Keywords

Other than pediatric restorative dentistry, other potentially invasive or painful dental and oral and maxillofacial procedures are commonplace outside of traditional operating room settings . Many of these procedures can involve significant surgical stimulation, bleeding, and postoperative pain. Cleft lip and palate repair, biopsies, urgent treatment of dental and maxillofacial trauma, or other procedures frequently present for treatment in dental offices, oral surgery offices, and even remote locations throughout the world without the traditional staffing, equipment, and protocols present in hospital-based care. In such surgeries, particular attention directed towards effective ambulatory anesthesia techniques, intra- and extraoral local anesthesia utilization, and adequate postoperative pain control strategies are key factors in successful and safe treatment in limited-resource environments.

One recent survey of oral and maxillofacial/otolaryngologic medical mission trips to low- and middle-income countries demonstrated approximately 1600 procedures of cleft lip, cleft palate, and combined cleft lip and palate repair over an 8-year period being performed worldwide [1]. As expected, an overwhelming majority of these procedures are performed on children. Likewise, triage and treatment of pediatric dental and oral trauma in settings outside of the operating room are commonplace in developed countries as well as in remote areas by nontraditional providers of dental or oral and maxillofacial care. Reports of the prevalence of dental trauma presenting to hospital emergency rooms other than dental emergencies range from 37% to 51% [2]. Even further, data has been stratified to highlight dental trauma having a pediatric male predilection and lateral luxations of primary central incisors as the most common dental injuries reported [3]. Along with trauma, planned surgeries, and nonoperating room care of dental and oral conditions, invasive diagnostic procedures, such as soft tissue biopsies, demand safe and effective sedation to produce optimum results.

The pre-procedural evaluation and choice of anesthetic or sedation plan are very similar to other settings explained in other chapters (Refer to Chap. 4) where pediatric patients must remain relatively immobile, have sufficient analgesia, and recover rapidly from the procedure. In pediatric deep sedation and general anesthesia , the individual tasked with administration and monitoring of sedation or anesthesia must be distinctly separate from the proceduralist, dentist, or surgeon [4]. Yet unlike procedural sedation for other procedures not involving the oral cavity, specific techniques and acute awareness to the airway are primary concerns in the choice and implementation of sedative and anesthetic medications. In most instances, the pediatric airway is intimately shared with the operating surgeon or dentist. Complicating factors to this shared airway include intraoral bleeding, increased likelihood of aspirating foreign objects (fractured dentition, surgical hardware, throat packing, etc.), and excessive salivary secretions. Additionally, the judicious use of traditional local anesthesia techniques for dental and oral surgery can facilitate these procedures and avoid complex and deeper planes of sedation or anesthesia for treatment. This chapter will outline the practical considerations involved in choosing, implementing, and conducting a reliable sedative technique and utilization of intraoral local anesthesia techniques for painful and invasive dental/oral and maxillofacial procedures.

Intraoral Local Anesthetic Techniques

In typical dental and oral surgery practice performed in office-based settings, the sole utilization of intraoral local anesthesia techniques can provide adequate pain control for minor to moderate procedures. Because of the office-based nature of much of dentistry, extraoral techniques of local anesthesia are uncommon, and all oral branches of the trigeminal ganglia are easily accessible from inside the mouth. Combined with moderate procedural sedation or deep sedation/general anesthesia, intraoral local anesthesia techniques arguably provide a decreased demand for anesthetic depth, rapid recovery, and prolonged analgesic and anesthetic effects into the postoperative period [5, 6].

Dental local anesthesia syringes allow the operator to aspirate with the thumb ring feature to avoid inadvertent intravascular injection. Depending on availability, dental local anesthesia syringes provide an efficient and convenient method to dispense a wide array of local anesthetic solutions in either plain varieties or those containing vasoconstrictors. Dental local anesthetic cartridges are standardized in volume and concentration of local anesthetic. If dental local anesthetic syringes are not available, disposable syringes are available with thumb rings to facilitate aspiration when injecting into the highly vascular oral cavity. Typically, small gauge needles are used in dental and oral surgical procedures ranging from 25- to 30-gauge needles (Fig. 25.1).

Fig. 25.1
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Typical aspirating dental local anesthesia syringe that accepts standard cartridges. (Photo by author)

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Maxillary Local Anesthesia

In pediatric patients, providing local anesthesia to the maxilla is relatively straightforward as the maxilla is primarily composed of highly porous cancellous bone covered by a thin layer of the periosteum. Maxillary bone, periodontium, buccal mucosa, palatal mucosa, and pulpal anesthesia can be anesthetized using common intraoral techniques frequently employed in dentistry. For procedures involving primary maxillary molars or surrounding hard and soft tissue, palatal infiltrations may be necessary to provide adequate anesthesia to these regions. Typically, minimal amounts (1–2 ml) of 2% lidocaine with epinephrine vasoconstrictor (1:100,000 concentration) provide effective surgical anesthesia for maxillary molar extractions when local anesthesia dosing recommendations are observed [7]. Slow injection technique coupled with an adequate depth of sedation commensurate to the patient’s age, pain tolerance, and proposed procedure must be considered in delivering local anesthesia infiltrations to the palate as these are poorly tolerated by non-sedated pediatric patients [8] (Fig. 25.2).

Fig. 25.2
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Maxillary infiltration performed by needle insertion into the height of mucobuccal fold. (Photo by author)

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Other techniques, such as palatal approaches to the nasopalatine and maxillary nerve are additional local anesthesia considerations for invasive surgeries involving the maxilla and associated soft tissue structures. Local anesthetic blockade of the maxillary nerve can be approached by both intraoral and extraoral approaches. Although beyond the scope and space of this chapter, the intraoral posterior superior alveolar nerve block and palatal access to the maxillary nerve are well described in the literature. Also, extraoral approaches to the maxillary nerve include suprazygomatic and infraorbital injections to provide adequate anesthesia to the maxilla and associated soft tissue [9] (Figs. 25.3 and 25.4).

Fig. 25.3
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Palatal infiltration with needle inserted adjacent to cotton swab locating the greater palatine foramen. (Photo by author)

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Fig. 25.4
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Extraoral approach to the infraorbital foramen using a dental syringe and patient under nitrous oxide inhalation sedation. (Photo by author)

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Mandibular Local Anesthesia

Depending on the age of the patient, the mandible, mandibular dentition, and associated soft tissue can be anesthetized via infiltrations, nerve block techniques, or a combination of both. Generally, in patients where mixed dentition is present (both deciduous and permanent dentition), intraoral infiltration techniques can provide adequate mandibular and pulpal anesthesia when local anesthesia solutions penetrate through the mandibular cortical plate into the inner cancellous bone. Once patients reach the approximate of 12 years, nerve block techniques should be heavily considered to provide mandibular pulpal anesthesia because of the lack of permeability of local anesthesia agents to anesthetize the mandibular nerve due to increased mandibular bone density.

For older pediatric patients where mandibular teeth consist of permanent dentition, local anesthesia blocks targeting the inferior alveolar nerve and associated branches (buccal nerve, lingual nerve, incisive nerve, or mental nerve) will be necessary. Dentist providers and oral and maxillofacial surgeons can perform various effective techniques beyond that of the traditional inferior alveolar nerve block technique described below.

Local anesthetic blockade of the inferior alveolar nerve can provide complete hemi-mandibular anesthesia of the dental pulps, associated alveolus and mandibular structures, and soft tissues depending on the technique. Typically, in dentistry, the intraoral Halstead mandibular block, or inferior alveolar nerve block , is performed by inserting a needle at an angle directed from the contralateral mandibular premolars so that the needle tip contacts the medial aspect of the contralateral ramus of the mandible at the level of, or slightly superior to, the mandibular foramen. Local anesthesia is deposited at the insertion of the inferior alveolar nerve into the mandibular foramen just superior to the lingula with a needle of sufficient length to penetrate the mucosa and intraoral musculature. The buccal aspect of soft tissue lateral to permanent molars will need to be anesthetized separately because of the buccal nerve, a branch of the anterior root of the mandibular nerve which branches off superior to the area of local anesthesia deposition [10]. Aspiration prior to injection of local anesthesia is necessary, just as in any blind needle insertion technique, to avoid inadvertent vascular injection of local anesthesia and vasoconstrictor, if used. Additionally, other techniques used to anesthetize the trigemninal nerve have been described and include the Gow-Gates, Vazirani-Akinosi, and lateral extraoral approaches [11]. Other extraoral methods described by Braun and Kantorowicz have been described along with the growing popularity of ultrasound-guided techniques [12] (Fig. 25.5).

Fig. 25.5
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Traditional inferior alveolar nerve block performed with aspirating dental syringe inserted from across the mandibular arch to the medial aspect of the ramus of the mandible. (Photo by author)

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Specific Dental Equipment and Safety Considerations

First and foremost, the use of sharp instrumentation near or around a patient’s eyes requires close monitoring of patient protection from unintended injury during sedation and anesthesia. Patients being fitted with protective goggles or eye protection is commonplace in clinical dentistry. Caustic chemicals, such as sodium hypochlorite and phosphoric acid used to etch tooth enamel for bonding procedures, and lasers and bright lights used to cure dental restorative adhesives and materials, to other foreign objects, such as tooth particles and restorative materials, are frequent hazards to patients undergoing any dental procedure, and the sedated pediatric patient should be protected against such potential injuries to the eyes. With mild to moderate degrees of sedation in the pediatric patient, unexpected patient movement can pose a threat to ocular injury with the close proximity of various instrumentation used in dental and maxillofacial surgeries.

The placement of a “throat pack” or throat screen in situations where the sedated patient is dependent upon a natural airway is crucial to prevent aspiration of foreign objects, salivary secretions, and blood. Depending on the procedure and depth of sedation (especially with natural, noninstrumented airway), the primary concern is to prevent laryngospasm and pulmonary aspiration. Typical airway adjuncts such as an oropharyngeal airway can be problematic with any type of dental or oral surgery as this may impede surgical access. Properly sized and atraumatically placed nasopharyngeal airways become the primary airway adjunct in most dental procedures, but they should be used with caution and careful preoperative evaluation in patients with developmental or traumatic deformities to nasal, nasopharyngeal, sphenoid, or palatal structures.

Additionally, if cotton gauze or other throat pack is used for the prevention of aspiration, extreme care must be exercised to prevent airway fires with administered supplemental oxygen. The dental handpiece has the capacity to provide an ignition source with a carbide or diamond-tipped burr rotating at greater than 100,000 rpm when it comes into contact with dental enamel, dentin, or other dental restorative materials. Simple prevention of flash airway fires in an enriched oxygen environment includes moistening the throat pack, providing adequate surgical suction near or at the head of the dental handpiece, and reducing supplemental oxygen to levels less than 30% [13].

Although somewhat rare, any manipulation of the midface and surgery in the oral cavity can trigger the trigeminocardiac, or oculo-cardiac, reflex in which significant bradycardia and even asystole have been reported [14]. Whenever pressure or stimulation to the trigeminal nerve occurs, as with and significant dental surgery involving the branches of the trigeminal ganglion may precipitate, a reflex arc may send efferent signals to the vagus nerve. Consideration in the administration of anticholinergic medications may prevent significant cardiovascular response to the trigeminocardiac reflex [15].

The mask ventilation of edentulous or partially edentulous patients has proven to be difficult because of the inadequacy of a mask seal with most available breathing masks. With younger children who are in the midst of mixed or loose dentition, pediatric patients who may have suffered significant trauma or even pediatric patients with congenitally missing teeth, having a variety of different sized masks, may make ventilation more effective by placing the caudal portion of the mask on the lower lip and holding the mask with two hands [16]. Mandibular fracture; an unusually shaped oral cavity, cleft palate/lip; or other injuries to the oral structures (alveolar fracture, partially avulsed dentition, traumatically reflected mucosa) may also complicate mask ventilation efforts, and other methods of providing effective ventilation must be explored prior to beginning any sedation. This may include ready and immediate access to supraglottic airways, emergency cricothyrotomy kits, or even positioning the typical anesthesia breathing mask “upside down” to facilitate adequate ventilation through the nose and place less posterior pressure onto the mandible [17].

An important sedation safety and operative risk to mitigate, especially with moderately to deeply sedated pediatric patients undergoing any procedure in the oral cavity, is the forceful and involuntary closure of the mouth. When possible, devices such as firm elastic bite blocks inserted on either side of opposing dentition work well to prevent damage to dentition, injury to proceduralists’ digits, or even closure of the lumen of an oral endotracheal tube or suction catheter. A ratcheting mouth prop, or Molt mouth prop, can be used on patients without dentition, and the jaws of the device should be positioned on the prominent areas of the available mandibular and maxillary alveolus. Care must be exercised in placing the ratcheting mouth gag to ensure external tissue of the cheek does not become entrapped in the ratcheting mechanism.

Depending on the nature of the procedure, various retractors are commonly employed to protect the tongue and provide improved surgical access to intraoral areas [18]. Care must be exercised to ensure traction or pressure on the tongue does not result in partial or complete airway closure with natural, or unprotected, airways during sedation and anesthesia (Figs. 25.6 and 25.7).

Fig. 25.6
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Pediatric rubber bite block. (Photo by author)

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Fig. 25.7
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Ratcheting “Molt” mouth prop. (Photo by author)

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Finally, and as mentioned above, the close proximity of supplemental oxygen to the surgical site can pose a risk for airway fire and flash burn hazards. High-speed rotary instruments, electrocautery, and rotating diamond or carbide dental burs against organic and inorganic materials can serve as ignition sources to materials and agents used in and throughout dental procedures. Precautions in using alcohol-based prep solutions and antiseptics; the use of petroleum-based lubricants (lip balm or lubricants) and dental handpiece lubricants; acknowledging the potential of cotton, paper, or plastic materials to burn; and recognizing that inhaled and exhaled supplemental oxygen and nitrous oxide can potentially lead to catastrophic burns should be exercised in any dental procedure with natural airways [19]. VanCleave et al. suggest that the use of intraoral suction with a reduction of supplemental oxygen to levels below 30% may reduce the risks of intraoperative burns and airway fires [20].

Procedural Sedation Techniques and Considerations

Practically any choice of sedation agent or combinations of sedation agents can be used for dental procedures that involve a moderate to high degree of pain. Inhalation sedation provided by inhaled nitrous oxide , intranasal dexmedetomidine, intramuscular ketamine, intravenous infusions of propofol, or oral administration of antihistamines or benzodiazepines have an extensive history of utility in these procedures [21].

Local anesthetic dosing recommendations (especially maximum), published by both the manufacturers and from national guidelines, should be observed during painful dental procedures. The American Academy of Pediatric Dentistry (AAPD) recommends 4.4 mg/kg as the maximum dose for lidocaine and 1.3 mg/kg for bupivacaine, with or without epinephrine as a vasoconstrictor [22]. In the United States, prefilled dental cartridges of 2% lidocaine and 0.5% bupivacaine are formulated with 1:100,000 and 1:200,000 epinephrine concentrations, respectively.

Monitoring with Special Considerations to Dental Procedural Sedation

Standard American Society of Anesthesiologists’ Monitoring Guidelines for Procedural Sedation and Analgesia apply to remote and nonoperating room sedation and anesthesia [23]. The shared airway and open oral opening may be problematic in achieving accurate and consistent capnography readings and, in many situations, may be affected by supplemental oxygen, positioning, nasopharyngeal airways, and surgical suction. The joint American Academy of Pediatrics/American Academy of Pediatric Dentistry (AAP/AAPD) Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures recommend the use of pretracheal stethoscopes during procedural sedation when natural airways are utilized for these types of procedures [24]. Arguably, and perhaps depending upon sedation provider training and experience, real-time and high-quality discrimination of airflow through the pediatric airway is audible through a pretracheal stethoscope and, in some instances, can detect fluid intrusion into the airway, impending partial airway obstruction, and even cardiac changes through carotid auscultation [25]. Nevertheless, given the operative environment of a shared airway, lack of sophistication in settings outside of a resource-rich environment, and ambient noise levels of dental surgical handpieces and high-volume suction apparatus, real-time auscultation may prove to be immensely valuable in such situations where traditional capnography can be obfuscated [26] (Figs. 25.8 and 25.9).

Fig. 25.8
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Wireless pretracheal stethoscope with earpiece. (Photo by author with permission of Sedation Resource)

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Fig. 25.9
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Placement of pretracheal stethoscope on a patient during deep sedation. (Photo by author)

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Usual end-tidal sampling from nasal cannulas can be problematic and challenging with natural airway and spontaneous [sic] during painful dental procedures. In these circumstances, capnography can be adapted to various devices in natural airway sedations by employing Luer-lock sampling connectors to nitrous oxide sedation nasal hoods as shown in Fig. 25.10.

Fig. 25.10
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Dental nitrous oxide nasal hood adapted for exhaled carbon dioxide gas sampling. (Photo by author)

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Other creative techniques used to obtain capnography include: substituting a shortened naso-endotracheal tube (nasal RAE) for the traditional soft rubber or polyvinylchloride nasopharyngeal airway (“nasal trumpet”) without passing it through the vocal cords [27]. The capnography sampling line used for an endotracheal tube can easily be adapted to the standard 15 mm connector on endotracheal tubes.

Type of Procedures and Considerations

Far from being a comprehensive list of complex dental and oral and maxillofacial procedures performed outside of a hospital operating room setting, the following procedures highlight the more common surgeries and the modalities of sedation, local anesthesia, and postoperative pain management strategies utilized in the treatment of potentially painful dental surgeries.

Dental Extractions

Although deciduous teeth typically exfoliate according to established tables of the eruption of permanent dentition, the need to surgically extract both deciduous and permanent teeth due to infection, trauma, orthodontic concerns, over-retained dentition, or other pathologies is commonplace. Typically, these procedures are performed on pediatric patients with local anesthesia with or without varying levels of minimal to deep sedation. Of particular concern for patients undergoing dental extraction surgery is the possibility of continued bleeding into the postoperative and recovery period, with accompanying risks for aspiration, laryngospasm, or even airway obstruction from coagulated blood.

Common to pediatric dental patients is the removal of supernumerary teeth, or teeth outside the number of the usual 20 deciduous and 32 permanent dentition. Beside extraneous dentition germinating from expected anatomic areas within the mandible and maxilla, extra dentition originating near the midline of maxillary central incisors also presents itself as a specific dental condition known as mesiodens , and generally accounts for 80% of all supernumerary dentition. The prevalence of mesiodens has been reported to be anywhere between 0.1% and 1.9% of the population and if left untreated can lead to orthodontic crowding, delayed eruption of permanent central incisors, root resorption, and cyst formation. Mesiodens are asymptomatic when identified in patients with primarily deciduous dentition into a mixed dentition stage later in development [28]. When local anesthesia is administered as an infiltration to the palate, there is a rapid uptake as the maxilla is composed of cancellous bone. The addition of a vasoconstrictor to the local anesthetic (commonly, 1:100,000 epinephrine) can aid in providing hemostasis for surgical identification of the mesiodens , and local anesthesia should be deposited as close to the supernumerary tooth or teeth as possible under radiographic guidance (Fig. 25.11).

Fig. 25.11
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Occlusal intraoral radiograph showing mesiodens developing in the palate of a pediatric patient. (Photo courtesy of Dr. Thomas Tanbonliong)

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Hemostasis using gauze can be achieved with ample pressure to the tooth socket or extraction sites until coagulation is achieved. If the socket has adequate depth, a resorbable packing material can be placed firmly to aid coagulation. In the case of multiple extractions, large cotton gauze rolls placed between the maxillary and mandibular arches can absorb residual bleeding from dental extractions. It is critical to remember that any sort of cotton gauze packing must be made easily retrievable in order to minimize the risk of obstruction or aspiration by securing it with a long dental floss “leash.”

Local anesthesia is commonly preferred to oral or parenteral narcotics in order to provide intraoperative anesthesia and postoperative analgesia. The administration of local anesthesia administered intraorally in the buccal mandibular or maxillary vestibule provides adequate anesthesia for most extractions and, in pediatric patients up to age 9, usually eliminates the need for nerve block [29]. Investigations looking into the efficacy of specific local anesthesia solutions have demonstrated increased efficacy of articaine hydrochloride infiltrations in the pediatric mandible as an alternative to nerve block technique [30]. For those patients who can tolerate vasoconstrictors with local anesthesia, epinephrine may aid in hemostasis in the soft tissue areas immediately adjacent to the extraction sites.

Finally, considerable debate exists over the administration of local anesthesia during deep sedation or general anesthesia for pediatric patients undergoing painful dental procedures. Intuitively, although a reduction in postoperative pain should accompany intraoral local anesthesia administration, multiple investigations fail to demonstrate a quantifiable reduction in pain intensity scores upon recovery from anesthesia or sedation [31]. Moreover, an increased potential for postoperative self-induced trauma, namely, lip and tongue biting, exists with “numbed” pediatric patients, and “profound alteration of orofacial sensation” may pose considerable distress for children unaccustomed or unable to comprehend this lack of sensation [32].

Cleft Lip and Palate Surgeries

Frequently, practitioners are called to perform repeated procedural sedations and general anesthetics for children undergoing various stages of cleft lip and/or cleft palate repair. In general, cleft palate and associate cleft lip can occur as commonly as 1 in 2000 live births [33]. When evaluating patients for cleft palate and lip repair, it should be noted that other associated syndromes may accompany the incomplete formation of these oral structures. Of particular importance is the recognition of those patients with retrognathia and glossoptosis and those who are obligate mouth breathers. These children can present challenges to achieving a good mask fit and effective positive pressure ventilation . Associated Pierre Robin sequence, facial abnormalities presenting with Stickler syndrome can complicate the airway management of these patients [34]. Because cleft palate and cleft lip repair can often be staged surgeries, requiring revision at a later time when healing and development progress, it is important to remember that previous airway and physiologic assessments may have changed.

Medical mission trips for cleft lip and palate repair are often conducted in remote areas far from traditional hospital operating room settings. Nontraditional recovery areas and lack of trained staffing may place demands on sedation and anesthetic techniques that facilitate rapid recovery from surgery with manageable levels of postoperative discomfort. Local anesthesia techniques reduce intra- and postop demands for sedation and analgesia and minimize the risk of airway compromise associated with narcotics. In resource-poor operating environments, cleft lip repair using solely local anesthesia has been used with success in adult patients [35]. Either an extraoral or intraoral infraorbital nerve block coupled with or without an external nasal nerve block, depending on the extent of the intended repair, provides complete soft tissue anesthesia and pulpal anesthesia for primary closure. Providing moderate procedural sedation with agents such as parenteral ketamine, midazolam, propofol, short-acting opioids, or alpha-2 agonists facilitates delivery of the local anesthetic to the region and can optimize surgical conditions with minimal movement during surgery. Some evidence exists to support earlier recovery times and a return to function with infraorbital nerve block local anesthesia administration in children less than 13 years of age [36].

Intraoperative sedation and anesthesia management can be complicated by the shared airway and surrounding structures by the surgical team. Protected airways with tracheal intubation are highly recommended for complex surgical repairs on young patients. A natural airway can be employed on older pediatric populations with less invasive surgeries. Sedation and anesthesia treatment plans call for careful maintenance and monitoring of the airway with adequate positioning, placement of packing, and prior plan for rescue. Specialized retractors often used in such surgeries (Fig. 25.12), such as the Millard-Dingman mouth retractor, can impede easy access for mask ventilation of airway rescue. Familiarity with the process of removing this instrument in the event of an airway emergency is critical for all sedation and anesthesia personnel.

Fig. 25.12
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Millard-Dingman oral retractor used in cleft surgeries. (Photo courtesy of Dr. Cynthia Fukami)

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With any pediatric oral and maxillofacial surgery, close consultation with the cleft team of surgeons is a priority in order to plan the management of primary surgeries and subsequent procedures. Planning for dental impression taking and appliance fabrication, among other associated procedures, is also an important consideration in the treatment planning sequence that can involve significant aspects of sedation and anesthesia planning for airway management [37]. For instance, when military-based medical aid missions are conducted in remote areas to treat various forms of cleft and craniofacial care, anesthesia providers are heavily integrated into these teams consisting of craniofacial surgeons, plastic surgeons, and speech-language pathologists performing complex triage and assessment [38].

Oral Trauma

Oral and maxillofacial trauma is a relatively smaller subset of injuries occurring in approximately 4.6% of overall pediatric trauma [39]. The presentation and complexity of these injuries can be quite complex, and a thorough evaluation of the patient is crucial in triaging the patient to appropriate care settings. Concomitant injuries are common, and the dynamic nature of injury and inflammation in soft and hard tissues of the oropharyngeal area demands a continual evaluation of the patency of the pediatric airway.

When oral and minor maxillofacial trauma is treated in a setting outside of a typical operating room, the combination of moderate procedural sedation coupled with local anesthesia can facilitate effective treatment. Partially or completely avulsed dentition, soft tissue trauma or lacerations, alveolar fractures, or even certain mandibular fractures have been treated in office-based or remote settings with local anesthesia augmented with various levels of procedural sedation and analgesia. As with many of the procedures outline above, precautions with airway access, hemorrhage, ventilation, specialized instrumentation, and overall patient safety apply when treating dental and oral injury in these settings which are remote from a hospital and a traditional operating room. Beware of surgeries involving complex fractures or oral infections impinging upon the pediatric airway. In these situations, special considerations must be observed when any level of central nervous system depression or general anesthesia is performed. Closure or collapse of the pediatric airway has been reported with cellulitis of the sublingual, submandibular, and submental spaces, known as Ludwig’s angina, with or without associated trismus when sedatives are administered [40]. Special considerations should be exercised when considering the suitability of performing those procedures in remote settings.

The prevalence of mandibular fracture in a pediatric population is greatly outweighed by other types of dental trauma. However, depending on the nature of the injury and associated trauma, mandibular fracture can be treated in a variety of ways outside of traditional surgical settings in hospitals [41]. One popular method of management and minimally invasive surgery for older pediatric patients involves the placement of arch bars or anchor screws on both maxillary and mandibular arches and placing the patient into intermaxillary, or maxillomandibular, fixation by means of elastic bands or other devices (Fig. 25.13). Fractures in the subcondylar, parasymphyseal, and angle of the mandible are commonly encountered in pediatric mandible trauma [42], and instability of the mandible may pose challenging for establishing adequate mask seal and positive pressure ventilation. It is critical to recognize and avoid the presence of a retained throat pack following surgery. In instances where patients have been secured into maxillomandibular fixation, retained throat packs have occluded airways and posed life-threatening foreign object airway obstruction [43]. Safeguards to prevent these critical incidents, especially when recommended surgical “time-outs” or sponge counts are not routinely performed, include redundancy in delegation (proceduralist, surgeon, and sedation/anesthesia provider) of the responsibility for removal of the packing [44], ensuring immediate availability and familiarity of the use of wire cutters through all phases of emergence and recovery from anesthesia and ensuring retrievability of the throat pack with tethering in the event of forceful closure or clenching of the mouth (Fig. 25.14).

Fig. 25.13
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Patient wired into maxillomandibular fixation. (Photo courtesy of Dr. Mana Saraghi)

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Fig. 25.14
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Wire cutters to remove elastics or wires used to position a patient into maxillomandibular fixation in mandible fracture. (Photo by author)

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Postoperative Analgesia

The complex nature of invasive or painful pediatric dental and oral surgery procedures requires sedation and anesthesia practitioners to collaborate with surgical teams concerning postoperative analgesic strategies appropriate for the surgery, the age of the patient, immediate postoperative care, and safety in a nonhospital recovery area or abbreviated discharge from surgery. Emergence delirium from deep sedation or general anesthesia can contribute to difficulty in the assessment of inadequate postoperative analgesia, and therefore, strategies to lessen the likelihood of post-sedation delirium or agitation should be incorporated. In some instances, the addition of midazolam or dexmedetomidine to sedation and anesthesia treatment plans has shown to be effective in reducing emergence delirium following dental procedures [45].

Some analgesics should be avoided altogether . For certain, the administration of codeine and codeine combination analgesics has been discontinued from routine use in pediatrics due to our current understanding that ultrafast metabolizers (CYP2D6 pharmacogenetics) of this prodrug can transform it to its active form, morphine, and provoke respiratory depression, anoxia, and in some cases, mortality [46]. Newer postoperative therapies for pain management include a reliance upon non-opioid analgesics, such as ibuprofen and acetaminophen, coupled with other agents, such as dexamethasone, dexmedetomidine, and a judicious use of local anesthesia [47]. Children with cleft palate are also at high risk for obstructive sleep apnea and warrant special considerations when considering postoperative opioid analgesics [48].

Along with long-acting local anesthetics such as bupivacaine, the relatively recent introduction of liposomal bupivacaine solutions has found utility in the management of postoperative dental and oral surgical pain [6]. Infiltrations of liposomal bupivacaine around dental extraction sites have been reported to provide a reduction in opioid analgesic rescue and may have some efficacy in providing substantial analgesia in patients able to tolerate postoperative anesthesia after dental or oral surgery. In these circumstances, important treatment planning should prioritize rapid restoration or rehabilitation of function, in order to facilitate feeding, speech, and patent airway maintenance.

The intraoperative and postoperative administration of nonsteroidal anti-inflammatory agents, such as ketorolac tromethamine, rectal diclofenac [49], and ibuprofen, or non-opioid analgesics such as intravenous acetaminophen has proven beneficial in pediatric surgery and avoids the complications associated with opioid analgesics [50]. Alternating regimens of nonsteroidal anti-inflammatories with acetaminophen for acute dental pain have been successful as compelling alternatives to opioid analgesic therapy. Broader utilizations of such therapies may reduce the complications associated with opioid administration [51]. Oral dexmedetomidine administration in the preoperative phase may also have some utility in reducing sedation and anesthesia-related postoperative emergence delirium [52]. Lastly, especially with dental surgeries that involve approximation of incisions or even oral-antral communication, strategies to minimize and avoid postoperative nausea and vomiting should be incorporated into the overall sedation and anesthesia treatment plan [53].

Conclusion

The movement towards treating pediatric patients with unique dental and oral needs in a remote setting is rapidly increasing as sedation techniques, pharmaceuticals, monitoring, and surgical proficiencies improve. Although almost any dental procedure can be perceived as painful, this chapter focused upon dental procedures with clear invasiveness beyond that of typical restorative dentistry. The concepts outlined in this chapter can easily be applied to other dental and oral procedures, such as soft tissue biopsies, surgical exposure, and bonding of dentition for orthodontic movement, or surgical placement of prostheses.

Complicating factors of noncooperation, bleeding, increased surgical stimulation, challenging pediatric airway anatomy, and specific surgical considerations discussed above are only small samplings of the complexities that must be considered when attempting to provide sedation or anesthesia in a venue outside of the typical hospital-based operating room. Augmentation of sedation and general anesthesia with perioperative local anesthesia in the oral cavity reduces the demand for analgesia intraoperatively and postoperatively to facilitate recovery for selected patient populations as well. Finally, the most important is the prioritization of maintaining a safe environment for pediatric patients, respecting the associated hazards of the surgical site, instrumentation, and delivery of supplemental oxygen near the pediatric airway. These risks should be assessed and considered with every setting, surgery, and preoperative assessment of the patient.