“a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

3. Definition General anesthesia”:
“a drug-induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance
in maintaining a patent airway, and positive-pressure
ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular
function. Cardiovascular function may be impaired.
American Academy of Pediatric Dentistry ( AAPD)

4. Definition General anesthesia”:
American Academy of Pediatric Dentistry ( AAPD)
a drug-induced state loss of consciousness
patients : not arousable (even by painful stimulation)
Ventilatory function : impaired
require positive-pressure ventilation
maintaining a patent airway
Cardiovascular function : impaired.

5. rationale for using general anesthesia in
the behavior management
the medical condition of the patient
• e.g.: need of pre- operative blood transfusion
the child needs extensive dental work
• e.g.: the procedure more safely in the hospital setting
The negative dental behavior

6. provide safe and comprehensive dental care for
the pediatric patient with behavior, medical, or
other problems that preclude treatment in the
office setting by eliminating cognitive, sensory,
and skeletal motor activity in order to facilitate
the delivery of quality comprehensive
diagnostic, restorative, and /or other dental
services.
Goals of General anesthesia”:

7. Goals of General anesthesia”:
• provide safe and comprehensive dental care
• Patients: behavior or medical problems
CANT do treatment in office setting
BY eliminating cognitive + sensory + skeletal
motor activity
delivery of quality comprehensive diagnostic +
restorative dental services

8. Indication of General anesthesia”:
• Patients with certain physical, mental, or medically
compromising conditions.
• Patients whom local anesthesia is ineffective.
• The extremely uncooperative, fearful, anxious,
physically resistant or uncommunicative child.
• Patients who have extensive orofacial and/or dental
trauma
• Patients with immediate comprehensive dental needs.

9. Contraindication of General anesthesia”:
• General anesthesia risk
• Respiratory infection
• Active systemic disease with elevated
temperature
• NPO guideline violation
• A healthy cooperative patient with
minimal dental needs

10. Psychological effects of hospitalization on
children
20 – 50 % of children :
behavior changes after
hospitalization.
Main factor: separation
from parents
Minimize negative behavior:
• Operative room tour.
• Favorite doll.
• Pre-induction sedation.
• Nonthreatening environment.
• Post- procedure sedation.
• Join the parents in the
recovery

11. Selection of Operating Room
Facility
OUT – PATIENT
(day surgery)
IN-PATIENT
(hospital setting)

12. Selection of Operating Room Facility
out –PATIENT ( day- surgery)
Patient
selection
Healthy, ASA I/II
advantages •more efficient
•better tolerated by
family
•more patient
friendly
In-PATIENT (hospital setting)
•ASA III and above
•children from
remote areas with
rampant decay
•questionable
parental
compliance with
pre and post
instructions
•possible need for
24 hours admission
Patient
selection

13. Dental rehabilitation under
GENERAL ANESTHESIA
1. MEDICAL AND DENTAL HISTORY
2. PRE OPERATIVE DENTAL EXMINAITION.
3. PARENTAL CONSULTATION
4. PEDIATRIC CONSULTATION
5. PRE OPERATIVE ANESTHESIA EXAMINATION
6. ONE WEEK BEFORE APPOINTMENT (CONSENT FORM)
7. PREOPERATIVE ORDERS
8. PATIENT ADMISSION
9. EQUIPMENT PREPARATION
10. ANESTHESIA INDUCTION
11. RESTOARTIVE PROCEDURE
12. POST OPERATIVE PROCEDURE
13. DISCHARGE AND FOLLOW UP CARE

14. 1- MEDICAL AND DENTAL HISTORY
Medical and dental history
Family and social history
Chief complain

15. Medical History
1. Disease or abnormalities.
2. Allergies or adverse drug reactions.
3.Current medications, dose, time,route and site
of administration.
4.Previous hospitalization
5.History of general anesthesia or sedations.
6.Family history.
7.Review of body system.
8.Age and body weight.

16. 2-PRE – OPERATIVE DENTAL EXAMNATION
2-Pre- operative dental examination
Clinical
examination
Extra- oral
(head and
neck physical
examination)
Intra- oral
Soft tissue Hard tissue
Radiographic
Examination

17. lips
tongue
Floor of the
mouth
Buccal mucosa
Hard/soft
palate
oropharynx
peridontium
Soft
tissue caries
Eruption
sequence
Occlusion
Hard
tissue

18. 3-PARENTAL CONSULTATION
explain to the parents:
• Discuss the reason/need for G.A
• Risks/benefits with G.A.
• Anticipated post-operative behavior.
• Need for a physical examination
• Need for laboratory tests.
• Need for medical consultation (if indicated).
• Admission process to the hospital/ one day surgery.
• Pre-surgical and post-surgical dietary precautions.

19. 4-PEDIATRIC CONSULTATION
PEDIATRIC CONSULTATION
PEDIATRIC Evaluation
Medical history
Review of body
system
ASA
classification
Request the needed laboratory
investigations
Pediatric
Review of the
laboratory
result

20. ASA Physical Status Classification
System
ASA I A normal healthy patient
ASA II A patient with MILD systemic disease
ASA III A patient with SEVERE systemic disease
ASA IV A patient with SEVERE systemic disease that
is a constant threat to life
ASA V A moribund patient who is not expected to
survive without the operation
ASA VI A declared brain-dead patient whose
organs are being removed for donor
purposes

21. Request the needed laboratory
investigation
CBC,PT,PTT,INR coagulation,
sickle cell screen,
HGsAg
thyroid function tests

22. 5-Pre operative anesthesia examination
 Tonsillar size classification.
The anesthetic recommendation:
• Cleared for the operation after the
pediatric clearance.
• Fasting from the midnight the day
before the surgery
• Preoperative medication (Midazolam)

23. Tonsillar size classification
 Classify +3 (more than 50% pharyngeal area occupied by tonsils)
↑ risk airway obstruction

24. Mallampati classification
Mallampati classification
Class 1: Full visibility of tonsils, uvula
and soft palate
Class 2: Visibility of hard and soft
palate, upper portion of
tonsils and uvula
Class 3: Soft and hard palate and
base of the uvula are visible
Class 4: Only Hard Palate visible

25. 6-ONE WEEK BEFORE APPOINTMENT
 LEGAL CONSENT IS SIGNED
 consent form for blood
transfusion in case of
emergency is signed
 The date of the operation.
 Informed consent
• Verbal and Written.
• wittiness.
• Explain benefits + risks +
alternatives to general
anesthesia.

26. 7 -PREOPERATIVE ORDERS
 Diet description and restrictions
 Laboratory studies needed for
anesthesia and surgery clearance
 Preoperative Medication
 Consultations requests as needed
 Oncall for operating rooms

27. Dietary precautions
 NPO guild line
Ingested Material Minimum Fasting Period (h)
Clear liquids: water, fruit juices
without pulp, carbonated
beverages, clear tea, black
coffee
2
Breast milk 4
Infant formula 6
Nonhuman milk: because
nonhuman milk is similar to solids
in gastric emptying time, the
amount ingested must be
considered when determining an
appropriate fasting period
6
Light meal: 6

28. Diet instructions
1.No milk or solids for 6-8 hours .
2.Clear liquids up to 3hours before
the procedure.

29. Reasons for diet instructions
 Prevent emesis during or
immediately after a sedative
procedure.
 uptake is maximized when the
stomach is empty.

30. 8-PATIENT ADMISSION
Admission order
• admit the patient for dental rehabilitation under
general anesthesia.
• Laboratory investigations.
• History and Physical examination.
• Notify the anesthesiology for pre operative
evaluation.
• Medications.
• consultations

31. 9-EQUIPMENT PREPARATION
Operating room protocol
• Follow occupational safety and health administration
( OSHA) guidelines.
• Standard scrub technique for sterile procedure.
• sterile gown + sterile gloves + protective barriers.
Intra oral dental procedure is a CLAEN procedure rather
than sterile procedure

32. 9-EQUIPMENT PREPARATION

34. Properties of inhalation
anesthesia
• In children;
induce anesthesia
Inhalation of halogenated volatile anesthetic agents
by : Face mask
Effect: depressing specific areas of the brain

35. Anesthetic potency :
Definition Concentration of the
agent required to
inhibit response to a
standard surgical
stimulus.
Measure by : Minimum alveolar
concentration ( MAC)

36. Fine adjustment of anesthetic administration
Made by monitoring the patient`s physiological
response
Heart rate , blood pressure , Respiratory rate

37. stages of
anesthesia
Stage 1
Relative +
total analgesia
Stage 2 Excitement
Stage 3
Surgical
anesthesia
Stage 4
Respiratory
paralysis

38. Inhalation anesthesia agent:
Nitrous
oxide
halothane
Isoflurane sevoflurane
Sevoflurane;
• Agent of choice for
inhalation induction
• Rapid induction
• Less respiratory
problems

39. Inhalation
anesthesia
sevoflurane
Maintenance
anesthesia
halothane
sevoflurane
isoflurane

40. Patient is in a stable anesthetic condition and
ready for the dental procedure

41. Perioral cleaning , draping and placement of throat
pack
Intra oral examination
Dental prophylaxis
Taking radiographs
Formulate the final treatment plan
11-RESTOARTIVE PROCEDURE

42. Perioral cleaning , draping and
placement of pharyngeal throat pack
• Clean the perioral area with three
sterile 4x4 inch gauze pads
(remove gross debris)
• Cover the patient` body by surgical
sheet
maintain the body temperature
provide clean field

43. • Draped the head by
three towels
• Form triangular
access space
• expose the mouth
• Expose the
nasotracheal tube

44. Throat pack
Technique Seal the pharngoplataine area by moist sterile gauze (
12 to 18 inch long )
Documentation Written documentation for time of placement
Written documentation for time of removal
Function 1. Reduce the escape of anesthetic agent.
2. Prevent any material from entering the pharynx
Requirement The gauze must be tightly packed around the tube
Ensure good seal

45. Operating room positions of the staff
while performing the necessary dental
procedures

46. • use mouth prop
• NOT impinge on
lips/tongue

47. Restorative dentistry in the
operating room
• use of local anesthesia
• Quadrant isolation by rubber dam.
• Topical application of fluoride for each
quadrant.
• Place restoration of GREATEST LONGEVITY
with the LEAST amount of maintenance.
• E.g : SSC > MOD filling

48. Advantages of restorative dental care
under general anesthesia
Excellent
patient
compliance
Increase quality
and quantity of
dental care.
Decrease
anxiety level

49. Intra operative complication
Dislodge/obstruct
endotracheal tube
IV infiltrate/
disconnect
Nasal bleeding
Lip/tongue
bleeding

50. Completion of the procedure
• Notify the anesthesiologist 10 minutes
before complete the procedure.
• Notify the recovery room.
• Debride the oral cavity.
• Remove the throat pack.

51. 12-POST OPERATIVE CARE
• Inform the nurse of post
surgical instructions.
• Establish ; potent airway +
stable vital signs.
• give the parents a brief report
of the treatment.
Written
prescriptions
Pain control
(acetaminophen)
Antibiotics
(Amoxicillin )
Antiemtics
(Zofranel)

52. Post operative order
outpatient order
Inpatient order
Operative report
Post instructions to the parents

53. OUT patient orders
• Monitor vital signs until stable.
• Disconnect IV when release from recovery.
• Start clear liquids in day surgery.
• Recall appointment.
• Analgesic prescription.
• Discharge from day surgery when meet
discharge criteria.

54. IN patient orders
• IV solution (e.g. ;5 % dextrose with ½ normal saline)
at rate (e.g. 40 ml/hr)
• Monitor vital signs q 15 minutes until stable then
routine.
• Elevate head 30 degree.
• Apply ice packs ( swelling)
• Apply pressure pack ( homeostasis)
• Start clear liquids as patient tolerated.
• Medications.

55. Operative report
• Type of dental procedure.
• Type of intubation.
• Teeth restored.
• Teeth extracted.
• Dental prophylaxis and topical fluoride application.
• Summary (length of the procedure, blood loss,
complications)
• Prognosis.
• Dentist name and signature.

56. Post instructions to the parents
 Discussing The diagnosis and the
treatment plan completed in the
operating room
 Discussing the Nature of the restoration
placed
 OHI, preventive programs
 Diet counseling
 Post operative medications
 Recall visit after 1 week

57. Post operative complication
Fever Nausea
Vomiting hypoxia
Bleeding

58. 13-DISCHARGE AND FOLLOW UP
CARE
 The patient is alert , fully awake
 Normal vital signs records
 The patient can drink and eat well
 No bleeding
 No severe pain
 Restorations intact and in place

59. Recommended Discharge Criteria
1. Cardiovascular function and airway patency :
satisfactory + stable
2. The patient is easily arousable.
3. protective reflexes: intact.
4. The patient can talk + sit up unaided
5. very young or handicapped children: return to he pre -
sedation level of responsiveness
6. The state of hydration : adequate.