Chapter 14

The Use of General Anesthesia in Behavior Management

Marcio A. da Fonseca

Travis Nelson

Most children can receive dental treatment through non-pharmacologic behavior management. However, some may benefit from pharmacologic adjuncts, such as general anesthesia (GA). GA is defined as a controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation and verbal commands (American Academy of Pediatric Dentistry 2012). It does not require cooperation from the patient, and thus may be desirable in select cases (Table 14-1). GA allows delivery of dental care in a way that protects the developing psyche and promotes the establishment of a lifelong therapeutic relationship (Nelson 2013).

Dentists feel that today’s children exhibit more challenging behaviors than in the past, which has created an increased demand for advanced behavior management, such as sedation and GA (Casamassimo et al. 2002, Wilson 2004). In a 2004 US study, 38% of pediatric dentists reported using GA services more often than they did in the previous five years, and 31% indicated that they would likely increase its use in the near future (Adair et al. 2004). Similarly, a recent retrospective study of specialty pediatric dental care in Sweden showed that the percentage of patients treated under GA has nearly doubled over the past twenty-five years (Klingberg et al. 2010). GA used to be one of the least desirable behavior management techniques, but over time parents have come to exhibit high levels of acceptance, with most agreeing to have their child treated in the operating room (OR) again if necessary (Savanheimo et al. 2005, Eaton et al. 2005, Amin et al. 2006). However, some parents may struggle to accept GA for their child’s dental care, blaming themselves for placing the child at such risk (Amin et al. 2006). When the original edition of this book was published, GA for dentistry was mostly done as an in-patient hospital procedure. In developed countries, procedures under GA can now be safely accomplished at an outpatient surgical facility or a dental office, leading to a short recovery period, no overnight stay, and lower costs than in a hospital. However, in many countries GA is not performed outside the OR due to regulatory practices (Wilson and Alcaino 2011). The increased acceptance of dental care under GA may be explained by the public’s familiarity with surgery provided on an outpatient basis. To accommodate this shift in practice, it is not uncommon to find dental anesthesiologists (i.e., dentists who have received formal training in anesthesiology) and nurse anesthetists working in the United States (Hicks et al. 2012). Unfortunately, patients from low- and middle-income countries face significant financial, cultural and structural barriers to access GA services, including distance to a surgical center; poor roads; lack of transportation; lack of facilities, equipment, and expertise; direct and indirect costs related to surgical care; and fear of undergoing GA (Grimes et al. 2011).

Although the use of GA is mostly uneventful, it is associated with greater morbidity and mortality than provision of dental care under local anesthetic (LA) or minimal sedation. Complications may include sore throat (14–64%), nausea and vomiting (20–30%), damage to the teeth (6.9%), and conscious awareness during the procedure (0.1–0.7%) (Jenkins and Baker 2003). Sleeping irregularities, vomiting, disruption of bodily functions, diarrhea, sore throat, bleeding, and mild to moderate pain are usually not significant enough to warrant medical attention (Mayeda and Wilson 2009), with most patients returning to their normal behavior within 24 hours (Needleman et al. 2008, Mayeda and Wilson 2009, Costa et al. 2011). For healthy individuals, the chance of death solely related to GA is estimated at approximately 1:100,000, increasing 5–10 times for high-risk patients and for emergency surgery (Jenkins and Baker 2003).

Table 14-1. Indications and Contraindications for GA. Copyright © 2012 American Academy of Pediatric Dentistry and reproduced with their permission.

Preoperative Considerations

Informed Consent

When preparing a family for GA, it is important to ensure that caregivers have enough information to make informed decisions. The dentist can facilitate this process through informed consent (IC). Unfortunately, studies of IC for GA show that parents often feel they are not adequately informed of its risks (Patel 2004, Shahid et al. 2008). In societies with a large influx of immigrants, cultural influences and language fluency must be taken into consideration when obtaining consent. Trained interpreters who have an understanding of cultural norms are very helpful in these situations. Family members, especially children, should not be used as interpreters. When children interpret, there is a reversal of power between them and their caretakers. Family members may also choose not to translate sensitive information, leading to potentially serious misunderstandings. It is crucial that the IC form and the pre-operative instruction paperwork be written in the language spoken by the legal guardians. Although IC must be obtained from an adult in pediatric dentistry, it is important to consider the child’s participation, or assent, in the process. Children between the ages of eight and thirteen years have shown a desire to be involved in discussions regarding their care and are highly satisfied with the treatment they receive when they are involved (Adewumi et al. 2001).

History And Physical Examination

To prevent problems during the delivery of GA, the dentist must gather a detailed medical history for the child and decide which venue is appropriate for the surgery, given the patient’s health status. For example, if the child is healthy, then dental care under GA is safe to be carried out at an outpatient facility. If the child has severe systemic disease, treatment should be done where there is ample and immediate medical care available to support an emergency situation. All patients must undergo a history and physical examination (H&P) within thirty days of the procedure. For healthy children, it is not uncommon to have the exam done by the anesthesiologist on the day of the surgery. Given their higher risk for complications, patients with special health care needs should have the H&P done by a physician who is thoroughly familiar with their health issues. It is imperative that the dentist discuss concerns related to the delivery of dental care with the physician and the anesthesiologist to anticipate complications (e.g., bleeding in a child with hemophilia). To facilitate comprehensive planning, many hospitals have a pre-anesthesia evaluation service in which all involved parts are consulted so that the patient, family, physicians, anesthesia care team, and dentist understand how the child will be cared for.

Preoperative Pain Management

Pediatric patients experience pain with equal or greater intensity as their adult counterparts (Cramton and Gruchala 2012). Dentists should educate themselves on accurate assessment of pain, as well as pharmacologic and non-pharmacologic methods of pain management. When that is not adequate, the child may suffer long-term consequences regarding future pain reactions (Cramton and Gruchala 2012).

A substantial percentage of children may experience moderate pain or worse following procedures under GA. Even though post-operative pain is the most common parental concern, many patients do not receive adequate analgesia (American Academy of Pediatrics 2001, Atan et al. 2004). Health care professionals and parents under-medicate children post-operatively, often due to misconceptions (Rony et al. 2010, Cramton and Gruchala 2012). Socio-economic status also seems to influence pain perception, with parents who have less education being more likely to report post-procedural pain for their children (Needleman et al. 2008). Therefore, good post-operative pain control starts before surgery. Providing tailored interventions to improve a caretaker’s knowledge of analgesia at an earlier stage and allowing ample time for discussion may improve parental attitude (Rony et al. 2010, Jensen 2012).

Preoperative Child Anxiety

Although GA is typically a humane and effective way to provide dental care, the surgical experience may have a negative psychological effect on some children. Between 50% and 75% of pediatric patients who undergo ambulatory surgery in the United States each year experience significant fear and anxiety (Kain et al. 1996c, Kotiniemi et al. 1997, Tzong et al. 2012). Thus, the anesthesia care team should anticipate and treat anxiety as part of the OR experience.

Preoperative fear may result from a child’s concerns about separation, pain, disfigurement, loss of loved ones, and loss of control or autonomy. Alterations of the family’s routine, wearing unfamiliar clothing (i.e, surgical gowns), and experiencing unknown equipment, sights, sounds, and smells also increase stress (Justus et al. 2006). Anxiety frequently causes resistance to the anesthesia mask, prolongs induction, and may require physical restraint of the child. Children may have specific fears of the mask (e.g., inability to breathe, claustrophobia, concerns about dying or not waking up), aversion (dislike of the feel or odor of the mask), and/or a true phobia (an irrational fear of the mask) (Przybylo et al. 2005, Aydin et al. 2008). Furthermore, a complex interplay of genetic and environmental influences determines how each child will respond to the OR experience. Shyness, passive coping style, high baseline anxiety, high parental anxiety, previous upsetting surgical experiences, and male gender are factors associated with anxiety and disruptive behavior in relation to the GA visit (Melamed et al. 1988, Quinonez et al. 1997, Kain et al. 2000b). Age should also be considered, as children between the ages of one and five years appear to be at highest risk for developing significant anxiety before surgery (Lumley et al. 1993, Kain et al. 1996b, c).

Other factors that may contribute to increased levels of anxiety include many people present during induction, a long waiting time between arrival at the facility and induction, having a mother who does not practice a religion, and negative memories of hospital experiences (Wollin et al. 2003). Playing at home with an anesthesia mask was shown to relieve mask-related anxiety, improving its acceptance and shortening the induction period (Aydin et al. 2008).

Preoperative Pharmacological Interventions to Reduce Anxiety

Induction of anesthesia appears to be the most stressful point of the entire GA experience (Kain et al. 1996c, Kain et al. 1998). Up to 25% of children cry, scream, try to avoid the anesthesia mask, and/or require restraint (Lumley et al. 1993, Kain et al. 1999). The principal pharmacological approach to facilitate induction of fearful patients is the use of sedative premedication. While other agents are available, midazolam is the most extensively researched pre-induction sedative, showing an effective anxiety reduction in the one to ten year age group, especially the most anxious children (Kain et al. 2004). It may also cause amnesia, which is desirable should the induction prove to be difficult (Stewart et al. 2006). However, a paradoxical negative response to midazolam may occur, especially in children with impulsive temperament (Roelofse and Joubert 1990, Wright et al. 2007). Midazolam may also cause delay in anesthetic emergence, recovery, and discharge as well as an increase in anxiety immediately following surgery (Viitanen et al. 1999a, b, Wright et al. 2007).

Preoperative Non-Pharmacological Interventions to Reduce Anxiety

Parental Presence During Induction

The practice of allowing parents to be present for their child’s induction is a highly debated topic. Suggested benefits of parental presence include eliminating separation anxiety, minimizing premedication use, increasing child cooperation, enhancing parental satisfaction, fulfilling parents’ perceived sense of duty to be present, and enhancing parental satisfaction with the medical care provided (Kain et al. 2003, Wright et al. 2007). Anesthesia care teams in the United States have increasingly allowed parental presence at induction (Kain et al. 2004). The presence of a calm parent is typically beneficial for an anxious child, whereas an anxious parent does not improve child behavior (Cameron et al. 1996, Kain et al. 1996a, Kain et al. 2006). Unfortunately, those who most desire to be present have higher levels of anxiety and tend to have more anxious children than parents who are not as interested in participation at induction (Caldwell-Andrews et al. 2005). When provided in the right context, both premedication and parental presence appear to improve child behavior (Kain et al. 1996c, Kain et al. 2000a). However, it should be recognized that some parents may experience unpleasant feelings related to the child’s induction (Mayeda and Wilson 2009).

Preoperative Preparation Programs

The goal of these programs is to provide information for the patient and the caretakers about the process (through OR tours, print materials, audiovisual methods, websites), model the experience (using videos or puppet shows), and teach coping strategies (with Child Life counselors), using age-appropriate language and imagery (Wright et al. 2007). Children who receive these interventions tend to exhibit less pre-surgical anxiety, even upon separation from their parents (Kain and Caldwell-Andrews 2005, Wright et al. 2007). Many factors should be considered when selecting a program, one of the most important being the child’s age. According to Piaget’s theory of cognitive development, children from three to six years (the preoperational stage of development) are not able to think logically: thus, preoperative preparation may have negative effects for them (Brewer et al. 2006). In contrast, children from seven to seventeen years have a strong desire for and benefit from comprehensive information, including details on post-operative pain (Kain et al. 1996b, Fortier et al. 2009). Timing of preparation is also important– the patient must be allowed to adequately process what was discussed. Children younger than six years should receive preparation no more than one week in advance, while older children benefit most if they are given information more than five days before surgery (Perry et al. 2012). Children with a history of surgical procedures who did not benefit from modeling and play programs should be enrolled in programs that teach coping skills before their next GA procedure (Kain et al. 1996b, Kain et al. 2005).

Parental anxiety is a significant risk factor for child anxiety; thus, caretakers should also receive pre-operative information. Preparation may be even more critical in day surgery than for inpatient procedures. Parents whose children will have outpatient surgery experience greater anxiety because the surgery unit provides little time to become accustomed to its environment (Mishel 1983). Caretakers who participate in pre-surgical programs exhibit decreased anxiety and show higher levels of satisfaction with the overall quality of care (Chan and Molassiotis 2002, Felder-Puig et al. 2003). Unfortunately, the benefits of these programs do not appear to extend to high-stress periods such as anesthetic induction, recovery, or even at 2 weeks postoperatively (Kain et al. 1996b, Kain and Caldwell-Andrews 2005, Wright et al. 2007).

Preoperative Dental and Surgical Plan

Given the high costs and possible complications of GA, and the fact that most children treated in the OR are high caries risk, an aggressive treatment approach is usually advocated. For example, using stainless steel crowns (SSC) for full coronal coverage in teeth with extensive decalcification should be considered. In dental care under GA, SSCs have a significantly lower failure rate than amalgams, while composites and composite strip crowns have the highest failure (Tate et al. 2002, Al-Eheideb and Herman 2003, Drummond et al. 2004). The tentative treatment plan should consider all potential scenarios, parental compliance with oral care, and longevity of the restorations.

The family must understand that the plan may change on the day of the procedure, particularly if no recent radiographs are available or if there is a long waiting period to schedule the OR visit. All possible treatments should be discussed in detail, including the appearance of the proposed materials, so as not to take the caretakers by surprise after the procedure is complete. For example, if crowns are planned for the maxillary primary incisors, it is wise to make the family aware that the teeth may need to be extracted if they are found to be abscessed or if too little tooth structure remains after caries removal. Additionally, financial issues, such as the potential need for pre-authorization from the medical and dental insurance companies, must be addressed.

Preoperative Call to the Family

A few days before the patient’s scheduled appointment, a staff person from the surgery center will call the family to discuss the plan for the day. Preoperative fasting guidelines (Table 14-2) should be discussed in detail both verbally and in writing (Apfelbaum et al. 2011). Fasting is crucial to reduce the severity of complications related to perioperative pulmonary aspiration of gastric content, to avoid delays or cancellation of the procedure, to decrease risk of dehydration or hypoglycemia from prolonged fasting, and to minimize perioperative morbidity such as aspiration pneumonia and respiratory disabilities (Apfelbaum et al. 2011).The time and location of the appointment, and payment and surgical pre-authorization information should also be reviewed. If the H&P was to be performed by a physician prior to the day of surgery, it is important to verify that the documentation clearing the patient for GA has been received. A second change of clothes should be brought in case the child soils those he is wearing. If the parent is planning to drive, a second adult should accompany them to ensure the child’s safety on the way home. Patients who have been sedated are at risk for post-procedural airway blockage and loss of head-righting reflex (Martinez and Wilson 2006), so the child should lie on the side in the car instead of on the back to avoid aspiration of gastric contents in case of vomiting. With a second adult present to assist the child, the driver can focus on the road.

Table 14-2. Pre-operative Fasting Recommendations for Healthy Patients Undergoing Elective Procedures (Apfelbaum et al. 2011). Reproduced with permission from Lippincott Williams & Wilkins.

*Water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.

**Typically consists of toast and clear liquids.

Perioperative Considerations

Upon arrival at the surgical facility, the child is given an identification bracelet. Some surgical centers will give the child a surgical gown, while others allow the child to be induced in their own clothes. A staff person, usually a nurse, takes the vital signs, height, and weight, and inquires about fasting and whether anything has changed since the H&P was completed, such as recent colds or asthma attacks. If the patient has a fever, wheezing, cough, runny nose, or has been exposed to a contagious or infective disease, the procedure may be cancelled. If the patient has violated the fasting recommendations, the procedure may be either cancelled or postponed to a later time on the same day to allow for emptying of gastric contents.

Once the admission assessment is complete, the anesthesiologist meets with the family in order to:

After the anesthesia evaluation, the pre-operative sedative (if warranted) is ordered for the nurse to administer right away. The dentist then meets with the family and child to review the preliminary treatment plan. Once all questions are clarified, the dental consent form can be signed. Questions about post-operative diet and dental pain management can be deferred until after the treatment is completed. Many parents inquire about whether the dentist will come out to discuss the clinical findings before starting the procedure. To keep the child under GA for the least amount of time to decrease risks and costs, it is better to do so only if there is an unusual finding that may alter the treatment plan significantly or if further consent is necessary. A pre-operative progress note should be written in the patient’s chart, documenting the encounter.

Intraoperative Considerations

The patient is brought into the OR, where identification is checked again. After GA induction, which is most commonly done with a facial mask, is completed, the caretaker is escorted out, padding is placed under pressure points, the patient is secured on the operating bed with safety straps, and an IV line is established for fluid maintenance. The most common calculation used />

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