T H E D E N T A L P A T I E N T W I T H S P E C I A L N E E D S

A R T I C L E

Spec Care Dent is t 29(1 ) 2009 17©2008 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2008.00057.x

A B S T R A C TGeneral anesthesia (GA) can play animportant role in the facilitation of dentaltreatment for individuals who presentwith challenging behaviors. This articlepresents a review of the literature dis-cussing indications for the utilization ofGA in the treatment of dental patientswith special needs.

The dental patient with special needs:a review of indications for treatmentunder general anesthesia

Nancy Dougherty, DMD

Director, Postgraduate Program in Pediatric Dentistry, North Bronx Healthcare Network; Clinical

Associate Professor, NYU College of Dentistry; Clinical Assistant Professor, Dentistry & Pediatrics,

Albert Einstein College of Medicine, Bronx, New York

Corresponding author e-mail: nid201@nyu.edu

Spec Care Dentist 29(1): 17-20, 2009

Some patients with special needs do,however, require interventions that gobeyond the scope of routine behaviormanagement techniques. These tech-niques can include desensitization,anti-anxiety medications, therapeuticimmobilization, sedation, and generalanesthesia (GA).

The original purpose of this articlewas to seek and disseminate evidence in the area of indications for use of GA with special needs dental patients.The literature that was found (see“Methodology”) made it apparent thatevidence in this area was not sufficientto provide a basis for guidelines. Thecurrent article is thus limited to a reviewof the literature concerned with dentaltreatment performed under GA and a discussion of indications for its utilization.

Methodo l ogyA literature search using the Medlinedatabase was conducted. The following

keywords were used in the search: general anesthesia, special needs, dentaltreatment, developmental disabilities,and cognitive impairment. The originalliterature search encompassed articleswritten between 1990 and 2006.However, because it was felt that thenumber of relevant papers was inade-quate, the search was extended toinclude articles from 1975 to the present.Also included were searches of theCochrane Database of SystematicReviews and websites of national and international dental organizations. Only articles and websites that providedEnglish language materials were considered.

Di scus s i onThe American Society ofAnesthesiologists (ASA) defines generalanesthesia (GA) as “a drug-induced lossof consciousness during which patientsare not arousable, even by painful stimu-lation. The ability to independently

I n t r oduc t i onDental patients with “special needs” can encompass a wide range of disabling condi-tions including intellectual disability, dementia, physical limitations, movementdisorders, behavioral disorders, and chronic medical conditions. Many of these individ-uals can be treated in routine dental settings with minimal special accommodations orwith interventions that are well within the scope of most dental professionals.1

KEY WORDS: general anesthesia,special needs, dental treatment, develop-mental disabilities, cognitive impairment

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maintain ventilatory function is oftenimpaired. Patients often require assis-tance in maintaining a patent airway, andpositive pressure ventilation may berequired because of depressed sponta-neous ventilation or drug-induceddepression of neuromuscular function.Cardiovascular function may beimpaired.”2

Malamed makes the point that, inrecent years, improvements in anti-anxi-ety medications and conscious sedativetechniques have decreased the need forGA.3 There remain, however, indicationsfor its use.

Before proceeding to a discussion ofindications for GA, it will be helpful toconsider advantages and disadvantages of its use. A partial list of advantages and disadvantages as cited by Malamed is included here:3

Advantages:1. Patient cooperation is not absolutely

essential.2. The patient is unconscious during

treatment.3. The patient does not respond to pain.4. Amnesia is present after the proce-

dure.5. Onset of action of GA is usually

rapid.6. Titration of drugs to produce the

desired effect is possible.Disadvantages:

1. The patient is unconscious duringtreatment (can be considered anadvantage as well as a disadvantage).

2. Patient protective reflexes aredepressed.

3. Vital signs are depressed.4. Advanced training is required for the

person administering GA.5. A team of professionals (rather than

an individual dentist) is required toprovide treatment.

6. Special anesthesia equipment isrequired.

7. A recovery area must be available for postoperative monitoring (in aprivate setting, the dental operatoryitself may serve as a recovery room).

8. Intraoperative and postoperativecomplications are more commonduring GA than during sedative procedures.

9. It is recommended that patientsreceiving GA should refrain fromdrinking clear liquids for at least 2hours preoperatively, and refrainfrom ingesting solids and nonhumanmilk for at least 6 hours preopera-tively.4

10. Patients receiving GA may requireextensive preoperative evaluation andtesting.A quick review of the above shows

that, although the advantages of GA areconsiderable, the disadvantages, andtheir relevance to each individualpatient’s physical and mental status,should be carefully considered by thedentist, patient, and/or patient guardianprior to making a decision to proceedwith treatment under GA.

Although there exists a body of liter-ature concerning dental treatmentutilizing GA for persons with handicap-ping conditions, most of the papersprovide minimal discussion of indica-tions for GA. The majority of these focuson particular anesthetic protocols, or areretrospective patient record reviews,citing outcomes and characteristics ofpatients treated under GA. Many of thearticles reviewed give the primary indica-tion for GA as an inability of the patientto cooperate for treatment, or a similargeneral term.5-9

Several papers provide additional ormore detailed indications for referral fortreatment with GA. Malamed provides alist of what he considers appropriateindications for use of GA, includingextreme anxiety and fear, young age,traumatic procedures, mental disability,physical disability, senility, and disorien-tation.3 Pohl et al. state that, in additionto a patient’s inability to cooperate forroutine dental treatment, treatment ofinjuries, and/or extensive odontogenicinfections may require use of GA.10

Nunn, in a review of other papers, men-tions extensive treatment needs, behaviormanagement problems, medically com-promised children, extreme youth,patients with handicaps, anxiety andlong distance from home to a dentist asrationales provided for GA referral. Inreviewing 265 cases performed underGA, Nunn specifies, by percentages, the

reasons for requesting GA services.Intellectual impairment and autism(cited as one category) was the most fre-quently cited rationale, at 30.2%.Multiple handicapping conditions(unspecified) was second, with 24.0%.Dental phobia accounted for 21.4%. Theremaining 24.4% was divided amongphysical handicaps, youth/volume ofwork, and noncooperation/volume ofwork.11

The American Academy of PediatricDentistry (AAPD) has issued Guidelineson the elective use of sedation and gen-eral anesthesia for pediatric patients. The guidelines include a list of indica-tions for the use of GA with thispopulation. The first indication is for“patients who are unable to cooperatedue to a lack of psychological or emo-tional maturity and/or mental, physicalor medical disability.” The AAPD alsostates that GA is indicated for patientswho are extremely fearful, anxious or not communicative, or in instanceswhere it may protect the “developingpsyche.” In terms of procedures (ratherthan patient types), the AAPD states thatGA is appropriate for significant surgicalprocedures, for instances when localanesthetic is ineffective due to acuteinfection, anatomic variation or allergy,or for patients needing immediate comprehensive care.12 In an additionalGuideline paper, the AAPD proposes thatalternative behavior management tech-niques should be considered prior to thedecision to utilize GA.13

The American Dental Association(ADA) has also issued Guidelines on theUse of General Anesthesia for Dentists.This document, however, does not dis-cuss the appropriateness of GA forspecific populations or dental treatmentprotocols. Rather, it focuses on definingsedative and anesthetic terminology, edu-cational requirements for the personadministering anesthesia, and technicaland legal requirements such as equip-ment, monitoring, documentation, andemergency management.14

One common theme in much of theliterature is the recommendation thatdental treatment under GA should onlybe considered after other behavioral

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interventions have been attempted andfound unsatisfactory or unsuccessful,although alternative treatment modalitiesare not always specified.3,7,9,10,13,14 Thiscaution is most likely due to a considera-tion of the disadvantages and risks of GAcited previously. As Holland states,“Treatment under general anesthesia iscarried out only as a last resort. Everyeffort is made to treat all patients in theconscious or sedated state and only thosewho cannot be so treated are consideredfor general anesthetic.”15

A brief discussion of behavior man-agement techniques that can be utilizedas alternatives to GA will help to illumi-nate why these techniques may be, attimes, unsuccessful.

Desensitization is a behavioral tech-nique in which an individual learns toreplace maladaptive or fearful responseswith adaptive, nonfearful responses.Connick et al. point out that, in orderfor desensitization to be effective, apatient must be able to communicateand participate in the process. The tech-niques will frequently meet with littlesuccess in individuals with severe toprofound compromises of cognitivefunctioning.16

Therapeutic restraint, either physical(i.e., a parent aids in holding a child) ormechanical (such as a papoose) is fre-quently effective in facilitating dentaltreatment for behaviorally resistant chil-dren. Its limitations become obvious,however, as individuals grow larger andstronger. For patients who offer severeresistance, restraint may not permit ade-quate treatment to be completed. Inother cases, combative patients may actu-ally pose a danger not only tothemselves, but also to the treatingdental staff. In these cases, GA can be anappropriate alternative.

Nitrous oxide analgesia can be highlyeffective in inducing relaxation in anx-ious patients. It does, however, require adegree of patient cooperation, in that thepatient must be willing to wear a nasalhood and understand the need to breathethrough the nose. Its usefulness is less-ened in patients who are extremelyfearful and display markedly disruptivebehavior.17

Anti-anxiety medications, similarly,can be very helpful in reducing psycho-logical stress associated with dentaltreatment. For those individuals who areon a daily regimen of psychotropic med-ications, however, the effectiveness of theanti-anxiety drugs may be considerablycompromised. The dentist also must beaware of any untoward interactions thatmay occur between anti-anxiety medica-tions and the patient’s routinemedications. Sappington and Woehrlenpoint out that the advantages ofdecreased apprehension should be bal-anced against such disadvantages as lackof drug predictability, possible sideeffects, and the need for emergency man-agement.18

Another area of interest pertains toexactly what constitutes appropriate fre-quencies for dental treatment under GA.A review of the literature did not revealany studies that address this issue. Onestudy by Maurer et al. examined recallintervals and the effect on restorativetreatment needs of patients with disabili-ties. The study found a slight trend(statistically insignificant) towardincreased caries in patients with recallintervals greater than 12 months, com-pared to those with shorter recallintervals. However, the 83 study partici-pants were all treatable in a routinedental setting. Therefore, treatmentunder sedation and/or GA was not dis-cussed. This study also did not evaluatethe impact of recall frequencies on gingi-val condition or periodontal disease.19

The AAPD provides Guidelines onPeriodicity of Examination andPreventive Dental Services for Children,but the guidelines specify that they per-tain only to children with nocontributing medical conditions who aredeveloping normally.20 This obviouslyexcludes the population with which weare concerned.

Several of the reviewed papers statethat dental treatment performed underGA should be comprehensive in nature,for the purpose of minimizing the needfor repeated procedures under GA.3,10,11

Only one paper actually states that half-yearly or annual recall appointments arearranged for patients who have been pre-

viously treated under GA, but it is notclear if these recall appointments are per-formed in a routine dental setting orunder GA.15

There were no papers found thatexplicitly discussed the advisability ofutilizing GA at set intervals for diagnos-tic and preventive procedures, as wouldbe performed at a “recall” visit in a rou-tine dental setting.

Conc lu s i onMost of the literature that pertains to useof GA for dental treatment agrees on itsappropriateness for facilitation of treat-ment for fearful and/or behaviorallyresistant individuals. There is, however,very little in the way of solid evidence tosupport other decisions, such as exactlywhat constitutes appropriate proceduresto be performed or optimal frequency oftreatment under GA. For example, whilesome practitioners may feel that it is inthe patient’s best interest to perform anannual examination and preventive treat-ment under GA, others may feel that itmore appropriate to schedule GA only attimes when obvious pathology isobserved and requires treatment. Thereare no controlled studies that examinethis, and, in reality, such a study is prob-ably highly unfeasible.

At the current time, with the lack ofany meaningful evidence in this area, itremains for each practitioner to beknowledgeable about each individualpatient’s cognitive functioning, behav-ioral capabilities, medical status, anddental treatment needs. Based on thisknowledge, the dental team and thepatient’s guardians (or patient, if he/sheis able to participate in the informedconsent process) must decide whichtreatment modality they feel is in thebest interests of the patient. The deci-sion-making process remains as much anart as a science.

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