Indications and Conditions for Paediatric General Anaesthetic

1. A patient is referred for a paediatric general anaesthetic.What are the indications for paediatric GA, and the circumstances and conditions justifying a GA Arkadiusz Dziedzic

2. „GA should be avoided where possible” (Poswillo 1990) Initial aim at the start of each treatment plan is to avoid the GA Do not assume GA is the only option because of the young age of the child or parents preference

3. General rules for GA treatment planning • More radical approach than for LA – aim to not only make a child dentally fit but to prevent a repeat GA in future • Not only to address current treatment needs but to plan ahead to ensure the child reaches adulthood with a healthy and functional dentition as well as a positive attitude towards dentistry

4. General rules for GA treatment planning • Plan to extract all teeth which have poor long term prognosis or questionable: haevily restored, worn, traumatised, structurally unsound • Aim not to „wake up with a hole” – all restorative care completed prior to GA or at GA

5. example: buccal abscess LLD, 6 years old child, marginal ridge breakdown LLD, LRD, ULE, discoloured, asymptomatic URA following trauma, URE – MO cavity on BWs rad • Acclimatisation • OHI, Prevention, Dietaryadvise • F/S on 6’s If co-op If unco-op • Restore URE, ULE (SSC) • XLA LLD, LRD • Monitor discolouredURA • XGA’s • LLD, LRD, • ULE, URE, URA

6. Paediatric Dental GA Main considerations • The co-operation and attitude of child • The perceived anxiety (phobic/learning dis.) • The complexity of the treatment plan • The medical status of the child: ASA I and II, majority of ASA III • Age above 2 y.o., weigh > 10 kg

7. Other Considerations • Additionalrisks • Treatmentathospital • Starving • Travel, Time, Cost (family/service) • Extent of caries: teethcannot be saved, likely to cause a pain/infection

8. Other Considerations • Orthodonticconsiderations: • anyseveremaloccclusionrequiresanorthodonticopinion • balance to preventcentrelineshift of permanent teeth: D’s and C’s and 6’s • no need to balance for incisor and E’s

9. If the full treatment will not be achieve under LA or LA/IH sedation then option is GA Essentially the tooth requiring the most difficult treatment drives this decision There are compromises – ie. teeth which could be restored under LA may need to be extracted under GA

10. GA Indications and Justification • Failure to achieve adequate pain control with alternative methods such as local anaesthesia or sedation • Essential dental treatment required to secure oral health to the well being of the childas a part of a long term treatment plan

11. Conditions suitable for GA • Alleviation of severe dental pain or the eradication of gross infection, • if no alternative care is feasible. • Symptomaticcariousteeth in morethan one quadrant • Multiple (single ?) extractions in a youngchild not compliant with LA and unsuitable for conscioussedation • Establishedallergy to LA

12. Conditions suitable for GA • Extraction of multiple deciduous teeth where there have been more than one episode of significant pain or infection/sepsis. • Extraction of first permanent molars which have poor prognosis in the mixed dentition.

13. Conditions rerely justify GA • Carious, asymptomatic teeth with no clinical or radiological signs of sepsis • Orthodontic extractions of sound permanent premolar teeth in a healthy child • Patient/Carer preference, exept where other techniques have alreay been tried

14. Circumstances which may override above limitations • Learning, emotional, physical impairement or a combination of two or more of these • Attempted treatment using LA alone or LA combined with conscious sedation and been unable to co-operate • Medical problems which are better controlled with the use of GA

15. GA contraindications • Alternative methods of pain control have not been fully explored and excluded • Medical conditions: acute respiratory tract infections at the time of the GA,excessively overweight, congenital heart defects. • Simple orthodontic extractions, conservative treatment of deciduous teeth (?), a single tooth extraction (?). • . ,

16. GA contraindications • . ,

17. GA assessment essentials • Examination, if not possible EUA • Radiographsessential – record of radiographsattempted • Diagnosis • Liaise with otherprofessionals: orthodontist and medicalcolleagues • Capacityassessmentifrequired

18. GA assessment essentials Reason of referral Presenting complaint and HPC Detailed medical history Dental history

19. GA assessment essentials • Clear treatment plan unless child cannot be examined • Pain and anxiety options discussed with GA to be considered only if other modalities have failed or are not appropriate • Risks of GA have been discussed • Discussed pain relief and methods of induction • Follow booking protocol

20. GA Referral Pack • Consent form • Internal referral proforma • Options for anxiety control • Patient information leaflet • GA checklist

21. National clinical guielines for the extractions of the first molars (2014) If the extraction of permanent teeth is indicated, where possible, get an orthodontic opinion

22. Special Considerations • Special needschild with cranio-facialmalformations – to considerobliquelateralradiographsduring GA arranged with radiologydepartment • Child requiresadditionalprocedureunder GA: grommetsremoval, botoxinjections in specialneedspatients with muscularspasms, maxillo-facialsurgery • . ,

23. Paediatric GA Challenging circumstances • Uncertain parental responsbility or double parental responsibility, eg. biological and foster parents • Different expectations of parents who are unable to agree together for dental treatment under GA • Parents happy to consent for certain treament, eg. single extraction under GA but reluctant to consent for multiple balanced extractions 

24. Paediatric GA Challenging circumstances • Young patientwhorecentlyhad GA for anymedicalconditions • Parentsrequested to combinedentaltreatmentunder GA along with otherproceduresdue to medicalreasons • Veryyoungchildbelow 2 y.o. • Medicalconditions in which GA cancause life-threteningcomplications

25. Problems arrisen at GA • GA consent not clear, veryprescriptive • Parentshaveunrealisticexpectations of whattreatmentcan be achieved: multiplerestorations on unrestorableteeth • Plannedrestorations on 6’s but unfortunatelyunrestorable, plannednot compensated/balancedextractions of 6’s • No radiographs

26. References • „Guidelines For The Management Of Children Referred For Dental Extractions Under General Anaesthesia”. Association of Paediatric Anaesthetists of Great Britain and Ireland. 2011 • StandardsandGuidelinesforGeneralAnaesthesiaforDentistry. London:The Royal CollegeofAnaesthetists,1999. • RCS.UK NationalGuidelines inPaediatricDentistry.Guideline forthe Useof General Anaesthesia. • Solent NHS. Internal Guidelines for Extraction of teeth under General Anaesthesia. 2015

27. To summarise • Clearindications for paediatric GA • Alwaysattemptotheroptions for pain and anxietycontrolifindicated • Moreradicaltreatment plan thanunder LA to preventrepeat • Communiation with parents/guardianssotheyhaverealisticexpectations of treatmentwhentheyarriveat GA

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