4 Dental Restorations

Introduction

Children who come to the OR for dental restorations generally fall into four categories:

• Extensive dental work required
• Uncooperative or mentally retarded
• Difficult airways that would make sedating them in dental clinic hazardous
• Sick patients, especially those with congenital heart disease getting “pre-pump” dental care

Anesthetic Requirements

Nasal Intubation – To facilitate exposure, a nasal RAE endotracheal tube is preferred. Nasal RAE tubes are performed so that the ventilator connection of the ETT points back over the forehead. The anesthesia tubing is padded and secured with a Velcro dental strap around the head.

Deep Anesthesia – The head and neck will be moved around during the procedure. Therefore, a relatively deep level of anesthesia and/or paralysis will be required to prevent bucking.

SBE Prophylaxis – Often indicated for the patients with congenital heart disease (see section labeled SBE Prophylaxis elsewhere in this manual for drugs and doses.)

Steroids – We are currently giving dexamethasone 0.5 mg/kg (10 mg maximum) to dental patients to reduce the swelling resulting from the dental dams and oral trauma, and also as an anti-emetic.

Technique for Nasal Intubation

After inducing anesthesia and either ventilating by mask or by oral endotracheal tube:

Vasoconstriction – Shrink nasal mucosa with 0.25% phenylephrine. Do not spray out of the plastic bottle – use the atomizers. Spraying directly from the plastic bottle aimed downward will send a liquid stream of phenylephrine into the nasopharynx.

Positioning – Place head in the classic “sniffing” position – neck flexed forward, head slightly extended. Turn head a few degrees toward the side of the nostril chosen for intubation to bring the tube tip toward the midline.

Lubrication – Lightly coat end of ETT with lidocaine jelly

Passage through nasal pharynx – Using gentle, constant pressure, advance the ETT along the floor of the nasal passage into the oropharynx. Never direct the ETT upward, since damage to the turbinates or even puncture of the cribriform plate may result. Do not use an up-and-down or twisting motion on the ETT to try to get it to pass – it will either go with gentle, constant pressure or you must use the other nostril or a smaller ETT. If you use the left nostril, initially rotate the tube “upside-down”, so that the sharp tip of the tube does not gouge the turbinate. Do not traumatize the nose for placement a nasal tube – if necessary, the surgeons can always work around an oral tube.

Warning – ETTs have not been found to reduce epistaxis. However, telescoping the end of the ETT in a red rubber catheter (10 French for ETT’s 5.0 and smaller, 12 French for larger ETT’s) and using the red rubber catheter to “guide” the ETT through the nose, shielding the stiff leading edge of the ETT from the nasal mucosa, significantly reduces epistaxis. Once the ETT enters the oral pharynx, the red rubber catheter is grabbed with a Magill forceps and disengaged from the ETT with an abrupt tug.

Passage through glottis – Occasionally the ETT will advance right into the trachea. Often, however, you will expose the glottis and guide the ETT through by grasping the ETT with Magill forceps and pushing it through. Be careful not to grab the cuff as it is easily ruptured by the Magills.

Often the ETT will begin to pass through the cords, but then “hang up”, since in children the anterior attachment of the cords is inferior to the posterior attachment. That is, the ETT will seem to pass through the posterior glottis, only to “hang up” at the anterior commissure. When this happens, rotate the tube at the nose 360 degrees as you gently advance, so that the bevel at the tip temporarily points posteriorly, and the tube will “pop” through easily. Never force a tube through the cords, since you can dislocate the arytenoids.

Confirm placement – End-tidal CO2 and bilateral auscultation, and also palpate the inflated cuff in the sternal notch. Check to make sure the uninflated tube leaks at 20 cmH2O or less.

Stabilize ETT – Place pad over the forehead, then wrap a Velcro strap around the patient’s head and over the ETT. Check that ears are not folded under the strap.

Temperature monitoring – Place temperature probe in left nares – or the side without the ETT.

References

Watt S, et al. Telescoping tracheal tubes into catheters minimizes epistaxis during nasotracheal intubation in children. Anesthesiology. 2007;106: 238-242.

2007 T. Wolfe