Hospital dentistry/general anesthesia
WHEN IS IT NECESSARY?
The continuum of dental care delivery ranges from being treated in a routine dental office setting with no anesthesia to being treated at a hospital with general anesthesia. The purpose of this chapter is to help demystify the question of “When is general anesthesia necessary?” by reviewing the concerns for the patient who is being considered for general anesthesia from a medical and dental perspective.
General anesthesia is considered when the most conservative options have been explored and the benefits of anesthesia outweigh the risks. Safety for the patient and dental team along with consideration of overall health benefits are the focus of the decision. General anesthesia is usually performed either in a surgery center or hospital. Hospitals have the advantage of providing an option of inpatient or outpatient settings, whereas most surgery centers offer only outpatient care. Outpatient surgery is common for most patients unless significant medical concerns or chronic medical conditions are in question. Not all hospitals have dental services or have dentists with operating room privileges. There is rapid growth in the need for safe and high-quality office-based anesthesia. To meet these needs, a special set of skills is required, which may require expanded exposure and experience during training (Perrott 2008; Wong 2010).
There should be a justified medical and dental rationale for seeking dentistry under general anesthesia. Medical complexity, physical limitations, and neurologic and psychological considerations are some of the common reasons for admissions. A suspicion of dental pathology that may exist or a prolonged period of undetermined oral condition would be a reasonable concern.
There is still a great need for more studies to assess the risk versus benefit for patients with developmental disorders and to stratify such risk in order to assist care providers in decision making as well as in sharing such risk concerns with patients, caretakers, and guardians (Messieha 2009). Most dental cases seen in the operating room are considered elective. The dental case only becomes emergent when the dental pathology is severe and the spread of infection is imminent and negatively contributes to the patient’s health and is possibly life threatening.
The term “hospital dentistry” is described as dentists that perform routine dentistry in a hospital clinic, dentists that consult bedside, and/or dentists that provide dentistry in the operating room.
In this chapter, we will focus on the definition of the term “hospital dentistry” as requiring general anesthesia in the operating room. The dental services that hospital dentistry provides can range from only extractions to all phases of dental disciplines including limited orthodontics, fixed prosthodontics, and endodontics. If planned in advance, additional necessary medical procedures can be combined during the time of general anesthesia. Routine medical procedures such as blood work, chemistry levels, ear exams, eye exams, gynecological exams, chest x-rays, cardioversions (shocking of the heart to return to normal synchronization), and podiatric procedures are just some of the medical procedures that can be done if the facility and the physician services are offered for the patient who cannot cooperate. It would be best to explore these options well in advance.
Medical necessity can encompass acquired and congenital medical diagnoses, physical limitations, emotional limitations, and physical limitations and/or developmental disabilities that make cooperation difficult. It is important to emphasize that not all patients with developmental disabilities (DDs), neurodevelopmental disabilities (NDs), or intellectual disabilities (IDs) need to be seen in the hospital. Once convinced that it would be safer to treat the patient under general anesthesia, the dentist concentrates on the dental needs, the intricacy of the procedures, and the amount of work that needs to be done. The choices of the appropriate hospital and anesthesia are then considered and selected.
For patients who cannot verbalize their oral condition, they may exhibit their concerns in changes in mood or changes in eating patterns. This patient may be more aggressive or more guarded in an area where there is some dental pathology. Fevers of unknown origin, bleeding from the mouth, or swelling of the face could be clues to an oral concern.
A preliminary oral pathology list is derived and carefully evaluated. An important aspect of diagnosing pathology is the question of etiology with respect to physiologic and biologic factors. How did the cavity or concern develop? Was it from neglect, or did the medical diagnosis/medications accentuate the spread of dental caries and periodontitis?
One of the important concerns is the oral condition secondary to medication and the treatment of the medical diagnosis. What predisposing factors can be mitigated to improve the final outcome? The caries risk assessment and the strategies for lowering risk are essential so that proper choices in treatment options are considered.
Ideally, a complete oral examination and dental radiographs are obtained, if the patient can tolerate them, prior to the operation. In cases where the patient is not cooperative for evaluation, oral sedation may be considered. Oral sedation should be discussed with the primary care provider if the patient is taking multiple medications. Patients with acute symptoms such as pain, swelling, and bleeding should have a greater urgency when scheduling as opposed to a case for a routine checkup. The amount of dental work and sophistication of the work needed will affect the amount of time needed and requested in the operating room (Wong 2009).
There are no absolute limitations to how many times a person can have general anesthesia, but it would be advised to lessen the risk of anesthesia by limiting the need for return hospital visits.
For cases that cannot be evaluated properly without deep sedation, the option could be to have sedation for the sole purpose of examination and radiographs and emergent treatment for suspected pathology, with another visit for comprehensive treatment. Having multiple surgeries increases the cost of the hospital cases as well as repeats the anesthesia risks. Of course, there are times when it is necessary to have additional surgery dates if the case is too complex, too lengthy, or additional follow-up procedures are indicated.
A hospital dentist is able to only perform procedures he or she has requested (and has privileges for) and has proven competence to perform. Should procedures be requested or needed that the dentist cannot perform, the dentist must decide whether another dentist with such privileges may be needed to complete the procedure.
Cases can be scheduled either on a first-come, first-served basis or by a triaged system (ranking of needs through clinical identifiers) that schedules based upon urgency (Wong 2009).
Assessing the patient’s understanding of his or her role and the importance of oral care is crucial to the overall treatment plan (Waldman et al. 2008). The patient who is aggressive and will not allow a caregiver or help in his or her oral hygiene does not give great promise for elaborate dental restorative options. A person who is physically unable to brush his or her teeth or floss is also one that does not lead the dentist toward complex dental restorations. Basically, cooperation and attention to care are key to a degree of dental work provided and its longevity. The patient who has physical limitations such as dexterity, limited mouth opening, and difficultly expectorating has additional considerations in terms of treatment options. Some of the challenges can be mitigated with a thorough caregiver’s attention and help.
For those patients who cannot physically maintain their oral health and are dependent upon their caregiver, there are additional concerns. The caregiver must have the understanding and the willingness to follow instructions for a good oral health care regime. If the caregiver is not following the instructions carefully, premature tooth loss can be a consequence.
Education and training for caregivers should become a standard of care early in the first year of life for any child with a developmental delay or any person, regardless of age, who experiences an illness or event that compromises his or her ability to provide self–oral health care (Ferguson & Cinotti 2009). Therefore, the caregiver’s ability to properly care for the mouth is crucial for the overall success of the dental treatment. It is in essence oral care therapy with the emphasis on remineralization of teeth.
The overarching goal of hospital dentistry should be to get the patient restored to optimal oral health and then be followed up with a preventive dentistry plan. The patient who needs hospital dentistry most likely has a high caries risk factor. If the dental caries risk factors are not addressed, the likelihood that the patient would be seen again soon for additional procedures, namely extractions, is great.
When the protective actions of saliva are impaired, the buffering capacity of saliva is reduced and it is unable to adequately neutralize the acids in the mouth. The quality and quantity of saliva is key to minimizing dental caries and extending the life of dental restorations (Featherstone 2004).
Once the hospital dentistry case is completed, the oral pathologies of caries and periodontitis should be corrected and the negative dental biofilm (bacterial plaque) should be neutralized. The hospital dental procedure is just a step in the healing process; the importance of follow-up care cannot be understated. If the biofilm is properly restored to health and a remineralization strategy is employed, the patient can lower his or her caries risk significantly for a longer period of time. Oral biofilm can be treated with int/>