Position: Supine, arms tucked
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes
Lead: Yes

Patient Population – Often dental cases are done on developmentally delayed patients or those with severe genetic disease who cannot tolerate local anesthetic in a clinical setting. With that in mind, its important to carefully assess anesthetic limitations and plan thoroughly.

Anesthetic Approach – GETT. Anesthetic induction (eg. mask induction or IV induction) will depend on the anesthetic limitations of the patient. Intubation can be with an oral or nasal ETT. If using a nasal tube, have the correct sized nasal RAE, nasal trumpet, Magill forceps, and Afrin ready. It is also adviseable to have a video laryngoscope close by. Placing the nasal RAE in warm saline before insertion will make the plastic more malleable to ease the insertion and reduce the risk of bleeding. The nasal trumpet can facilitate bag-masking and also ease the insertion of the nasal RAE.

Induction and Intubation – If using a nasal Rae, there will be a sequence of things to do relatively quickly. First, after induction, tape the eyes to protect them from the Afrin (any surplus or inaccurately directed medication could accidentally reach the eyes). Next, spray Afrin in the nare you anticipate using for intubation. Then place a lubricated nasal trumpet. In the case of a mask induction, there will be a little bit of time before the IV is started. Once the IV is started, and you have administered the necessary drugs, you can remove the trumpet and intubate through the same nare.

Time – The surgical time depends on the extent of tooth corrosion, how many teeth are getting taken out, and how bad the bleeding is. Time could be anywhere between 1-4 hours.

Pain control – Often, multiple teeth are extracted, which results in increased post-op pain. It is important to consider pain control in this patient population as they may not be able to clearly communicate their pain levels.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.