Early Childhood Caries

• Caries are the most common chronic infection in early childhood, significantly contributing to school absenteeism.
• Caries lead to pain, infection, aesthetic issues, and difficulties in basic functions like eating and speaking for children.
• Approximately 56% of children aged 2-3 and 80% of children by age 17 experience caries.
• Lower-income pediatric populations are disproportionately affected by dental caries, reaching epidemic levels.
• Office-based anesthesia makes dental surgery safer, more convenient, and cost-effective.

Pathophysiology

• Dental caries is a primary cause of chronic infections in early childhood, leading to school absence, with a prevalence five to eight times greater than asthma.
• Caries can cause pain, aesthetic embarrassment, and difficulties in eating, swallowing, chewing, and speaking.
• Early childhood caries significantly impacts both primary ("baby teeth") and permanent ("adult teeth") dentition, as infection in primary teeth can disrupt the development of permanent teeth.
• Caries involve the molecular destruction of calcified tooth structures (enamel, dentin, and cementum), potentially reaching the dental pulp.
• Untreated caries can lead to tooth loss, chewing difficulties, altered facial structure, and infection.
• Oral bacteria, especially Streptococcus mutans, produce acidic metabolites that cause caries.
• Biofilm/dental plaque is a sticky mass of oral bacteria, saliva, proteins, and food debris.
• Periodontal structures consist of gingiva (gums), oral mucosal tissue, periodontal membrane, and jawbones.
• Biofilm causes caries, periodontal inflammation, and destructive periodontal disease.
• Bacterial endotoxins from oral bacteria entering the bloodstream can lead to coronary artery disease by releasing inflammatory mediators affecting the heart's coronary vasculature.
• Untreated caries can result in severe systemic infections, osteomyelitis, and brain infections.
• Pediatric dentists and pediatricians advise that a child's first dental visit should occur at the age of 1 year
• The oral flora of infants develops from oral and bodily contact with primary caregivers, so oral hygiene is very important.

Surgical Treatment of Caries

• A dentist will excavate the caries from the tooth and then replace the lost structure with silver amalgam or glass-filled composite.
• More extensive caries with pulpal invasion are treated by carefully excavating the caries and removing any pulpal remnants in the crown.
• The remaining pulpal tissue is mummified with formocresol.
• The tooth is then restored with a stainless-steel crown.
• Root canals are not performed on primary teeth due to potential exfoliation of the tooth when the adult teeth erupt.
• Dental hand pieces (drills) and dental lasers use a lot of water, which must be suctioned up to prevent airway stimulation.
• Airway stimulation can cause coughing or laryngospasm.

Anesthesia Management and Considerations

• Daily oral hygiene is important for pediatric patients, emphasizing the removal of biofilm through brushing and flossing by parents or guardians.
• Infants with no erupted teeth should have their mouths cleaned daily with a wet washcloth to remove biofilm.
• Autism is a neurologic developmental disorder that can impair language, social interaction, behavior, and cognitive function.
• Autistic patients may have moderate mental deficits, with females sometimes displaying severe mental dysfunction and a male-to-female ratio of 3:1.
• Chronic pharmacologic treatments for autism can cause motor impairment affecting speech and swallowing, CNS depression, orthostatic hypotension, excessive salivation (sialorrhea), or dry mouth (xerostomia).
• Other symptoms in autistic patients include altered taste (dysgeusia), teeth grinding (bruxism), stomatitis, and glossitis.
• Autistic patients commonly have gastroesophageal reflux disease (GERD) and prefer low-textured foods, increasing their risk for dental disease.
• Anesthetists and dentists must consider patient medical condition, behaviour, and the capabilities of the dental staff when dealing with pediatric patients to ensure safety.
• A presurgical consultation is necessary to meet the patient and parents/guardians to perform detailed health history, gauge patient temperament, and discuss procedural rules
• These include NPO policies, the need for physician consultation, and evaluate the risks and benefits of premedication.
• Anesthesia assessment on the day of surgery is important as there could be a current medical conditions or uncontrollable temperament which may necessitate cancellation.
• Patients with severe behavioral issues should be referred to a pediatric dentist for treatment in an ambulatory surgical center or operating room under general anesthesia.
• Preoperative oral medication should be given after the patient uses the restroom to prevent movement after it takes effect.
• Oral midazolam mixed with liquid ibuprofen or acetaminophen is a common premedication, dosed based on ideal body weight.
• Before administering oral or IV agents, a complete anesthesia setup is required, complying with the Guidelines for Office-Based Anesthesia set forth by the American Association of Nurse Anesthetists.
• Oral premedication can reduce separation anxiety and aid with IV line insertion, as well as for its amnestic effects.
• A quiet, non-stimulating environment, along with a warm blanket, helps the patient rest and feel secure.
• The anesthetist must assess the physiologic effects of the premedication and reassure caregivers as needed.
• Approximately 30% of the pediatric patient population in the United States is considered obese, and the incidence is expected to increase.
• Childhood obesity predisposes individuals to a variety of pathologic disease processes in adulthood, including type 2 diabetes mellitus, coronary artery disease, hypertension, cancer, joint disease, gallbladder disease, and pulmonary disease.
• Calculating body mass index (BMI) for pediatric patients is based on data collected by the Centers for Disease Control and Prevention and accounts for the child's age, height, and weight and is compared with children considered to have ideal BMI.
• Several physiologic factors that may complicate the anesthetic course include increased metabolic rate, decreased functional residual capacity (FRC), redundant airway tissue, and difficult ventilation/intubation.
• Because the metabolic rate in school-aged children is greater compared with an adult, short periods of hypoventilation or apnea will result in rapid desaturation.
• The FRC and specifically the residual volume (RV) are decreased in obesity, leading to rapid desaturation during hypoventilation or apnea, therefore preoxygenation is imperative.
• Obesity increases the possibility of developing redundant airway tissue that can cause complete airway obstruction when anesthetic agents are administered
• Difficult ventilation and intubation can cause an airway emergency, necessitating rapid airway intervention because of the presence of redundant airway tissue and other physical characteristics associated with obesity such as thick neck and a large tongue.
• The dental chair is adjusted to accommodate the needs of the dentist, small patients can be cushioned on a standard dental chair with a large pillow placed horizontally on the dental chair, along with a small dog bone-shaped travel pillow under the neck, also foam pads or rolled towels may also be used for padding the bony prominences and properly positioning the arms, and a blanket can be used to maintain cleanliness and to decrease heat loss.
• Before administration of anesthesia, it is imperative to apply electrocardiogram (ECG) leads, pulse oximetry, blood pressure cuff, precordial stethoscope, and a temperature monitor.
• In order to decrease patient movement, inhalation of a nonhypoxic mixture of nitrous oxide and oxygen can be titrated to effect while supporting the patient's head and face and assessing for possible patient movement, also consider using a subcutaneous bolus of 2% plain lidocaine, administered with a 29-gauge insulin syringe at the IV insertion site, and the IV catheter is secured with tape and possibly gauze wrap to avoid inadvertent removal.
• Administration of an anti-sialagogue such as glycopyrrolate is used to decrease intraoral secretions.
• Suction must be available to evacuate saliva from the floor of the mouth and from the buccal vestibules.
• Nitrous oxide is discontinued and oxygen at flow at 3 L/min via mask is for at least 5 minutes to avoid diffusion hypoxia.
• Sedation is achieved and maintained by administering propofol by infusion; both eyes are carefully taped to avoid corneal abrasions.
• A special dental laryngeal mask airway (LMA) is available to assist the anesthesia provider to maintain and safeguard the airway; it can be adapted to work with dental nitrous oxide/oxygen delivery systems or attached to an anesthesia machine.
• Due to the increased metabolic rate that is characteristic of children, a propofol infusion is titrated to effect, typically 100 to 150 mcg/kg/min maintenance, though patients experiencing stimulating dental procedures require noticeably higher maintenance infusion rates of propofol.
• Advantages to the use of propofol include ability to titrate, relatively short half-life, and potential antiemetic effects.
• If the patient will require dental extractions, the anesthetist may consider administering incremental doses of fentanyl.
• Ketamine may also be titrated to help stabilize and control behaviorally agitated patients.
• Midazolam will help decrease the possibility of postoperative emergence delirium; due to a synergistic anesthetic effect, the addition of these adjunctive agents will reduce the maintenance infusion rate of propofol.
• Dexamethasone is frequently administered to decrease post extraction swelling and inhibit nausea and vomiting, and a serotonin receptor antagonist such as ondansetron is used as nausea and vomiting prophylaxis, as well as ketorolac can be used to decrease postoperative pain.

Postoperative Period

• Emergence after a propofol infusion is frequently prolonged, even without the use of narcotics.
• Context-sensitive half-time explains this phenomenon; a lipid-soluble medication administered by infusion is sequestered in tissue over time, causing prolonged sedative effects dependent on the duration and total dose of the drug.
• Airway support is continued with the oral bite block in place, allowing access to the posterior pharynx for suctioning.
• Gently supporting and reorienting the patient upon emergence is essential.
• It is prudent to bring only one caregiver/parent to the operatory after the patient has nearly emerged and is stable.
• Explain to the caregiver that the patient may exhibit emergence delirium.
• Recovery can occur in the dental operatory or a well-equipped recovery area, which should be quiet and staffed by a well-trained assistant.
• Modified Aldrete signs are used for postanesthetic assessment, assigning an objective score to activity, respirations, circulation, consciousness, and color.
• Discharge is appropriate when a patient is stable and has a minimum modified Aldrete score of 10.
• Pediatric patients anesthetized in an office-based setting are typically discharged after approximately 20 to 30 minutes.
• Discharge times are often longer if narcotics are used for analgesia.

Supplies Necessary for Pediatric Dental Surgery Anesthesia

Utilities

• Backup power (uninterruptible power supply).

Equipment

• Patient monitor including pulse oximeter, electrocardiogram, and blood pressure monitor with adequate-sized cuffs.
• Liquid crystal body temperature stickers.
• Emergency E cylinder oxygen tanks.
• Positive pressure ventilation sources, including an Ambu bag with properly sized facemasks.
• Defibrillator (charged) or AED.
• Suction source or machine, tubing, suction catheters, and Yankauer suctions; plan for emergency suction in case of power failure.
• Anesthesia cart for organizing supplies: endotracheal equipment, laryngeal mask airways, face-masks, nasal cannulas, disposable facemasks with oxygen tubing, oral and nasal airways, syringes (tuberculin, 3, 5, 10, 30, 60 mL), 18-gauge 1.5-inch needles, 20- and 22-gauge IV catheters, tourniquets, IV fluids and tubing, alcohol pads, adhesive tape, disposable gloves, and stethoscope.
• Medication syringe pump.
• Emergency medications: atropine, glycopyrrolate, epinephrine, ephedrine, phenylephrine, lidocaine, diphenhydramine, hydrocortisone, and a bronchial dilator inhaler (e.g., albuterol).

Additional Emergency Equipment and Supplies

• Cricothyrotomy kit.

Indications for Office-Based Anesthesia

• Uncooperative/unmanageable behavior.
• Patient requires immediate dental treatment.
• Inability to thoroughly examine.
• Inability to obtain intraoral dental radiographs.
• Necessity for little or no patient movement or no swallowing.
• Mentally challenged child or adult patients.
• Hypersalivation.
• Small mouth.
• Large tongue.
• Inability to attain intraoral local anesthesia.
• Claustrophobia.
• Need for comprehensive dental treatment in multiple quadrants.
• Need for tooth extraction(s).
• Desire for convenience and significant cost savings.

Considerations for Postponement or Cancellation

• Patient is not within accepted NPO guidelines.
• Recent upper respiratory infection.
• Unwilling or unable to allow premedication.
• Systemic infection other than dental causes.
• Inability to transfer or position the patient for dental surgery.
• Inability to obtain intravenous access.
• Inadequate number of needed assistants.
• Parental or caregiver interference.

Advantages of the Dental Laryngeal Mask Airway

• Protects the airway from dental debris, saliva, secretions, and blood.
• Provides a secure airway.
• Is easily placed.
• Is relatively atraumatic to the patient's mouth, throat, and airway.
• Can be adapted to work with dental nitrous oxide/oxygen machines or an anesthesia machine.
• Can be repositioned from side to side for better dental access.
• Allows disconnection and reconnection at its midpoint to check occlusion.