreiner, 1994). All of these guidelines are predicated
on normal gastrointestinal function. If the patient has abnor-
mal gastrointestinal function, more conservative fasting orders
must be considered.
Oral, intranasal or transoral, parenteral, and rectal routes for
administration of sedative medications are used during proce-
dural sedation. Pediatric dentists have traditionally and preferen-
tially used the oral route to administer premedication (Primosch
and Bender, 2001). The old practice of having the parents admin-
ister a prescribed oral medication at home has been fraught with
danger to the toddler and young child. Airway obstruction and
emesis with aspiration were real complications of that practice.
For reasons of safety, the practice has changed. Children are now
brought to the treatment facility or dental office 1 hour ahead
of the scheduled procedure time, and the oral premedication is
administered under the guidance of the pediatric dentist. Two of
the most popular agents have been hydroxyzine (1 to 2 mg/kg)
and chloral hydrate (50 to 75 mg/kg; maximal dosage, 2 g). These
agents have had a good success rate and a reasonable margin of
safety. In addition, nitrous oxide may be given in conjunction
with the usual administration of local anesthetic blocks (Moore
et al., 1984; Shapira et al., 1992). More potent oral agents, such
as ketamine, diazepam, and midazolam, are also given in the
treatment facility or dental office. The practitioner must allow
a reasonable time for onset of action before dental treatment
(Sullivan et al., 2001). Oral midazolam has gained widespread
popularity because of its reasonable margin of safety in addition
to its rapid onset for either premedication before general anes-
thesia or as the main agent for procedural sedation (Kupietzky
and Houpt, 1993; Levine et al., 1993). These agents may be given
alone or with another agent (Dallman et al., 2001; Bui et al.,
2002; Nathan and Vargas, 2002).
Mild oxygen desaturation has been noted and is easily treated
with supplemental oxygen and repositioning of the patient’s
1034   P a r t  III    Clinical Management of Specialized Surgical Problems
airway. In some cases, when nitrous oxide was added to the
oral premedication, the degree of hypoxemia increased (Litman
et al., 1998a). The use of traditional monitors such as clinical
observation, blood pressure, and pulse was clearly insufficient
to assess the degree of hypoxemia. Pulse oximetry, capnogra-
phy, and precordial stethoscopes have become necessary to ade-
quately assess and prevent poor outcomes despite limitations
in the pediatric dental environment (Anderson and Vann, 1988;
Poiset et al., 1990; Wilson, 1990; Dunn-Russell et al., 1993). The
use of supplemental oxygen also helps to reduce hypoxemia.
Novel means of improving oxygenation include the delivery of
supplemental oxygen via the saliva injector and the use of exter-
nal nasal dilators (Milnes, 2002; Moses and Lieberman, 2003).
Intranasal or transoral administration of water-soluble agents
such as ketamine, midazolam, or sufentanil produces effective
sedation and premedication for procedural sedation. However,
sufentanil produces a significantly high incidence of respiratory
depression, even in relatively small dosages (1.0 mcg/kg) and is
not recommended (Abrams et al., 1993). Midazolam (0.5 mg/kg
orally, or 0.2 to 0.3 mg/kg intranasally) is ideal for creating a
milieu in which the child is easily separated from the parent. It
also transforms a disruptive child into a quiescent child in the
dental chair with minimal desaturation (Abrams et al., 1993;
Levine et al., 1993). However, once the handpiece (dental drill)
was activated, the noise distracted the child sufficiently that the
pediatric dentist could not efficiently treat the child (Theroux
et al., 1994). Despite the popularity of oral sedation, one group
of investigators found that there was no relationship between
oral sedation and behavior of the children in the dental office
on subsequent visits (McComb et al., 2002).
The rectal route of administration for procedural sedation
and premedication has enjoyed popularity with only a small
number of practitioners. Midazolam (1.0 mg/kg or even higher
dosages) has been used for procedural sedation and for premed-
ication. Onset of action usually occurs within 15 to 30 min-
utes (Roelofse and Van der Bijl, 1991). The main drawback to
rectal administration of these agents is the risk of expulsion of
the sedative and the unreliable uptake from the distal colonic
mucosa.
Many drugs have been used as parenteral agents for proce-
dural sedation in pediatric dentistry. Opioids, benzodiazepines,
antihistamines, ultra-short-acting barbiturates, and dissocia-
tives have been used successfully. All have had some negative
features as well. Short-acting agents with acceptable margins
of safety in dental sedation include methohexital, meperi-
dine, ketamine, diazepam, and midazolam. Respiratory depres-
sion and concomitant hypoxia have been the recurrent theme
in parenteral sedation by pediatric dentists (Allen, 1992; Coté
et al., 2000a, 2000b). As previously mentioned, clinical obser-
vation was insufficient and the airway was subsequently lost.
Because of the fine line between moderate procedural seda-
tion, deep sedation, and general anesthesia, the dentist and
assistant who administer procedural sedation must be experi-
enced in recognizing and handling cardiorespiratory depres-
sion. Electrocardiography, pulse oximetry, blood pressure,
capnography, and precordial stethoscope are essential moni-
tors (American Academy of Pediatrics and American Academy
of Pediatric Dentistry, 2006).
Other drawbacks to intravenous sedation in pediatric den-
tistry have been the potential for inflicted pain to achieve
intravenous access and the lack of familiarity with drug com-
binations on the part of the practitioner. The child’s fear of
pain from a needle puncture has been successfully addressed
by inhalation of nitrous oxide in oxygen or the transmucosal
administration of midazolam. Use of EMLA (eutectic mixture of
local anesthetics, 2.5% lidocaine, and 2.5% prilocaine) cream
or topical (ELA-Max) lidocaine cream before venipuncture has
been successful in reducing or eliminating needle puncture
pain (Nilsson et al., 1994; Koh et al., 2004). Also, EMLA- and
lidocaine-impregnated patches have been used intraorally with
varying success before local anesthetic blocks and local pro-
cedures before the insertion of rubber dam clamps (Stecker
et al., 2002). The main disadvantage of the use of the transder-
mal local anesthetics in EMLA cream is that it requires applica-
tion at least 45 minutes to 1 hour before a painful procedure.
ELA-Max is faster and requires approximately 30 minutes to
take effect (Koh et al., 2004).
General Anesthesia
The American Academy of Pediatric Dentistry (2002d) has issued
guidelines for the indications for general anesthesia for children
having dental procedures (Box 32-1). Nunn et al. (1995) also
described the indications for general anesthesia in 265 pediatric
patients. These indications include extensive treatment needs,
behavior management issues, medically compromised children,
extreme anxiety, and physical disabilities. The most common
indication, accounting for 30.6% of the anesthesias, was intel-
lectual impairment and autism. Dental phobia accounted for
21.4% of the patients.
Behavioral issues are a very common indication for sedation
or general anesthesia in children. The behavioral issues may
stem from fear and anxiety or an abnormality in development
such as autism, autism spectrum disorders, cerebral palsy with
mental retardation, and Down syndrome.
Fear of dental procedures affects all ages. For some it may be
so strong that dental visits are avoided altogether. In children,
anxiety prior to a surgical or dental procedure centers on the
fear of pain, loss of control, and separation from the parent or
guardian. Preoperative anxiety and its risk factors are discussed
in Chapter 8, Psychological Aspects of Pediatric Anesthesia,
and Chapter 9, Preoperative Preparation. Children most at risk
Box 32-1 American Academy of
Pediatric Dentistry Guidelines for the
Elective Use of Sedation and General
Anesthesia
l Patients who are unable to cooperate due to a lack of psy-
chological or emotional maturity and/or mental, physical, or
medical disability
l Patients who are extremely fearful, anxious, or non-commu-
nicative or in instances where it may protect the developing
psyche.
l Patients who require significant surgical intervention or in
instances where local anesthetic may be ineffective like an
acute infection, anatomic variation, or allergy or patients
needing immediate comprehensive care.
From the American Academy of Pediatric Dentistry: Guidelines for the
elective use of conscious sedation, deep sedation and general anesthesia
in pediatric dental patients, Pediatr Dent 24:74, 2002.
 C h a p t e r 32    Anesthesia for Pediatric Dentistry   1035

for heightened anxiety are between 1 and 5 years old and have
TABLE 32-3. Antibiotic for Subacute Bacterial
divorced ­parents, previous negative medical experiences, and
Endocarditis (SBE) Prophylaxis
heightened emotionality (Kain et al, 2007).
Autism is an abnormality in neurodevelopment that results
Single Dose 30 to 60 min
in abnormal social interactions and recurrent repetitive behav- before Procedure
ior. The diagnostic criteria include age of onset of less than 3
years old, severe abnormality of social reciprocity, severe abnor- Indication Agent Adults Children
mality of communication development, and restrictive, repeti- No contraindications Amoxicillin (oral)    2 g 50 mg/kg
tive patterns of behavior and imagination (Klein and Nowak,
Unable to take oral Ampicillin (IM or IV)    2 g 50 mg/kg
1998). The incidence of autism is increasing and is now esti-
medication OR cefazolin or    1 g 50 mg/kg
mated to be 1 to 2 per 1000 (Newschaffer et al., 2007). Autism ceftriaxone (IM or IV)
spectrum disorders are a heterogeneous group of disorders
Allergic to penicillins Cephalexin (oral)    2 g 50 mg/kg
that include autism, Asperger’s syndrome, Rett syndrome, and or ampicillin OR clindamycin (oral) 600 mg 20 mg/kg
Pervasive Developmental Disorder-Not Otherwise Specified OR azithromycin or 500 mg 15 mg/kg
(PDD-NOS). Children with autism and autism spectrum disor- clarithromycin (oral)
ders can be uncooperative and often require behavioral inter- Allergic to penicillins Cefazolin or ceftriaxone    1 g 50 mg/kg
ventions, sedation, or general anesthesia to complete a dental or ampicillin and (IM or IV)
examination or procedure. unable to take oral OR clindamycin (IM 600 mg 20 mg/kg
The child with significant medical disorders may require medication or IV)
the assistance of an anesthesiologist during dental care. Some Adapted from the AHA SBE guidelines 2007, Table 4.
of these medical disorders may include the child with a known IM, Intramuscular; IV, intravenous.
difficult airway, congenital cardiac disease, or multiple coex-
isting disorders. Children with cyanotic congenital heart dis-
ease may require SBE prophylaxis (Box 32-2). The appropriate
antibiotic selection is summarized in Table 32-3. Patients with Benzodiazepines are a very effective anxiolytic. Adults or
one of the cardiac conditions in Box 32-2 having dental proce- adolescents can be given diazepam. In one study, patients
dures that manipulate the gingival tissue or periapical region with autism were sedated more effectively with midazolam
of the teeth or perforate the oral mucosa require SBE prophy- (0.5  mg/kg) than with diazepam (0.3 mg/kg) (Pisalchaiyong
laxis. Procedures that do not require prophylaxis include rou- et al., 2005). In younger children, midazolam can be admin-
tine anesthetic injections through noninfected tissue, taking istered orally in a commercially flavored liquid or the con-
dental radiographs, placement of removable prosthodontic or centrated intravenous solution can be given intranasally. The
orthodontic appliances, adjustment of orthodontic appliances, recommended dosage for midazolam is 0.5 mg/kg and 0.2 mg/kg
placement of orthodontic brackets, shedding of deciduous teeth, for oral and nasal administration, respectively (Davis et al,
and bleeding from trauma to the lips (Wilson et al., 2007). 1995; Kain et al, 2000). Buccal midazolam (0.2 mg/kg) was
described for dental procedures but found not to be effective
(Hosey et al., 2009). Ketamine can also be administered alone
Premedication
or in combination with midazolam. This combination is effec-
Patients presenting for general anesthesia often require a tive and provides both anxiolysis and analgesia. The dosage
premedication to reduce anxiety and enhance cooperation. of oral ketamine is 3 to 10 mg/kg. When combined with oral
midazolam, the dosage is typically 3 to 6 mg/kg. This combi-
nation has been described to be very effective in patients with
developmental delay. In this case report, the authors suggest
Box 32-2 Indications for the Use using a flavored soda such as Dr. Pepper to mask the bitter fla-
of Subacute Bacterial Endocarditis vor of the medication (Shah et al., 2009).
Prophylaxis Clonidine has also been described as a premedicant for anxi-
l Presence of a prosthetic cardiac valve or prosthetic material olysis for children prior to surgical procedures. There are some
for cardiac valve repair significant advantages. It has no bitter taste, it may provide
l Previous infective endocarditis some analgesia, and it may decrease the incidence of emer-
l Congenital heart disease (CHD), including the following: gence agitation, and it may decrease postoperative nausea and
l Unrepaired cyanotic CHD, including palliative shunts and vomiting. A significant disadvantage is its slow onset time (30
conduits to 45 minutes) (Almenrader et al., 2007; Dahmani et al., 2010).
l Completely repaired congenital heart defect with pros-
α2-Agonists have been used in patients with autism, autism
thetic material or device, whether placed by surgery or spectrum disorders, and attention deficit hyperactivity disorder
by catheter intervention, during the first 6 months after (ADHD) and have been shown to have some benefit (Ming et al.,
the procedure
l Repaired CHD with residual defects at the site or adja-
2008; Scahill, 2009). Clonidine may be an effective premedica-
cent to the site of a prosthetic patch or prosthetic device tion for these patients when they present for dental procedures.
(which inhibit endothelialization) The dosage of oral clonidine for sedation is 4 mcg/kg.
l Cardiac transplantation recipients who develop cardiac
valvulopathy Induction and Maintenance
Adapted from the AHA SBE guidelines, 2007. There is no standard anesthetic for children having dental
procedures. Patients that require a general anesthetic require
1036   P a r t  III    Clinical Management of Specialized Surgical Problems
medications that will allow them to remain motionless dur-
ing repeated painful stimuli without feeling pain or having
recall. This can be achieved with intravenous or inhalational
anesthetics. The principles that guide the selection of anesthet-
ics depend on the underlying medical disorders and the pro-
cedure being performed. In the United States, the traditional
induction technique for general anesthesia in the pediatric age
group has been inhalational anesthesia. The anesthesia mask
is coated with a pleasant scent such as a fruit-scented lip balm.
Sevoflurane, nitrous oxide, and oxygen is administered using
high flows and concentrations while the anesthesiologist tells
a story or employs another distraction technique. Intravenous
induction techniques may include the use of a transdermal local
anesthetic (ELA-Max), followed by the insertion of an intrave-
nous cannula and subsequent administration of an appropri-
ate intravenous agent, most commonly propofol or thiopental
(Zuckerberg, 1994). Propofol can be mixed with lidocaine (1 mL
of 1% lidocaine added to 9 mL of 1% propofol) to minimize local
irritation and pain (see Chapter 13, Induction, Maintenance,
and Recovery). Other, less commonly used techniques for the
induction of general anesthesia include rectal administration
of methohexital, thiopental, ketamine, or midazolam (Martone
et al., 1991; Roelofse and Van der Bijl, 1991; Zuckerberg, 1994).
The nasal or oral transmucosal administration of water-­soluble
agents such as ketamine or midazolam has also been used
(Levine et al., 1993).
When all other attempts have been futile for a child with
intellectual or emotional handicaps, an intramuscular injection
of ketamine and glycopyrrolate with or without midazolam is
used. These techniques should be attempted only with appro-
priate monitoring and when oxygen, self-inflating resuscitation
bag, and suction are available.
Once general anesthesia is induced, intravenous access
and the airway are secured. All monitors may be placed before
or after induction of anesthesia, depending on the coopera-
tion of the patient. When possible, the first monitors that are
placed, regardless of the timing of their placement, should be
pulse oximetry and a precordial stethoscope. Careful position-
ing, padding, and application of thermal conservation devices
must be accomplished before beginning dental treatment (see
Chapter 13, Induction, Maintenance, and Recovery).
Maintenance of anesthesia for the pediatric patient having
dental surgery can be accomplished with either an inhalation
technique or an intravenous technique. Sevoflurane is used
very commonly as an inhaled anesthetic for outpatient anes-
thesia. Its use has been described in children having dental
procedures. Desflurane is also commonly used for outpatient
procedures because of its relatively low blood gas solubility.
There does not appear to be a significant advantage of either of
these agents over the other for ambulatory anesthesia in terms
of clinically significant discharge times. A potential concern
for desflurane is its effect on airway reactivity. Patients recov-
ering from desflurane may experience more coughing than
those receiving sevoflurane (White et  al., 2009). This occurs
because, unlike sevoflurane, desflurane increases airway resis-
tance in children having anesthesia. Patients with bronchial
hyperreactivity (asthma, upper respiratory tract infections,
and bronchopulmonary dysplasia) may be particularly prone
to the bronchospastic effects of desflurane and should prob-
ably avoid this agent (von Ungern-Sternberg et  al., 2008).
If an intravenous agent is chosen for maintenance, an ideal
agent may be propofol. It has the advantage of a short ­duration
of action along with its antiemetic benefits (Coté, 1994).
Remifentanil is also an appropriate choice.
Studies have not demonstrated benefit of one anesthetic
technique over another for dental procedures. Konig et al,
(2009), in a double-blind study, compared a sevoflurane-based
anesthetic with a propofol-based anesthetic and found no dif-
ference in emergence delirium or postoperative pain. However,
there was significantly less postoperative nausea and vomiting
in the propofol group. Children with autism may have increased
propofol requirements when compared with other children
with intellectual impairments. In a retrospective study, Asahi
and others (2009) found that an increased amount of propo-
fol was required to achieve adequate sedation in children with
autism.
Postoperative pain management for children having den-
tal surgery is best accomplished with a multimodal technique.
Intraoperatively, the dentist can place dental nerve blocks prior
to dental extractions. Nonsteroidal antiinflammatory agents
such as ketorolac are very effective for dental pain. The phar-
macology of ketorolac has been established in infants and chil-
dren. A dosage of 0.5 mg/kg provides adequate analgesic plasma
levels, and it is cleared at a faster rate in infants, even in those
less than 6 months old, than in adults (Lynn et al., 2007; Zuppa
et  al., 2009). Analgesia may also be supplemented with mor-
phine (0.05 to 0.10 mg/kg), or fentanyl (1 to 4 mcg/kg).
Airway Management
Management of the airway during general anesthesia for den-
tistry begins with mask ventilation. If the patient has a NAM
device in place, it can be removed before initiating mask venti-
lation. If the device does not interfere with mask ventilation, it
can be left in place until the airway is instrumented. Intubation
for dental procedures is typically performed nasally to keep the
mouth clear for the dentist or oral surgeon. During the preop-
erative examination, a history of epistaxis should be elicited,
and the nares should be inspected for evidence or recent nose-
bleeds. A child who is old enough may be able to breath through
the nares individually to determine which one is more patent.
Despite these preoperative tests, epistaxis may still be a signifi-
cant issue.
Preparation of the nasal cavity is essential to minimize the
risk of bleeding and to optimize the laryngoscopic or fiberoptic
view. Once the child has been anesthetized, a mucosal vasocon-
strictor such as oxymetazoline (Afrin) is applied to the nasal
mucosa in both nares. The dosage for the child between 2 to
5 years of age is 2 to 3 drops of a 0.025% solution in each nos-
tril (Mcgee et al., 2009). Oxymetazoline can be administered as
drops or it can be applied via nasal cottonoids. There is con-
troversy regarding the use of topical vasoconstrictors. Some
pediatric anesthesiologists choose not to use topical vasocon-
strictors (phenylephrine or oxymetazoline) because of concern
about cardiac complications (e.g., pulmonary edema and car-
diac arrest) (Thrush, 1995; Groudine et al., 2000). Systemic
absorption of the vasoconstrictor can result in profound sys-
temic vasoconstriction and hypertension. Pulmonary edema
occurs secondary to β-blockade treatment of the hypertension.
Before introduction of the nasal endotracheal tube, each
naris should be assessed to determine which is the most patent.
A lubricated nasal pharyngeal airway can be passed into each
naris to accomplish this. The most effective way to determine
the best anatomic route for nasal intubation is to fiberoptically

inspect each nares. Previously unidentified anatomic abnormal-
ities are most likely to be found with this technique (Smith and
Reid, 1999).
Other techniques to minimize bleeding during nasotracheal
intubation in children include reducing the size of the endotra-
cheal tube (ETT) by a half to a full size, warming it in warmed
saline, and telescoping its end into a rubber catheter (Elwood
et al., 2002; Watt et al., 2007). The incidence of bleeding appears
to be reduced when the ETT is warmed in saline. The reduction
in bleeding is even more pronounced when its tip is covered
with a rubber catheter prior to introduction into the naris. In
Watt’s study, 56% of children who had a room temperature ETT
placed had clinically significant bleeding. This was reduced to
39% if the ETT was exposed to warm saline, and it was reduced
even further (to 5%) when the tube was telescoped with a rub-
ber catheter. A final technique is to use an obturator, which can
be an esophageal stethoscope (Seo et al., 2007), a suction cath-
eter (Herlich et al., 1996), or a fiberoptic scope. Beside bleeding,
complications of nasotracheal intubation include bacteremia,
dislodgment of adenoidal tissue, and laceration of aerodigestive
mucosa with subsequent false passage. Turbinate ulceration
may also occur. Fiberoptic guidance of nasotracheal intuba-
tion may reduce some of the attendant comorbidities that the
anesthesiologist may face (Herlich, 1991). Once the tip of the
ETT is positioned in the posterior pharynx, it can be guided into
the larynx with direct laryngoscopy or with a flexible fiberoptic
scope.
Nasotracheal tubes need to be secured in a way that avoids
alar pressure (Fig. 32-9). Prolonged alar pressure can result in
tissue ischemia and loss. In addition, the eyes must be protected
and the forehead padded.
Fiberoptic intubation may become the rule rather than the
exception in patients with facial trauma (Kaban, 1993), man-
dibulofacial dysostosis (Treacher Collins syndrome), and other
congenital craniofacial anomalies (Pierre Robin sequence,
Goldenhar’s syndrome). These patients frequently have palatal
clefts and severe dental problems that require dental therapy
and possibly orthognathic surgery (Gendelman and Herlich,
1993).
Patients with a history of recurrent epistaxis, recent nasal
trauma, or recent head trauma should potentially not have a
nasal intubation performed. In these patients, a straight ETT
n  FIGURE 32-9. One method of taping a nasotracheal tube. Note
there is no alar pressure.
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1037
or an oral RAE tube can be used. A preformed orotracheal tube,
such as the oral RAE tube, may be disadvantageous because it
is designed to be a midline tube. Moving the preformed tube to
either side of the mouth may cause an eccentric positioning in
the trachea. An endobronchial intubation may create difficul-
ties in ventilation. If orotracheal intubation is needed, a  con-
ventional ETT easily moves to either side of the mouth and
oropharynx with the compensatory eccentric tracheal position
of the tube. Another concern with moving an oral ETT from side
to side is the increased risk of unintentional extubation. An oral
tube also decreases the ability of the dental operator to place
a rubber dam and complete the dental treatment efficiently.
Suboptimal position and placement of dental instruments may
also occur when an orotracheal tube is in place. A pharyngeal
pack reduces the likelihood that blood and debris are intro-
duced into the aerodigestive tract. Noting the times of insertion
and pack removal from the pharynx on the anesthesia record
reduces the risk of airway embarrassment postoperatively.
The armored version of the LMA, or flexible LMA, may be
indicated for some pediatric dental patients who need dental
care under general anesthesia. The advantages of the LMA are
its ease of placement and tolerance in the spontaneously ven-
tilating patient. Like an orotracheal tube, it has disadvantages,
including its presence in the oral cavity, the interference with
rubber dam placement, and its larger size in comparison with a
standard orotracheal tube. With a skilled pediatric dentist per-
forming restorative dentistry or surgical procedures, minimal
hemorrhage may be seen on the LMA at the end of the proce-
dure (Alexander, 1990; Webster et al., 1993).
Despite meticulous technique on the part of the pediatric
dentist who is placing a rubber dam, dental materials may lodge
in the oropharynx and subsequently enter the laryngotrache-
obronchial tree. Hence, a gentle but thorough cleaning and
­suctioning of the oropharynx before extubation are mandatory.
POSTOPERATIVE PROBLEMS
Most postoperative problems related to pediatric dentistry are
common to many other surgical procedures. Postoperative
pain, prolonged emergence difficulties with voiding and ambu-
lation, and nausea and vomiting are all seen in pediatric dental
patients. However, even after brief general anesthetics for den-
tal procedures, significant hypoxemia may be encountered that
is not relieved by administering supplemental oxygen alone.
A British study demonstrated that experienced postanesthesia
nursing after dental procedures was the most effective means of
preventing and treating hypoxemia (Lanigan, 1992).
Postoperative pain may be obviated by the early intraoper-
ative administration of analgesics such as morphine (0.05 to
0.1  mg/kg) or fentanyl (1 to 2 mcg/kg). In addition, an acet-
aminophen suppository (30 to 40 mg/kg), given shortly before
the end of the procedure, confers additional analgesia with min-
imal side effects. Oral acetaminophen (10 to 15 mg/kg) may be
even more effective if given preoperatively (Yaster et al., 1994).
Postoperative nausea and vomiting have numerous causes in
the pediatric dental population. A common cause is swallowed
blood. Once intraoral bleeding has ceased, the nausea and vom-
iting from this cause usually abate. Opioid use and abdominal
distention caused by bag-mask ventilation with upper airway
obstruction or with excessive pressure may also produce post-
operative nausea and vomiting. Nitrous oxide is a controversial
1038   P a r t  III    Clinical Management of Specialized Surgical Problems
cause of postoperative nausea and vomiting. A cause of emesis
or nausea unique to dentistry is the inadvertent ingestion of
intraoperatively administered topical fluorides to reduce dental
caries (Mathewson and Primosch, 1995).
With prolonged postoperative nausea and vomiting,
increased hydration and antiemetics may be administered with
their attendant caveats, including bladder distention, extrapy-
ramidal effects, and prolonged sedation (Herlich et al., 1996).
Ondansetron (100 to 150 mcg/kg) is effective at lessening the
severity of postoperative nausea and vomiting when adminis-
tered prophylactically. Dexamethasone (0.1 to 0.2 mg/kg, up
to a maximum of 10 mg) is another highly effective medica-
tion for the prevention and treatment of postoperative nausea
and vomiting, especially in conjunction with ondansetron (see
Chapter 13, Induction, Maintenance, and Recovery). Moderate
dose metoclopramide (0.5 mg/kg) has been described prophy-
lactically in children having tonsillectomies, but it is less effec-
tive than ondansetron (0.1 mg/kg) (Bolton et al., 2007). If the
emesis is severe enough to warrant admission to the hospital
for control and rehydration, the pediatric dentist requires the
services of a primary care physician (presumably a pediatri-
cian) to assume the overall management of the pediatric dental
patient. Fluid and electrolyte management, as well as general
patient welfare issues, may be beyond the scope and comfort
level of the pediatric dentist. Patients with refractory vomit-
ing requiring admission should have their serum sodium mea-
sured to look for hyponatremia.
Some postoperative problems appear more frequently among
patients who have had dental rehabilitation, surgical removal of
impacted teeth, or other surgical lesions. Postoperative hyper-
pyrexia seems to occur with greater frequency in patients in
whom intraoral dental procedures have been performed. One
group investigated preschool-age children to ascertain the
etiology of such febrile states. In a randomized fashion, some
children were given oral antibiotics 1 hour before their pro-
cedure. All children received general anesthesia with nasotra-
cheal intubation and subsequent packing of the oropharynx to
reduce the incidence of aspiration of gastric contents and blood.
Ventilation was controlled to reduce the likelihood of atelectasis
as a cause of postoperative temperature elevation. Intravenous
fluid therapy was administered to both groups to reduce the
contribution of dehydration as a cause of postoperative tem-
perature elevation. The two groups were found to have equal
rates of significant postoperative temperature elevation. The
authors suggested that other perioperative etiologies should be
investigated, including anesthetic effects on temperature regu-
lation during dental procedures (Holan et al., 1993). There may
be certain dentally induced pyrogens, or an antibiotic with a
broader spectrum may be needed to cover the organism causing
the hyperpyrexic bacteremia.
Nasotracheal intubation, as previously described, is the pre-
ferred method of airway protection. However, transient post-
operative epistaxis is not uncommon in patients with boggy
turbinates, traumatic intubation or extubation, or relatively
stenotic nares (Herlich et al., 1996). Usually, direct pressure
adequately treats the problem. Rarely, vasoconstrictors and
intranasal packing are needed to treat the epistaxis.
Other sequelae of traumatic intubations or extubations, such
as croup or generalized laryngeal edema, may need to be treated
with intravenous dexamethasone (0.4 mg/kg) immediately after
a traumatic or oversized intubation, and possible vasoconstric-
tors such as racemic epinephrine may be used after extubation.
Postobstruction or negative pressure pulmonary edema
may be seen in children with large muscle mass or obesity. The
patients are usually adolescents, but this can occur in children
as young as 5 years (Van Kooy and Gargiulo, 2000; Ciavarro and
Kelly, 2002).
Postoperative oral bleeding should be treated with direct
intraoral pressure if a site can be located. Generalized ooz-
ing of blood may be treated with gauze dental packs that have
large extraoral tails for retrieval. The oral packs act as com-
pression dressings, which should be left in place for 2 hours
and not be replaced unless there is significant ongoing hem-
orrhage. Premature removal or replacement dislodges clots
that have not sufficiently matured and retracted into the dental
socket. Persistent, minor oral hemorrhage after extraction may
also be created. Dislodgment of recently cemented crowns or
appliances, inadvertent movement of dental packs, or avulsion
of loose teeth not previously extracted may require the pres-
ence of the dentist in the postanesthesia care unit to treat the
problem.
Dental Complications of Anesthesia
The dental complications of anesthetic care are varied, usu-
ally minor, but a frequent source of malpractice claims. Most
minor injuries are settled without going through malprac-
tice litigation. The incidence of periperative dental injury is
based on retrospective data and varies from 0.02% to 0.05%
(Lockhart et al., 1986; Warner et al., 1999; Newland et al.,
2007). In one study of a large tertiary medical center, the fre-
quency of perianesthetic dental trauma requiring repair, stabi-
lization, or removal of the tooth was approximately 1 in 4500
cases (Warner et al., 1999). Nevertheless, the anesthesiologist
must be aware of the potential pitfalls and take appropriate
safeguards. If a dental complication of anesthesia does occur,
a dental consultation should be obtained as soon as possible.
Also, the chief of the anesthesia department, the hospital’s risk
manager, and the patient’s family should be notified. Patients
old enough to understand what has transpired should also be
informed.
The neonate is not immune from the dental complications of
anesthesia. Laryngoscopy of the neonatal oral cavity may result
in excoriation or laceration of the gum pads. Unilateral right- or
left-sided hypoplastic enamel defects may be seen in the primary
maxillary incisors as a result of laryngoscopy during the neona-
tal period (Angelos et al., 1989). Oropharyngeal airways, as well
as suction devices, may also cause lacerations or excoriation of
the intraoral soft tissues. Prophylactic use of water-soluble lubri-
cants or saline solution applied to any of  these devices before
their placement reduces the likelihood of intraoral trauma.
Many children and their parents are aware of loose primary
teeth during the preoperative visit. However, a careful examina-
tion, including a mobility check of each primary tooth before
induction of general anesthesia, is appropriate (Maxwell et al.,
1994).
If an excessively loose primary tooth is noted during the
exfoliative phase, the parents should be informed, and it may
be safely removed by the anesthesiologist once general anes-
thesia has been induced. In this increasingly litigious society,
a separate, written consent may be necessary for removal of the
loose primary tooth by the anesthesiologist. A gauze barrier
is placed lingually to prevent inadvertent introduction of the

tooth into more distal locations in the respiratory or gastroin-
testinal tract. Subsequently, a second gauze is wrapped around
the loose tooth to be extracted. With a twisting and snapping
action, the tooth is easily removed. The tooth is usually missing
most or all of its root structure. The reason for the root struc-
ture loss is the natural resorptive processes that occur from the
underlying permanent tooth that is beginning to erupt. If some
of the root structure remains in the extraction site, no attempt
should be made to retrieve it. The retrieval process may cause
damage to the erupting permanent tooth bud. Also, the remain-
ing root fragment naturally and harmlessly sequesters into the
oral cavity (Herlich et al., 1996).
Conditions that may predispose the pediatric patient to
dental avulsions under general anesthetic conditions include
the scissors-like action of the anesthesiologist’s fingers in the
mouth opening before laryngoscopy. If this maneuver is accom-
plished using the incisors, the likelihood of inadvertent avulsion
is increased. The mouth-opening maneuvers should be accom-
plished by using the molars whenever possible to take advantage
of their inherent dental stability as well as to effect the largest
opening possible. The use of oropharyngeal airways in the pedi-
atric or adult patient as a bite block should be avoided for simi-
lar reasons. The anterior teeth are single rooted. If the patient
closes the mouth with excessive force, the force transmitted by
the tooth is essentially perpendicular to the airway and leads
to increased risk of avulsion or fracture. The ideal technique
uses gauze bite blocks with a long retrieval tag placed along the
molar teeth. The forces are now directed toward softer mate-
rial and the multirooted molar teeth, which are more likely to
sustain and evenly disperse the vertical, shear forces (Herlich,
1990; Herlich et al., 1996).
The inadvertent avulsion of loose primary teeth may never-
theless be unavoidable during airway manipulations. If a pri-
mary tooth is avulsed, it is imperative that it be retrieved. The
tooth is usually found elsewhere in the mouth or outside of the
oral cavity. It may also be found on the patient’s gown or bed
sheets or on the floor. If it cannot be located in these likely
places, anteroposterior and lateral thoracoabdominal radio-
graphs are necessary to locate the tooth. If the tooth is found
in the digestive tract, it should pass without incident within
several days. If the tooth is found in the tracheobronchial tree,
however, it must be retrieved by whatever means necessary,
including thoracotomy. The sequelae of leaving a foreign body
in the tracheobronchial tree are extremely dangerous (Herlich,
1990; Herlich et al., 1996).
If a primary tooth was lost and then retrieved, it should not
be reimplanted. Such attempts are usually futile because of its
advanced root resorption before exfoliation. Reimplantation
of a primary tooth may also cause significant damage to the
underlying permanent tooth bud. However, if the avulsed tooth
is a permanent tooth and morphologically intact, attempts
should be made to reimplant it as soon as possible. The suc-
cess of dental reimplantation depends on early reimplanta-
tion. Because the periodontal ligament has remnants attached
to the tooth that are crucial to the success of reimplantation,
the avulsed tooth should not be scrubbed with any material.
Ideal preparation consists of gentle rinsing of the tooth in cool
physiologic saline solution to remove crude debris and gross
clots. Then the tooth should be placed in a cool saline-soaked
gauze pad until a dentist can reimplant it, either in the oper-
ating room or as early as possible during the postoperative
period.
C h a p t e r 32    Anesthesia for Pediatric Dentistry   1039
Reimplantation also includes splinting of the tooth to one or
two adjacent teeth on each side of the reimplanted tooth to con-
fer stability. Despite early reimplantation, failures exist and may
necessitate root canal therapy or extraction at an unspecified
later date. The time course of reimplantation failure is unpre-
dictable (Herlich, 1990), but if reimplantation occurs within
30 minutes, success may be as high as 90% (Kainuma et al.,
1996).
Pediatric dentistry has made many advances to conserve
tooth structure and space if deciduous teeth are lost pre-
maturely. Various polymer and metal crown structures may
be bonded or cemented in place. Normal intraoral forces
or untoward unnatural forces may cause these prosthetic
devices to be loosened or avulsed during airway manipula-
tions. For the most part, they may be easily recemented or
bonded postoperatively. Most hospital dental consultants are
able to rebond or recement these prostheses in place without
difficulty.
Interceptive orthodontic appliances, such as mandibular
lingual arch wires or maxillary segmental orthodontic wires,
or both, are bonded by brackets to the teeth. These appliances
may become loosened or avulsed during airway maneuvers.
Like other prosthetic devices, they may also be recemented or
bonded postoperatively with little harm to the patient or denti-
tion (Herlich, 1990).
In general, a thorough preoperative history and examina-
tion and prudent warnings to the parent reduce dissatisfaction
when inadvertent dental complications do occur. Congenital
craniofacial anomalies, such as palatal clefts, mandibulofa-
cial dysostosis (Treacher Collins syndrome), Pierre Robin
sequence, and hemifacial microsomia, may indeed increase
the likelihood of dental complications because of intubation
difficulties. Congenital dental anomalies, such as amelogen-
esis imperfecta or dentinogenesis imperfecta, may subject the
patient to dental fracture with even the most trivial airway
manipulations.
Acquired dental problems, such as milk-bottle caries syn-
drome, occur on the lingual surfaces of teeth in children
who are regularly put to bed with a bottle of milk, formula,
or glucose water. These carious lesions tend to require exten-
sive pediatric dental rehabilitation in very young patients for
whom prolonged dental visits are not feasible. As mentioned,
those lesions may also be subject to the dental complications
of anesthesia.
Pharmacologic agents such as oncologic chemotherapy,
chronic inhaled or systemic steroids, diphenylhydantoin, and
nifedipine may also cause intraoral or dental damage. A child
with a blood dyscrasia or one who has had head and neck radio-
therapy may also be subject to dental complications of anesthe-
sia. Blood dyscrasias predispose the child to increased intraoral
hemorrhage even during daily oral hygiene activities such as
tooth brushing.
Head and neck radiation result in significant xerostomia
(dry mouth) because of the destruction of the salivary glands.
Because normal salivary flow has been eliminated, these chil-
dren are at a very high risk for cervical (gumline) caries and
possible dental complications during anesthesia. Regardless of
the severity or nature of the injury, any head, neck, and oral
trauma may predispose a patient to dental complications of
anesthesia. With proper planning and care, the patient will
have fewer and less severe dental complications (Herlich et al.,
1996).
1040   P a r t  III    Clinical Management of Specialized Surgical Problems
SUMMARY
A diverse and potentially challenging pediatric population
requires dental care. For the most part, the dental needs of
children are largely unappreciated by physicians, short of their
personal experience in the dental chair. This chapter addresses
dental issues from the viewpoint of anatomy, physiology, and
dental growth and development. The dentist’s needs and tech-
nical refinements are elaborated to prepare the anesthesiolo-
gist to deal with the spectrum of dental procedures. Particular
attention is paid to the behavioral and physiologic needs of the
pediatric dental population. Nonpharmacologic, pharmaco-
logic, and practical technical strategies are suggested for both
the dental operatory and the operating room settings. The pit-
falls and complications of each anesthetic technique are given
to reduce the learning curve and the anesthesiologist’s anxi-
ety when problems do arise, as well as to provide a background
for future clinical research. Gentleness and understanding
of the pediatric dental patient are required to meet the chal-
lenges facing the anesthesiologist and to ultimately improve
patient care.
For questions and answers on topics in this chapter, go to
“Chapter Questions” at www.expertconsult.com.
R eferences
Complete references used in this text can be found online at
www.expertconsult.com.