상단 PDF Dental treatment under general anesthesia for patients with severe disabilities

Patients with disabilities have difficulties tolerating in-office dental treatment due to limitations relating to cooperation and/or physical problems. Therefore, they often require general anesthesia or sedation to facilitate safe treatment. When deciding on dental treatment under general anesthesia, the plan should be carefully determined because compared to general patients, patients with disabilities are more likely to experience anesthetic complications because of their underlying medical conditions and potential drug interactions. Clinicians prefer simpler and more aggressive dental treatment procedures, such as extraction, since patients with impairment have difficulty maintaining oral hygiene, resulting in a high incidence of recurrent caries or restorative failures. This study aimed to review the available literature and discuss what dentists and anesthesiologists should consider when providing dental treatment to patients with severe disability under general anesthesia.

Methods: The anesthesia records of patients under general anesthesia for dental treatment were reviewed, and data were collected. Healthy patients under general anesthesia for dental phobia or severe gagging reflex were designated as the control group. Patients with disabilities were divided into two groups: those not taking any medication and those taking antiepileptic medications. The awakening time was evaluated in 354 patients who underwent dental treatment under general anesthesia (92 healthy patients, 183 patients with disabilities, and 79 patients with disabilities taking an antiepileptic drug). Based on the data recorded in anesthesia records, the awakening time was calculated, and statistical processes were used to determine the factors affecting awakening time.

1. Discharge instructions and follow up care via phone call In this study, post-discharge follow-up telephone calls were made to the caregivers of patients receiving dental treatment under general anesthesia or deep sedation, at the disabled outpatient unit of the Seoul National Univer- sity Dental Hospital. Caregivers were provided with educational pamphlets containing discharge instructions (such as immediately notifying the hospital and medical faculties in case of the patients developing complica- tions). Anesthesiology unit nurses were instructed to make post-discharge follow-up telephone calls to the caregivers on the morning after hospital discharge to inquire about the recovery status of the patient and to provide appropriate intervention, if necessary. Additional training regarding the appropriate care of patients developing complications at home (post-discharge) was provided. The caregivers received an additional phone call within a week of discharge, which evaluated the recovery and in-home care status of the patients, as well as the patient satisfaction level regarding the discharge education and post-discharge care provided.

In patients with special needs, there is no standard anesthetic approach due to varying clinical conditions. The aim of this study was to provide literature content about the anesthetic approaches used by us in patients with special needs. Methods: The medical records of 710 patients with special health care needs treated under general anesthesia or sedation were reviewed retrospectively. Demographic data, the American Society of Anesthesiologists classification, Mallampati score, anesthesia duration, anesthesia type, anesthetic and analgesic agents used, dental treatment performed, secondary diseases, and complications in the perioperative period were recorded. Patients were evaluated under five groups: Down syndrome, other syndromes, psychiatric disorders, physical disabilities, and complicated medical story.

The clinical experience of committed dentists is another factor that enhances the benefits of extensive treatment in special needs patients with many limitations. The insightful treatmen[r]

The dental assessment of any patient undergoing general anesthesia would ideally involve a thorough clinical examination and pre-operative radiographs to allow a treatment plan to be established. This would facilitate appropriate informed consent and adequate planning for the procedure. As mentioned above, one of the main indications for treatment of patients under general anesthesia is their lack of compliance during basic procedures—often including examination. As a result, a large part of treatment planning comprises estimations of the patients’ treatment needs, as well as ensuring that adequate time, facilities, and equipment are available to accommodate these needs. There has been minimal discussion in the literature about whether other forms of sedation are sufficient to increase cooperation in patients with special needs and thus enable a more thorough pre-operative assessment [5].

1 Department of Pediatric Dentistry, School of Dentistry, Dankook University, 2 Department of Anesthesiology, School of Dentistry, Dankook University, Cheonan, Korea Background: The most important reason for pre-operative administration of medication is to reduce anxiety. Alleviation of fear and anxiety about surgery enables patients to remain comfortable during treatment.

Results: Of 19 patients in the study, 8 were males and 11 were females, with a mean age of 32.9 years. The patients included 11 with mental retardation, 3 with autism, 2 with cerebral palsy, 2 with schizophrenia, and 1 with a brain disorder; 2 patients also had seizure disorders. All were incapable of oral self-care due to serious cognitive impairment and could not cooperate with normal dental treatment. A total of 27 rounds of general anesthesia and 1 round of intravenous sedation were performed for implant surgery. Implant placement was performed in 3 patients whose prosthesis records could not be found, while 3 other patients had less than 1 year of follow-up after prosthetic treatment. When the criteria for implant success or failure were applied in 13 remaining patients, 3 implant failures occurred in 59 total treatments. The cumulative survival rate of implants over an average of 43.3 months (15-116 months) was 94.9%.

Reports on foreign body aspiration during general anesthesia for dental treatments are rare. Accidental foreign body ingestion has been reported in patients before waking from anesthesia, when the lung function has not fully recovered [3]. No aspiration cases during dental treatments under stable general anesthesia have been reported because these treatments allow neither voluntary movements nor reflex actions.

Results: Mean age of patients was about 70 years; mean duration of Alzheimer’s disease since diagnosis was 6.3 years. Severity was assessed using the global deterioration scale; 62.8% of patients were in level ≥ 6. Mean duration of anesthesia was 178 minutes for general anesthesia and 85 minutes for intravenous sedation. Mean recovery time was 65 minutes. Eleven patients underwent intravenous sedation using propofol, and 22/32 cases involved total intravenous anesthesia using propofol and remifentanil. Anesthesia was maintained with desflurane for other patients. While maintaining anesthesia, inotropic and atropine were used for eight and four patients, respectively. No patient developed postoperative delirium. All patients were discharged without complications.

2. Methods General anesthesia was planned at the pediatric dental clinic for outpatients who were incapable of behavioral control, had a severe disability, or whose behavior could not be controlled by sedation due to extensive treatment and lack of cooperation. After admission on the day of the procedure, the patient’s preparedness for anesthesia administration was evaluated, and anesthesia was im- mediately induced without other pre-treatments. Patients did not change into a hospital gown; their guardian was allowed to stay with them during anesthesia induction and leave the room after loss of consciousness. For pediatric patients and patients with disabilities, anesthesia in- duction is more problematic than maintenance. Therefore, before venipuncture the anesthesia induction process was sub-classified into four categories according to the patient’s degree of cooperation: 1. in patients who coo- perated well, an intravenous anesthetic was administered after venipuncture; 2. in cases where persuasion and conciliation were possible, sevoflurane was additionally administered by inhalation following anesthesia induction with nitrous oxide; 3. in cases where persuasion was difficult and there was strong resistance, a high con- centration of sevoflurane was administered after placing the patient under physical restraint; 4. in patients who strongly resisted and would not enter the treatment room, mild sedation was first induced with a pre-treatment of midazolam nasal spray before administration of a high concentration of sevoflurane. Following these procedures, a typical general anesthetic protocol was used [3].

Therefore, while it is important to treat dental problems in intellectually disabled pediatric patients whose parents are also intellectually disabled, it is just as important to teach parents about oral care for children in a way that is easy for them to understand. Through communication with not only patients, but also their parents, an en- vironment in which patients can receive positive oral care over a long-term period should be created. Increasing numbers of dental procedures that involve anesthesia as a means to manage patient behavior are being performed today, and common anesthetics are used in outpatient clinics during general anesthesia due to their rapid onset of action and good reversibility upon ceasing the administration [7]. In the hospital this study focused on, it was also common for general anesthesia to be perfor- med on intellectually disabled patients, who are unlikely to cooperate during dental procedures in an outpatient operation room.

Cerebral palsy is a non-progressive disorder resulting from central nervous system damage caused by multiple factors. Almost all cerebral palsy patients have a movement disorder that makes dental treatment difficult. Oral hygiene management is difficult and the risks for periodontitis, dental caries and loss of multiple teeth are high. Placement of dental implants for multiple missing teeth in cerebral palsy patients needs multiple rounds of general anesthesia, and the prognosis is poor despite the expense. Therefore, making the decision to perform multiple dental implant treatments on cerebral palsy patients is difficult. A 33-year-old female patient with cerebral palsy and mental retardation was scheduled for multiple implant treatments. She underwent computed tomography (CT) under sedation and the operation of nine dental implants under general anesthesia. Implant-supported fixed prosthesis treatment was completed. During follow-up, she had the anterior incisors extracted and underwent the surgery of 3 additional dental implants, completing the prosthetic treatment. Although oral parafunctions existed due to cerebral palsy, no implant failure was observed 9 years after the first implant surgery.

Generally, the purpose of premedication using seda- tives such as midazolam is to reduce anxiety about anesthesia and surgery, and not to induce lower consci- ousness. However, most studies that used premedication for the purpose of inducing lower consciousness did so to control behavior in pediatric patients with no cognitive impairment. Therefore, it is difficult to use such findings to set an appropriate dose for adult patients with disabilities. In particular, overdoses of oral sedatives in patients with cerebral palsy or brain lesions puts them at risk of respiratory depression. A study on premedi- cation for dental treatment in adult patients with disabilities reported that when midazolam was administered by IM injection (0.15 mg/kg) and orally (0.3

CASE A 58-year-old man presented to the Department of Advanced General Dentistry, Dankook University College of Dentistry in 2017 for comprehensive dental treatment. The patient was diagnosed with amyotrophic lateral sclerosis (ALS) after a spinal cord injury nine years prior to presentation in a traffic accident and no medication was prescribed. He was 178 cm tall and weighed 44 kg. He was unable to walk because of weakness of the lower limbs, and therefore presented in a wheelchair. He could not hold his head up because of atrophy of his neck muscles. There was a clear general

Compared to general population, patients with schizophrenia usually have poor dental hygiene [12]. Our patient initially had minor symptoms of schizophrenia, good oral care, and was compliant toward general dental treatment. And the patient’s guardian was extremely cooperative and responsible toward the oral treatment and for the patient’s oral health-care. After tooth extraction, the patient’s condition was presumed to satisfy the following conditions: 1) Intact socket walls; 2) Facial bone wall at least 1 mm thick; 3) Thick soft tissue; 4) No acute infection at extracted site; and 5) Availability of the bone apical and palatal to the socket to provide primary stability [13]. Therefore, an immediate implan- tation after tooth extraction was decided. In November 2015, 30 months after first implant prosthesis placement, the panoramic images showed no abnormalities and no other clinically significant problem was found. In May 2018, 12 months after second implant prosthesis placement, good clinical outcomes were obtained.

and repeatedly to desensitize the patient. The effects of behavioral techniques vary among patients; even if the techniques work for some patients, it may not help them undergo dental treatment successfully. Another disadvan- tage is that the techniques are time-consuming. Topical anesthesia of the oral mucosa has been effective for some patients but worsened symptoms in others, with general anesthesia being chosen as an alternative. The risks associated with general anesthesia and high costs still make it a last resort, and there is high demand for IV sedation because of its relatively high level of safety, and quick recovery [5].

A 38-year-old woman, with the chief complaint of multiple caries, was referred to the Department of Dental Anesthesiology from the Department of Conservative Dentistry, Seoul National University Dental Hospital, for treatment under general anesthesia, because she could not endure pain under local anesthesia. She was diagnosed with osteoporosis and type I CRPS and was undergoing treatment. The symptoms of CRPS began 18 years ago following percutaneous endoscopic laser discectomy. The symptoms began in the lower back and hips spreading all over the body. She feels extreme pain even during urination and defecation. She received a morphine pump implantation 2 years ago and is receiving continuous infusion of morphine 4.33 mg per day, to a maximum of 5 times of 0.499 mg bolus a day when needed. Tweleve to fifteen tablets of 5mg oxycodone were taken 10 times a day and 600mg gabapentin were taken 3 times a day.

DISCUSSION PWS is a rare genetic disorder with characteristic gradual eating disorder changes according to age. Dentists should know about the features of PWS because affected patients have various dental symptoms. Traumatic injuries in PWS patients are common due to hypotonia. Various congenital tooth malformations are also common. Ram- pant caries occurs readily due to poor oral hygiene arising from intellectual disabilities accompanied by frequent food intake, decreased salivary flow, and increased salivary viscosity. Additionally, conscious sedation or general anesthesia is typically needed because of poor cooperation.

INTRODUCTION Perioperative dental injury and aspiration of dental prosthesis or tooth are rare complications that could induce catastrophic consequences, such as esophageal perforation and mediastinitis [1-4]. Ham et al. [5] reported that the incidence of perioperative dental injury was 0.03%. To prevent dental injury during anesthesia, pre- operative assessment and precautions need to be under- taken; however, this is not a completely preventable complication, and anesthesiologists need to assess the dental condition preoperatively and clearly document the patient’s dental condition [6]. Early diagnosis and imme- diate treatment, including surgical removal of the impacted dental prosthesis in the esophagus, are crucial to prevent these complications [7]. We report a case of esophageal impaction of a dental bridge with a review of the literature. The patient provided informed consent for publication as a case report.