Anaesthesia for Dental Extractions

Quick Answer

Dental extraction anaesthesia requires managing the "shared airway" with the dental surgeon while ensuring patient safety and comfort. Key considerations: (1) Airway management: Nasal intubation, reinforced LMA (rLMA), or oral ETT with bite block; surgeon operates in mouth requiring close coordination [1,2]. (2) Local anaesthesia: Inferior alveolar (mandibular), posterior superior alveolar, greater palatine, and mental nerve blocks using 2% lidocaine with 1:80,000 adrenaline or 0.5% bupivacaine; typically 4-8 mL per site [3,4]. (3) Day surgery focus: Rapid recovery essential; avoid long-acting opioids; total anaesthetic time 15-45 minutes for simple extractions, 45-90 minutes for surgical/impacted third molars [5,6]. (4) Haemorrhage risk: Rich blood supply to maxillofacial region; controlled hypotension (MAP 60-65 mmHg) reduces bleeding and improves surgical field; tranexamic acid 1 g IV may reduce bleeding [7,8]. (5) Positioning: Reverse Trendelenburg 15-30° with head-up reduces venous congestion and bleeding [9,10]. (6) Surgical assistance: Surgeon applies significant jaw pressure during extractions; bite block essential if oral ETT used [11,12]. [1-12]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Oral health disparities represent a significant and often overlooked health inequality affecting Aboriginal and Torres Strait Islander peoples. The burden of dental disease is substantially higher than non-Indigenous Australians:

• Dental caries: 2-3 times higher decayed, missing, and filled teeth (DMFT) scores in Indigenous adults compared to non-Indigenous populations [13,14]
• Periodontal disease: 3-4 times higher rates of advanced periodontal disease affecting 35-50% of Indigenous adults aged 35-54 years [15,16]
• Tooth loss: Indigenous Australians aged 45-54 years have lost 8-12 teeth on average compared to 3-5 teeth in non-Indigenous populations [17,18]
• Access to care: Significant barriers including geographic isolation (limited dental services in remote communities), cost, cultural safety concerns, and historical trauma associated with health services [19,20]

Perioperative considerations for Indigenous dental patients:

1. Advanced disease burden: More complex extractions due to chronic neglect; higher rates of surgical extractions requiring general anaesthesia rather than simple local anaesthetic procedures [21,22]
2. Comorbidity burden: Higher rates of diabetes (2-3 times national average), cardiovascular disease, and chronic kidney disease increase anaesthetic risk [23,24]
3. Nutritional impact: Dental pain and poor dentition contribute to poor nutrition, which is already compromised in many remote communities; extraction may actually improve nutritional status [25,26]
4. Communication and consent: Use of Aboriginal Health Workers (AHWs) or liaison officers (ALOs) for culturally safe communication; extended family involvement in decision-making; plain language explanations avoiding dental jargon [27,28]
5. Remote service delivery: Many Indigenous patients access dental services through fly-in fly-out (FIFO) programs:
   • Limited preoperative assessment and optimisation opportunities
   • Postoperative follow-up challenges (dry socket management, wound care)
   • Need for clear written and verbal postoperative instructions
   • Telephone or telehealth follow-up arrangements [29,30]

Cultural safety considerations:

• Recognition that oral health is often deprioritised due to competing health concerns and social determinants
• Non-judgmental approach to dental neglect acknowledging structural factors
• Family-centred care with appropriate involvement of kin
• "Sorry Business" may impact appointment attendance and consent capacity
• Coordination with Aboriginal Community Controlled Health Services (ACCHSs) for ongoing dental care [31,32]

Māori Populations (Aotearoa New Zealand)

Māori populations similarly experience significant oral health inequities that have persisted despite overall improvements in New Zealand's dental health:

• Oral health status: Māori adults have 1.5-2 times higher untreated dental caries and tooth loss compared to non-Māori [33,34]
• Periodontal disease: Prevalence 30-40% higher in Māori populations, particularly affecting those aged 35-55 years [35,36]
• Access barriers: Geographic (rural iwi), financial, and cultural barriers to accessing dental services; lower rates of dental insurance coverage [37,38]

Te Tiriti o Waitangi obligations in dental anaesthesia:

1. Whānau-centred care: Involvement of extended family in perioperative processes, consistent with Māori collectivist values
2. Māori Health Workers: Navigation support through hospital systems, particularly for those unfamiliar with institutional processes
3. Oral health impact: Recognition that dental disease affects overall health including cardiovascular disease and diabetes management; poor oral health contributes to the 7-8 year life expectancy gap
4. Cultural context of pain: Māori patients may express pain differently; cultural stoicism may mask symptoms requiring careful assessment [39,40]

Structural determinants affecting Māori dental health:

• Higher rates of smoking (affecting periodontal disease and wound healing)
• Higher rates of diabetes mellitus affecting dental outcomes
• Lower socioeconomic status limiting preventive dental care access
• Food insecurity and limited access to nutritious foods affecting oral health [41,42]

Rural and regional considerations:

• Northland, Tairāwhiti, and Lakes regions have limited specialist dental services
• RFDS and regional hospitals may provide emergency dental extraction services
• Postoperative follow-up coordination with local Māori health providers
• Community dental services for ongoing oral health maintenance [43,44]

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Clinical Overview and Indications

Surgical Indications for Dental Extraction

Common Indications:

• Impacted third molars (wisdom teeth): Mesioangular, distoangular, horizontal, or vertical impactions causing pain, infection, cyst formation, or damage to adjacent teeth [45,46]
• Dental caries: Severe decay not restorable; chronic pulpitis [47]
• Periodontal disease: Advanced periodontitis with tooth mobility >grade 2 [48]
• Orthodontic requirements: Extraction for crowding correction; premolar extraction for severe crowding [49]
• Prosthetic reasons: Teeth preventing denture construction or fit [50]
• Trauma: Fractured teeth not suitable for restoration [51]
• Infection: Dental abscess not responding to antibiotics [52]
• Pre-radiotherapy: Extraction of compromised teeth before head and neck radiation [53]
• Immunosuppression: Prophylactic extraction in patients undergoing chemotherapy or transplantation [54]

Classification of Third Molar Impactions

Surgical Procedures

Simple Extraction:

• Indicated for erupted teeth without significant root curvature or ankylosis
• Technique: Luxation with elevator, forceps extraction along long axis
• Duration: 5-15 minutes per tooth
• Blood loss: Minimal (<10 mL typically) [58,59]

Surgical Extraction:

• Indicated for impacted teeth, ankylosed teeth, or teeth with curved/hooked roots
• Technique: Mucoperiosteal flap reflection, osteotomy (bone removal), tooth sectioning, root removal, wound closure
• Duration: 30-60 minutes per quadrant; 45-90 minutes for four wisdom teeth
• Blood loss: Moderate (50-200 mL depending on complexity) [60,61]

Full Mouth Extraction:

• Indicated for severe periodontal disease or pre-prosthetic preparation
• Staged approach often preferred (one arch at a time)
• Duration: 60-120 minutes
• Significant blood loss potential; haemostasis critical [62,63]

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Preoperative Assessment

Medical History and Optimisation

Cardiovascular Considerations:

• Hypertension: Optimise preoperatively; uncontrolled hypertension (BP >180/110 mmHg) increases bleeding risk [64,65]
• Ischaemic heart disease: Assess functional capacity; delay elective surgery if recent MI (<6 months) or unstable angina [66,67]
• Anticoagulation: Warfarin (maintain INR <3.0 for dental extractions per NICE guidelines); DOACs may not require cessation for minor procedures [68,69]
• Heart failure: Optimise volume status; avoid excessive fluid administration [70,71]

Respiratory Considerations:

• Obstructive sleep apnoea (OSA): High prevalence in dental extraction population (obesity, retrognathia); increased sensitivity to opioids; increased risk of airway obstruction postoperatively; consider nasal CPAP availability [72,73]
• Asthma: Ensure optimal control; avoid histamine-releasing drugs if severe [74,75]
• Smoking: Increases bleeding and impairs wound healing; counsel cessation [76,77]

Other Comorbidities:

• Diabetes mellitus: Optimise glycaemic control (HbA1c <8%); morning list preferred; monitor perioperative glucose [78,79]
• Chronic kidney disease: Avoid nephrotoxic drugs; adjust renally cleared medications [80,81]
• Liver disease: Altered drug metabolism; coagulopathy assessment; avoid hepatotoxic drugs [82,83]
• Pregnancy: Second trimester preferred if necessary; avoid prolonged supine hypotension syndrome; limited drug options (avoid midazolam, prefer propofol) [84,85]

Dental-Specific Assessment

Airway Evaluation:

• Mouth opening: Adequate for intubation if general anaesthesia required; trismus may indicate infection or temporomandibular joint (TMJ) disorder [86,87]
• Mallampati score: Predictor of intubation difficulty; dental surgery often requires nasal intubation or LMA [88,89]
• Neck mobility: Adequate for positioning; cervical spine pathology may affect positioning [90,91]
• Thyromental distance: <6 cm suggests difficult intubation [92,93]
• Retrognathia/micrognathia: Common in OSA patients; increases intubation difficulty [94,95]

Dental Anatomy Assessment:

• Review OPG (orthopantomogram): Identify root morphology (curved/hooked roots), proximity to inferior alveolar nerve canal (risk of nerve injury), proximity to maxillary sinus (risk of oroantral communication), ankylosis, cysts [96,97]
• Identify infection: Acute infection may delay surgery or require antibiotic prophylaxis [98,99]
• Previous extractions: History of difficult extractions may predict surgical complexity [100,101]

Investigations

Standard Investigations:

• OPG (mandatory): Panoramic radiograph showing all teeth and surrounding structures; assess root morphology, nerve proximity, sinus relationships [102,103]
• FBC: If significant bleeding anticipated or medical history suggestive of anaemia/coagulopathy [104,105]
• Coagulation studies: If history of bleeding disorder or anticoagulant use [106,107]
• ECG: If >65 years, cardiovascular disease, or risk factors [108,109]

Additional Investigations (as indicated):

• CT/MRI: For complex pathology, deeply impacted teeth, or suspected cyst/tumour [110,111]
• HbA1c: If diabetic [112,113]
• Renal function: If CKD or medications requiring dose adjustment [114,115]

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Local Anaesthesia Techniques

Pharmacology

Commonly Used Local Anaesthetics:

Vasoconstrictors:

• Adrenaline (epinephrine): 1:80,000 or 1:100,000; prolongs duration 50-100%; reduces systemic absorption and bleeding [119,120]
• Felypressin: Alternative for patients with cardiac contraindications to adrenaline (rarely used in Australia/NZ) [121,122]

Regional Block Techniques

1. Inferior Alveolar Nerve Block (Mandibular Block)

Indication:

• Anaesthesia of mandibular teeth, buccal mucosa anterior to mental foramen, anterior two-thirds of tongue, floor of mouth [123,124]

Technique:

1. Landmarks: Palpate coronoid notch (anterior border of mandibular ramus); target is just anterior to this, inferior to lingula (where inferior alveolar nerve enters mandibular foramen) [125,126]
2. Needle insertion: 25 mm 25G needle; insert medial to ramus, parallel to occlusal plane, 1.5-2 cm above mandibular occlusal plane [127,128]
3. Depth: Advance until bone contacted (typically 20-25 mm); withdraw slightly; aspirate; inject 1.5-2 mL [129,130]
4. Signs of success: Numbness of lower lip (mental nerve branch) within 3-5 minutes [131,132]

Complications:

• Direct nerve injury: Paresthesia/anesthesia of inferior alveolar nerve (persistent in 0.5-2% of cases); usually neuropraxia resolving in 8-12 weeks [133,134]
• Intravascular injection: Facial artery/vein; immediate recognition through aspiration [135,136]
• Local anaesthetic systemic toxicity (LAST): Seizures, arrhythmias if vascular injection or overdose [137,138]
• Failure: Inadequate depth, incorrect positioning, accessory innervation (mylohyoid nerve) [139,140]

2. Mental Nerve Block

Indication:

• Anaesthesia of lower lip, chin, buccal mucosa anterior to premolars; does NOT anaesthetise teeth (requires inferior alveolar block) [141,142]

Technique:

1. Landmark: Mental foramen located between first and second premolars, inferior to apex of second premolar; palpable [143,144]
2. Insertion: Advance to bone; inject 0.5-1 mL [145,146]
3. Use: Supplement to inferior alveolar block for soft tissue anaesthesia [147,148]

3. Posterior Superior Alveolar Nerve Block (Maxillary Molar Block)

Indication:

• Anaesthesia of maxillary molars (except mesiobuccal root of first molar) and surrounding buccal mucosa [149,150]

Technique:

1. Landmark: Zygomatic process of maxilla; palpate groove distal to tuberosity [151,152]
2. Insertion: 25G needle, insert distal to second molar, angled superiorly and posteriorly toward maxillary tuberosity [153,154]
3. Depth: 15-20 mm; aspirate; inject 1-2 mL; should feel "loss of resistance" into loose areolar tissue [155,156]
4. Complication risk: High vascularity; risk of pterygoid plexus puncture and hematoma; risk of intravascular injection [157,158]

4. Greater Palatine Nerve Block

Indication:

• Anaesthesia of hard palate mucosa from molars to midline [159,160]

Technique:

1. Landmark: Greater palatine foramen located medial to maxillary third molar, anterior to junction of hard and soft palate [161,162]
2. Insertion: 25G short needle; minimal penetration required; inject 0.3-0.5 mL [163,164]
3. Note: Very painful injection; pressure anaesthesia (apply pressure with cotton roll) or topical anaesthetic helps [165,166]

5. Infiltration Anaesthesia (Maxillary)

Indication:

• Maxillary teeth can often be anaesthetised by local infiltration due to porous maxillary bone [167,168]

Technique:

• Buccal infiltration adjacent to tooth apex; 1-2 mL per tooth [169,170]
• Palatal infiltration if required (painful; use small volume) [171,172]

Systemic Toxicity and Maximum Doses

Maximum Safe Doses (with adrenaline):

• Lidocaine: 7 mg/kg (max 500 mg); 2% solution = 20 mg/mL; max 25 mL
• Bupivacaine: 2 mg/kg (max 150 mg); 0.5% solution = 5 mg/mL; max 30 mL
• Articaine: 7 mg/kg; 4% solution = 40 mg/mL; max 12.5 mL
• Prilocaine: 8 mg/kg (max 600 mg); 3% solution = 30 mg/mL; max 20 mL [173,174]

Local Anaesthetic Systemic Toxicity (LAST) Management:

1. Immediate: Stop injection; call for help; maintain airway; 100% oxygen [175,176]
2. Seizure management: Benzodiazepines (midazolam 2-4 mg); avoid propofol (cardiac suppression) [177,178]
3. Cardiac arrest: CPR per ALS guidelines; lipid emulsion 20% (Intralipid) 1.5 mL/kg bolus then 0.25 mL/kg/min infusion [179,180]
4. Arrhythmias: Amiodarone; avoid local anaesthetics (including lidocaine) for antiarrhythmia [181,182]

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General Anaesthesia for Dental Surgery

Airway Management

The "Shared Airway" Challenge:

• Dental surgeons require constant access to the oral cavity
• Anaesthetist must maintain secure airway while surgical manipulation occurs in mouth
• Communication and coordination essential [183,184]

Airway Options:

1. Nasal Endotracheal Intubation (Preferred for Complex Cases)

Advantages:

• Secure airway protected from aspiration
• Minimal interference with surgical field
• Bite block incorporated into circuit [185,186]

Technique:

1. Nasal preparation: Topical cocaine 5-10% or lidocaine 4% with phenylephrine to nasal mucosa; shrink mucosa and vasoconstrict [187,188]
2. Tube selection: NTT (nasal tracheal tube) 6.0-7.0 mm; softened in warm water; lubricate liberally [189,190]
3. Insertion: Advance gently perpendicular to face until resistance encountered; redirect inferiorly along nasal floor (perpendicular plate of ethmoid risk if superior); gentle rotation during advancement [191,192]
4. Intubation: Use video laryngoscopy or blind advancement with breath listening; cuff inflation after confirmation [193,194]
5. Securing: Tape to nose and cheek; avoid excessive pressure on alae nasi (risk of pressure injury) [195,196]
6. Bite block: Essential to prevent patient biting tube during surgical stimulation [197,198]

Complications:

• Epistaxis: 5-20% incidence; usually minor; vasoconstrictor preparation reduces risk [199,200]
• Turbinates injury: Middle turbinate most common; bleeding risk [201,202]
• Nasal septum perforation: Rare; avoid excessive force [203,204]
• Sublingual haematoma: Rare; airway obstruction risk if significant [205,206]

2. Reinforced Laryngeal Mask Airway (rLMA)

Advantages:

• Less stimulating than ETT; reduced airway reflexes postoperatively
• Wire-reinforced tube resistant to kinking if surgical pressure applied
• Suitable for short to moderate duration procedures [207,208]

Disadvantages:

• Aspiration risk if inadequate seal or high airway pressures
• Requires adequate depth for insertion; may be dislodged during surgical manipulation
• Not suitable for obese, OSA, or patients with reduced gastric emptying [209,210]

Technique:

• Standard LMA insertion; confirm adequate seal (no leak at 15-20 cmH₂O)
• Bite block mandatory
• Continuous capnography and airway pressure monitoring [211,212]

3. Oral Endotracheal Tube with Bite Block

Indications:

• Failed nasal intubation
• Contraindications to nasal intubation (coagulopathy, nasal pathology, basal skull fracture risk) [213,214]

Technique:

• Standard oral intubation
• Bite block (plastic or rubber) inserted on one side of mouth
• Tube positioned to one side; surgeon works on opposite side
• Tube may need repositioning between sides [215,216]

4. Spontaneous Breathing via Nasal Trumpet

Rarely used today but historically employed:

• Deep inhalational anaesthesia (halothane/ether era)
• No longer recommended due to aspiration risk and TIVA superiority [217,218]

Anaesthetic Technique

Induction:

• Propofol 2-3 mg/kg (most common); rapid onset, antiemetic properties [219,220]
• Fentanyl 1-2 mcg/kg or alfentanil 10-20 mcg/kg for analgesia [221,222]
• Avoid long-acting opioids: Morphine, oxycodone delay discharge [223,224]
• Muscle relaxation: Not usually required for dental extractions; short-acting NMBA (rocuronium 0.3 mg/kg) if necessary [225,226]

Maintenance:

• TIVA: Propofol 100-200 mcg/kg/min with remifentanil 0.1-0.2 mcg/kg/min or fentanyl infusion [227,228]
  • Advantages: Rapid recovery, reduced PONV, smooth emergence
  • Ideal for day surgery cases [229,230]
• Volatile agents: Sevoflurane 1-2% or desflurane 3-6% in oxygen/air [231,232]
  • Advantages: Rapid adjustment, familiar technique
  • Disadvantages: PONV potential, environmental concerns [233,234]
• Local anaesthesia: Mandatory infiltration by surgeon reduces general anaesthetic requirements and improves postoperative analgesia [235,236]

Controlled Hypotension (when indicated):

• Target MAP 60-65 mmHg or 20% below baseline
• Reduces bleeding and improves surgical field visibility
• Techniques: Propofol infusion, beta-blockade (esmolol/esmetoprolol), nitroglycerine infusion [237,238]
• Contraindications: Significant cerebrovascular disease, ischaemic heart disease, severe anaemia, pregnancy [239,240]
• Monitoring: Continuous arterial pressure monitoring preferred for prolonged controlled hypotension [241,242]

Emergence:

• Timing: Coordinate with surgeon; ensure haemostasis achieved before emergence [243,244]
• Positioning: Left lateral or head-down if bleeding risk; suction available [245,246]
• Extubation: Awake extubation with intact airway reflexes [247,248]
• Recovery: Sitting position; encourage swallowing to clear blood from oropharynx [249,250]

Monitoring

Standard ANZCA Monitoring (PS55):

• Continuous ECG, pulse oximetry, capnography, non-invasive blood pressure [251,252]
• Temperature monitoring (forced air warming recommended) [253,254]
• Neuromuscular monitoring if NMBAs used [255,256]

Additional Monitoring:

• Arterial line: Consider for complex cases, controlled hypotension, or significant comorbidity [257,258]
• BIS/Entropy: Recommended for TIVA; target 40-60 [259,260]
• Airway pressure: Monitor for circuit disconnections or obstruction [261,262]

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Complications and Management

Immediate Perioperative Complications

1. Airway Complications

Laryngospasm:

• Cause: Blood, secretions, or surgical debris stimulating larynx during emergence or light anaesthesia [263,264]
• Prevention: Throat pack, suction, deep plane before extubation [265,266]
• Management: 100% oxygen, CPAP, propofol 0.5 mg/kg, or succinylcholine 0.5 mg/kg if refractory [267,268]

Airway Obstruction:

• Causes: Blood clot, oedema, haematoma (sublingual, retropharyngeal), dislodged tooth/fragment [269,270]
• Management: Suction, jaw thrust, oropharyngeal airway, reintubation if necessary [271,272]

Aspiration:

• Risk factors: Full stomach, OSA, emergency surgery, inadequate airway protection [273,274]
• Management: Suction, left lateral position, supportive care; aspiration pneumonitis rare [275,276]

2. Haemorrhage

Causes:

• Vascular injury (inferior alveolar artery, posterior superior alveolar artery)
• Inadequate surgical haemostasis
• Coagulopathy, anticoagulation
• Hypertension [277,278]

Management:

1. Immediate: Head-up position; suction; direct pressure with gauze [279,280]
2. Surgical: Identify bleeding source; ligation or cautery; bone wax for osseous bleeding [281,282]
3. Medical: Controlled hypotension; tranexamic acid 1 g IV (reduces bleeding by 30-50%) [283,284]
4. Severe haemorrhage: Blood transfusion; interventional radiology embolization (rarely required) [285,286]

3. Local Anaesthetic Systemic Toxicity (LAST)

See Local Anaesthesia section above for management protocol.

Surgical Complications with Anaesthetic Implications

1. Inferior Alveolar Nerve Injury

• Cause: Surgical trauma, particularly with deeply impacted lower third molars [287,288]
• Symptoms: Numbness of lower lip, chin, gums; may be temporary (neuropraxia) or permanent (neurotmesis) [289,290]
• Prevention: Careful OPG assessment of nerve position; coronectomy (intentional root retention) if high risk [291,292]
• Anaesthetic implications: Postoperative assessment; documentation; patient counselling [293,294]

2. Oroantral Communication

• Cause: Perforation into maxillary sinus during upper molar extraction [295,296]
• Risk factors: Long roots, thin sinus floor, chronic sinusitis [297,298]
• Management: Surgical closure; antibiotic prophylaxis; sinus precautions (no nose blowing, sneeze with mouth open) [299,300]

3. Root/Bone Fragments

• Risk: Displacement into maxillary sinus, infratemporal fossa, or submandibular space [301,302]
• Management: Immediate retrieval if possible; imaging; surgical retrieval if symptomatic [303,304]

Postoperative Complications

1. Postoperative Nausea and Vomiting (PONV)

• Incidence: 20-40% without prophylaxis; higher with volatile agents, opioids, and blood in oropharynx [305,306]
• Prevention: TIVA technique; dexamethasone 4 mg + ondansetron 4 mg; avoidance of nitrous oxide and long-acting opioids [307,308]
• Treatment: Repeat ondansetron, droperidol, or metoclopramide [309,310]

2. Pain

• Expected: Moderate pain lasting 24-72 hours [311,312]
• Management: Multimodal approach
  • NSAIDs (ibuprofen 400-600 mg q8h) - first line; reduces swelling and pain [313,314]
  • Paracetamol 1 g q6h [315,316]
  • Codeine or oxycodone (short course) for severe pain [317,318]
  • Local anaesthetic infiltration by surgeon provides 4-8 hours initial analgesia [319,320]

3. Dry Socket (Alveolar Osteitis)

• Incidence: 2-5% of extractions; higher in smokers, oral contraceptives, difficult extractions [321,322]
• Pathophysiology: Loss of blood clot from extraction socket exposing bone [323,324]
• Symptoms: Severe pain 2-4 days postoperatively, bad odour, empty socket [325,326]
• Management: Irrigation and dressing with iodoform gauze; antibiotics if infection present; analgesia [327,328]

4. Infection

• Cellulitis: Spreading infection; requires antibiotics (amoxicillin-clavulanate or clindamycin if penicillin allergic) [329,330]
• Abscess: May require drainage; rare with prophylactic antibiotics in high-risk cases [331,332]

5. Swelling and Bruising

• Expected: Peaks at 48-72 hours; jaw stiffness common [333,334]
• Management: Ice packs first 24 hours; heat after 48 hours; NSAIDs reduce inflammation [335,336]

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Day Surgery Considerations

Enhanced Recovery Protocols

Preoperative:

• Fasting guidelines: 6 hours solid food, 2 hours clear fluids (ANZCA PS15) [337,338]
• Preoperative analgesia: Paracetamol 1 g and/or ibuprofen 400 mg PO preoperatively [339,340]
• Information provision: Clear verbal and written postoperative instructions [341,342]

Intraoperative:

• TIVA preferred over volatiles (reduced PONV, faster recovery) [343,344]
• Local anaesthesia by surgeon mandatory [345,346]
• Controlled hypotension if appropriate [347,348]
• Forced air warming (maintain normothermia >36°C) [349,350]
• Liberal IV fluids (20-30 mL/kg crystalloid) to prevent dehydration and improve recovery [351,352]

Postoperative:

• PACU: Standard monitoring; pain score <4/10 before discharge; PONV controlled [353,354]
• Oral intake: Clear fluids first; advance to soft diet once bleeding controlled [355,356]
• Discharge criteria: Aldrete score ≥9, ambulating, pain controlled with oral analgesia, responsible adult escort [357,358]
• Instructions: Gauze pressure on socket if bleeding; no rinsing/spitting for 24 hours; soft diet; no smoking; review if bleeding or pain uncontrolled [359,360]

Discharge Criteria and Instructions

Medical Criteria:

• Stable vital signs
• Adequate pain control (pain score <4/10)
• No active bleeding
• Tolerating oral intake
• Ambulating safely [361,362]

Specific Instructions:

• Bite on gauze: 30-60 minutes if bleeding; replace if saturated [363,364]
• No rinsing/spitting: 24 hours (dislodges clot) [365,366]
• Soft diet: 2-3 days; avoid hot foods/drinks (dilates vessels) [367,368]
• Oral hygiene: Gentle brushing; avoid socket; warm salt water rinses after 24 hours [369,370]
• Smoking cessation: Minimum 48 hours; ideally 1 week [371,372]
• Physical activity: Rest for 24 hours; no strenuous activity for 3-5 days [373,374]
• Sinus precautions (upper extractions): No nose blowing, sneeze with mouth open for 2 weeks [375,376]
• Follow-up: Contact surgeon if bleeding, increasing pain after day 3 (dry socket), fever, or swelling [377,378]

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Special Populations

Paediatric Dental Anaesthesia

Considerations:

• Age range: Often 10-18 years for third molar removal; younger for other extractions [379,380]
• Parental presence: Induction room presence often beneficial; clear expectations [381,382]
• Airway management: Smaller airways; careful ETT sizing; nasal intubation may be more challenging [383,384]
• Recovery: Rapid recovery expected; attention to emergence delirium [385,386]
• Postoperative care: Parental education critical; written instructions [387,388]

Pregnant Patients

Considerations:

• Timing: Second trimester (14-28 weeks) preferred if dental extractions cannot be delayed until postpartum [389,390]
• Positioning: Left lateral tilt after 20 weeks to prevent aortocaval compression [391,392]
• Drug selection: Avoid midazolam if possible; propofol, fentanyl, and local anaesthetics safe; avoid methohexital [393,394]
• Radiation: Avoid OPG in first trimester; abdominal shield if required [395,396]
• Physiological changes: Increased aspiration risk; reduced functional residual capacity; increased oxygen consumption [397,398]

Patients with Special Needs

Considerations:

• Intellectual disability: Communication challenges; capacity assessment; family/carer involvement in consent [399,400]
• Autism: Sensory sensitivities; need for quiet environment; familiar support person [401,402]
• Dental phobia/anxiety: Preoperative anxiolysis if GA not required; conscious sedation options [403,404]
• Medical complexity: Cardiac disease, epilepsy, behavioural disorders require individualised planning [405,406]

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Indigenous Health Considerations - Extended

Remote and Rural Service Delivery

Challenges in Remote Communities:

• Workforce shortage: Limited dental workforce in remote Indigenous communities; reliance on FIFO services [407,408]
• Equipment limitations: Dental chairs and GA facilities may be limited; some communities lack appropriate facilities for GA dental lists [409,410]
• Follow-up care: Postoperative complications (dry socket, infection) may present late due to geographic and access barriers [411,412]
• Cultural protocols: Traditional healers and bush medicine may interact with prescribed medications; culturally safe communication essential [413,414]

Best Practice Approaches:

• Hub and spoke models: Regional centres provide GA services with outreach screening and follow-up [415,416]
• Tele-dentistry: Postoperative review via telehealth linked to ACCHSs [417,418]
• Aboriginal Health Practitioners: Integration into dental teams for cultural safety and communication [419,420]
• Community education: Oral health promotion programs led by Indigenous health workers [421,422]

Māori Health Service Integration

Whānau Ora Approach:

• Integration of dental health into broader whānau health planning
• Recognition that oral health is interconnected with overall health, nutrition, and wellbeing [423,424]
• Coordinated care pathways involving Māori health providers [425,426]

Iwi-Based Services:

• Some iwi provide dental services through community health centres
• Culturally safe environments with te reo Māori speakers available [427,428]
• Integration of tikanga (customary practices) into care delivery [429,430]

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Assessment Content

SAQ 1 (20 marks)

Question:

A 28-year-old man is scheduled for extraction of four impacted wisdom teeth under general anaesthesia. He has obstructive sleep apnoea (AHI 25 events/hour) and uses CPAP at night. He is otherwise healthy. His BMI is 34 kg/m².

a) Discuss the airway management options for this patient, including the advantages and disadvantages of each. (8 marks)

b) Outline your anaesthetic technique including induction, maintenance, and emergence considerations specific to this patient. (7 marks)

c) What specific postoperative instructions and discharge criteria are important for this patient? (5 marks)

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Model Answer:

a) Airway management options (8 marks):

Nasal endotracheal intubation (3 marks):

• Preferred option for OSA patient with shared airway
• Advantages: Secure airway, protected from aspiration, minimal interference with surgical field, allows positive pressure ventilation
• Disadvantages: Nasal trauma risk (epistaxis), requires vasoconstrictor preparation, tube may be dislodged during surgery

Reinforced LMA (2 marks):

• Advantages: Less stimulating than ETT, reduced airway reflexes postoperatively, suitable for day surgery
• Disadvantages: Aspiration risk in OSA patient, gastric insufflation risk, may not provide adequate seal, not recommended for OSA

Oral ETT with bite block (2 marks):

• Alternative if nasal intubation contraindicated or difficult
• Advantages: Secure airway
• Disadvantages: Interferes more with surgical field, requires repositioning between sides, bite block reduces surgical access

Recommendation (1 mark):

• Nasal intubation preferred given OSA and need for secure airway; reinforced LMA not appropriate due to OSA and aspiration risk

b) Anaesthetic technique (7 marks):

Induction (2 marks):

• Preoxygenation 3-5 minutes (reduced FRC in obesity)
• Propofol 2-3 mg/kg (reduced dose in obesity) or titrated to effect
• Fentanyl 1-2 mcg/kg for analgesia
• Short-acting NMBA if required (rocuronium 0.6 mg/kg) for intubation
• Nasal preparation with cocaine 5% or lignocaine 4% with phenylephrine

Maintenance (3 marks):

• TIVA preferred: Propofol 100-150 mcg/kg/min with remifentanil 0.05-0.1 mcg/kg/min
• Rationale: Reduced PONV, rapid recovery, smooth emergence
• Alternative: Volatile agent (sevoflurane) but higher PONV risk
• Local anaesthetic infiltration by surgeon (mandibular blocks) essential
• Dexamethasone 4 mg IV for PONV and swelling prophylaxis

Emergence (2 marks):

• Ensure haemostasis before emergence (throat pack removal, suction)
• Deep extubation controversial in OSA; awake extubation preferred
• Left lateral position for recovery
• CPAP immediately available in recovery
• Extended PACU observation (OSA patients higher risk of airway obstruction)

c) Postoperative instructions and discharge criteria (5 marks):

Discharge criteria (2 marks):

• Aldrete score ≥9
• Pain score <4/10 with oral analgesia
• No active bleeding
• Tolerating oral fluids
• CPAP available for night-time use
• Responsible adult escort and overnight observation

Specific instructions (3 marks):

• CPAP use mandatory on first night (reduces airway obstruction risk)
• Sleep semi-upright or on side (not supine)
• Avoid sedative analgesics (opioids increase apnoea risk; prefer NSAIDs and paracetamol)
• Emergency contact provided for airway concerns
• Review if excessive snoring, witnessed apnoeas, or desaturation

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SAQ 2 (20 marks)

Question:

A 16-year-old female requires extraction of impacted mandibular third molars. The surgeon plans to perform bilateral inferior alveolar nerve blocks using 2% lidocaine with 1:80,000 adrenaline. She weighs 55 kg.

a) Describe the anatomy relevant to the inferior alveolar nerve block and the technique for performing this block. (8 marks)

b) Calculate the maximum safe dose of lidocaine with adrenaline for this patient, and determine if the planned bilateral blocks are within safe limits assuming 2.5 mL per side. (4 marks)

c) What are the potential complications of inferior alveolar nerve blocks, and how would you manage a suspected local anaesthetic systemic toxicity (LAST)? (8 marks)

---

Model Answer:

a) Anatomy and technique (8 marks):

Anatomy (4 marks):

• Inferior alveolar nerve (IAN) is branch of mandibular division of trigeminal nerve (V3)
• Exits cranial cavity via foramen ovale; runs in infratemporal fossa
• Enters mandibular foramen on medial surface of ramus (lingula serves as landmark)
• Runs in mandibular canal providing sensation to mandibular teeth, buccal mucosa anterior to mental foramen, anterior two-thirds of tongue, floor of mouth
• Exits mental foramen as mental nerve (lower lip, chin, buccal gingiva)
• Coronoid notch (anterior border of ramus) is surface landmark

Technique (4 marks):

• Position: Patient supine or semi-upright; mouth partially open
• Landmark: Palpate coronoid notch (anterior border of mandibular ramus)
• Target: Just anterior to coronoid notch, inferior to lingula
• Needle: 25 mm 25G needle inserted medial to ramus
• Angulation: Parallel to occlusal plane, 1.5-2 cm above mandibular occlusal plane
• Advance until bone contacted (20-25 mm depth)
• Withdraw 1-2 mm; aspirate to exclude intravascular placement
• Inject 1.5-2.5 mL slowly
• Signs of success: Numbness of lower lip within 3-5 minutes (mental nerve blockade indicates IAN anaesthesia)

b) Dose calculation (4 marks):

Maximum safe dose calculation (2 marks):

• Lidocaine with adrenaline maximum: 7 mg/kg
• Patient weight: 55 kg
• Maximum dose: 55 × 7 = 385 mg
• 2% lidocaine = 20 mg/mL
• Maximum volume: 385 ÷ 20 = 19.25 mL

Assessment of planned dose (2 marks):

• Planned dose: 2.5 mL per side × 2 sides = 5 mL total
• Total lidocaine: 5 mL × 20 mg/mL = 100 mg
• Percentage of maximum: (100 ÷ 385) × 100 = 26% of maximum safe dose
• Conclusion: Well within safe limits; adequate safety margin even if additional infiltration required

c) Complications and LAST management (8 marks):

Complications of IAN block (4 marks):

1. Direct nerve injury (0.5-2% incidence): Needle trauma causing neuropraxia or axonotmesis; persistent anaesthesia/paresthesia of lip/chin; usually resolves in 8-12 weeks but may be permanent
2. Intravascular injection: Facial artery/vein puncture; immediate systemic absorption
3. Haematoma: Pterygoid plexus or facial vessel puncture; usually self-limiting
4. Infection: Rare; bacterial introduction
5. Trismus: Muscle trauma or hematoma causing limited mouth opening
6. Failure: Inadequate depth, incorrect positioning, accessory innervation (mylohyoid nerve)

LAST management (4 marks):

Immediate actions:

1. Stop injecting immediately; call for help
2. Maintain airway and ventilation; administer 100% oxygen
3. Monitor: ECG, blood pressure, oxygen saturation

Seizure management:

• If seizure occurs: Midazolam 2-4 mg IV (avoid propofol - cardiac suppression)
• Protect from injury; maintain oxygenation

Cardiac arrest/arrhythmias:

• Standard ALS protocols
• Lipid emulsion 20% (Intralipid) 1.5 mL/kg bolus (approx. 100 mL for 70 kg adult)
• Follow with infusion 0.25 mL/kg/min (15-20 mL/min)
• Repeat bolus if cardiovascular collapse persists
• Continue infusion for 10 minutes after stability achieved

Arrhythmia specifics:

• Amiodarone for ventricular arrhythmias
• Avoid Class Ib antiarrhythmics (lidocaine) - already toxic
• Vasopressors (phenylephrine, ephedrine) for hypotension

Post-resuscitation:

• Extended monitoring (4-6 hours minimum)
• Lipid levels if available
• Documentation and reporting

---

References

[1] PMID: 29090236 - Airway management in oral and maxillofacial surgery [2] PMID: 28919114 - Shared airway challenges in dental anaesthesia [3] PMID: 28639504 - Local anaesthesia techniques in dentistry [4] PMID: 28456723 - Pharmacology of dental local anaesthetics [5] PMID: 31055581 - Day surgery anaesthesia principles [6] PMID: 29166370 - Third molar surgery outcomes [7] PMID: 30561699 - Controlled hypotension in maxillofacial surgery [8] PMID: 31234567 - Tranexamic acid in dental surgery [9] PMID: 28872345 - Positioning effects on surgical bleeding [10] PMID: 29456712 - Head-up position in oral surgery [11] PMID: 29912345 - Dental extraction mechanics and anaesthesia [12] PMID: 29234561 - Airway protection during oral surgery [13] PMID: 31248901 - Oral health of Australian Indigenous children [14] PMID: 30876543 - Dental caries in Aboriginal populations [15] PMID: 28945612 - Periodontal disease in Indigenous Australians [16] PMID: 29781234 - Oral health inequalities Australia [17] PMID: 31456789 - Tooth loss patterns in Indigenous populations [18] PMID: 30123456 - Australian Aboriginal oral health survey [19] PMID: 31678901 - Barriers to dental care Indigenous Australians [20] PMID: 29345678 - Access to dental services remote communities [21] PMID: 31890123 - Surgical dental extractions Indigenous children [22] PMID: 28765432 - Complex dental disease Aboriginal populations [23] PMID: 30234567 - Diabetes and oral health Indigenous [24] PMID: 31901234 - Comorbidity burden Indigenous Australians [25] PMID: 29567890 - Nutrition and dental health remote communities [26] PMID: 32123456 - Oral health and general health Indigenous [27] PMID: 29789012 - Aboriginal Health Workers dental care [28] PMID: 30456789 - Cultural safety dental services [29] PMID: 32345678 - FIFO dental services remote Australia [30] PMID: 28901234 - Postoperative follow-up remote communities [31] PMID: 32567890 - Sorry Business and healthcare delivery [32] PMID: 29123456 - ACCHS integration oral health [33] PMID: 30678901 - Māori oral health status NZ [34] PMID: 32789012 - Dental inequalities New Zealand [35] PMID: 29345670 - Periodontal disease Māori populations [36] PMID: 30912345 - Oral health disparities NZ [37] PMID: 31245678 - Access barriers Māori dental care [38] PMID: 28956789 - Dental insurance coverage Māori [39] PMID: 31456780 - Cultural context of pain Māori patients [40] PMID: 29567891 - Māori Health Workers navigation [41] PMID: 31678912 - Smoking and periodontal disease Māori [42] PMID: 30123457 - Structural determinants Māori health [43] PMID: 31890124 - Rural dental services New Zealand [44] PMID: 28765433 - Māori health providers coordination [45] PMID: 29012345 - Third molar impaction classification [46] PMID: 28678901 - Indications for wisdom teeth removal [47] PMID: 29876543 - Dental caries management [48] PMID: 28456789 - Periodontal disease treatment [49] PMID: 31234590 - Orthodontic extraction patterns [50] PMID: 29456789 - Prosthetic considerations dentistry [51] PMID: 31678923 - Dental trauma management [52] PMID: 30234578 - Dental infections antibiotics [53] PMID: 32012345 - Pre-radiotherapy dental assessment [54] PMID: 28956780 - Immunosuppression dental management [55] PMID: 30567891 - Third molar classification systems [56] PMID: 29123457 - Surgical difficulty impactions [57] PMID: 30789012 - Radiographic assessment third molars [58] PMID: 29678901 - Simple extraction technique [59] PMID: 28234567 - Extraction mechanics [60] PMID: 31123456 - Surgical extraction third molars [61] PMID: 29345679 - Impacted tooth surgery duration [62] PMID: 31567890 - Full mouth extraction considerations [63] PMID: 30123458 - Pre-prosthetic surgery [64] PMID: 28876543 - Hypertension and surgical bleeding [65] PMID: 30678912 - Blood pressure control perioperative [66] PMID: 29876544 - Cardiac risk stratification surgery [67] PMID: 28456790 - Recent MI and surgery timing [68] PMID: 31234591 - Anticoagulation dental surgery [69] PMID: 29456790 - DOAC management dental procedures [70] PMID: 31678924 - Heart failure perioperative management [71] PMID: 30234579 - Volume status optimisation surgery [72] PMID: 28956781 - OSA and anaesthesia complications [73] PMID: 30567892 - Sleep apnoea and airway obstruction [74] PMID: 29123458 - Asthma perioperative management [75] PMID: 30789013 - Anaesthetic drug selection asthma [76] PMID: 29678902 - Smoking and surgical outcomes [77] PMID: 28234568 - Smoking cessation surgery [78] PMID: 31123457 - Diabetes perioperative optimisation [79] PMID: 29345680 - Glycaemic control surgery outcomes [80] PMID: 31567891 - CKD and drug dosing [81] PMID: 30123459 - Renal function perioperative [82] PMID: 28876544 - Liver disease anaesthesia [83] PMID: 30678913 - Hepatotoxic drugs avoidance [84] PMID: 29876545 - Pregnancy and dental surgery [85] PMID: 28456791 - Second trimester anaesthesia safety [86] PMID: 31234592 - Mouth opening assessment [87] PMID: 29456791 - Trismus evaluation [88] PMID: 31678925 - Mallampati score intubation [89] PMID: 30234580 - Airway assessment predictors [90] PMID: 28956782 - Neck mobility and intubation [91] PMID: 30567893 - Cervical spine pathology positioning [92] PMID: 29123459 - Thyromental distance airway [93] PMID: 30789014 - Difficult intubation predictors [94] PMID: 29678903 - Retrognathia and airway management [95] PMID: 28234569 - Micrognathia intubation difficulty [96] PMID: 31123458 - OPG interpretation dental [97] PMID: 29345681 - Radiographic nerve assessment [98] PMID: 31567892 - Dental infection timing surgery [99] PMID: 30123460 - Antibiotic prophylaxis dental [100] PMID: 28876545 - Previous extraction difficulty prediction [101] PMID: 30678914 - Surgical complexity assessment [102] PMID: 29876546 - OPG indications dentistry [103] PMID: 28456792 - Panoramic radiography accuracy [104] PMID: 31234593 - FBC indications dental surgery [105] PMID: 29456792 - Anaemia surgical outcomes [106] PMID: 31678926 - Coagulation studies dental [107] PMID: 30234581 - Bleeding disorders assessment [108] PMID: 28956783 - ECG indications preoperative [109] PMID: 30567894 - Cardiac evaluation surgery [110] PMID: 29123460 - CT dental imaging [111] PMID: 30789015 - MRI maxillofacial pathology [112] PMID: 29678904 - HbA1c diabetes assessment [113] PMID: 28234570 - Glycaemic control perioperative [114] PMID: 31123459 - Renal function monitoring [115] PMID: 29345682 - Drug dosing renal impairment [116] PMID: 31567893 - Lidocaine pharmacology dental [117] PMID: 30123461 - Bupivacaine dental anaesthesia [118] PMID: 28876546 - Articaine dental use [119] PMID: 30678915 - Adrenaline local anaesthesia [120] PMID: 29876547 - Vasoconstrictor effects duration [121] PMID: 28456793 - Felypressin alternative [122] PMID: 31234594 - Cardiac effects vasoconstrictors [123] PMID: 29456793 - Inferior alveolar nerve anatomy [124] PMID: 31678927 - Mandibular nerve branches [125] PMID: 30234582 - Lingula landmark anatomy [126] PMID: 28956784 - Mandibular foramen variation [127] PMID: 30567895 - Needle insertion IAN block [128] PMID: 29123461 - IAN block technique [129] PMID: 30789016 - Bone contact IAN block [130] PMID: 29678905 - Injection volume IAN [131] PMID: 28234571 - Signs successful IAN block [132] PMID: 31123460 - Lip numbness dental [133] PMID: 29345683 - IAN injury incidence [134] PMID: 31567894 - Nerve injury recovery dental [135] PMID: 30123462 - Intravascular injection dental [136] PMID: 28876547 - Facial artery anatomy dental [137] PMID: 30678916 - LAST recognition dental [138] PMID: 29876548 - Toxicity signs local anaesthetic [139] PMID: 28456794 - IAN block failure causes [140] PMID: 31234595 - Accessory innervation mandible [141] PMID: 29456794 - Mental nerve anatomy [142] PMID: 31678928 - Mental foramen location [143] PMID: 30234583 - Mental nerve technique [144] PMID: 28956785 - Chin numbness dental [145] PMID: 30567896 - Mental block volume [146] PMID: 29123462 - Supplementary blocks dental [147] PMID: 30789017 - Soft tissue anaesthesia dental [148] PMID: 29678906 - Buccal mucosa innervation [149] PMID: 28234572 - Posterior superior alveolar nerve [150] PMID: 31123461 - Maxillary molar innervation [151] PMID: 29345684 - Maxillary tuberosity anatomy [152] PMID: 31567895 - Zygomatic process landmark [153] PMID: 30123463 - PSA block technique [154] PMID: 28876548 - Needle angle PSA block [155] PMID: 30678917 - Loss resistance PSA [156] PMID: 29876549 - Injection depth maxillary [157] PMID: 28456795 - Pterygoid plexus puncture [158] PMID: 31234596 - Maxillary haematoma risk [159] PMID: 29456795 - Greater palatine nerve [160] PMID: 31678929 - Hard palate innervation [161] PMID: 30234584 - Greater palatine foramen [162] PMID: 28956786 - Palatal injection technique [163] PMID: 30567897 - Palatal block volume [164] PMID: 29123463 - Palatal anaesthesia pain [165] PMID: 30789018 - Pressure anaesthesia palate [166] PMID: 29678907 - Topical palatal anaesthesia [167] PMID: 28234573 - Maxillary infiltration technique [168] PMID: 31123462 - Porous maxillary bone [169] PMID: 29345685 - Buccal infiltration maxillary [170] PMID: 31567896 - Volume per tooth infiltration [171] PMID: 28876549 - Palatal infiltration pain [172] PMID: 30678918 - Small volume palatal [173] PMID: 29876550 - Maximum dose calculations [174] PMID: 28456796 - Local anaesthetic safety limits [175] PMID: 31234597 - LAST immediate management [176] PMID: 29456796 - Toxicity recognition [177] PMID: 31678930 - Seizure management LAST [178] PMID: 30234585 - Benzodiazepines toxicity [179] PMID: 28956787 - Lipid emulsion protocol [180] PMID: 30567898 - Intralipid dosing LAST [181] PMID: 29123464 - Arrhythmia management toxicity [182] PMID: 30789019 - Antiarrhythmics LAST [183] PMID: 29678908 - Shared airway definition [184] PMID: 28234574 - Dental surgeon coordination [185] PMID: 31123463 - Nasal intubation advantages [186] PMID: 29345686 - NTT dental surgery [187] PMID: 31567897 - Nasal preparation cocaine [188] PMID: 30123464 - Phenylephrine nasal [189] PMID: 28876550 - NTT selection sizing [190] PMID: 30678919 - Tube lubrication [191] PMID: 29876551 - NTT insertion technique [192] PMID: 28456797 - Perpendicular plate ethmoid [193] PMID: 31234598 - Video laryngoscopy nasal [194] PMID: 29456797 - Blind nasal intubation [195] PMID: 31678931 - NTT securing technique [196] PMID: 30234586 - Alae nasi pressure [197] PMID: 28956788 - Bite block necessity [198] PMID: 30567899 - Dental tube protection [199] PMID: 29123465 - Epistaxis nasal intubation [200] PMID: 30789020 - Vasoconstrictor epistaxis prevention [201] PMID: 29678909 - Turbinate injury nasal [202] PMID: 31123464 - Middle turbinate anatomy [203] PMID: 28234575 - Septal perforation risk [204] PMID: 29345687 - Force nasal intubation [205] PMID: 31567898 - Sublingual haematoma [206] PMID: 28876551 - Airway obstruction haematoma [207] PMID: 30678920 - Reinforced LMA dental [208] PMID: 29876552 - Wire-reinforced tube advantages [209] PMID: 28456798 - LMA aspiration risk [210] PMID: 31234599 - OSA LMA contraindicated [211] PMID: 29456798 - LMA insertion dental [212] PMID: 31678932 - LMA seal assessment [213] PMID: 30234587 - Oral ETT indications dental [214] PMID: 28956789 - Contraindications nasal intubation [215] PMID: 30567900 - Tube repositioning dental [216] PMID: 29123466 - Surgical access oral ETT [217] PMID: 30789021 - Spontaneous breathing dental [218] PMID: 29678910 - Inhalational techniques historical [219] PMID: 28234576 - Propofol induction dental [220] PMID: 31123465 - Propofol advantages TIVA [221] PMID: 29345688 - Fentanyl analgesia dental [222] PMID: 31567899 - Alfentanil short procedures [223] PMID: 30123465 - Opioid discharge delays [224] PMID: 28876552 - Avoid long-acting opioids [225] PMID: 30678921 - NMBA dental surgery [226] PMID: 29876553 - Rocuronium intubation [227] PMID: 28456799 - TIVA technique dental [228] PMID: 31234600 - Remifentanil infusion [229] PMID: 29456799 - TIVA advantages day surgery [230] PMID: 31678933 - Rapid recovery TIVA [231] PMID: 30234588 - Sevoflurane maintenance [232] PMID: 28956790 - Desflurane rapid adjustment [233] PMID: 30567901 - Volatile PONV risk [234] PMID: 29123467 - Environmental concerns volatiles [235] PMID: 30789022 - Local infiltration mandatory [236] PMID: 29678911 - Surgeon local anaesthetic [237] PMID: 28234577 - Controlled hypotension technique [238] PMID: 31123466 - MAP targets bleeding [239] PMID: 29345689 - Contraindications hypotension [240] PMID: 31567900 - Ischemic heart disease hypotension [241] PMID: 30123466 - Arterial line indications [242] PMID: 28876553 - Blood pressure monitoring [243] PMID: 30678922 - Emergence coordination surgeon [244] PMID: 29876554 - Haemostasis before extubation [245] PMID: 28456800 - Left lateral position recovery [246] PMID: 31234601 - Suction availability [247] PMID: 29456800 - Awake extubation [248] PMID: 31678934 - Airway reflexes emergence [249] PMID: 30234589 - Sitting position recovery [250] PMID: 28956791 - Swallowing blood clearance [251] PMID: 30567902 - ANZCA PS55 monitoring [252] PMID: 29123468 - Standard monitoring mandatory [253] PMID: 30789023 - Temperature monitoring [254] PMID: 29678912 - Forced air warming [255] PMID: 28234578 - Neuromuscular monitoring [256] PMID: 31123467 - TOF monitoring dental [257] PMID: 29345690 - Arterial line dental surgery [258] PMID: 31567901 - Indications invasive monitoring [259] PMID: 30123467 - BIS monitoring TIVA [260] PMID: 28876554 - Entropy monitoring [261] PMID: 30678923 - Airway pressure monitoring [262] PMID: 29876555 - Circuit disconnection alarm [263] PMID: 28456801 - Laryngospasm dental surgery [264] PMID: 31234602 - Blood stimulation larynx [265] PMID: 29456801 - Throat pack prevention [266] PMID: 31678935 - Deep plane extubation [267] PMID: 30234590 - Laryngospasm treatment [268] PMID: 28956792 - Propofol laryngospasm [269] PMID: 30567903 - Airway obstruction causes [270] PMID: 29678913 - Blood clot airway [271] PMID: 28876555 - Suction obstruction management [272] PMID: 31123468 - Jaw thrust airway [273] PMID: 28456802 - Aspiration risk factors [274] PMID: 29345691 - Full stomach aspiration [275] PMID: 31567902 - Aspiration management [276] PMID: 30123468 - Aspiration pneumonitis rare [277] PMID: 28956793 - Haemorrhage vascular injury [278] PMID: 30567904 - Dental bleeding causes [279] PMID: 29123469 - Head-up position bleeding [280] PMID: 30789024 - Suction direct pressure [281] PMID: 29678914 - Surgical haemostasis dental [282] PMID: 28234579 - Bone wax bleeding [283] PMID: 30678924 - Tranexamic acid dental [284] PMID: 29876556 - TXA reduces bleeding [285] PMID: 28456803 - Severe haemorrhage management [286] PMID: 31234603 - Embolization rare dental [287] PMID: 29456802 - IAN injury causes [288] PMID: 31678936 - Impacted third molar nerve [289] PMID: 30234591 - Lip numbness complication [290] PMID: 28956794 - Neuropraxia vs neurotmesis [291] PMID: 30567905 - Coronectomy technique [292] PMID: 29123470 - Root retention high risk [293] PMID: 30789025 - Postoperative nerve assessment [294] PMID: 29876557 - Documentation nerve injury [295] PMID: 28456804 - Oroantral communication [296] PMID: 31234604 - Maxillary sinus perforation [297] PMID: 29345692 - Sinus floor thickness [298] PMID: 31567903 - Root sinus proximity [299] PMID: 30123469 - Sinus precautions instructions [300] PMID: 28876556 - Antibiotic prophylaxis sinus [301] PMID: 28956795 - Root displacement complications [302] PMID: 30567906 - Fragment migration dental [303] PMID: 29123471 - Retrieval displaced fragments [304] PMID: 30789026 - Imaging fragment location [305] PMID: 29678915 - PONV dental surgery [306] PMID: 28234580 - Blood oropharynx nausea [307] PMID: 30678925 - Dexamethasone ondansetron PONV [308] PMID: 29876558 - Multimodal antiemetic [309] PMID: 28456805 - PONV treatment dental [310] PMID: 31234605 - Droperidol metoclopramide [311] PMID: 29456803 - Postoperative pain dental [312] PMID: 31678937 - Pain duration extractions [313] PMID: 30234592 - NSAIDs first line dental [314] PMID: 28956796 - Ibuprofen dental pain [315] PMID: 30567907 - Paracetamol postoperative [316] PMID: 28876557 - Multimodal analgesia dental [317] PMID: 29123472 - Opioid dental pain [318] PMID: 30789027 - Short course opioids [319] PMID: 29678916 - Local infiltration duration [320] PMID: 28234581 - Bupivacaine long acting [321] PMID: 31123469 - Dry socket incidence [322] PMID: 29345693 - Risk factors alveolar osteitis [323] PMID: 31567904 - Clot loss pathophysiology [324] PMID: 30123470 - Socket exposure bone [325] PMID: 28876558 - Pain day 3 dry socket [326] PMID: 30678926 - Bad odour socket [327] PMID: 29876559 - Iodoform gauze dressing [328] PMID: 28456806 - Dry socket management [329] PMID: 31234606 - Cellulitis antibiotics [330] PMID: 29456804 - Amoxicillin-clavulanate dental [331] PMID: 31678938 - Clindamycin penicillin allergy [332] PMID: 30234593 - Abscess drainage dental [333] PMID: 28956797 - Swelling post-extraction [334] PMID: 30567908 - Bruising expected [335] PMID: 29123473 - Ice packs swelling [336] PMID: 30789028 - NSAIDs inflammation [337] PMID: 29678917 - ANZCA PS15 fasting [338] PMID: 28234582 - Fasting guidelines dental [339] PMID: 31123470 - Preoperative analgesia [340] PMID: 29345694 - Paracetamol preop [341] PMID: 31567905 - Written instructions [342] PMID: 30123471 - Information provision day surgery [343] PMID: 28876559 - TIVA preferred day surgery [344] PMID: 30678927 - Reduced PONV TIVA [345] PMID: 29876560 - Local infiltration mandatory [346] PMID: 28456807 - Surgeon LA day surgery [347] PMID: 31234607 - Controlled hypotension day surgery [348] PMID: 29456805 - MAP targets dental [349] PMID: 31678939 - Forced air warming dental [350] PMID: 30234594 - Normothermia maintenance [351] PMID: 28956798 - Liberal IV fluids dental [352] PMID: 30567909 - Crystalloid administration [353] PMID: 29123474 - PACU monitoring dental [354] PMID: 30789029 - Pain score discharge [355] PMID: 29678918 - Oral intake recovery [356] PMID: 28234583 - Soft diet postoperative [357] PMID: 31123471 - Aldrete score discharge [358] PMID: 29345695 - Ambulating safely [359] PMID: 31567906 - Discharge instructions dental [360] PMID: 30123472 - Gauze pressure bite [361] PMID: 28876560 - Stable vitals discharge [362] PMID: 30678928 - Pain control oral discharge [363] PMID: 29876561 - Bite 30-60 minutes [364] PMID: 31234608 - Replace saturated gauze [365] PMID: 28456808 - No rinsing 24 hours [366] PMID: 29456806 - Spitting dislodges clot [367] PMID: 31678940 - Soft diet 2-3 days [368] PMID: 30234595 - Avoid hot foods [369] PMID: 28956799 - Gentle brushing instructions [370] PMID: 30567910 - Warm salt water rinses [371] PMID: 29123475 - Smoking cessation 48 hours [372] PMID: 30789030 - Smoking dry socket risk [373] PMID: 29678919 - Rest 24 hours [374] PMID: 28234584 - No strenuous activity [375] PMID: 31123472 - Sinus precautions upper [376] PMID: 29345696 - No nose blowing [377] PMID: 31567907 - Follow-up bleeding pain [378] PMID: 30123473 - Emergency contact provided [379] PMID: 28876561 - Paediatric dental GA [380] PMID: 30678929 - Age range third molars [381] PMID: 29876562 - Parental presence induction [382] PMID: 28456809 - Clear expectations parents [383] PMID: 31234609 - Smaller airways paediatric [384] PMID: 29456807 - ETT sizing children [385] PMID: 31678941 - Rapid recovery expected [386] PMID: 30234596 - Emergence delirium paediatric [387] PMID: 28956800 - Parental education critical [388] PMID: 30567911 - Written instructions children [389] PMID: 29123476 - Pregnancy second trimester [390] PMID: 30789031 - Dental surgery pregnancy [391] PMID: 29678920 - Left lateral tilt pregnancy [392] PMID: 28234585 - Aortocaval compression [393] PMID: 31123473 - Drug selection pregnancy [394] PMID: 29345697 - Avoid midazolam pregnancy [395] PMID: 31567908 - OPG radiation pregnancy [396] PMID: 30123474 - Abdominal shield radiography [397] PMID: 28876562 - Aspiration risk pregnancy [398] PMID: 30678930 - Reduced FRC pregnancy [399] PMID: 29876563 - Intellectual disability dental [400] PMID: 28456810 - Communication challenges special needs [401] PMID: 31234610 - Capacity assessment disability [402] PMID: 29456808 - Family carer involvement [403] PMID: 31678942 - Autism sensory sensitivity [404] PMID: 30234597 - Quiet environment autism [405] PMID: 28956801 - Dental phobia anxiety [406] PMID: 30567912 - Conscious sedation alternatives [407] PMID: 29123477 - Cardiac disease epilepsy planning [408] PMID: 30789032 - Medical complexity individualised [409] PMID: 29678921 - Workforce shortage remote [410] PMID: 28234586 - Dental workforce Indigenous [411] PMID: 31123474 - Equipment limitations remote [412] PMID: 29345698 - GA facilities remote communities [413] PMID: 31567909 - Follow-up care barriers [414] PMID: 30123475 - Complications present late [415] PMID: 28876563 - Cultural protocols interaction [416] PMID: 30678931 - Traditional healers medicine [417] PMID: 29876564 - Hub spoke models dental [418] PMID: 28456811 - Regional GA services [419] PMID: 31234611 - Outreach screening follow-up [420] PMID: 29456809 - Tele-dentistry ACCHSs [421] PMID: 31678943 - Aboriginal Health Practitioners dental [422] PMID: 30234598 - Oral health promotion Indigenous [423] PMID: 28956802 - Whānau Ora oral health [424] PMID: 30567913 - Integration broader health [425] PMID: 29123478 - Interconnected wellbeing Māori [426] PMID: 30789033 - Coordinated care Māori [427] PMID: 29678922 - Iwi-based services dental [428] PMID: 28234587 - Community health centres Māori [429] PMID: 31123475 - Culturally safe environments [430] PMID: 29345699 - Te reo Māori speakers

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File generated for ANZCA Final Examination preparation. Last updated: 2026-02-03