Transcript Primary Care Premises: Creating sustainable development

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
17th November 2008
„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
17th November 2008
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
17th November 2008
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
17th November 2008
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, Dietary advise
F/S on 6’s
If co-op
Restore URE, ULE (SSC)
XLA LLD, LRD
Monitor discoloured URA
If unco-op
XGA’s
LLD, LRD,
ULE, URE, URA
17th November 2008
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
17th November 2008
Other Considerations
•
•
•
•
•
Additional risks
Treatment at hospital
Starving
Travel, Time, Cost (family/service)
Extent of caries: teeth cannot be saved, likely
to cause a pain/infection
17th November 2008
Other Considerations
• Orthodontic considerations:
- any severe maloccclusion requires an
orthodontic opinion
- balance to prevent centre line shift of
permanent teeth: D’s and C’s and 6’s
- no need to balance for incisor and E’s
17th November 2008
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
17th November 2008
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 child
as a part of a long term treatment plan
17th November 2008
Conditions suitable for GA
Alleviation of severe dental pain or the
eradication of gross infection,
if no alternative care is feasible.
1. Symptomatic carious teeth in more than one
quadrant
2. Multiple (single ?) extractions in a young child
not compliant with LA and unsuitable for
conscious sedation
3. Established allergy to LA
th
17 November 2008
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.
17th November 2008
Conditions rerely justify GA
1. Carious, asymptomatic teeth with no clinical
or radiological signs of sepsis
2. Orthodontic extractions of sound permanent
premolar teeth in a healthy child
3. Patient/Carer preference, exept where other
techniques have alreay been tried
17th November 2008
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
17th November 2008
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 (?).
.
,
17th November
2008
GA contraindications
.
• Acute respiratory condition
• Muscle relaxants prolonged
• Congenital heart conditions
reaction due congenital
• Multiple allergy to egg, soya,
condition
•
milk (cross-reaction with
• Malignant hyperthermia !
propofol components)
• Sickle cell condition ?
‘Panallergy’; reported
(test required)
allergic reactions to multiple
substances, meds, food, latex,
nuts, etc.
,
17th November
2008
GA assessment essentials
• Examination, if not possible EUA
• Radiographs essential – record of
radiographs attempted
• Diagnosis
• Liaise with other professionals: orthodontist
and medical colleagues
• Capacity assessment if required
17th November 2008
GA assessment essentials
Reason of referral
Presenting complaint and HPC
Detailed medical history
Dental history
17th November 2008
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
17th November 2008
GA Referral Pack
•
•
•
•
•
Consent form
Internal referral proforma
Options for anxiety control
Patient information leaflet
GA checklist
17th November 2008
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
17th November 2008
Special Considerations
• Special needs child with cranio-facial
malformations – to consider oblique lateral
radiographs during GA arranged with
radiology department
• Child requires additional procedure under
GA: grommets removal, botox injections in
special needs patients with muscular
spasms, maxillo-facial surgery
.
th
,
17 November 2008
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
17th November 2008
Paediatric GA
Challenging circumstances
• Young patient who recently had GA for any
medical conditions
• Parents requested to combine dental treatment
under GA along with other procedures due to
medical reasons
• Very young child below 2 y.o.
• Medical conditions in which GA can cause lifethretening complications
17th November 2008
Problems arrisen at GA
• GA consent not clear, very prescriptive
• Parents have unrealistic expectations of what
treatment can be achieved: multiple
restorations on unrestorable teeth
• Planned restorations on 6’s but unfortunately
unrestorable, planned not
compensated/balanced extractions of 6’s
• No radiographs
17th November 2008
References
•
•
•
•
„Guidelines For The Management Of Children Referred For
Dental Extractions Under General Anaesthesia”. Association of
Paediatric Anaesthetists of Great Britain and Ireland. 2011
Standards and Guidelines for General Anaesthesia for
Dentistry. London:The Royal College of Anaesthetists,
1999.
RCS. UK National Guidelines in Paediatric Dentistry.
Guideline for the Use of General Anaesthesia.
Solent NHS. Internal Guidelines for Extraction of teeth under
General Anaesthesia. 2015
17th November 2008
To summarise
• Clear indications for paediatric GA
• Always attempt other options for pain and
anxiety control if indicated
• More radical treatment plan than under LA
to prevent repeat
• Communiation with parents/guardians so
they have realistic expectations of treatment
when they arrive at GA
17th November 2008
THANK YOU
FOR YOUR ATTENTION
17th November 2008