Hospital Dentistry

Integrating Hospital Dentistry Into the General Dental Practice

Ronald J. Sani, DDS, and Richard O. Spencer, DDS

Copyright 2001 Journal of the California Dental Association.

Societal trends and medical advances have resulted in increased numbers of physically and/or psychologically challenged individuals living within our communities. For some of these individuals, hospital dentistry with general anesthesia provides the only means by which general dental services may be provided. This paper presents considerations of significance to the general dentist wishing to incorporate outpatient hospital dentistry into his or her private practice.

Today’s health care delivery system offers several design options for the delivery of surgical services. These include hospital operating rooms, short-stay surgical centers, outpatient surgical centers, and private office surgical suites. The anesthetic services provided within these facilities also offer several options including "local with anesthesia staff standby," sedation/analgesia (i.e., monitored anesthesia care), and general anesthesia. General dental services may be provided within any of these facility designs and may utilize any of these anesthesia options.

Additionally, the term hospital dentistry can be used to describe the delivery of dental services within any or all of the various hospital environments (clinics, patient ward rooms, intensive care units, emergency rooms, operating rooms, etc.). This article, however, limits its discussion to the provision of outpatient general dental services utilizing general anesthesia within the hospital operating room and describes the major considerations that must be addressed by dentists wishing to incorporate these services into their general dental practices.

Throughout the evolution of hospitals, their timeless mission has remained the provision of care for the sick and injured. They remain institutions for the collective provision of a greater variety of services than is available through the individual practitioner.¹ Hospitals also provide services for individuals who are unable to receive treatment in the conventional private office setting. For these individuals, whose physical and/or psychological status prevents the conventional provision of dental treatment, the hospital operating room often serves as the only access for restorative dental treatment.² It is within this context that the authors have integrated hospital dentistry into their general dental practices.

The use of general anesthesia is but one of the spectrum of techniques available to assist the general dentist with the delivery of dental services. This spectrum of techniques ranges from use of no anesthesia, to nondrug psychosedative techniques, to local anesthesia, to drug-induced-sedative techniques, to general anesthesia.³ This spectrum also represents a continuum of increasing influence over the patient’s state of consciousness ranging from no influence (no anesthesia), to obliteration of pain perception only (local anesthesia), to a reduction of consciousness (sedation), to loss of both consciousness and pain perception (general anesthesia).

Societal Trends

The overwhelming majority of patients presenting for general dental services are treated successfully without general anesthesia. However, general dentists are seeing increased numbers of patients whose physical and/or psychological status dictates that their only means of receiving restorative dental services is with the use of general anesthesia. During the past 30 years, more than 75 percent of the developmentally disabled residents of state institutions have been deinstitutionalized. During the same period, the numbers of residents from psychiatric institutions decreased by 97 percent.⁴ These individuals are now living in our communities and are relying upon community health providers, including dentists, for management of their health needs. As the population ages, increasing numbers of individuals are surviving long enough to develop advanced stages of chronically degenerative diseases such as Alzheimer’s disease, Parkinson’s disease, cardiovascular disease, etc.⁵ The physiological and psychological changes that accompany these maladies can progress to the point of preventing the patient from tolerating general dental services in the conventional dental office setting.

It has been estimated that 80 percent to 85 percent of children are manageable for general dental procedures utilizing routine behavioral techniques. The remaining 15 percent to 20 percent require more-aggressive management techniques, including pharmacological intervention. The child’s age, cognitive development, temperament, and degree of fear and anxiety can serve to prevent adequate behavioral control with therapeutic doses of sedative agents. The anatomic and physiologic characteristics of the pediatric respiratory and cardiovascular systems cause the young patient to be more susceptible to respiratory and cardiovascular failure as the depth of sedation increases. Rather than intentionally increasing the depth of sedation in an attempt to manage a difficult pediatric patient, it is prudent to defer pharmacological management to individuals trained in the administration of general anesthesia and management of its associated complications (anesthetists, anesthesiologists).⁶

It is interesting to note that, while the physical and psychological status of all patients must be evaluated prior to treatment, it is most commonly the patient’s behavioral status that determines the method of patient management employed.⁷ Those patients exhibiting the most severe behavioral problems are managed most predictably utilizing general anesthesia for the delivery of dental restorative procedures.

The physical and psychological factors contributing to the need for utilizing general anesthesia also serve to prevent these individuals from receiving routine and regular preventive dental services. Extremely resistant behaviors also prevent the provision of adequate daily oral hygiene. Consequently, the typical general dental patient requiring general anesthesia for treatment presents with extensive restorative needs, which can involve the full spectrum of services provided in the general dental office. When providing dental treatment utilizing general anesthesia, the goal is to satisfy all of the patient’s restorative dental needs in a single operating room session. However, when deciding upon the specific dental procedures to be provided, due consideration must be given to the patient’s developmental potential.⁸ In patients whose developmental status is not expected to improve to the point of allowing the provision of adequate oral hygiene and preventive dental procedures, the prudent treatment plan will avoid the inclusion of services whose success depends upon close postoperative monitoring or repeated follow-up services (i.e., implant placement, orthodontic treatment, etc.).

Selecting an Appropriate Hospital

When integrating hospital dentistry into the general dental practice, one of the first considerations must be the identification of an appropriate hospital or hospitals. An initial evaluation of the hospital’s mission must be made to ensure that it is consistent with the population of patients for whom the general dentist is providing services. For example, a children’s hospital may not be receptive to the treatment of adult patients. Also, for-profit hospitals that are founded and governed by investors may not be receptive to the provision of services for patients with limited reimbursement benefits for hospital services. Similarly, veterans hospitals and HMO-type hospitals (i.e., Kaiser Permanente) allow for provision of services to specific member patient populations.

Most commonly, those hospitals already familiar with hospital dental services are most easily approached regarding utilization of the operating room for the provision of such services. These can include teaching hospitals with general practice residency programs and/or other surgical facilities that already have general dentists on staff. Dentist members of hospital medical staffs serve as valuable resources for locating the most appropriate surgical facility.

Hospital Staffing Issues

Of equal importance with consideration of the hospital’s mission are auxiliary staffing issues. All hospital auxiliary surgical staffs are well-trained in instrumentation and procedures associated with medical surgical services performed in their respective surgical suites. However, their education and training includes nothing relevant to general dental instrumentation or procedures, which renders them unqualified to assist the general dentist with the provision of those services. It is essential that trained dental assistants be available to assist the general dentist in the operating room. The most qualified auxiliary person to utilize in the hospital operating room is the general dentist’s usual chairside dental assistant. Circumstances within the teaching hospital environment may also allow for the utilization of hospital-employed dental assisting staff from the in-house GPR program.

Therefore, when evaluating the possible affiliation with a specific hospital, it is important to inquire about policies regarding the utilization of dental assisting personnel within the operating room.

Hospital Equipment Issues

While the availability of proper equipment does not guarantee optimum treatment results, the absence of proper equipment almost certainly compromises treatment. In the general dentist’s private dental office, procedures are completed utilizing instrumentation, supplies, and equipment of one’s personal preference. In the hospital operating room, the general dentist may be sharing instruments, supplies, and equipment with other colleagues. Also, for financial reasons and for the promotion of increased efficiency and instrument utilization, hospitals prefer to maintain instruments, supplies, and equipment that can be standardized to the preferences of multiple staff members. To this end, the general dentist must be willing to allow for a certain latitude with personal preferences or be willing to transport preferred items from the office for personal use in the operating room (Figure 1).

Accordingly, when evaluating hospitals, one should inquire about the specifics of hospital-supplied dental equipment available for use in the operating room and the staff dentist’s obligations for supplying equipment. Also, hospital dental equipment should be inspected and evaluated to ensure compatibility with the equipment and supplies provided by the general dentist. For example, aspects of equipment to consider include the compatibility of the dentist-supplied handpieces with the hospital-supplied dental unit, availability and compatibility of water hookups for the dentist-supplied ultrasonic scaling unit, etc.

Also, when bringing powered dental equipment into the operating room from one’s private office, the equipment must first be evaluated and approved for safety by the hospital’s biomedical engineering department. Such an evaluation should be completed prior to the time of surgery so as to prevent delays with the availability of needed equipment.

Hospital Scheduling Issues

Scheduling is the process by which operating room time is reserved for a procedure, and it is done through the hospital’s surgical scheduling office. Once the procedure is scheduled, appropriate hospital equipment and personnel are assigned to the appropriate surgical suite as necessary. Because of patient differences, variances in surgical techniques, unpredictability of surgical complications, etc., surgical schedules are never precise; however, every effort is made to keep them as accurate as possible. Also, during the course of a operating room’s schedule for the day, it frequently becomes necessary to include additional surgical cases to satisfy patients’ emergent needs. Life-threatening emergency surgical needs, of course, have precedence over scheduled procedures and are accommodated into the existing surgical schedule by postponing elective procedures. Consequently, the surgical schedule often changes throughout the day.

The fluctuating nature of the hospital’s surgical schedule can cause difficulties when one is attempting to merge the hospital’s surgical schedule with the more-rigid dental office schedule of patient appointments. The following two tactics are offered as suggestions to assist with avoiding difficulties:

* Schedule for the beginning of the surgical day. All hospital operating rooms have a definite time for which the initial surgical cases of the day are scheduled to start. All subsequent procedures are scheduled on a "to follow" basis with their individual start times estimated from the proposed surgical times. Consequently, the initial surgical procedure is subject to less variation in start time.

* Obtain "block time." Block time is hospital operating room time that is reserved for the use of an individual staff surgeon on a regular and repetitive basis. The staff surgeon then "fills" the assigned block time with surgical cases, thereby avoiding the need to schedule against other surgical services. This allows for the usual scheduling of patient appointments through the private office at times other than assigned block times

Block time is usually not granted until one has completed the probationary staff period (see Applying for Hospital Staff and Obtaining Privileges) and has demonstrated an ability to consistently utilize the block time requested. However, when evaluating hospitals, one should inquire about the availability of block time for new staff members.

If the hospital provides dental equipment, the availability and portability of the equipment can have scheduling implications. For example, if the same dental equipment needs to be shared by all dentists on staff and, because of design, its use is restricted to a single surgical suite, the scheduling of procedures utilizing that equipment could become competitive and restrictive. Similarly, the limited availability of hospital-employed dental auxiliary staff could have a restrictive effect on the scheduling of general dental procedures.

Applying for Hospital Staff and Obtaining Privileges

When desiring to provide patient services in the hospital, the practitioner must first obtain both staff membership and privileges.

Hospital staff membership identifies one’s affiliation with the respective hospital and carries with it certain obligations as outlined in the hospital’s bylaws. These may include obligations to attend specific staff meetings, to serve on assigned committees, to satisfy hospital continuing education requirements, etc. Hospital staff appointment is based upon an evaluation of requirements as outlined in the hospital bylaws. These requirement usually include education, licensure, degree, health, office proximity, and personal character.¹

Within each hospital, individual staff members are allowed to provide only those services and to perform only those treatments for which they have been granted privileges. Hospital privileges are specific treatment procedures for which the applicant has demonstrated satisfactory training, experience, and competence.¹ The list of hospital privileges outlines and defines those procedures that the individual practitioner may perform within the respective hospital. The burden for proof of competence when applying for new or additional privileges is always with the applicant.

Application Process

The application process begins with a request for a staff application packet from the hospital medical staff office. This request may be made by way of telephone, letter, or personal visit. The request should include the applicant’s desire to provide general dental services in the hospital’s operating room so that the proper privilege sheet will be included with the applicant’s packet.

The formal application includes requests for detailed information regarding the applicant’s professional qualifications and character as reported by professional peer references identified by the applicant. Additional information regarding the applicant’s current hospital affiliations, professional liability status, and verification of continuing education is also requested. Required supporting documentation usually includes copies of the applicant’s current professional state license registration, Drug Enforcement Agency registration certificate, and curriculum vitae.

Part of the application process also involves an interview with the departmental chair (sometimes the department of surgery) who then makes the final decision on which clinical privileges to recommend to the credential committee for approval.

Once the application process is complete, the new medical staff member may be accepted on a probationary status and assigned a proctor for review of the applicant’s clinical performance during the probationary period.

The entire application process may require several months to a year for completion. Once the application forms and supporting documentation are completed, however, the applicant may be granted temporary privileges. Temporary privileges are of benefit for allowing utilization of the hospital operating room during the completion of the formal application process. Temporary privileges are awarded for a finite period and do not excuse the practitioner from completing the entire application process.

Preoperative Patient Evaluation

Most general dental procedures, whether completed in the private office or in the hospital operating room, are considered "elective" procedures in that their delay provides no immediate threat to the patient’s life. As such, any patient presenting for such elective procedures should be in optimum general health.⁹ Optimum general health does not imply freedom from health problems but, rather, a state of health in which those problems are being properly managed.

To properly assess a patient’s health status, a preoperative patient evaluation must be completed. The goals of the preoperative patient evaluation remain the same regardless of the anesthetic methods utilized or the dental treatment procedures provided. Specifically, these goals include establishing the diagnosis, determining pre-existent medical conditions, discovering concomitant disease, managing emergencies, and patient management.¹⁰

Establishing the preoperative diagnosis includes categorizing the patient into one of the following groups of increasing anesthetic risk as defined by the American Society of Anesthesiologists:

* ASA I -- A normal healthy patient;

* ASA II -- A patient with mild systemic disease;

* ASA III -- A patient with severe systemic disease; and

* ASA IV -- A patient with severe systemic disease that is a constant threat to life.¹¹

Classification in this manner provides a generalized impression of the complexity of the patient’s medical condition thereby allowing for an estimation of the patient’s risk and morbidity associated with the administration of general anesthesia.¹² Anesthesia staff should be informed when scheduling ASA III- and IV-type patients because a preoperative anesthesia consultation may be required.

The patient’s disease status forms the basis of the classification system. Pre-existing medical conditions and the presence of concomitant disease have profound implications for both the risk classification and the patient’s specific treatment requirements. Pre-existing medical conditions are documented through the patient history -- including a medical history, relevant family and social history -- and a review of systems. The presence of concomitant disease is discovered through the patient physical examination and diagnostic laboratory studies. Hospital bylaws and practitioner experience, training, and competence determine responsibility for completion of the preoperative patient "history and physical." The authors have found it prudent to order the history and physical through the patient’s private physician for preoperative review by both the treating dentist and the anesthesia staff. It should be noted, however, that some hospitals require the preoperative history and physical to be completed by a member of their medical staffs. In some instances, anesthesia staff will complete the history and physical examination during their preoperative patient evaluation. In any event, the treating dentist should clarify the individual hospital and anesthesia department requirements prior to arranging for completion of the patient’s preoperative history and physical examination.

Most hospital and anesthesia departments have policies regarding the specifics of preoperative laboratory tests performed and time requirements within which these preoperative assessments must be completed. Commonly, the preoperative patient data must be obtained within 30 days of the surgical procedure; however, individual hospital policies may vary. Therefore, adequate time must be allowed for completion of these studies prior to the surgery date.

Examples of specific laboratory studies for the preoperative screening of asymptomatic, healthy patients scheduled for general dental procedures are reflected in Table 1.¹² However, the specific laboratory studies utilized depend upon the patient’s health status as reflected through the history and physical.

The data obtained during the preoperative patient assessment assist with the management of patient emergencies by alerting the practitioner to those situations that place the patient at risk. As such, the preoperative assessment is critical for appropriate patient management preoperatively, intraoperatively, and postoperatively.

The one aspect of the preoperative patient assessment that remains the responsibility of the general dentist is the oral examination. The detail and complexity of the preoperative oral examination are dictated by the presenting status of the patient. The behavioral patterns of some patients allow for only the most cursory of visual oral examinations. Other patients present with physical limitations that prevent obtaining standard intraoral radiographs. Still other patients are receptive to the full variety of oral and diagnostic procedures available to the general dentist.

The collection of preoperative oral diagnostic data is critical to treatment planning and surgical scheduling. However, if patient circumstances prevent preoperative collection of this data, then necessary oral diagnostic procedures are completed at the time of surgery utilizing general anesthesia.

Preoperative Patient/Guardian Discussion

The primary purposes of the preoperative discussion are to obtain informed consent to proceed with treatment and to give preoperative patient instructions.

Informed consent is the process by which the proposed treatment procedures are outlined; the risks, benefits, and alternatives to the proposed treatment are described; and questions are answered, so that a decision can be made as to one’s desire to receive the proposed treatment. In the event of treatment refusal, an explanation of the possible consequences of such refusal must also be included.¹³ For those patients who are unable to consent for themselves, either due to age or mental status, informed consent must be obtained from the individual who is legally able to render such a decision on behalf of the patient. When dealing with minors of separated or combined households, it is necessary to determine which parent has legal authority to consent for patient treatment.

Since significant amounts of dental treatment are often rendered during a single operating session, part of the preoperative discussion should include the financial obligations for treatment. In the experience of the authors, most patients receiving hospital dental services are Medi-Cal beneficiaries; and a discussion of financial obligations is, therefore, not relevant. Occasionally, however, the patient requiring hospital dentistry is either the beneficiary of privately funded insurance or has no insurance involvement. Financial obligations and payment arrangements for these situations should be established prior to the initiation of treatment.

As uncooperative behaviors often prevent an accurate preoperative evaluation of the hospital dental patient, it is many times impossible to compose an accurate preoperative itemization of dental services and associated charges. During financial discussions, therefore, it must be emphasized that the estimated charges are based upon a limited evaluation of the patient and that final dental charges will be based on the actual treatment rendered in accordance with the oral findings discovered at the time of treatment.

Additionally, whenever services are provided within the hospital, hospital-related charges accrue. These charges are often based upon the use of equipment, use of disposable materials, and length of treatment time. With the utilization of anesthesia services, additional anesthesiology staff charges also accrue. During financial discussions, therefore, it should also be emphasized that hospital and anesthesia related-charges are not within the purview of the general dentist and that relevant financial arrangements should be discussed with the respective medical insurance company and/or the hospital and anesthesiology group.

Preoperative instructions to the patient should also include directions to the hospital and the preoperative area within the hospital, arrangements for personal transportation to and from the hospital, preoperative management of medications, provisions for personal and oral hygiene, and preoperative dietary orders.

Preoperative dietary guidelines usually include nothing by mouth in healthy adults and children for two to six hours preoperatively, depending upon the material ingested.¹⁴ The goals of preoperative fasting are to decrease both gastric pH and stomach content to reduce the severity of pneumonitis associated with the aspiration of stomach contents. Fortunately, clinically significant aspiration of gastric contents is rare in healthy patients undergoing elective surgical procedures.

Studies have shown the absence of untoward effects on gastric fluid volume and pH with the ingestion of up to 250 ml of clear liquids two to three hours preoperatively.^15,16 The American Society of Anesthesiologists has developed fasting guidelines relevant to different classifications of ingested materials (Table 2).¹⁴ Inquiries regarding preoperative dietary guidelines for specific hospitals, however, should be directed to their respective departments of anesthesiology. The importance of these guidelines should be emphasized to the patient and/or guardian as administration of general anesthesia would be delayed or cancelled for a failure to adhere to them.

Provision of Patient Treatment in the Operating Room

Most operating room services associated with the general dental patient are provided on an outpatient basis. As such, the patient arrives at the hospital one hour prior to the scheduled surgical time and is released following adequate recovery from general anesthesia (approximately 1 1/2 to 2 hours following completion of treatment) without formal admission to the hospital.

During the hour prior to the initiation of treatment, preoperative vital signs (blood pressure, pulse, respiration, temperature, weight) are obtained; and the patient is changed into a hospital surgical gown. The patient is interviewed and evaluated by a member of the anesthesia staff including a review of the preoperative history and physical and laboratory studies.

Also during this period, the treating dentist visits the patient and/or guardian to review the proposed treatment procedures and answer any final questions. A surgery consent is signed and witnessed, and a preoperative note is entered into the patient’s chart reflecting completion of the informed consent process.

The preoperative preparation also includes the placement of an intravenous catheter to allow for administration of medications during the anesthetic management of the patient. If the patient’s behavior is resistant and combative to the point of posing a danger to himself or herself and/or the hospital staff, the administration of intramuscular medications may be required to render the patient safely manageable and to facilitate placement of the IV. Young children are often administered oral sedation to facilitate separation from their parents for transport to the operating room. In the operating room, sedation is enhanced with inhalation agents, via full face mask, to allow for comfortable placement of the IV prior to administration of general anesthesia.

Although the immediate preoperative management of the patient is at the direction of the anesthesia staff, a preoperative consultation between the treating dentist and the anesthesia staff is important to the surgical preparation for a patient’s special needs. Useful information for this consultation include the following:

* A summary of the patient’s psychological and health status;

* The anticipated length of the treatment and a summary of the procedures to be completed;

* The intubation and patient positioning requirements of the procedure; and

* The positioning of operating room personnel and equipment.

A summary of the patient’s psychological and health status is valuable to supplement the information obtained from the patient’s medical records and to clarify specific patient needs associated with the completion of treatment; such as the need for antibiotic prophylaxis, wheelchair transport, preoperative sedation, and language interpretation, as well as the intellectual abilities of the patient, behavioral history, etc. The summary is obtained from the physician’s history and physical.

The anticipated length of the treatment and a summary of the treatment procedures are important to assist the anesthesia staff with determining the optimum anesthesia technique to be utilized and with anticipating the immediate postoperative needs of the patient. For example, the anesthesia and postoperative requirements associated with the 45-minute minor restorative dental case are much different than those associated with the five-hour general dental case that includes endodontic procedures, multiple extractions, and gingival surgery. These differences are better addressed by a staff that is prepared to anticipate their needs.

The intubation and patient positioning requirements are critical for achieving optimum access to the oral cavity. Intubation involves the placement of an endotracheal tube into the patient’s trachea for preservation of a patent airway and administration of gases (oxygen and/or anesthetic gases). Placement of the endotracheal tube is by either the oral or nasal routes. If placed orally (Figure 2), the endotracheal tube must be repeatedly repositioned to allow access to all regions of the oral cavity during completion of general dental procedures. These repositioning procedures not only prove to be a major inconvenience, but also increase the risks for tracheal trauma and for dislodging the endotracheal tube. Additionally, since the oral position of the endotracheal tube places it within the surgical field, there is increased risk for damaging the endotracheal tube during completion of treatment procedures. In the authors’ opinions, the preferred route for placement of the endotracheal tube for general dental procedures is, therefore, via the nasal route. Once placed, the nasoendotracheal tube is secured into position and stabilized until the patient emerges from general anesthesia following the completion of all dental treatment (Figure 3).

Patient positioning refers to the placement of the patient on the surgical table and is determined by the nature of the surgical procedure, the surgeon’s preferred approach, and the anesthesia technique. During general anesthesia, patients are immobile and unable to reposition themselves to relieve pressure areas, which puts them at increased risk for joint damage, muscle strain, peripheral nerve damage, interference with peripheral circulation, and skin breakdown.¹⁷ The physiologic positioning of the patient, therefore, is as important to the outcome as adequate preoperative preparation and safe anesthetic technique.

The criteria for physiologic patient positioning to prevent injury from pressure, obstruction, or stretching are:

* No interference with respiration;

* No interference with circulation;

* No pressure on peripheral nerves;

* Minimal skin pressure;

* Provide accessibility to the operative site;

* Provide accessibility for anesthetic administration;

* Maintenance of proper body alignment to prevent undue musculoskeletal strain; and

* Provide for individual patient physical requirements (obesity, scoliosis, joint contractures, arthritis, etc.).¹⁸

The surgical position of the general dental patient is achieved by placing him or her in a supine position with the body tilted 30 degrees from the horizontal to place the head lower than the feet (Figure 4). A soft, supportive pad is frequently placed beneath the patient’s shoulders to accentuate head tilt for improved visualization of the oral cavity. Depending upon the size of the patient and the design of the surgical table, it is usually advantageous to place the patient diagonally with head and feet directed to opposing corners of the table. The patient’s head is placed in the corner of the surgical table closest to the dental assistant to allow for better oral access by both dentist and dental assistant. (Some surgical tables allow for attachment of a narrowed head extension in lieu of diagonal positioning of the patient.)

Once surgical positioning of the patient is achieved, physiologic positioning is completed by ensuring that proper musculoskeletal balance is stabilized for maintenance throughout the surgical procedure. Special attention is directed to the patient’s extremities and large joints to prevent complications arising from prolonged pressure. In patients exhibiting musculoskeletal abnormalities, additional padding and draping procedures are employed to maintain the individual’s unique physiologic position throughout the surgical procedure.

When positioning equipment and personnel for provision of general dental treatment within the operating room, the primary goal is to simulate the treatment positioning of staff and equipment in the private dental office.¹⁹ Specifically, both the dentist and assisting staff should be seated so they have unobstructed access to the oral cavity and dental equipment (Figure 5). To this end, both the hospital nursing staff and the anesthesia staff are positioned somewhat remotely from the patient’s head. Diagrams A and B identify optimal positions for personnel utilizing one and two dental auxiliaries respectively. These diagrams are modifications from those developed by Drs. Ronald Johnson, Clemens Full and Dale Redig.²⁰ Also illustrated are diagonal patient positioning on the standard surgical table and patient positioning utilizing a narrowed head extension. Positions are depicted for a right-handed dentist and should be reversed to accommodate a left-handed operator.

Depending upon the design of the surgical table and the position of the controlling levers and pedals, it is usually advantageous to reverse the surgical table prior to patient positioning to allow for placement of the dentist’s knees and legs beneath the surgical table while seated. Following reversal of the surgical table, the patient is then positioned as previously described; and the surgical table is tilted and lowered to allow the dentist and auxiliary staff to remain seated throughout the procedure.

Most hospital operating rooms are larger than dental operatories, and the use of fixed dental cabinetry and equipment can present a distinct disadvantage when seeking to focus equipment and personnel on the patient’s oral cavity. The use of mobile equipment (dental cart, storage cabinet, X-ray equipment) and preset instrument trays allows for the most efficient delivery of general dental treatment within the hospital operating room²¹ (Figures 6a and b).

Dental Treatment in the Operating Room

Provision of general dental treatment within the hospital operating room includes the following phases:

* Isolation of the surgical field;

* Collection of dental diagnostic data;

* Composing the treatment plan; and

* Completing the dental procedures.

Isolation of the Surgical Field

Isolation of the surgical field refers to procedures employed in an attempt to separate the surgical area from the rest of the operating room environment for the purpose of preventing cross-contamination. Most medical surgical procedures are considered sterile, and surgical isolation is directed toward the preservation of sterility in the immediate vicinity of the surgical site. Intraoral procedures, however, are considered clean or clean-contaminated, as it is impossible to sterilize the oral cavity.²² Consequently, neither the treating dentist nor the auxiliary staff are bound to adhere to the strict guidelines of surgical scrub technique. Appropriate gowning, gloving, eye protection, and masks are employed as are appropriate in the dental office setting, with the addition of hospital-required surgical attire ("scrubs," hair covers, and sometimes shoe covers) while in the operating room.

The following additional patient draping techniques are utilized, however, for increased protection of the general dental patient during general anesthesia:

* Head drape;

* Body drape;

* Throat pack; and

* Rubber dam.

Head drape: The head drape is placed for the purposes of protecting the patient from contaminated and abrasive debris created during the provision of restorative dental procedures and for securing the nasoendotracheal tube. Particular attention is directed toward protection of the patient’s eyes and the nares through which the nasoendotracheal tube is placed. During the head-draping procedure, some practitioners prefer the patient’s eyes to be lubricated with an ophthalmic ointment, covered with a 2-inch-by-6-inch petroleum-jelly-impregnated gauze, and taped shut. Other practitioners consider just taping of the patient’s eyes to be adequate. A standard surgical towel is then used to wrap the head, and the edges are securely taped to seal against the patient’s face. The nasoendotracheal tube is supported over the head wrap utilizing a folded surgical towel and is positioned to prevent blanching of the adjacent nares. (Prolonged blanching of the nares can result in tissue ischemia to the point of necrosis, resulting in a potentially serious cosmetic nasal defect.) Once properly positioned, the nasoendotracheal tube is secured by passing surgical tape completely around the patient’s draped head (Figure 3). Alternative head drape designs are sometimes employed to achieve the same goals and to satisfy an individual practitioner’s preferences.

Body drape: The body drape extends from the area of the patient’s neck to beyond the feet and laterally beyond the borders of the surgical table to cover the patient’s entire body inferior to the mandible. When the body drape is placed, particular attention is directed toward arrangement of leads from monitoring equipment and IV lines to ensure proper functioning without interference from surgical procedures or placement of excessive pressure against the patient’s skin. During dental radiographic procedures, a lead apron is placed over the patient’s neck and torso and removed immediately following completion of radiographs.

Throat pack: During general anesthesia, the patient loses the ability to swallow and cough. Also, particularly when using an uncuffed endotracheal tube, leakage can occur between the endotracheal tube and the wall of the trachea. The patient is, therefore, susceptible to contamination of the respiratory and/or gastrointestinal tracks from dental debris and oral irrigants associated with dental procedures. Dental personnel are also susceptible to the effects of anesthetic gases that leak from a poorly sealed endotracheal tube. To prevent these untoward occurrences, a continuous gauze throat pack is placed between the tonsillar pillars to isolate the oral cavity from the patient’s respiratory and gastrointestinal tracks.²³

Rubber dam: The rubber dam is utilized during provision of all restorative and endodontic procedures within the operating room. The rubber dam assists with the retraction of tissues, provision of a clean and dry operating field, protection of the patient’s respiratory and gastrointestinal tracts from misplaced or broken instruments, medicaments, irrigants, and/or dentinal debris, isolation of the teeth for improved restorative technique, and protection of dental personnel from contamination with the patient’s oral secretions²⁴ (Figure 7).

Collection of Dental Diagnostic Data

The collection of diagnostic data is the process of accumulating information regarding the patient’s dental condition. This information is obtained through dental examination procedures and dental diagnostic testing procedures. Ideally, these procedures are completed preoperatively. However, when the patient’s physical and/or psychological status dictates, these procedures are completed following the administration of general anesthesia. During general anesthesia, the patient is unable to actively participate in these procedures, so that only objective diagnostic techniques may be utilized. Subjective diagnostic techniques, i.e., those requiring interpretation and reporting by the patient, are of little use during general anesthesia.

In the operating room, dental examination and radiographic procedures are completed following patient draping procedures (with the exception of rubber dam application). Dental radiographs are developed immediately and evaluated. The diagnostic data is recorded and analyzed to arrive at a dental diagnosis.

Composing the Treatment Plan

Establishing a treatment plan involves organizing treatment procedures to satisfy the patient’s dental diagnostic needs. When prioritizing dental procedures in the operating room, treatment usually progresses from least traumatic to most traumatic. Performing the most traumatic procedures toward the end of treatment prevents associated bleeding and swelling from interfering with subsequent procedures. Prophylaxis procedures are completed first, often before the dental examination, to expose tooth surfaces for complete evaluation and facilitate placement of dental restorations. Endodontic procedures are completed before restorative procedures; and restorative procedures requiring isolation for bonding are completed prior to other restorative procedures. Extractions and other surgical procedures are completed last, unless required to facilitate completion of restorations.

Completing the Dental Procedures

Completion of dental procedures then progress according to the treatment plan. Restorative procedures and techniques are utilized in the operating room as they are in the dental office. Endodontic treatments are completed as one-appointment procedures because of patient limitations for follow-up care. Extractions employ the use of resorbable sutures and hemostatic agents (surgicel, gelfoam) to assist with management of postoperative bleeding.²⁵ Soft-tissue surgeries are completed utilizing electrocautery techniques, laser techniques, or primary tissue closure with resorbable sutures.

Following completion of the patient’s dental treatment, the oral cavity is inspected to ensure removal of all foreign debris; the oral cavity is irrigated and suctioned; and the continuous gauze throat pack is removed. Extraction sites are covered with 4-inch-by-4-inch gauze, folded to allow a free end to extend from the oral cavity for easy removal. Some dentists also secure the free ends of the oral gauze to the patient’s face with tape during the early postoperative period. (It is beneficial to utilize gauze containing radiopaque markers to assist with postoperative patient assessment in the event that a gauze pack becomes "lost.") The patient’s face is then wiped clean, and all surgical drapes are removed. The anesthesiologist allows the patient to emerge from general anesthesia; spontaneous breathing is restored; and the nasoendotracheal tube is removed. The patient is transported to the postanesthesia recovery room for management of continued recovery for eventual release from the hospital’s care.

Hospital Charting Requirements

Charting requirements refer to the documentation that must be included in the chart of a patient receiving hospital outpatient treatment utilizing general anesthesia. Individual hospitals have differing requirements as to both the identity of the documents and the content of each of the individual documents. It is beyond the scope of this article to present an outline of hospital charting requirements, except to mention that they may include the following:

* Preoperative history and physical;

* Preoperative laboratory values;

* Preoperative note;

* Operative note;

* Postoperative note;

* Surgical dictation;

* Discharge note; and

* Discharge orders.

The practitioner should inquire with the individual hospital to clarify the institution’s specific charting requirements.

Postoperative Office Visit

The postoperative office visit is scheduled with the treating dentist’s office one week following completion of the outpatient surgical procedure. The purposes of the postoperative visit are:

* To inspect the oral cavity for evaluation of healing, function of restorations, and adequacy of oral hygiene practices;

* To answer patient and/or guardian questions; and

* To review oral hygiene and dietary guidelines for prevention of future patient dental problems.

Conclusion

The majority of patients seeking general dental care are receptive to the conventional provision of treatment through the private office setting. The physical and/or psychological status of certain patients, however, prevents utilization of conventional office treatment methods. Increasing numbers of these patients are seeking care through their community general dentist because of the following:

* Societal trends toward deinstitutionalizing the mentally retarded/developmentally disabled;

* Medical advances resulting in increased numbers of individuals surviving to the advanced stages of chronically debilitating diseases;

* Legal implications and parental attitudes toward the treatment of uncooperative children; and

* The anatomic and physiologic characteristics of young children complicating the use of sedative techniques in the dental office setting.

For these patients, general anesthesia offers the most predictable and often only avenue for the receipt of general dental care. This paper has presented significant considerations for the general dentist to evaluate when seeking to integrate outpatient hospital dentistry into his or her private practice.

Authors

Ronald Sani, DDS, is in private general dental practice, which includes provision of hospital dental services. He currently serves on the adjunct faculty of the University of the Pacific School of Dentistry as assistant chief of dentistry -- GPR, University Medical Center, Fresno, Calif. He also serves on staff at Kaiser Permanente Medical Center, Fresno; University Medical Center, Fresno; and Valley Children’s Hospital, Madera, Calif.

Richard O. Spencer, DDS, is in private general dental practice, which includes provision of hospital dental services. He currently serves on staff at Kaiser Permanente Medical Center, Fresno, Calif; University Medical Center, Fresno; and Valley Children’s Hospital, Madera, Calif. He is also a member of the California Dental Association’s Judicial Council.

References

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To request a printed copy of this article, please contact/Ronald J. Sani, DDS, 1705 N. Fine Ave., Suite 102, Fresno, CA 93727 or at rsani@earthlink.net.

Legends

Table 1. PREOPERATIVE LABORATORY TESTS FOR SCREENING HEALTHY PATIENTS – GENERAL DENTAL PROCEDURES

Table 2. SUMMARY OF FASTING RECOMMENDATIONS TO REDUCE THE RISK OF PULMONARY ASPIRATION ¹

¹ These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee a complete gastric emptying has occurred.

² The fasting periods noted above apply to all ages.

³ Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.

⁴ Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.

⁵ A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.

Figure 1. Portable "tool chest" used to transport office instruments and supplies to the hospital.

Figure 2. Oral position of the endotracheal tube.

Figure 3. Nasoendotracheal tube secured with the head drape.

Figure 4. Position of the surgical table tilted 30 degrees from the horizontal to place the head lower than the feet.

Figure 5. Treatment positioning of dentist and assistant for unobstructed access to the patient’s oral cavity and the dental equipment.

Figure 6a. Mobile X-ray equipment.

Figure 6b. Mobile dental cart.

Figure 7. "Surgical field" isolated with the rubber dam in place.

Diagram A. Position of personnel and equipment for utilization of a single dental assistant and "diagonal" patient positioning on a standard surgical table.

Diagram B. Positioning of personnel and equipment for utilization of two dental assistants and the use of a narrowed head extension on the surgical table.