Indian Journal of Anaesthesia 2008;52:Suppl (5):725-737

General Anaesthesia for Dentistry

Naveen Malhotra
Summary
The first general anaesthetics administered were for dental extractions. General anaesthesia for dentistry is not
without risk and should not be undertaken as a first-line means of anxiety control. Considerations should always be
given to the possibility of local anaesthetic techniques with or without conscious sedation. Patients requiring general
anaesthesia for dental work are frequently children or individuals with learning difficulties. The standards of general
anaesthesia for dentistry should be the same as those in any other setting.

General anaesthesia in dentistry covers three main types of surgical procedures: Dental chair anaesthesia, Day
care anaesthesia and In-patient anaesthesia. All standard equipments, gadgets, monitors and drugs for anaesthesia
and resuscitation should be available and checked before administering anaesthesia. Each individual must have had
appropriate experience of, and training in dental anaesthesia. Sevoflurane has largely replaced halothane as agent of
choice for inhalation induction of anaesthesia and propofol is agent of choice for intravenous induction. The transpar-
ent neonatal mask for nasal ventilation offers significant advantages. Laryngeal mask airway is being used for all but
the simplest extractions. The most commonly used operating position is semi-supine. In recovery, airway obstruction
is common in patients undergoing dental procedures and they should be closely supervised by an experienced nurse.
Routes of tracheal intubation in maxillo-facial surgical procedures are: oro-tracheal intubation, nasal intubation, retro-
molar intubation and submento-tracheal intubation. A team of vigilant and experienced anaesthesiologist and dental
surgeon is able to prevent and manage the complications associated with dental procedures under general anaesthe-
sia.

Keywords Surgery: Dental; Anaesthesia: General.

Introduction work routinely in operation theatres.4 Majority of the

There is a long historical association between
Anaesthesia and Dentistry. Some of the initial
anaesthetics given were for dental extractions.1, 2 The
first general anaesthetic administered for a dental ex-
traction is credited to Horace Wells. Wells, on 11th
December 1844, underwent extraction of one of his
own wisdom teeth by a colleague whilst under the in-
fluence of nitrous oxide. In 1846, William Morton, a
pupil of Wells, successfully demonstrated the proper-
ties of ether to facilitate dental extraction in Massachu-
setts.3
Dentistry, in its surgical and restorative aspect, is
in majority based on office practice. Limited dentists
dental procedures can be performed under local ana-
esthesia which is inherently safe. Most dentists are skilled
in techniques of local anaesthetics and nerve blocks.5
General anaesthesia should not be used as a method of
anxiety control but for pain control, because more spe-
cific methods (local anaesthesia with or without con-
scious sedation and behaviour management techniques6)
are available to manage anxiety. All general anaesthetics
are associated with some risk and modern dentistry is
based on the principle that all potentially painful treat-
ment should be performed under local anaesthesia, if
at all possible. General anaesthesia should be strictly
limited to those patients and clinical situations in which
local anaesthesia (with or without sedation) is not an
option. 7-13

Associate Professor, Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Sciences (PGIMS),
Rohtak-124001 (Haryana) Correspondence to: Naveen Malhotra, 128/19, Naveen Niketan, Civil Hospital Road, Rohtak-124001
(Haryana), E-mail: naveen_m2000@yahoo.com

725
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
In 1970s and 1980s there were numerous deaths,
often in healthy children undergoing simple dental pro-
cedures under general anaesthesia. The reasons were
multifactorial, including administration of anaesthesia in
conditions with substandard monitoring, assistance and
resuscitation equipments. Also, patients were poorly
prepared for anaesthesia and surgery.3 However, cur-
rently there is a world wide trend that increasing num-
ber of children are receiving dental treatment under
general anaesthesia.14-16.
General anaesthesia in dentistry covers three main
types of surgical procedures: 3
1. Dental chair anaesthesia: It is outpatient
anaesthesia, mainly for simple extraction of teeth espe-
cially in children.
2. Day care anaesthesia: It is for minor oral
surgery.
3. In patient anaesthesia: It is for complicated
extractions, oral surgical procedures and maxillofacial
surgical procedures.
Indications of general anaesthesia in den-
tistry 3, 7, 8, 12
Decisions about general anaesthesia can only be
made on an individual patient basis, but its use in den-
tistry should be limited to:
1. Acute infection: In such clinical situations it
would be impossible to achieve adequate local anaes-
thesia and so complete treatment without pain, e.g.
management of acute dento-alveolar abscess and se-
vere pulpitis. In these conditions, drug therapy or drain-
age procedures with other methods of pain relief are
inappropriate or unsuccessful. The local anaesthetic may
not be effective in such conditions because of local
change in pH and there is a risk of spreading infection
also.
2. Children: Majority of out-patient general ana-
esthesia in dentistry is administered to small children
726
who may not tolerate dental surgery under local anaes-
thesia or some may be failures of attempts using local
anaesthesia. It is recommended that only specialist pae-
diatric anaesthetists should administer general anaes-
thesia to very young children.
3. Mentally challenged patients: Such patients,
because of problems related to physical/mental disabil-
ity, are unlikely to allow safe completion of treatment
under local anaesthesia.
4. Dental phobia: Patients in whom long-term
dental phobia will be induced or prolonged are admin-
istered general anaesthesia in first sitting. The long term
aim in such patients should be the graduated introduc-
tion of treatment under local anaesthesia using, if nec-
essary, conscious sedation and behaviour management
techniques.
5. Allergy to local anaesthetics: It is rare and
is due to amide group of local anaesthetics. The pre-
servative methylparaben can also cause allergic reac-
tions. However, allergic reaction should be differenti-
ated from vasovagal attacks, palpitation and flushing
occurring as a result of absorption of adrenaline present
in local anaesthetic solution.
6. Extensive dentistry & facio-maxillary sur-
gery: Local anaesthesia is unsuitable in an awake pa-
tient when the dentistry is likely to be extensive.
General principles
Patient assessment
The initial screening of patients for general anaes-
thesia should be performed as for any other anaesthetic.
The anaesthesiologists should always be ready to dis-
cuss with dental colleagues policies for general anaes-
thesia, and their implications for an individual patient,
to allow efficient patient management. 3, 12
The Clinical setting
Defining the setting in which a general anaesthetic
Naveen Malhotra. General anaesthesia for dentistry
is administered must take into account the worst case
scenario because the uneventful anaesthetic is not the
problem. Complications of modern anaesthesia are rare,
but skilled team work is required to prevent permanent
harm to the patient. The further away from the support
of other clinical services that an anaesthetic is adminis-
tered, the greater is the risk of death should a compli-
cation occur. Ideally, all general anaesthetics for den-
tistry should be administered within the administrative
aegis of the range of services typically provided by.
The location of any such facility must allow easy ac-
cess for emergency services.8
Equipments, monitors and drugs
All standard equipments, gadgets, monitors and
drugs for anaesthesia and resuscitation should be avail-
able and checked before administering anaesthesia. This
includes (not exclusive) anaesthesia machine, vaporiz-
ers, oxygen, nitrous oxide, breathing circuits (adult and
paediatric), nasal and facial masks, oral and nasal air-
ways, different laryngoscopes with all sizes of blades,
all range of nasal and oral tracheal tubes, independent
suction apparatus, etc. SAFE agents (Short acting fast
emergence) have particular place in day care anaes-
thesia.3, 7
Minimum monitoring standards during anaesthe-
sia should be followed. Peripheral arterial oxygen satu-
ration, ECG, non-invasive blood pressure and
capnography (when tracheal intubation is performed)
should always be done. A precordial stethoscope can
be very helpful. The anaesthesiologist should be clini-
cally vigilant and continuously monitor colour of lips
and mucosa, and movements of chest and reservoir
bag. The alarms of monitors should never be switched
off.10, 11
All resuscitation drugs and equipments, including
defibrillator should be immediately available. Moreover,
the whole staff should be adequately trained in resusci-
tation (adult and paediatric). The dental chair should
be capable of head-down tilt and should be movable in
the event of power failure. The anaesthetist must check
727
all the equipment before use and there should be im-
mediate access to spare apparatus in the event of fail-
ure. Maintenance must be in accordance with the
manufacturers instructions. Facilities for the supply and
storage of medical gases must meet the relevant regu-
lations.8
Staffing standards
Each individual must have had appropriate expe-
rience of, and training in, dental anaesthesia. The
anaesthesiologist must have a dedicated assistant (op-
erating department assistant or practitioner, nurse or
dental nurse) with recognised training in this role and
no other contemporaneous responsibilities. Because the
dentist also requires assistance, a minimum of four
people are required for any procedure under general
anaesthesia. Until consciousness returns, a patient re-
covering from general anaesthesia must be appropri-
ately protected and monitored continuously in adequate
recovery facilities. Such monitoring should be under-
taken by the anaesthesiologist or a dedicated individual
who is appropriately trained, and directly responsible
to the anaesthesiologist. 8
Aftercare
The brief nature of most dental procedures means
that the majority of patients may be managed on an
ambulatory basis. Modern anaesthetic drugs permit
rapid recovery of consciousness and early discharge,
but it should be recognised that it may take more than
24 hours for all traces of the agents to be eliminated.
Thus when, in the opinion of the anaesthesiologist, pa-
tients are ready for discharge they must be accompa-
nied by a responsible, legally competent adult who has
been given clear instructions regarding the implications
of anaesthetic hangover effects. All patients must be
assessed specifically for fitness for discharge by the
anaesthesiologist. The administration of general
anaesthetics for longer periods of time demands a level
of recovery facility that can only be provided in a mod-
ern day-surgery unit, and standard criteria for the du-
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
ration of day-stay procedures apply. 7-9
Types of dental surgery
Dental surgery comprises exodontia, which is re-
moval of teeth, and conservation, which is filling them,
crowning them and other restorative measures.
Exodontia : Removal of teeth, it is usually a short
procedure.
Conservation: Conservation operations take longer
and often involve using a drill, which squirts water, so a
pharyngeal pack is necessary to prevent aspiration even
with a cuffed endotracheal tube.11
Consent
Written and informed consent by the patient or
parent/ guardian if the patient is minor or mentally chal-
lenged.
Dental chair anaesthesia
The common indications are:
1. Children: Majority of patients are children be-
tween ages 4 and 10 years requiring extraction of tooth/
teeth. Such patients frequently have upper respiratory
tract infection.
2. Adult patients with acute infection.
3. Mentally challenged patients.
Only ASA physical status class I & II patients
should be administered Dental Chair Anaesthesia or
Office-Based anaesthesia care. Patients with compro-
mised airway requiring advanced airway management
devices, haemodynamic instability requiring invasive
monitoring and those who require prolonged post-op-
erative care should be operated in an in-patient setting.
Congenital cardiac anomalies and syndromes (predis-
posing to difficult airway, unstable spine, etc) should
be specifically looked for in paediatric patients. 3, 7, 11, 17,
18
728
Pre-anaesthetic preparation
The patient is explained about the anaesthetic
and dental procedure and clear fluids are allowed up
to 4 hours preoperatively. A proper consent should al-
ways be taken. The patient must be accompanied be-
fore and after the surgery and supervised by an adult
for 24 hours.
Premedication
This is not usual, but may be used in children with
especially challenging behaviour. Chloral hydrate (50-
100mg.kg-1), trimeprazine (2mg.kg-1) or midazolam
(0.50.75 mg.kg-1) may be given orally mixed with a
small quantity of juice to disguise the taste, or intrana-
sally (midazolam 0.20.3 mg.kg-1). The patients are in-
structed to empty their bladder and bowels before sur-
gery.10, 11
Induction of anaesthesia
In small children, gaseous induction using
sevoflurane (with parental presence) is often easiest.
Since its introduction, sevoflurane has largely replaced
halothane as agent of choice because inhalation is quick
and smooth and there are limited cardiovascular and
respiratory effects.19 Sevoflurane supplementation of
66% nitrous oxide in oxygen is used. Sevoflurane may
either be introduced in 2% increments every 2 to 3
breaths to a maximum of 8%, with maintenance of ana-
esthesia at or around 4%, or it may be introduced at
the maximum concentration of 8%, with maintenance
at 4%. Induction using 8% sevoflurane does not ap-
pear to cause any adverse effects.20 However, if
sevoflurane is not available halothane is preferred over
isoflurane that is irritant and can lead on to coughing
and laryngospasm.21 Desflurane offers the advantage
of reduction in recovery time.22 A pulse oximeter and
ECG should be placed before the child goes to sleep.
A cannula must be inserted once the child is asleep for
all but the briefest general anaesthetic, for example ex-
traction of one tooth that takes a couple of seconds.
Naveen Malhotra. General anaesthesia for dentistry
Older children may be offered a choice of gas-
eous or intravenous induction, and letting them decide
is a good way of enlisting cooperation because the child
feels less threatened. Propofol is agent of choice for
intravenous induction and it ensures clear headed re-
covery and good anti-emesis, however thiopentone can
also be used. Ketamine has delayed recovery charac-
teristics and induces dysphoria. Application of local
anaesthetic cream (EMLA) to the skin will ensure that
insertion of the cannula is painless. However, it has to
be applied one hour prior to procedure which can be
difficult in out-patient setting.3, 11
Airway for exodontia
The type of airway chosen depends on the sur-
gery, and it is vital to liaise with the surgeon. Extraction
of a few easy baby teeth is done using a transparent
neonatal mask over the nares. The surgeon inserts a
gauze pack from one buccal sulcus to the other in or-
der to prevent too much mouth breathing and aspira-
tion of tooth fragments. A gag or bite-block is posi-
tioned on the side opposite the extractions to open the
mouth. However, the nasal mask is still used by some
dental anaesthetists (Fig. 1). The transparent neonatal
mask has significant advantages: the external nares can
be seen with a transparent mask so that it is possible to
check that they are not obstructed, and misting of the
Fig.1 Mask for nasal ventilation
729
mask may indicate breathing. Still, constant vigilance is
needed as the bag on the breathing circuit may not move
even with adequate ventilation, and no CO2 trace will
be obtained.3, 11 Adenotonsillar hypertrophy can com-
promise the nasal airway and nasopharyngeal airways
have been shown to significantly improve airway pa-
tency and reduce episodes of airway obstruction.23
Laryngeal mask airway (LMA) is being used for
all but the simplest extractions. It provides some bar-
rier to aspiration when compared to mask. The
armoured variety is more suitable as its tube is nar-
rower and takes up less room in the mouth and its flex-
ibility makes it easier to keep out of the dentists way.
It is important to hold the LMA firmly in place during
the surgery because it has a tendency to move. Down-
ward pressure on the jaw during extractions may ob-
struct it.24-25
The airway is shared by the anaesthesiologist and
dentist. Too large mouth gag should not be used be-
cause it can make airway maintenance difficult. The oral
pack should not be placed too far posteriorly in the
mouth, otherwise it can compromise nasal airway. The
anaesthetist must hold the patients head both to pre-
vent excessive movement of the neck, which can cause
pain postoperatively, and to provide support to the jaw
and counter pressure to the dentists pushing and pull-
ing.
Operating position
The operating position is controversial. Tradition-
ally, patients sat upright in the dental chair but it can
cause postural hypotension. The sitting position has
gradually become less common for dental surgery un-
der general anaesthetic. In the supine position, the inci-
dence of airway obstruction is high due to falling back
of tongue and there is greater risk of pharyngeal soiling
due to blood. Overall, maintaining airway with nasal
mask is difficult in supine position. The most commonly
used position is semi-supine. In this position, erect head
and neck helps in maintenance of airway, besides car-
diovascular and respiratory advantages of semi-reclin-
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
ing position and elevated legs.3, 7, 11
Airway for conservation
Operations for dental conservation and periodon-
tal procedures tend to take longer and to involve quan-
tities of water being squirted into the mouth. They should
therefore be performed with an endotracheal tube and
pharyngeal pack in place to prevent aspiration, which
can otherwise occur even with a cuffed tube. It is usual
to intubate nasally. An LMA makes the surgery difficult
because it leaves little space for the dental drill and suc-
tion.11
Maintenance
For short operations it is often easier to use a tech-
nique involving spontaneous respiration of inhalational
agent, nitrous oxide and oxygen, which gives flexibility
and rapid recovery. Using 50% inspired oxygen con-
centration is beneficial and has been shown to decrease
the incidence and severity of hypoxaemic episodes.
Incremental doses/continuous/ target controlled infu-
sion of propofol can be used for maintenance of ana-
esthesia. For extensive and complicated restorations,
it is better to paralyse and ventilate the patient.
Recovery
The tooth sockets continue to bleed after dental
extraction, especially in the presence of infection. Ini-
tially, patients are best nursed in left lateral position with
a degree of head-down tilt to encourage drainage of
any blood and secretions away from the larynx and
administered 100% oxygen. Thorough but gentle oro-
pharyngeal suctioning is done. The LMA or endotra-
cheal tube should not be removed until the cough reflex
has returned. Removal of the LMA while the child is
still deeply anaesthetized has been associated with lower
oxygen saturations in dental patients.26 A study of deaths
related to dental anaesthesia found that more than half
occurred in recovery.27 Significant desaturation is com-
mon after brief dental anaesthesia and the principal
cause is airway obstruction, these patients should be
730
supervised by an experienced nurse. Oxygen supple-
mentation ameliorates the severity of desaturation but
does not prevent it. 28 The patients are monitored in the
recovery area for at least 30 minutes before returning
to dental clinic. No oral fluids are given for 2-3 hours
to avoid vomiting and aspiration.
Postoperative analgesia
Extraction of baby teeth is not especially painful.
The main problem is the psychological trauma of wak-
ing up uncomfortable in a strange place. It is important
that the parents are present, and the administration of
paracetamol 10-15 mg.kg-1 is usually all that is needed.
Analgesia may be given rectally (paracetamol or
diclofenac suppositories) during the operation, but for
short operations this is of no major advantage.
Ibuprofen or paracetamol may be given orally in liquid
form in recovery.
The extraction of adult teeth is undoubtedly pain-
ful. Non-steroidal analgesics are effective, and it has
been shown that oral diclofenac given on admission is
as effective as rectal diclofenac given peroperatively.11
Fitness for discharge
Patients should be clinically observed to be alert,
oriented, able to stand and walk unassisted, and
haemodynamically stable. There should be no obvious
surgical complications. Simple scoring systems, like
Aldrete post anaesthetic recovery score (uses colour,
respiration, circulation, consciousness and activity as
criteria) can be applied.7
Day care anaesthesia
In day care facility, patient undergoes formal ad-
mission to the hospital but is discharged home later in
the day. The procedures which are usually done are
minor oral surgical procedures including laser treatment
and limited extractions. The surgical procedure usually
lasts not longer than one hour and there are no antici-
pated post operative complications. The patients are
Naveen Malhotra. General anaesthesia for dentistry
usually adults belonging to ASA physical status class I
or II. They are accompanied by a responsible adult
and home circumstances should be suitable for con-
tinuing post-operative care.
Patients are assessed formally by the
anaesthesiologist and investigated. Usually for patients
below 40 years complete blood examination and urine
complete examination is done. For patients aged 40
years or more an ECG is done. Adequate preopera-
tive fasting is necessary, usually six hours for adults and
four hours for children. If patient is anxious, premedi-
cation is advised in form of oral alprazolam or
midazolam, but it can delay recovery. A proper con-
sent is taken. Intravenous induction with propofol is
done in adults and older children. Neuromuscular block-
ade is achieved with atracurium or vecuronium. The
use of depolarizing neuromuscular blocking agent suc-
cinylcholine is best avoided in such predominantly am-
bulatory patients because of muscle pains. Naso-tra-
cheal intubation is commonly done but oro-tracheal in-
tubation can be done if only one side of the mouth is to
be operated. Pharynx is properly packed. Anaesthesia
is maintained with administration of halothane /
sevoflurane and nitrous oxide in oxygen. Diclofenac and
dexamethasone are administered to reduce pain and
swelling. Local anaesthetic may be infiltrated into the
sockets by the surgeon, or a block is performed if sur-
gery is limited to one or two quadrants. For more ex-
tensive procedures, short acting opioid like fentanyl is
administered. Long acting opioid, like morphine is
avoided in day care surgery.3, 11
In- patient anaesthesia
It is for complicated extractions, oral surgical pro-
cedures and maxillofacial surgical procedures (fixation
of maxillary, mandibular and nasal fractures, mandibu-
lar set back, maxillary advancement, osteotomies and
removal of tumours.
Pre-anaesthetic evaluation
It is same as for any other major operation. How-
731
ever, it is pertinent to note that these patients can have
swelling of face, missing or loose teeth, pain and tris-
mus limiting the mouth opening or a maxillo-mandibu-
lar fixation may be in situ. Thorough airway evaluation
should be done and necessary radiographs evaluated,
especially the antero-posterior and lateral views of neck.
The nasal patency should be done to facilitate nasal
intubation. Such patients may have polytrauma and
complete evaluation is necessary, including complete
haemogram. Neurological evaluation is necessary in
patients with co-existing head injury. The electrolyte
status must be assessed because such patients have a
limited oral intake (usually liquids). 3, 7
Principles of airway management7, 29
1. Patients with complex maxillo-facial injuries are
potential difficult airway patients. Difficult airway trol-
ley should be checked and immediately available.
2. Do not administer neuromuscular blocking
agent until it is possible to do mask ventilation.
3. Maxillo-Mandibular Fixation:
It is important to understand that in patients with
panfacial trauma, surgical reconstruction often involves
intraoperative maxillo-mandibular fixation to restore
dental occlusion and it is the important aspect of surgi-
cal procedure. The fixation is done with high tensile
strength elastic bands (common) or classical wires.
Discuss with the surgeon, the possibility of removing
maxillo-mandibular fixation just before induction of ana-
esthesia. Removal of bands/wires can make airway
management quite easier. It can be redone intra-op-
eratively after securing the airway. If possible, subse-
quent removal at the end of surgery makes tracheal
extubation and recovery simple. The maxillo-mandibular
fixation can be finally put in situ in the ward once pa-
tient is fully conscious and airway oedema subsided.
4. Throat pack is put to prevent ingestion of blood
into the stomach or its settling above the cuff of tra-
cheal tube.
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)

5. A reinforced or flexo-metallic tube is most com-
monly used for tracheal intubation.
6. Such patients commonly receive steroids
perioperatively to reduce airway oedema.
7. A tongue suture is applied if there is gross air-
way oedema and mouth is open.
8. Displacement of tracheal tube can occur be-
cause the tracheal tube is quite close to the surgical
field. Proper fixation of tracheal tube should be done
and anaesthesiologist should be vigilant to promptly
detect it.
9. Routes of tracheal intubation
A) Oral tracheal intubation:
It can be done under direct laryngoscopic view,
fiberoptic bronchoscope guided, by using lighted stylet,
through LMA (guided by fiberoptic bronchoscope) or
intubating LMA. Oro-tracheal intubation is not feasible
if intraoperative maxillo-mandibular fixation is to be
done.30
nasotracheal tube. Further, the presence of nasotracheal
tube can interfere with the surgical reconstruction of
naso-orbital - ethmoid (NOE) complex.31-33
C) Retromolar intubation 34, 35
When orotracheal intubation is not feasible and
nasotracheal intubation contraindicated, retromolar in-
tubation is indicated to secure the airway perioperatively.
In this technique, oral endotracheal intubation is done
with a flexometallic tracheal tube which is then placed
in the retromolar region. The retromolar space is the
space behind the last erupted upper and lower molar
teeth. The retromolar tube is stabilized in position by
fixation to first or second molar tooth in figure of eight
fashion. (Fig. 2) It allows intraoperative maxillo-man-
dibular fixation, thus restoring dental occlusion, which
is the important step for successful facio-maxillary sur-
gery.

B)Nasal intubation:
It is the most common route of tracheal intuba-
tion. It can be laryngoscope guided, fiberoptic bron-
choscope guided or blind. Depending upon the clinical
Fig 2 Retromolar Intubation
circumstances the patient may be anaesthetized and
breathing spontaneously or paralyzed, or may be The adequacy of retromolar space can be deter-
awake. Nasal passage is well prepared with a vaso- mined by introducing the index finger in the patients
constrictor and a topical anaesthetic. mouth and asking him or her to close the mouth. If there
is no compression on finger, the retromolar space is
However, nasotracheal intubation is not possible
adequate. Success of retromolar intubation can also
in some patients (10-15%) due to associated skull base
be increased by selecting one size smaller tracheal tube
fractures, cerebrospinal fluid rhinorrhoea (any attempt
which has a corresponding smaller outer diameter.
towards nasotracheal intubation may lead to passage
of tracheal tube into cranium, meningitis, sepsis and Advantage: This technique avoids the need of
epistaxis), fractures of nasal skeleton and anatomical any surgical technique i.e. tracheostomy and submento-
obstruction of nasal airway (deviated nasal septum, tracheal intubation for securing airway perioperatively.
nasal spur, and hypertrophied nasal turbinates). These
conditions cause physical obstruction to the passage of Disadvantages: These are minor and avoidable-

732
Naveen Malhotra. General anaesthesia for dentistry
1. The tracheal tube can interfere with the main
surgical field and positioning and application of dental
fixation devices.
2. Too jealous fixation of flexometallic tracheal
tube with wire ligature should not be done because it
can deform the tube.
D) Submento-tracheal intubation 29, 36-39
Submento- tracheal intubation is an alternate
technique of airway management in patients with cranio
- faciomaxillary trauma when retromolar intubation is
not possible. It is an alternative to short-term tracheo-
stomy.
Technique
Orotracheal intubation with reinforced
(flexometallic) endotracheal tube is done using stan-
dard general anaesthesia technique. At the start of pro-
cedure, nitrous oxide in switched off and patient is ad-
ministered 100% oxygen. A 1.5-2 cm incision is made
in the submental region parallel and medial to the infe-
rior border of the mandible. The incision is lateral to
the anterior belly of digastric muscle. When ever pos-
sible, the right side is preferred because it allows better
visualization of the intraoral position of tracheal tube
with direct laryngoscopy. The incision is extended
intraorally by blunt dissection with artery forceps through
the subcutaneous layers, mylohyoid muscle, submucosa
and mucosa. The intraoral opening is lateral to the sub-
mandibular and sublingual ducts. Thus, a submental
tunnel is created.
The tracheal tube is briefly disconnected from
the breathing circuit and the tube connector is removed
from the tube. The pilot balloon followed by the tra-
cheal tube is gently pulled out through the submental
tunnel. During this step, the endotracheal tube is stabi-
lized intraorally manually or by Maggils forceps. The
tube connector is reattached and endotracheal tube is
connected to the anaesthesia breathing circuit. Bilat-
eral air entry is checked. The distance marking on the
733
endotracheal tube at the submental skin exit point is
noted. It is usually 2 cm more than the oral fixation.
This helps in checking the tube position intraoperatively.
The tube is fixed in position with suture (as chest tube
drain). (Fig. 3)
Fig 3 Submento-Tracheal Intubation
Intraorally, the tracheal tube lies in the sublin-
gual sulcus between the tongue and mandible. It is away
from the surgical field and allows intraoperative maxillo-
mandibular fixation. The total procedure is usually com-
pleted within 5-10 minutes and the blood loss is mini-
mal (<10ml). At the end of surgical procedure,
submento- tracheal intubation is converted back to
orotracheal intubation. The reinforced tube can be pulled
out through the submental tunnel also. The submental
incision is closed not so tightly with interrupted skin
sutures. The intraoral incision heals secondarily.
Perioperative care
Antibiotic cover is provided, same as for
trauma patients, as per institutional protocol. Oral hy-
giene is maintained with 0.2% chlorhexidiene glauconate
mouthwash 4-6 times per day. The submental incision
is not closed so tightly to allow certain degree of drain-
age and helps in preventing infectious complications.
Antiseptic dressing is done. Stitches are removed on
sixth postoperative day. The scar is almost invisible af-
ter two months.
The submental endotracheal tube has been left
in situ for up to three days. Mechanical ventilation can
be instituted through it in the intensive care unit. Tra-
cheal suction with a lubricated catheter can be easily
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
done through the submentally placed tube. The avail-
ability of reinforced tracheal tubes made of polyvinyl
chloride has the advantage of a low pressure, high vol-
ume tracheal tube cuff. However, when submental en-
dotracheal tube is not removed, it is mandatory that
immediate access to oral airway is ensured at all times.
Maxillo-mandibular fixation should be deferred till ex-
tubation and confirmation of secure airway. If maxillo-
mandibular fixation is necessary then cutter should be
immediately available. If reinforced tube is removed
outside the operating room, then after extubation clo-
sure of submental incision is done under local anaes-
thesia.
Damaged submento tracheal tube (leaking cuff,
loose universal connector) can be replaced success-
fully with the use of tracheal tube exchanger, while the
tracheal tube is placed submentally. The apparent steep
angle of insertion in the submental approach can be
negotiated successfully.
Advantages
This technique provides a secure airway, un-
obstructed intraoral surgical field, allows intraopera-
tive maxillo-mandibular fixation and avoids complica-
tions of tracheostomy. It is a simple, safe and useful
technique with very low morbidity.
Disadvantages
It can cause trauma to submandibular duct,
sublingual gland or duct and facial nerve or lingual nerve.
Superficial infection of the submental wound can occur
which if not treated properly can result in oro-cutane-
ous fistula. Incidence of hypertrophic scarring is low.
E) Retrograde intubation and tracheostomy: very
rarely required.
Airway management in patients with cranio-
facio-maxillary trauma is a challenge for both
anaesthesiologists and surgeons. It requires close in-
teraction between them. Retromolar intubation is a
734
simple, easy and non invasive technique of tracheal in-
tubation when oral intubation is not feasible and
nasotracheal intubation is contraindicated. When ret-
romolar intubation is not possible, submento-oral intu-
bation is a relatively harmless alternative to tracheo-
stomy for securing the airway perioperatively.
Complications of dental anaesthesia
1. Hypoxaemia:
During dental chair anaesthesia, there is high po-
tential for airway obstruction resulting in hypoxaemia.
This can result from inhalation of teeth, crowns, por-
tions of filling, etc. A sudden decrease in arterial oxy-
gen saturation by up to 10% can occur under general
anaesthesia due to upper airway obstruction at the time
of insertion of the dental prop and pack and during
extractions. This obstruction is accentuated by coex-
isting rhinitis and hypertrophied adenoids and tonsils in
young children. Further, in such patients airway clo-
sure occurs at lung volumes well above functional re-
sidual capacity (FRC), producing a large intrapulmo-
nary shunt. During general anaesthesia, there is further
reduction in FRC and intrapulmonary shunt is exacer-
bated and together with propensity for upper airway
obstruction, there is greater tendency to hypoxia.28, 40,
41
Increasing fractional inspired oxygen concentra-
tion to 0.3 reduces the incidence and severity of
peroperative desaturation. However, increasing the
FiO2 further to 0.5 has not been shown to result in
more improvement in oxygen saturation.42, 43 Applica-
tion of 5cm H2O continuous positive airway pressure
(CPAP) can result in significant reduction in incidence
and severity of peroperative arterial desaturation by
increasing FRC and overcoming partial airway obstruc-
tion.44
2. Arrhythmias:
There is high incidence of cardiac arrhythmias,
especially with the use of halothane. They are usually
Naveen Malhotra. General anaesthesia for dentistry
attributed to light anaesthesia, elevated levels of cat-
echolamines and trigeminal nerve stimulation. They are
increased in the presence of hypercarbia or hypoxia.
The arrhythmias usually occur during extraction of teeth
but are transient, seldom require treatment and respond
to cessation of pull on the tooth.45
3. Subcutaneous emphysema:
Subcutaneous emphysema of face and cervical
areas, although rare but can occur due to the use of air
driven, ultra-high speed dental instruments. The air en-
ters along the mandibular periosteum at the operative
site. Nitrous oxide is discontinued on detection of em-
physema and respiratory parameters closely moni-
tored.46
4. Dislocation of temporo-mandibular joint: It
occurs not infrequently in children if mouth is opened
widely. It can predispose to airway obstruction due to
alteration in position of tongue. It can be easily reduced
at the end of surgery.
5. Operating room pollution: Dental surgeries
are areas of high contamination with anaesthetic gases.
Efficient ventilation (12-15 room changes of air per hour)
and scavenging are required.
6. Hyperthermia: Tissue destruction, environ-
mental temperature during surgery, administration of
certain drugs, dehydration and bacteraemia have all
been implicated in temperature rise after anaesthesia.
Procedures provoking bacteraemia (extractions) can
be managed by routine administration of antibiotics.6, 47
7. Non-compliance of post-operative instruc-
tions: Patients undergoing day surgical procedures are
given instructions not to drink alcohol, drive vehicles or
make important decisions for 24 hours. Some patients
do not comply with these instructions. Compliance can
be improved by physician reinforcement of instructions
and patient education.48
Conscious sedation
735
Definition: It is a minimally depressed level of
consciousness that retains the patients ability to inde-
pendently and continuously maintain an airway and re-
spond appropriately to physical stimulation and verbal
command. It is produced by a pharmacological or non-
pharmacological method or a combination thereof. In
dentistry, it is used to reinforce positive suggestion and
reassurance in a way which allows dental treatment to
be performed with minimal physiological and psycho-
logical stress, and enhanced physical comfort. The tech-
nique must carry a margin of safety wide enough to
render loss of consciousness highly unlikely.13
Conscious sedation may be induced by any one
of the following modalities:
1. Oral administration of a single sedative drug
(midazolam, diazepam, alprazolam, lorazepam,
zolpidem, promethazine, chloral hydrate).
2. Nitrous oxide and oxygen
3. Combination of oral sedative drugs or nitrous
oxide and oxygen with an oral sedative drug
4. Parenteral administration of sedative drugs (in-
travenous- midazolam, propofol; intramuscular; sub-
cutaneous; submucosal or intranasal-midazolam).
Relative analgesia
It is an inhalation sedation technique consisting of
three elements: First, administration of low to moder-
ate concentration of nitrous oxide in oxygen (0-70%);
Second, as nitrous oxide begins to exert its pharmaco-
logical effects, the patient is subjected to reassuring and
semi-hypnotic suggestions; and thirdly the use of fail-
safe equipment with a range of safety features, espe-
cially preventing accidental administration of 100% ni-
trous oxide.50 Sevoflurane 0.1-0.3% and 40% nitrous
oxide in oxygen has been used for inhalational con-
scious sedation in children undergoing dental treat-
ment.51
To conclude, provision of treatment under gen-
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
eral anaesthesia in selected children is justified and such
services should be provided safely, effectively and effi-
ciently in the appropriate environment. Dental treatment
under general anaesthesia can be carried out in a day
care facility with a high level of patient and parent sat-
isfaction. Anaesthetic management by a qualified and
experienced person and dental treatment by a qualified
operator allow the procedure to be carried out with
minimal morbidity.
If the otherwise well-trained anaesthesiologist fails
to meet the challenge of office dentistry, the field is left
by default to either the poorly trained physician, or the
dentist who may be tempted to essay surgery and ana-
esthesia simultaneously. In either case, the patient is
poorly served, and anaesthesia slips backward, not
forward.49
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