CHAPTER 15 Hospital Dental Services for Children and the Use of General Anesthesia
Dentists can provide essential services to patients within an operating room setting in addition to providing consultative and emergency services. Staff membership is necessary. National commissions such as the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) issue the standards for hospital governance for all hospital services.
In recent years, with the increasing number of general practice residencies and postdoctoral specialty programs, the qualified dentist finds that hospital staff privileges are a necessity. Active involvement in hospital dentistry has added a rewarding component to the practice of many dentists. Many hospitals have incorporated not only dental specialties but also general dental services, providing a comprehensive health care facility in which to serve the community.
Additional requirements may have to be met to obtain staff privileges. Many hospitals ask staff members to sign a “Delineation of Privileges” form indicating the procedures that staff members are qualified to perform and that are accepted by the governing body of the hospital. In addition, the applicant must show proof of professional liability insurance, and membership in the American Dental Association is desirable.
In a children’s hospital, dentists might be required to have adequate advanced training to treat and manage children in the hospital. The requirements may include a dental residency of 1 to 4 years in a teaching hospital in which the dentist (1) gains experience in recording and evaluating the medical history and current medical status of children; (2) receives instruction in physical examination techniques and in recognition of conditions that may influence dental treatment decisions; (3) learns to initiate appropriate medical consultations when a problem arises during treatment; (4) learns the procedure for admitting, monitoring, and discharging children; and (5) develops proficiency in operating room protocol. A rotation in which the dental resident was actively involved in administering general anesthetics to children is highly desirable. Current certification in basic cardiopulmonary resuscitation should be maintained by all members of the hospital’s professional staff, including dentists.
As active members of the hospital staff, dentists should be aware of the hospital’s bylaws, rules, regulations, and meetings. A copy of the bylaws should be obtained for easy reference. Fully understanding the responsibilities of staff membership will enable dentists to treat their patients within the established protocol of the institution. Most important, dentists should endeavor to provide the highest quality care within the specialty area for which they are trained. The American Academy of Pediatric Dentistry encourages the participation of pediatric dentistry practitioners on hospital medical-dental staffs, recognizes the American Dental Association as a corporate member of the Joint Commission, and encourages hospital member pediatric dentists to maintain strict adherence to the rules and regulations of the policies of the hospital medical staff.
The use of general anesthesia for dental care in children is sometimes necessary to provide safe, efficient, and effective care. Depending on the patient, this will be done in an ambulatory care setting or inpatient hospital setting. It should be only one component of the dentist’s overall treatment regimen. Oral hygiene and preventive care must be implemented at the onset of treatment with parents or guardians and patients to eliminate the cause of the dental problem.
The safety of the patient and practitioner, as well as the need to diagnose and treat, must justify the use of general anesthesia. All available management techniques, including acceptable restraints and sedation, should be considered before the decision is made to use a general anesthetic. Crespi and Friedman cite several authors who agree in recommending that at least one or two attempts be made using conventional behavior management techniques or conscious sedation before general anesthesia is considered.1
Parental or guardian written consent must be obtained before the use of general anesthesia. Documentation regarding dental treatment needs, unmanageability in the dental setting, and contributory medical problems must be included in the patient’s hospital record. Records must be clearly written so others are able to read and understand them. Review organizations examine dental admissions for proper documentation in the hospital chart for insurance payment and quality assurance purposes.
If the benefits of the procedure outweigh the risk of anesthesia, there are few if any contraindications to general anesthesia. However, when a concern about the medical condition exists, an anesthesia consult would be desirable. Patients for whom general anesthesia is usually contraindicated include those with a medical contraindication to general anesthesia and healthy and cooperative patients with minimal dental needs.
Hospitalization is a frequent source of anxiety for children. According to King and Nielson, 20% to 50% of children demonstrate some degree of behavioral change after hospitalization.2 Separation of the child from the parent appears to be a significant factor in post-hospitalization anxiety, although other causes are also documented. Allowing the parent to stay with the child during the hospitalization, and especially to be present when the child leaves for and returns from surgery, can reduce anxiety for the child and parent alike.
According to Camm and colleagues, postoperative behavioral changes reported by mothers in a limited sample of children who received dental treatment with general anesthesia in a hospital were similar to those observed in children who received treatment under conscious sedation in a dental clinic.3 Mothers of children receiving dental treatment with general anesthesia in a hospital setting were found to experience more stress during the procedure. Ways to decrease these stresses include the following: providing a prior tour of the operating room facility, informing the parents of the status of the child during the procedure, and letting them know that “everything is all right.” Seventy-five percent of the children receiving general anesthesia exhibited some type of behavioral change. Positive changes included less fuss about eating, fewer temper tantrums, and better appetite. Negative changes included biting the fingernails, becoming upset when left alone, being more cautious or avoiding new things, staying with the parent more, needing more attention, and being afraid of the dark. Ways to minimize negative changes include (1) involving the child in the operating room tour, (2) allowing the child to bring along a favorite doll or toy, (3) giving preinduction sedation, (4) providing a nonthreatening environment, (5) giving postprocedure sedation as needed, and (6) allowing parents to rejoin their children as early as possible in the recovery area.
To limit the severity and duration of psychologic disturbances, the dentist should strive to reduce parental apprehension concerning the operative procedure. Because children often sense apprehension in their parents, effectively reducing the parents’ anxiety will put the child more at ease. Thoroughly explaining the procedure, describing the normal postanesthetic side effects, and familiarizing the child and parents with the hospital can reduce postoperative anxiety.
Peretz and colleagues concluded that children treated for early childhood caries under general anesthesia or under conscious sedation at a very young age behaved similarly or better in a follow-up examination approximately 14 months after treatment than at their pretreatment visit, as measured by the Frankl scale and by the “sitting pattern.”4
Fuhrer and colleagues found children were more likely to exhibit positive behavior at their 6-month recall appointment following dental treatment for childhood caries under general anesthesia versus those treated under oral conscious sedation.5
During the past 30 years, the popularity of outpatient anesthesia and surgery has continually increased. Currently more than 70% of all pediatric surgical and diagnostic procedures are performed on an outpatient basis. The criteria for and advantages of ambulatory general anesthesia procedures are well recognized. The increasing cost of inpatient hospital care, advances in anesthetic management, and quality assessment of patient care have led to changes in preoperative and postoperative management of many surgical procedures done under general anesthesia that were previously assumed to be possible only on an inpatient basis. Ambulatory care is more expeditious, better tolerated both by family and hospital teams, and less traumatic for the patient. Development of freestanding ambulatory care surgical centers (i.e., same-day surgery centers) and hospital ambulatory surgical care areas has cut health care costs for consumers and third-party providers. The advances in perioperative anesthesia care are related to the wider availability of more highly qualified anesthesia care providers (board-certified anesthesiologists with subspecialty training) and the availability of modern, safer short-acting anesthetic and adjuvant drugs and monitoring equipment. A number of studies have reported a significant decrease in anesthesia-related morbidity and mortality in children over the past 2 decades.
Good patient selection is an important criterion of a successful outpatient surgery program. A young child or adolescent who requires a general anesthetic and is free of any significant medical disorders (i.e., is categorized as class I or II on the American Society of Anesthesiologists (ASA) physical status classification—see Box 14-1) can be considered a candidate for outpatient surgery. Certain patients with well-controlled chronic systemic diseases such as asthma, diabetes, and congenital heart disease can also be considered for outpatient anesthesia following prior consultation with an anesthesiologist.
When the outpatient surgery is planned, the child undergoes a complete preoperative evaluation, including a comprehensive medical history and physical examination, anesthesia assessment, and limited hematologic evaluation. Many medical facilities allow this preadmission preparation to be performed outside of the medical outpatient treatment facility. Biery and associates suggest that routine laboratory tests, such as urinalysis and complete blood count with indices and electrolyte levels, are not cost effective nor are they necessary for patients categorized as ASA class I in whom the prior complete medical history and physical examination was unremarkable.6
As an outpatient, the child should be brought by the parents to the hospital at least 1½ hours before the dental surgery. The nursing staff will verify that all preoperative instructions have been followed and that the appropriate laboratory tests have been performed. Several hours after the procedure is completed, the patient is released to the parent or guardian. Postoperative instructions are given, and a follow-up appointment is scheduled.
The dentist will be more responsible for team communication, physical assessment, management, and postoperative evaluation for outpatient procedures under general anesthesia than for inpatient procedures. Ferretti reported that pediatric outpatient general anesthesia patients must have reliable parents or guardians to qualify for treatment.7 For example, the parents must have transportation available to return the child to the hospital in case postoperative complications develop at home.
The child should be treated as an inpatient if a medical condition exists that requires close follow-up, if the child lives outside the general area of the hospital, or if the parents demonstrate questionable ability to comply with preoperative or postoperative instructions. In many instances, medically or developmentally disabled patients with multiple problems requiring lengthy dental treatment are not good candidates for ambulatory care using general anesthesia. However, even some of these patients can be managed in an ambulatory setting when they are properly assessed and when no postoperative complications are anticipated.
Once the decision has been made that a general anesthetic would be preferable for a pediatric patient, the dentist should evaluate the child’s medical history, the current medical status, and the possibility of complications resulting from the procedure. This risk assessment process is discussed in Chapter 14, and the patientclassification categories are shown in Box 14-1. The parents should be told of any potential complications, and their informed consent must be obtained (Fig. 15-1).474
Intraoperative medical complications of dental patients with and without disabilities undergoing general anesthesia have been reported at 0% to 1.4%. In a survey of 200 pediatric dental general anesthesia cases, Enger and Mourino indicated that the most common postoperative complications following general anesthesia in children younger than the age of 5 years were vomiting, fever, and sore throat.8 Treatment of complications consisted of administration of antiemetic medications for nausea with vomiting, ice chips for sore throat, and acetaminophen (Tylenol) for fever postoperatively. Bradley and Lynch found that no significant long-term complications resulting from anesthesia or operative procedures were observed in 100 disabled and nondisabled patients.9
The Joint Commission requires that all patients admitted to a hospital or treated under general anesthesia as an outpatient have a physical examination performed by a physician or qualified dentist. The child’s physician must therefore be consulted for the completion of a comprehensive medical history and physical examination (Box 15-1). If the physician is not a member of the hospital staff, a staff physician should complete the medical history and physical examination before admission. The dentist should perform a thorough intraoral examination and submit a record of the findings together with a summary of the child’s dental history and the reason for admission (Box 15-2). The hospital must be notified to reserve an appropriate surgical suite and a bed for the child. Two weeks before admission or an outpatient dental surgery appointment, a letter containing general instructions concerning the procedure, results of the dental examination, and pertinent dates and times should be mailed to the parents.