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The Role of General Anaesthesia in Special Care &
Paediatric Dentistry; Inclusion Criteria and Clinical
Indications.
Arkadiusz Dziedzic, DDS, PhD

Department of Conservative Dentistry with Endodontics, Medical University of Silesia

Abstract option for the provision of efficient and comprehensive dental care
to individuals with special needs.
Dental practitioners dealing with children and individuals with
special needs can be supported by the provision of general It should be emphasised that a general anaesthetic cannot be
anaesthesia for the most challenging patients in situations where considered a technique of choice; for dental fear and anxiety
other options are insufficient. The availability of general control and the use of standard local anaesthesia with, when
anaesthesia will further the aim of extending access to the widest necessary, the adjunct of conscious sedation modalities ought to
range of dental care to the greatest number of patients regardless be the first-line means undertaken for all dental patients.3
of disability, age or phobia. The objective is to ensure patients have Alternative methods are often successful, too. An assessment of
a pain-free and healthy mouth, and any necessary treatment in the patients referred for GA with Oldham Community Dental Service
most appropriate setting related to their specific needs. A strictly demonstrated that only 25% of them were subsequently referred
individual and holistic approach is required when evaluating the for GA and the rest of the patients accepted dental treatment with
risk versus benefit of proceeding with general anaesthesia for routine local anaesthesia or required inhalation sedation.4
delivery of dental treatment particularly for children and special Moreover, the mean cost of dental care under general anaesthesia
needs individuals. It is vitally important to consider and address all appears to be three times higher than for sedation.5 However, in
relevant factors specific to this particular group of patients selected cases, dental treatment under general anaesthesia
including assessment of capacity, validity of consent, and any frequently seems to be the only option for these patients who are
specific medical, social and behavioural issues. The other sedation unable to cope with routine dental treatment by any other means.6
modalities must be always taken into consideration.
Such children and adults with various disabilities requiring dental
This article emphasises the crucial decision-making role of dentists treatment can be safely managed with minimal morbidity
in the referral process for dental treatment under general following valid consent for the proposed procedure under GA in a
anaesthesia and the need for multidisciplinary co-operation hospital setting, supported fully by anaesthetists who are
between dental practitioners, community and hospital services. registered specialists. According to de Sousa et al.7 general
anaesthesia provided for children with early childhood caries
resulted in substantial improvements in parents’ ratings of their
child's oral health-related quality of life and the impact on their
Introduction families. As recommended by National Clinical Guidelines in
Despite the current trend of reducing the indications for general Paediatric Dentistry, UK8, for each healthy paediatric patient the
anaesthesia (GA) in dental patients, this approach has still a well- first line approach to managing anxious children in dental office
established place in dental care, and is particularly appropriate for ought to involve individual behavioural management and the use
patients with special and specific dental needs.1, 2 Community and of local anaesthetic, which can be supplemented with conscious
other public sector dentists deliver specialist care to patients from sedation. Dental treatment under GA of the patient with special
priority groups and general anaesthesia remains an important needs in a hospital setting has several essential benefits9 that will
frequently outweigh the well-known disadvantages (Table 1).
Table 1. The main benefits and drawbacks of dental treatment provided under general anaesthesia in hospital settings.

Advantages of GA Disadvantages of GA

Secured airway control High cost, approximately ten times higher than local
anaesthesia
Constant monitoring, including ECG
More ‘dangerous’ than other options for patients with
Appropriate critical care and recovery facilities
medical co-morbidities, higher risk of serious, general
Appropriately trained staff health complications
Facilitates a planned programme of dental treatment under relatively Specialised facilities and clinical support including post-
controlled conditions during a single session operative supervision
Highly suitable for unco-operative patients with special needs who Adult patient can be requested not to work for 24 hours
require a deep sedation/deep anaesthesia after GA, children should not attend the school a day after.
Often, the only available option to make the patient ‘dentally fit’ and pre- The experience may be potentially traumatic for very
vent from further odontogenic complications and health consequences young patients

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Table 2. Clinical indications and justifications for DGA (Royal College of Surgeons UK guidance, modified)

Conditions suitable for DGA Conditions rarely justifying DGA

• Failure to achieve adequate pain control with alternative methods • Carious, asymptomatic teeth with no clinical or
such as local anaesthesia or sedation radiological signs of infection
• Essential dental treatment required to secure oral health to the well- • Orthodontic extractions of sound permanent premolar
being of the child as a part of a long term treatment plan teeth in a healthy child
• Extraction of multiple deciduous teeth where there have been more • Patient/Carer preference, except where other
than one episode of significant pain or infection/sepsis. techniques have already been tried
• Extraction of first permanent molars which have poor prognosis in • Alternative methods of pain control have not been
the mixed dentition. fully explored and excluded

Indications for dental general require periodically repeated DGA because of recurrent dental
problems meaning this is the only option by which to provide
anaesthesia them with comprehensive dental care. A study by Albadri et al.
If treatment cannot be given under local anaesthesia (LA), or local found an incidence of 6.4% of repeat GA for children.14 With young
anaesthetic and conscious sedation, then the option is GA. children and the primary dentition, it is important to balance
Essentially the tooth requiring the most difficult treatment drives dental arches in case of multiple extractions of deciduous teeth,
this decision. There are some compromises, though, e.g. teeth that when possible. Hence, it is necessary to extract bilaterally
could be restored under LA with the adjunct of conscious sedation deciduous first molars and deciduous canines to prevent centre
may need to be extracted under GA. line discrepancy.

The clinical indications for dental treatment under GA (DGA) in Before prescribing DGA for older children or teenagers a dentist
patients with special needs are limited to certain conditions and should also consider the suitability of the novel modified
should be considered as the last method of choice after taking techniques of conscious sedation, including intranasal and
into account other available modalities of dental patient intravenous sedation, and combined inhalation sedation with a
management10, 11 (Table 2). They include: lack of co-operation due to mixture of nitrous oxide and sevoflurane15. Table 3 presents clinical
age or disability, dental cases in which other sedation techniques indications for the use of pain and anxiety control measures in
have been unsuccessful, severe dental phobia, including needle- different groups of patients: general anaesthesia, inhalation
phobic patients who are unable to accept routine dental sedation, oral sedation, transmucosal sedation and intravenous
treatment; a confirmed allergy (rarely) or hypersensitivity to the sedation.
constituents in local anaesthetic preparations where the use of
local anaesthesia is contraindicated.12, 13 General anaesthesia for dental patients with special needs can be
combined with other procedures if required e.g. grommets
The vast majority of special needs patients referred for DGA require operation, percutaneous endoscopic gastrostomy (PEG) tube
extractions of unrestorable and symptomatic teeth in order to placement/replacement, incision of operculum, Botox injection for
resolve their dental problems associated with pain, infection, etc. muscle spasms (cerebral palsy), and cleft palate operation.
Less commonly, dental procedures under GA may involve the Tonsillectomy is not generally recommended due to the risk of
restoration of teeth and scaling to prevent/treat periodontal extensive bleeding. Dental radiographs can also be taken during
problems. GA solely for the purpose of a thorough dental GA, using mainly an extra-oral lateral oblique technique, especially
assessment can be occasionally justified if unco-operative patients in patients with complex maxillofacial malformations. Potentially, it
with special needs display symptoms of odontogenic origin may be possible to take intra-oral radiographs with a hand-held
(pain/swelling) and are unable to assist diagnosis by indicating the portable X-ray machine.16
origin or severity of their dental problem. Restorative treatment of
teeth with poor long-term prognosis should not be carried out. The DGA session is usually arranged as a day-case anaesthesia for
Special needs patients with communication difficulties will simple dental extractions of deciduous teeth, usually for children
typically provide sufficient information through various types of of age 4–10, minor oral surgeries or exodontia of carious
expression, for instance, by pointing, holding a hand, biting objects, permanent teeth for those with learning disabilities.
refusing to eat, avoiding cold/hot stimuli, grinding or clenching.
Some more complex dental procedures can also be potentially
performed, if clinically justified and necessary to secure patient’s Legislation and guidelines
oral health; they include: stainless steel crowns (Hall technique), According to current guidelines, GA should only be performed in a
impressions for immediate dentures (rarely), immediate denture fit, Hospital setting and requires a trained anaesthetist supported by a
impressions or single stage RCT on an anterior tooth. dedicated assistant.13 The Intercollegiate Advisory Committee for
Sedation in Dentistry (IACSD, UK) proposes that all children under
As a general rule, a repeat GA for dental purposes must be avoided the age of 8 who cannot cope with inhalation sedation/local
and is undesirable due to serious risk of morbidity, potential anaesthesia must be managed in hospital with a consultant
mortality and the impact on a child13, and may reflect deficiencies anaesthetist and a paediatric dentist-led team.17 However, the
in patient management and treatment planning. However, there necessity for, and the practicality of such a proposal is in dispute
are patients who are not compliant with either routine dental and the guidance remains under consideration. It is the
treatment with local anaesthesia or conscious sedation, and who responsibility of the referring dental practitioner to justify the

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Table 3. Clinical indications (examples) for the use of pain and anxiety control measures depending on patient’s co-operation,
medical conditions and co-morbidities, age and other special needs

General anaesthesia Inhalation sedation Oral sedation, transmucosal sedation,

intravenous sedation

children < 12 years

healthy child, not compliant with routine partially co-operative child above 5 years
local anaesthetic/inhalation sedation old, single extraction of
despite an attempt, multiple extractions of symptomatic/asymptomatic unrestorable
symptomatic unrestorable deciduous teeth deciduous tooth N/A

disabled child with special needs, lack of co- anxious, partially co-operative child above
operation, extractions/restorations of 5 years old who requires restorative care of
symptomatic deciduous and permanent symptomatic/asymptomatic deciduous
teeth teeth/permanent molars

failed inhalation sedation

adolescents 12-16 years old

special needs child, lack of co-operation, mildly phobic teenager, extractions of moderately phobic, fairly co-operative
extractions of retained deciduous teeth carious, unrestorable permanent teeth also healthy or special needs teenager,
e.g. premolars due to orthodontic reasons balanced/compensation extractions of
severely phobic healthy adolescent, permanent molars (orthodontic reason),
unsuccessful attempt with routine dental teenager with severe gag reflex
care failed inhalation sedation

failed conscious sedation

adults

severely phobic and medically compromised adult with mild phobia, medically adult with severe phobia or medically
adult with ASA I/II and carefully selected compromised who requires restorative or compromised requires extensive
ASA III surgical treatment restorative or surgical treatment

special needs unco-operative adult with co-operative, special needs adult, able to partially co-operative and anxious,
recurrent dental problem with unknown understand and retain information special needs adult, able to understand
origin (EUA) regarding inhalation sedation, requires and retain the information about
restorative or surgical treatment proposed treatment under intravenous
failed conscious sedation sedation

indications for use of DGA in the referral letter. Table 4 presents • Can the patient be treated dentally under GA considering
the core considerations for paediatric DGA. current guidelines?
• Does the patient have special requirements? (a hoist,
The referring dentist should provide the treatment under local transport, a wheelchair, etc.)
anaesthesia and/or conscious sedation first and discuss possible • Is there a need to proceed with capacity assessment and
risks related to GA. It is compulsory to carry out a detailed medical subsequently, a best interest meeting?
history check, and a copy of the referral letter must be retained in • Is it possible to offer alternative options for pain and
the patient’s clinical record. All children requiring dental treatment anxiety control? (conscious sedation with IS, IV, TM)
should be assessed before the operation in order to determine the • Are appropriate facilities for dental treatment under GA
most appropriate form of pain and anxiety management.13 The available?
treating dentist will need to consider all the following questions • Are there appropriate recovery facilities and is there access
before formulating a dental treatment plan that entails the use of to critical care facilities?
deep sedation and general anaesthesia: • Do an experienced anaesthetist and GA dental team offer
• Has the referring dentist fully explained all the risks of GA? support?
• Is the clinical case suitable for GA considering co-operation • Has a thorough pre-assessment been carried out during a
and general health status? separate appointment?
• Does the patient meet the criteria for dental treatment • Has valid and informed consent for dental treatment under
under GA? GA been provided?

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The special care dentist responsible for the patient’s oral heath form of GA. Individual assessment using ASA scale (American
must make a balanced decision regarding the treatment that suits Society of Anaesthetists) is recommended for GA.13 Optionally,
the patient best, taking into account their behavioural capabilities, airways assessment using the PSA scale (1-4) can be considered for
cognitive functions and medical condition. The best interest of the the use of laryngeal mask (supraglottic) or intubation.
patient must remain at the forefront of decision-making
processes18. The decision should be made together with the patient The special precautions ('alarm bells') which need to be carefully
and the next of kin or a guardian (a special guardian) of the considered before prescribing DGA may be related to22: BMI score >
patient19. In cases where a patient lacks capacity and has no next of 40 (severely bariatric patient), chronic severe respiratory conditions
kin, formal local procedures must be followed. Capacity assessment (e.g. idiopathic sarcoidosis), polyaddiction to drugs, previous
comprises the first stage of capacity evaluation, followed by a best adverse reactions to any analgesics or anaesthetics,
interest decision (meeting). In the UK, an independent mental care anticoagulation, congenital heart dysfunction (children), posture
advocate (IMCA) must be appointed in accordance with the Mental constitution: short neck including severe obesity, cervical spine
Health Act if a person is ‘un-befriended’ and there is no known injury/defect/deformation, possible airways problems, continuous
next of kin or relative20. Written consent must be completed on the home oxygen supply, transplants, polypharmacy, multiple allergies
proper form. Potential risks need to be written and explained to to eggs, soya, milk (propofol cross-reactivity?), sickle cell condition
the parent, legal guardian or patient who should finally sign the (additional tests needed). Table 5 presents the general rules for GA
consent form. treatment planning.

Table 4. Main considerations for paediatric DGA (Royal College Table 5. General rules for DGA treatment planning in
of Surgeons guidance, modified) paediatric and special care dentistry (Solent NHS. Internal
Guidelines for Extraction of Teeth under General Anaesthesia,
• The co-operation and attitude of child 2015)
• The perceived anxiety of the child
• More radical approach than for LA – aim to not only make a
• The complexity of the treatment plan
child dentally fit but to prevent a repeat GA in future
• The medical status of the child: ASA I and II, majority of ASA III
• Not only to address current treatment needs but to plan
• Age, usually above 2 years old, weight exceeds 10 kg ahead to ensure the child reaches adulthood with a healthy
• Additional and increased risk compared to non-GA sedation and functional dentition as well as a positive attitude towards
and analgesia techniques dentistry
• Treatment at hospital • Plan to extract all teeth which have poor long term prognosis
• Starving, travel, time, cost for family and service or are questionable: heavily restored, worn, traumatised,
structurally unsound. All restorative care completed prior to
• Extent of caries: teeth cannot be saved, likely to cause a
GA or at GA
pain/infection, may potentially affect a permanent dentition
• Orthodontic considerations
Limitations of general anaesthesia in
Preliminary assessment persons with special needs
A robust GA pre-assessment should be carried out during a The clinical cases not suitable for DGA are: simple orthodontic
separate appointment allowing sufficient time for discussion. The extractions, asymptomatic dental problems, extraction of a single
meeting should not be rushed as proper explanation, fully deciduous tooth where natural exfoliation is imminent, basic
informed consent and careful treatment planning21 are necessary. dental examination, scale and polish/debridement where no other
When it comes to routine medication, the general treatment is planned and there is no evidence of odontogenic
recommendation for the vast majority of patients is to take their infection. Because of the 'complex nature' of the GA procedure and
usual drugs at the usual time and at the usual dose. Each patient the increased risk of complications, there are obvious limitations
should be treated as an individual and as a special case, bearing in for dental treatment under GA23.
mind all specific variations on the day in question. This is because
health, condition, mood and general well-being of special needs General anaesthesia can be restricted in totally unco-operative
patients may change significantly and will often vary from day to patients with complex special needs and predicted difficulties with
day. It is fundamental to consider each patient as a dynamic cannulation, multiple deformities and abnormalities, complex
individual whose physical and mental state can change without polypharmacy and severe adverse reactions to certain medications
notice. administered intravenously, e.g. muscle relaxants due to congenital
susceptibility24,25. The restrictions and contraindications for dental
When it is not possible to have a comprehensive examination or treatment under GA are listed in Table 6.
appropriate laboratory tests done prior to administering care, due
to a patient’s mental/learning disability, the dentist responsible for
referring a patient should document the reasons preventing the Medically compromised dental
recommended pre-operative management. Age is an important
consideration when assessing children for GA. Healthy three-year-
patient
olds can be accepted for simple, quick DGA sessions. However, it is The anaesthetist should be informed and made aware of all
necessary to discuss the suitability of children under the age of medications taken by the patient preparing for dental procedures
three with an anaesthetist before agreeing to refer them for any under GA. For the vast majority of medications prescribed for

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Table 6. Contra-indications for provision of dental care with the use of DGA.

Non-valid consent for GA procedure History of severe side effects related to sedatives, including
confirmed anaphylactic reaction to sedative medications
No clinical indication/justification for GA, e.g. GA only to be used
for proper dental examination and/or oral hygiene in healthy Genetic disorders affecting metabolism, pharmacokinetics and
phobic person effect of sedatives and/or muscles relaxants: malignant
Existing dental problem which is causing no obvious pain or hyperthermia, acetylcholine esterase metabolism disorder, sickle
discomfort, etc. (e.g. retained, asymptomatic roots) cell anaemia

Lack of appropriate facilities or properly trained staff

Single, dental problem which can be resolved successfully using

other techniques: LA, RA, IV

common medical conditions there are no specific restrictions and

precautions and there is no need for dose adjustment either Parents or legal guardians who request dental treatment under
before or after the DGA session. Generally, anti-hypertensive drugs, GA to be combined with other procedures due to medical reasons
bronchodilators, antiepileptic drugs and medications for •
cardiovascular diseases should be continued without alteration. Severely medically compromised elderly patients
Special attention should be paid to anxiolytic drugs and •
tranquilisers as they may interact with medications used for pre- Inherited medical conditions which are known to increase the
anaesthesia sedation. The patient’s physician, consultant or risk of life-threatening complications following GA
specialist must be consulted in all cases involving diabetic drugs •
and corticosteroid pharmacotherapy26. Additionally, patients can Is a single deciduous tooth extraction under GA in unco-
confirm an allergy to topical anaesthetic gel, e.g. EMLA used for operative child with periodontitis and/or an abscess justified?
cannulation procedures, perhaps during a previous experience of Are there other alternatives?
IV sedation or GA. •
Should an unco-operative patient in pain waiting for a second
The main intra- and post-operative complications may include: orthodontic opinion regarding extractions of carious permanent
non-fatal ventricular arrhythmia, fall in blood pressure or teeth be prioritised for GA referral?
hypertension, laryngospasm, airway problems resulting in a •
desaturation of oxygen27. If current standards are strictly followed, Is GA ever justified in order to advance purely orthodontic
complications during DGA sessions will most likely be treatment ?
multifactorial, including unpredictable reactions to intravenous •
sedatives or relaxant/myolytic drugs, compromised respiratory Are balanced, compensating multiple extractions under GA
capacity, cardiac depression, etc. In addition to complications justified for non-orthodontic reasons, such as compromised first
relating to the GA, the dental treatment provided under GA itself permanent molars (hypoplastic) in phobic patients ?
precipitates specific problems or circumstances that need to be •
resolved efficiently. Table 7 contains the list of challenges related to A family history of prolonged reaction to muscle relaxants
dental treatment under GA in children and special needs patients. (mepivacurium, pancuronium, etc.) may indicate a genetic
predisposition to complications following GA which patients
Table 7. Challenging situations which can arise when may describe as an ‘allergy’
considering dental treatment under GA •
Clinical holding of a young patient or patients with special
Uncertain parental responsibility or double parental needs may be necessary during cannulation
responsibility, e.g. biological, adoptive, step and foster parents Oblique lateral radiographs arranged during GA need to be
• considered in case of cranio-facial malformations
Different expectations of parents who cannot agree on their
consent for dental treatment under GA for their child
• The referring dentist and secondary dental care operator, i.e.
Parents happy to consent for a specific treatment or procedure, community dentist or special dental care consultant, must ensure
e.g. single extraction of one affected and symptomatic tooth that there is an accompanying adult with parental responsibility
under GA but are reluctant to or apprehensive about for any child seen (biological parents, adoptive parents, special
consenting to multiple balanced extractions guardians). Verbal information documented with written advice is
• imperative as the patient may have a varied number of carers who
Patients with special needs who have no next-of-kin family may need to refer to this information. Instructions for patients and
members carers (both verbal and written) must be provided. After a DGA
• session, patients must be properly assessed before discharging.
Young patients who have had GA for a medical condition Post-operative advice must be given in writing12,13. Figure 1
within the last 3 months presents an example of internal protocol recommendations when
• referring a patient for dental treatment under GA.

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Figure 1. Flowchart representing an internal protocol for
dental general anaesthetic referral.

Full dental assessment and charting completed.

Where appropriate, radiographs need to be taken
(printed copies of radiographs should be attached to patient file)

a
Medical history re-checked with parent/legal guardian/patient and entered on
computer record. They should be specifically asked about family history with GA and
any issues followed up. Potential and known allergies checked.

a
Number and location of teeth for extraction/restoration explained to patients/parents/legal guardian.
Use tooth notation and also ‘layman’s’ description of teeth to be removed or treated
(eg. three baby teeth).
a

GA pack completion
Internal general anaesthetic referral
a

Written consent completed on proper form: Written treatment plan signed by patient/legal
children: Consent form 2, adults: Consent form 1, guardian/parents
patient with lack of capacity to consent – Consent Copy of signed Consent Form given to parents or legal
form 4, guardian
Copy of signed consent form given to parents or
legal guardian
a

Check list completed

• up-to-date medical history in the records
• obtained informed consent
• enclosed necessary radiographs
• treatment plan clearly marked
• capacity and best interest assessed if applicable
• relevant correspondence from medical/dental professional enclosed
a

Pre and post-operative GA instructions Post-operative outcomes discussed. Both

in writing short term (eg. uncomfortable mouth) and
long term consequences to tooth extractions
(eg. crowding).
a

Approximate waiting time for GA given and patient informed that they will be contacted by
telephone with appointment. Patient / parent / legal guardian are informed where to seek urgent
treatment whilst on the waiting list.

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Summary 5. Prabhu N T, Nunn J H, Evans D J. A comparison of costs in providing dental care
for special needs patients under sedation or general anaesthesia in the North
East of England. Prim Dent Care. 2006;13:125-8.
In conclusion, all dentists providing dental care under GA must
6. Goodwin M, Sanders C, Pretty I A. A study of the provision of hospital based
remember the following: dental general anaesthetic services for children in the northwest of England: part
1. DGA should be avoided where possible and therefore the 1 - a comparison of service delivery between six hospitals. BMC Oral Health.
initial aim at the start of each treatment plan is to avoid the 2015;15:50.
GA. Dentists should not assume that DGA is the only option 7. de Souza M C, Harrison M, Marshman Z. Oral health-related quality of life
following dental treatment under general anaesthesia for early childhood caries -
because of the young age of the child or parent’s preference. a UK-based study. Int J Paediatr Dent. 2016;17.
2. Dental treatment under GA has to be limited to predictable, 8. Hosey M T; UK National Clinical Guidelines in Pediatric Dentistry. UK National
long-term successful outcomes and one-stage procedures. Clinical Guidelines in Paediatric Dentistry. Managing anxious children: the use of
3. Valid, fully informed consent is paramount and mandatory, conscious sedation in paediatric dentistry. Int J Paediatr Dent. 2002;12:359-72.
9. Adewale L. Anaesthesia for paediatric dentistry. Contin Educ Anaesth Crit Care
obtained from an appropriate person: parents, legal guardians, Pain 2012; 12: 288-294.
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along with best interest meeting, with patient’s next of kin, GPs, for provision of dental treatment to patients younger than 18 years. Cochrane
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team, recovery staff, ward nurses, etc. Under General Anaesthesia. Association of Paediatric Anaesthetists of Great
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14. Albadri S S, Jarad F D, Lee G T, et al. The frequency of repeat general anaesthesia
Despite the fact that general anaesthesia plays an important role for teeth extractions in children. Int J Paediatr Dent. 2006;16:45-8.
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