Acta Anaesthesiologica Taiwanica 50 (2016)

(2016) 122e125
(2012)

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Acta Anaesthesiologica Taiwanica

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Review Article

Dental anesthesia for patients with special needs

Yi-Chia Wang, I-Hua Lin, Chi-Hsiang Huang*, Shou-Zen Fan
Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: To offer individualized dental treatment to certain patients who cannot tolerate dental treatment,
Received 14 June 2016
2012 sedation or general anesthesia is required. The needs could be either medical, mental, or psychological.
Received in revised form The most common indications for sedation or general anesthesia are lack of cooperation, multiple
19 June 2016
2012
morbidities, and pediatric autism. In adults, cognitive impairment and multiple morbidities are most
Accepted 22 June 2016
2012
commonly encountered indications. Because of suboptimal home care, incomplete medical history, poor
preoperative management, lack of cooperation, and developmental abnormalities, it is a challenge to
Key words:
prepare anesthesia for patients with special needs. The American Society of Anesthesiology (ASA) has
anesthesia, dental;
dental care for disabled;
proposed guidelines for office-based anesthesia for ambulatory surgery. In patients with ASA physical
sedation status IV and V, sedation or general anesthesia for treatment in the dental office is not recommended.
The distinction between sedation levels and general anesthesia is not clear. If intravenous general
anesthesia without tracheal intubation is chosen for dental procedures, full cooperation between the
dentist, dental assistant, and anesthesiologist is needed. Teamwork between the dentist and healthcare
provider is key to achieve safe and successful dental treatment under sedation or general anesthesia in
the patient with special needs.
Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights
reserved.

1. Introduction
Special needs is terminology used in clinical diagnostic and
functional development to describe individuals who require assis-
tance for disabilities that may be medical, mental, or psychological.
These patients have been called disabled, impaired, or handi-
capped. The definition of disability is any restriction or lack of
ability to perform an activity in a normal way or within the manner
considered normal for a human being, whereas impairment refers
to any loss or abnormality in physiologic as well as anatomic
structural function. Handicapped is defined as the disadvantage of
a given individual, resulting from an impairment of disability, that
limits or prevents the fulfillment of expectation or a role that is
normal for an individual. These words might imply a sense of
despise, and the medical treatments were considered to be mercy
on the inferiors. Therefore, these terms have been replaced with
a more neutral term special need. Every person has an equal right to
medical care. As medical care providers, we should individualize
our treatment and service and ensure delivery of optimal medical
resources for individuals with special needs.
* Corresponding author. Department of Anesthesiology, National Taiwan
University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan.
E-mail address: tee.ntuh@gmail.com (C.-H. Huang).
The health condition and functional status in patients with special
needs are interrelated.1 Dental caries is the most common oral problem
in children in most of the developing countries. There is a higher inci-
dence of dental caries in patients with special needs because of inad-
equate plaque removal due to motor, sensory, or intellectual disabilities
in these patients. Malocclusion also affects oral health and increases
caries prevalence.2 For example, patients with Down syndrome tend to
have more dental anomalies, poorer periodontal health, and fewer
dental visits than age- and sex-matched control groups.3,4 The most
common reasons for not receiving regular dental care for dental
conditions are unawareness of the dental condition and the importance
of dental visits.4 Until 2010, there were 107,000 special-needs patients
in Taiwan, and the number is increasing. Oral health education and the
interventions of sedation and general anesthesia should be instituted
for management of dental health conditions.
2. Dental fear and phobia
Sedation and general anesthesia can help those who are unable
to tolerate the pain of dental treatment, such as individuals who
experience anxiety and fear during dental visits, those with
cognitive impairment or motor dysfunction, children, and those
unable to tolerate physical stress. Studies of dental fear and anxiety
showed that the prevalence of dentophobia was approximately 10%
in the general population.5 Dentophobic patients usually seek

1875-4597/$ e see front matter Copyright Ó 2016

2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.aat.2012.08.009
Dental anesthesia for patients with special needs
dental care with reluctance only when they have symptomatic
dental conditions such as severe toothache or dental abscess. Thus,
these patients are more likely to delay treatment, resulting in more
extensive or severe conditions. This vicious cycle leads to the
continuation or exacerbation of existing dental fear, causing a cycle
of avoidance.6 In particular, women are more inclined to have
dental fear. Patients aged from 40 to 64 years old have the highest
prevalence of dental fear, and people older than 80 years old have
the lowest prevalence.7
3. Characteristics of patients with special needs
Proper preanesthetic evaluation and preparation are important.
Mild anesthetic complications do occur in people with special
needs.8 However, suboptimal home care, incomplete medical
history, poor preoperative management, lack of cooperation, and
developmental abnormalities in people with special needs make
preanesthetic preparation more difficult. Full cooperation between
caretaker and dentist is important.
The most common indications for dental anesthesia in patients
younger than 14 years are lack of cooperation, multiple morbidities,
and autism. In our hospital, the main reasons for anesthesia in
adults with special needs are cognitive impairment and multiple
morbidities. Cognitive impairment defines patients who are
developmentally delayed and those who have dementia. Appro-
priate sedation or general anesthesia could ease the process of
dental treatment in patients who are unable to cooperate during
the dental visit. Motor dysfunction includes parkinsonism, cerebral
palsy, and other diseases that cause uncontrolled tremor. Sedation
or general anesthesia is sometimes required so that these patients
can keep their mouth open for the treatment. Children can be
considered another special needs population. Children younger
than 3 years are usually uncooperative with their dentists, resulting
in the use of papoose boards and physical restraints during the
dental visit. For lengthy and extensive treatment, sedation and
general anesthesia could ease the tension and fighting among
children, parents, and dentists. In addition, children with congen-
ital conditions such as congenital heart disease and hydrocephalus
may complicate the anesthetic decision and management.9 For
those who have severe cardiovascular disease or other systemic
disease, stress-induced sympathetic tone activation may be
harmful due to increased heart rate and systemic vascular resis-
tance. Proper sedation and general anesthesia could be considered
to tamper the stress effects.
3.1. Down syndrome
The incidence of Down syndrome, characterized by an anomaly
of chromosome 21, is estimated to be per 800 to 1000 births.10
Children with this condition have characteristic features such as
low-set ears, small teeth, a flattened nose, stunted growth, atypical
fingerprints, and hypotonia. They are developmentally delayed and
constitute most of the dental patients with special needs. Generally,
these patients are more obese, and vascular access may be difficult
in young Down syndrome patients.11 On the other hand, these
patients have large tonsils and adenoids, a small subglottic area,
prolapsed epiglottis, and a large tongue.12 Airway management
might be difficult because of the anatomic abnormalities. Advanced
airway device and video-assisted intubation devices should be
available for tracheal intubation. For those in whom ventilation is
difficult, sedation is not recommended. Approximately 10% to 40%
of children with Down syndrome have atlantoaxial instability.13
Unnecessary head extension during dental treatment should be
avoided to prevent subluxation in these patients. Approximately
40% of patients with Down syndrome have congenital heart
123
anomalies.14 Consultation with a cardiologist is needed before
anesthesia, especially for those with complex heart disease. Due to
complex craniofacial and cardiovascular abnormalities, patients
with Down syndrome tend to have increased anesthetic compli-
cations, such as bradycardia on anesthetic induction, airway
obstruction, and postintubation croup.15,16 Anesthesiologists
should be aware of these potential problems and be prepared for
counteraction.
3.2. Cerebral palsy
Cerebral palsy comprises a group of nonprogressive motor
conditions manifested by physical disabilities in development due
to brain injuries during the antenatal, perinatal, or postnatal
period.17 The prevalence is approximately two per 1000 live
births.18e20 Patients with cerebral palsy tend to have complicated
dental problems due to lack of lip seal, higher malocclusion rate,
temporomandibular disorder, difficulty swallowing, and associated
malnutrition and aspiration pneumonia.21e24 Their oral hygiene
status is also the burden of the caregivers.25 Patients with cerebral
palsy usually have additional disability attributable to central
nervous system damage, such as cognitive impairment, visual or
hearing problems, seizures, and communication and behavioral
disturbances, as well as the chronic systemic problems resulting
from their disease. Severity of cerebral palsy is often associated
with postoperative complications. Airway maintenance during
anesthetic induction may be complicated by excessive secretions.
Tracheal intubation should be performed if this is a concern or if
there is a history of gastroesophageal reflux. Children with cerebral
palsy are often physically small for their age. Tracheal tube size
selection should be based on the patients’ age. Careful positioning
is of paramount importance in the child with spastic cerebral palsy
to forestall nerve or muscle damage. Fixed contractures may add
difficulty to positioning. The responses to anesthetic agents may
also differ. There may be resistance to nondepolarizing muscle
relaxants.17 There appears to be a close correlation between
severity of preoperative cerebral palsy and postoperative compli-
cations. The risk of perioperative adverse events was 63.1%, mostly
of hypothermia and hypotension. Factors associated with increased
risk included American Society of Anesthesiologists (ASA) physical
status score of 2 or higher, history of seizures, upper airway
hypotonia, general surgery procedures, and adulthood.26
3.3. Epilepsy
Epilepsy is a common chronic neurologic disease resulting
from abnormal hypersynchronous neuronal activity in the brain.27
It is important for anesthesiologists to identify the type,
frequency, severity, and triggering factors of epilepsy. Anesthesi-
ologists must understand the proconvulsant and anticonvulsant
properties of drugs used in anesthesia and minimize the risk of
seizure activity in the intraoperative and postoperative periods.
Because antiepileptic drugs could produce sedation or inhibit
metabolizing enzymes, the dosages of general anesthetic should
be reduced considerably if they are concomitantly used. Patients
partaking of a ketogenic diet must be evaluated before anesthesia.
A ketogenic diet is high in fat and low in protein and carbohy-
drates. Maintaining therapeutic ketosis and modifying the acid-
base balance are particularly important to prevent seizures in
patients on a ketogenic diet. Propofol, sevoflurane, and acetated
Ringer solution have been reported to be safely used in children
on a ketogenic diet.28,29 Due to the risk of metabolic acidosis,
serum pH or bicarbonate levels should be monitored in cases with
longer course.30
124
3.4. Autism
Autism is a developmental disorder that is usually diagnosed
before age 3 years. Children with autism have characteristic
symptoms such as impaired social interactions, verbal and
nonverbal communication deficiencies, limited activities and
disinterest, repetitive behaviors, and difficult responses to changes
in routine. Some of them have other behavioral disturbances such
as self-mutilation, aggression, and psychiatric symptoms. Some
autistic patients take medications for behavior control to help them
integrate effectively in the educational and rehabilitative process.31
Early communication with the patient’s families, flexibility to
individualize the anesthetic plan, and awareness of possible inter-
action of behavior medications and anesthetics are important in
management of these patients.32
4. Environment for office-based dental anesthesia
The ASA has developed guidelines for office-based anesthesia
and ambulatory surgery. Office-based facilities, although incom-
parable with those of the hospital, should comply with all federal,
state, and local rules or regulations. Environmentally, there should
be a reliable source of oxygen, suction, resuscitation equipment,
and available emergency drugs. There should be an appropriate
anesthesia apparatus or equipment with necessary monitoring.
Monitoring resources should include the competent responsible
personnel, noninvasive blood pressure monitor, pulse oximeter,
electrocardiography, and stethoscope and capnograph.33 If anes-
thesia is to be provided for pediatric patients, the required equip-
ment should be suitable for children of all ages. Sufficient electrical
outlets and adequate illumination are necessary. There should be
enough spaces for necessary equipment and the serving medical
staff. For life-threatening situations, an emergency cart, defibril-
lator, and advanced airway management tool should be on hand.
The anesthesiologist should be present during the intraoperative
period until the patient has been safely discharged from anesthetic
care.34
5. Patient selection in outpatient setting
Complications (mainly mild or moderate) associated with
administration of anesthesia occur at approximately 20%. Airway
obstruction and nausea and vomiting are the most common
complications. ASA classification, anesthetic technique, preexisting
medical condition, and dental procedures are all contributable
factors.35 Patients with ASA class IV and V are not recommended for
sedation or general anesthesia in the dental office. Patients with
ASA class III should be evaluated by the anesthesiologist respon-
sible for the decision.
6. Depth of anesthesia
Sedation and general anesthesia can be graded as mild,
moderate, and deep, and by different levels of consciousness,
ventilation status, and cardiovascular function. Patients in deep
sedation are not easily arousable, but could be responsive to painful
stimulation. Their ventilation may not be adequate and assisted
respiration is needed with patent airway. There is no clear
boundary between the levels of sedation; with the same dosage of
drug, a patient might cross from moderate sedation to deep seda-
tion. There is the likelihood of adverse events after being subjected
to sedation. It is of paramount importance to watch patients’ airway
and ventilation after sedative administration, and discharge criteria
should be observed strictly.36 Even with oral anxiolytic agents,
which have a wide margin of safety in adults, serious complications
Y.-C. Wang et al.
have been reported with conscious sedation, especially in young
children. Most serious adverse events are related to potentially
avoidable respiratory complications.37
7. Nonintubated general anesthesia
If intravenous general anesthesia without tracheal intubation is
chosen for dental anesthesia, it is required to keep excellent
cooperation between the dentist, dental assistant, and anesthesi-
ologist. Because the airway is not secured by placement of the
endotracheal tube, aspiration, laryngospasm, and hypoxia could
occur with disappointing results. It is suggested to have a dental
treatment plan in place in advance to forestall complications. In
addition, patients in whom perceptive difficult ventilation and
difficult laryngeal mask insertion are evident are not good candi-
dates for nonintubated general anesthesia. Patients should strictly
follow fasting rules to decrease the risk of aspiration. Effective local
anesthesia helps maintain an acceptable anesthetic level. A throat
pack and efficient suction are important to avoid flooding of the
mouth by rinsing water and facilitate removal of secretion or
debris. Delivery devices such as infusion pumps for drugs such as
propofol, when coupled with computers, can help regulate the
infusion rate and control the sedative effect. Bispectral index-
guided target-controlled infusion of propofol has been used for
patients with intellectual disabilities.38 Due to complex physical
condition and various medication commonly used for patients with
special needs, the use of target- controlled infusion needs more
evidence of its efficacy and safety. Patient-controlled sedation
might be the trend for optimal conscious sedation in the future.39
8. Conclusion
Anesthesia provides optimal conditions for dental treatment for
special needs. Additional care should be undertaken based on
patients’ special physical problems, psychological needs, and social
support. An individualized anesthetic plan and management and
teamwork between the dentist and anesthesiologist are key points
to materialize safe, successful, and satisfactory anesthetic conduct
for these patients.
Disclosure
The authors have no financial interests related to the material in
the manuscript.
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