General anaesthesia in special care dentistry: Part 3. case series

Case 1: the unsuccessful sedation case

A 35-year-old patient with Angelman's syndrome, well-controlled epilepsy, and severe learning disability was referred by her general medical practitioner to the special care dental service as she had not had a dental examination for several years. She attended with her mother, who reported progressive discolouration of her maxillary right central incisor. The patient had sustained several falls over the years related to epileptic seizures. The patient was non-verbal and could not reliably communicate pain to her family or carers in her supported-living accommodation. Her medications included lorazepam, clonazepam, paracetamol, cetirizine and desogestrel. She had no known drug allergies. The patient last had a general anaesthetic as a child for a dental examination and restorations.

Owing to behaviours which challenge, it was not possible to undertake any level of examination or radiographs for the patient. The treating dentist, parents and a key support worker undertook a best-interest meeting. A decision was made to undertake a full dental examination and carry out treatment as required under intravenous sedation with pre-medication and low-level clinical holding.

At the patient's sedation appointment, the patient was administered 10 mg of intranasal midazolam via a mucosal atomization device. After 10 minutes, the patient appeared more relaxed, but was still very resistant to cannulation, so a further 10 mg of intranasal midazolam was administered. After 5 minutes, the patient was more relaxed and successfully cannulated. After titration of 3 mg midazolam, the patient was still resistant to dental examination, and owing to head movements, it was only possible to undertake a simple examination with a mirror. It was noted that tooth UR1 had a dull yellow discolouration, but there was no mobility or sinus tract. The LR8 was mesio-angularly impacted with evidence of food-trapping, caries and gingival inflammation. The UL6 and LR6 had large amalgam restorations. Radiographic examination was not possible under sedation, and treatment was indicated due to suspected caries on the LR8. It was not safe to undertake the treatment needed under IV sedation on this visit. The treatment modalities were re-discussed with the patient's family and care team, and a best-interest decision made to manage her dental care under general anaesthesia. The patient's general practitioner was informed who requested opportunistic blood tests to be undertaken under GA as part of her annual health checks.

On the day of the procedure, the patient presented with her mother and two support workers in a private waiting area. The anaesthetist made a decision to try a higher dose of oral midazolam instead of intra-nasal midazolam and 35 mg oral midazolam was administered covertly in a cup mixed with fruit concentrate. A Starlight sensory toy box was used as distraction during the wait for her pre-medication to work. She accepted cannulation with her mother's support, low-level clinical holding, and music therapy, and the patient was anaesthetized. Clinical and radiographic examination found no peri-apical pathology associated with the UR1, deep distal caries in tooth LR7 secondary to a mesio-angularly impacted LR8, which also showed signs of occlusal caries (Figure 1). Following a discussion between the two treating clinicians, treatment included professional full-mouth scaling, removal of teeth LR7 and LR8, packing of sockets and suturing, and fluoride varnish application. Once completed, the patient was extubated and recovered in a side room in the recovery area with her mother and support workers present.

Case 2: patient with behaviours which challenge

A non-verbal 25-year-old male with severe learning disability, attention deficit hyperactivity disorder (ADHD), autistic spectrum disorder and care-resistant behaviours was referred to a dental hospital for care. Born abroad, he had moved to the UK at the age of 9 years with his mother who was his main carer. A funded care package included daily two-to-one support from carers, although he struggled to remain in education or attend a day centre owing to his behaviours.

His mother reported a progression of self-injurious behaviours (SIB). It was suspected that these had a dental origin because he had started hitting his mouth over the previous 3–4 months. He had been refusing toothbrushing and stopped eating harder foods. A comprehensive dental examination had not been possible.

At the clinic, he had refused to sit down and had been pacing, presenting with hyperactivity, poor attention span, property damage risk and physical aggression towards self (slapping face, hitting head) and others (throwing of objects, kicking, hitting and scratching). He had thickened skin on his face and hand from self-injurious slapping and biting. He also showed some stimming behaviours, including rocking, flapping and interlocking of legs. Medications included carbamazepine and risperidone, which had limited effects on his behaviours. To aid sleeping, the patient was prescribed melatonin by his doctor along with lorazepam to manage anxiety as required. It was reported that sensory overload and changes in routines would upset him.

His mother also requested investigations to rule out ear and eye problems. He was also due for a physical health check that was impossible to carry out without pharmacological intervention. He had not had a blood test since 2017, and there had been concern around the side effects of medications and his weight gain while on risperidone.

In view of his behaviour limiting the suitability of delivering treatment with sedation or local anaesthesia, and his multidisciplinary treatment needs, treatment under a single visit general anaesthesia was proposed. A best-interest meeting was held between dental consultants, ophthalmology lead, anaesthetic consultant, general medical practitioner (GP), the learning disability team and the family as part of his multidisciplinary team (MDT) planning. General anaesthesia was justified on the basis that sedation was unlikely to work, and multiple surgical specialities had the potential to work together to provide holistic care under one episode of GA. An acclimatization visit to the theatre waiting area and preparation of the patient using a story board were attempted.

On the day of the operation, a side room was organized for the patient in admission and recovery. A learning disability nurse who had previously met the patient and the family attended and kept the patient company throughout the wait for his pre-medication to work, as well as during induction. He had 20 mg oral midazolam and 300 μg clonidine as pre-medications, but was not sufficiently sedated, so a further 300 mg oral ketamine was given. Gas induction was carried out with clinical holding, and a nasal endotracheal tube and throat pack were placed following induction. Dental, ear and ophthalmology assessments were carried out, as well as blood tests and an echocardiogram (ECG) to facilitate his annual health check.

Eye examination (Figure 2) revealed dry eyes, a short-sighted right eye and an incidental finding of an inoperable retinal detachment in his left eye with a brunescent, hypermature cataract and no fundal view. Examination of the ear canals (Figure 3) showed bilateral impaction with ear wax and redness around the tympanic membrane. Micro-suction removal of the ear wax was carried out under microscope. The tympanic membrane was intact.

Dental examination showed a few carious lesions, poor oral hygiene with generalized soft and hard deposits, but minimal bone loss as confirmed by radiographs (Figure 4). There was generalized gingivitis and anterior recession as a result of calculus.

His dental diagnoses included fissure caries LR8, buccal caries into dentine LL68 and generalized gingivitis. Restorations of the LL6 and LL8 teeth, full mouth scaling and topical fluoride varnish were carried out.

Recovery was uneventful and the patient was discharged on the same day. Eye drops were recommended to maintain comfort and health of his eyes although these may not have been possible to administer owing to his care-resistant behaviours.

Case 3: patient requiring multidisciplinary care

A 28-year-old male with a severe learning disability was referred to the special care dental department by his GP to rule out a dental source of pain and infection due to new-onset severe self-injurious behaviour. The patient was also under the care of a community psychiatrist who advised the GP to refer him for a dental opinion.

The patient had a diagnosis of autistic spectrum disorder, severe learning disability with a history of self-harm and attention-deficit-hyperactivity disorder. He had no allergies, and his medications included lorazepam, loperamide, citalopram, clonazepam, cetirizine, cholecalciferol and melatonin. He was non-verbal and his parents reported that he frequently thumped his head against his knees. He had sustained several fractures to his mandible, orbit and nasal bones as a result of self-injurious behaviours that had been managed conservatively following a CT scan of his facial bones under GA 3 years previously. He wore a protective helmet to minimize injuries. There were no concerns over changes in eating or sleeping habits; however, the patient did have episodes of facial swelling for which the aetiology was unclear.

He did not have a regular dentist and did not cope well with dental reviews. It had been 8 years since his previous dental examination and treatment had been carried out under general anaesthesia. He did not like the assistance of others when brushing his teeth and he had a very high-sugar diet, consuming chocolate daily. He was frequently visited by his parents and had one-to-one support in his supported living facility with three-to-one support when out of home.

Before the appointment, the learning disability nurse contacted the dental team to advise that his behaviours could escalate if he was kept waiting and that he would have three carers supporting him to his appointment. He was assigned a quiet area on arrival to minimize waiting time around other people.

Clinical examination was not possible because he was pacing across the dental surgery and could not cope with sitting down for a brief assessment. A diffuse swelling around his right mandibular region was noted. He did not cope with either an intra-oral or panoramic radiograph. It was not possible to rule out a dental cause without pharmacological intervention.

A mental capacity assessment concluded that he did not have capacity to consent for dental intervention with pharmacological support. A best-interest meeting was arranged, which included his family, two of his support workers, the care home manager, his GP, his psychiatrist and two special care dentists. The background, indications and treatment plan were outlined. The different treatment options and modalities were discussed (inhalation sedation, intravenous sedation and general anaeasthesia, with and without a pre-medication) including the option of no treatment. It was unanimously agreed that an examination under general anaesthesia facilitated by a pre-medication and clinical holding was in his best interest with a view to complete any necessary treatment. Additionally, the GP requested blood tests and an ECG as part of the patient's annual health check, along with flu and COVID booster vaccinations. His psychiatrist requested an MRI to investigate the presence of any long-term brain injury secondary to his behaviours which challenge.

In order to plan his care safely and effectively, several members of hospital staff were contacted. The occupational health nurse was prepared to source and administer the vaccines. The anaesthetic and recovery team were informed of the patient's behaviour as well as the need for blood tests and an ECG.

After completing a risk assessment for an MRI with the anaesthetist and imaging team, reasonable adjustments were arranged for this procedure to be completed concurrently under GA (including ensuring that the mobile GA equipment had no magnetic metal components). Adequate time was allocated (in collaboration with the anaesthetic, dental nursing and reception team) and a date for the procedure was confirmed with all the relevant people.

The patient presented on the morning of his treatment with two of his support workers and his mother, having fasted for 6 hours prior and having taken his regular medication with some water. He was escorted to a private waiting area to avoid overstimulation from other patients. After the necessary checks were completed, he was covertly given oral midazolam diluted with some clear juice through his family, but spat out the contents. Intranasal midazolam (20 mg of 40 mg/ml) was then administered with clinical holding. The nasal dose was higher than usual as lower doses had not been effective when he was anesthetized on previous occasions. After 10 minutes, the patient was relaxed enough to sit on the operating bed and was cannulated with two-person clinical holding. Intravenous induction of anaesthesia was administered, and a nasal tube was inserted.

Clinical and radiographic assessment revealed chronic apical periodontitis on tooth LR6 secondary to caries, and periodontal disease secondary to poor oral hygiene (Figure 5). Debridement of his teeth was completed, as well as removal of LR6, packing and suturing of socket, and fluoride varnish application. An ECG and blood tests were performed concurrently, which were found to be normal. The anaesthetic team modified their set-up into a mobile GA unit and facilitated the patient's transfer to the radiography department for an MRI (Figures 6 and 7). Once completed, he returned to theatre and was extubated. He recovered in a side room in recovery with his carers present.

Case 4: patient with complex medical history

A 33-year-old male patient with autistic spectrum disorder, anxiety, depression and obesity (body mass index (BMI) 60 kg/m2, weight 250 kg and height 205 cm) presented to the community dental service through a referral from his general dental practitioner requesting treatment with sedation. There had been a history of multiple dental abscesses treated with antibiotics, and the patient had refused all dental treatment prior to this. He had successfully been treated with IV sedation in the community dental service 10 years prior; however, he had since gained a significant amount of weight and had been diagnosed with severe sleep apnoea. As a result, the patient had started using a CPAP (continuous positive airway pressure) machine at night.

In view of his high BMI, a clinic appointment was arranged using a bariatric chair. The need for multiple dental extractions and restorations was identified at the assessment appointment (Figure 8). Alternative options of anxiety management were discussed, such as inhalation sedation and psychological support. This patient was not suitable for IV sedation as an outpatient in primary care owing to the increased airway risks, ASA 3 status and multiple items of treatment required.⁴ As a result of his level of dental anxiety and treatment needs, treatment under general anaesthesia was agreed, and an anaesthetic assessment was arranged with a consultant anaesthetist. The outcomes of the anaesthetic assessment included the requirement for an inpatient overnight bed with bariatric facilities, and two senior anaesthetists to be assigned to the operating list with specific airway support available.

An awake fibre-optic nasal intubation was recommended⁵ owing to the anticipated difficult airway; however, the patient did not consent to this. He felt he would be unable to tolerate this and although there were increased anaesthetic risks with intubation, an IV induction was agreed upon. There was additional theatre equipment required for this case (Figure 9); these included venous access imaging due to difficult venepuncture and the Oxford help pillow for better airway positioning for the bariatric patient.

CPAP was advised for the initial recovery period⁵ and the patient brought his own machine. A hover mat was used to transfer the patient from the operating table to the recovery bed. During the initial stages of the anaesthetic induction, the ventilation pressures were low and the patient was positioned and treated semi-supine to aid ventilation.

Both the operator and the assistant required steps due to the height and positioning of the patient. Dental examination showed poor oral hygiene with generalized soft and hard deposits. Comprehensive dental treatment was provided that included extraction of LR67, UR46 and UL6, packing and suturing of sockets, restoration of UR5 and scaling. The LR6 required surgical removal.

Despite considerations and adaptations in anaesthesia provision, patients with obesity may experience prolonged recovery, and are at greater risk of peri-operative complications, such as venous thromboembolism (VTE) and cardiorespiratory compromise.^6,7 In this case, the patient was monitored overnight as an inpatient with his CPAP machine, and was discharged home the next day.

Case 5: the older patient

A 68-year-old autistic female patient with severe learning disability, bipolar disorder, dysphagia and atrial fibrillation presented to the community dental service via a referral from her general medical practitioner. Her carers were concerned that she was struggling to eat and was resisting tooth brushing, which was a change in her behaviours. Her medications included olanzapine, bisoprolol, sodium valproate, vitamin D and cetirizine. She was moderately frail and highly dependent on others for activities of daily living, but could self-transfer from a wheelchair.

Co-operation with dental examination was limited due to compliance; however, on visual examination, there was evidence of generalized advanced periodontal disease and carious retained roots. Her dental condition could have been contributing to decreased oral intake and aversion to oral care. Treatment options included active monitoring or dental intervention that would require sedation or general anaesthesia. A mental capacity assessment was undertaken, and the patient was assessed to lack capacity for dental treatment. A best-interest meeting was arranged with the patient's next of kin, who held lasting power of attorney for health and wellbeing, and the care home manager where the patient resided. All agreed that dental examination and treatment under GA would be in the patient's best interests due to her dysphagia and anticipated treatment needs. It was explained that treatment would depend on clinical and radiographic findings, and that there was a strong possibility that removal of all the remaining teeth would be required.

An anaesthetic assessment was arranged with a consultant anaesthetist, who was able to review the results of a recent ECG; there was a 60–65% left ventricle ejection fraction and good systolic function. The patient was deemed suitable for treatment as a day case with routine IV induction and nasal tube intubation. The patient was planned to be first on the list and assigned to a side room.

Under general anaesthesia, dental examination and peri-apical radiographs of the remaining teeth showed advanced bone loss and generalized caries (Figure 10). All teeth were grade 2–3 mobile. The remaining dentition was deemed to have poor prognosis. The two special care dentists providing the treatment considered whether any teeth could be restored or maintained to an acceptable standard, however, it was agreed that a full dental clearance would be in the patient's best interests to prevent pain and infection, and to avoid a repeat general anaesthesia. Increasing age would most likely result in increasing comorbidities for further treatment under anaesthesia. The patient was discharged home the same day with emphasis on pre-emptive pain control advice to the carer, as well as close monitoring of fluid intake.

Discussion

Patients undergoing a general anaesthetic on the special care dental list may be patients with unpredictable behaviours which challenge owing to autistic spectrum disorder and learning disability, patients with complex medical issues or patients with severe phobia or a combination of the above. Each of these conditions requires careful assessment and consideration when deciding on the best treatment modality for the patient (Table 1). Where possible, patients should be optimized, and elective procedures postponed until it is safer for patients. Conditions such as obesity have significant dental, physiological and psychosocial impacts, as well as impacting on many aspects of anaesthesia. A dedicated society for bariatric anaesthetics makes recommendations to improve the safety of anaesthesia for patients with obesity.⁵

Some special care patients always require a general anaesthetic in hospital because their condition renders safe delivery of care difficult by any other means (Figure 11) after the less invasive options, such as psychological support, local anaesthesia and sedation, have been considered.² In some areas, GA is only offered to these patients when obvious dental disease is present, whereas in other locations, patients can have a routine examination with X-rays under general anaesthetic as part of their oral care programme.⁸ Although GA may be more resource intensive than sedation, treatment completion under sedation may require more visits, which can be distressing for patients and their caregivers, hence GA should be considered for extensive or complex treatment in multiple quadrants, especially when the social situation is complex.⁹ Older or frail patients are less likely to be offered GA because they are at a greater risk of morbidity and mortality during pharmacological intervention due to reduced physiological reserve, increased pharmacodynamic sensitivity and risk of post-operative cognitive decline.^10,11 In all cases, the benefits of having a GA need to be carefully balanced against the risks, with a comprehensive consent or best-interest decision process in place. It is also best practice to avoid the need for a repeat general anaesthesia in the near future so that treatments provided by this approach ideally should be predictable and definitive.¹¹ Dental clearance is sometimes indicated as a result (such as in Case 5); after which the post-operative pain could potentially impact on function, including swallowing and eating. These can lead to serious consequences, such as dehydration and weight loss, hence early input from the speech and language (SLT), or dietitian team may be useful. It would also be helpful to prepare the carers or family if dental clearance is likely for two reasons: for a post-operative care package to be in place; and to address the potential emotional impact of tooth loss on the patient and those who care for them.

In this case series, all patients had obvious dental treatment needs or dental concerns identified that justified the GA. Four of the five patients lacked capacity, and the decision to provide dental treatment under general anaesthetic was made in their best interests, considering patient factors, extent of treatment needs, previous history of pharmacological support, and family preference (because they are the people who know the patient best and how the patient would cope during and after the procedure). A general anaesthetic mitigated the risks of intravenous sedation through intubation,⁷ which provided a secure and safe airway in Cases 4 and 5.

In all these cases, reasonable adjustments had been carried out to make the process as comfortable and stress free as possible for the patients and their carers.¹² It is often good practice to allocate special care patients to a side room in admission and in recovery to avoid overstimulation and to minimize distress to patients and other service users. Special care patients should also not be kept waiting for too long to prevent distress from developing or escalating. If this is not possible, distraction with music, iPads or games should be considered. Help from the learning disability nurse team can be enlisted because the team is well equipped and experienced in managing the emotional needs of this group of patients and their families. As discussed in Part 1 of this series, a look-around visit or story board could also help prepare the patient for their first GA appointment. For female patients, the ward nurses will have been informed to not insist on a pregnancy test where patients are non-compliant. Family members or carers are allowed into the anaesthetic room and are called to recovery as soon as patients are waking up to ensure patients have familiar faces present when they are going to sleep and when they are waking up. Patients are allowed to wear their own clothes instead of having to change into hospital gowns.

Most dental GA is planned as a day-case surgery, but in some exceptional medically complex cases, there is contingency planning in place for an overnight bed and handover to other teams with overnight cover, such as the maxillofacial surgery team. As part of reasonable adjustments, discharge of an agitated or distressed patient should not be delayed for the patient to meet the usual discharge criteria of having eaten, drunk and passed urine, as long as the anaesthetic and dental team have been informed.^13,14

A multidisciplinary team approach should be organized where possible to optimize the patient's general anaesthetic care episode,¹³ to pre-empt and reduce the need for a repeat general anaesthetic in close succession, and to promote a holistic care approach to patient management. Often, patients who lack capacity have carers or family who advocate for them. As part of the assessment and treatment planning appointment, they are consulted regarding any outstanding or pending health investigations the patient needs. The special care dental team is well placed to work with other medical and surgical specialties so that other planned procedures can be ‘piggybacked’ on to the dental list under one general anaesthetic.⁸ This should always be considered in hospitals where there are multiple specialties working under the same roof – and provided that linking with other procedures does not unduly delay the dental treatment. Types of procedures commonly facilitated by the special care dentistry team in the authors' experience range from ophthalmology assessment, gynaecological examination, endoscopy, biopsy, ear nose and throat assessment, audiology assessment, podiatry, radiographic assessment, PEG change to nail clipping and haircut. Cases 2 and 3 are examples of where an MDT approach worked very well and contributed to patients' general health outcomes. A routine blood test taken at the same time as dental treatment under GA is a useful, reasonable adjustment for people that may otherwise find it difficult to cope with blood tests for their annual health check.^11,14 It also helps to monitor side effects of medications, such as anti-psychotics. Such approach to patient-centred care under GA reduces inequality in this vulnerable group of patients and reduces distress caused by complex behaviours in the outpatient setting.¹⁵ It also helps to save resources and costs when there may potentially be multiple appointment attempts. However, MDT planning can be time-consuming to co-ordinate and resource intensive to organize for the dental team. A close working relationship with contacts in different teams helps to facilitate the process. Incidental findings, such as visual impairment in Case 2, show the added value of MDT in dental general anaesthetic. In Case 2, it helped to explain the patient's behaviours of squinting and covering one eye and guided future management and treatment to improve patient's quality of life.

Sedative pre-medication is essential for achieving co-operation for induction in the most challenging group of special care patients, but the acceptance and response to pre-medication can be unpredictable. The practice and protocol of pre-medication vary across sites/trusts and are dependent on anaesthetist's preference, patient factors and drug availability. Previous GA history provides useful information for reference, but recent changes in medication, general health and behaviour history should be considered in determining the choice, dose and route of pre-medication. Oral midazolam or clonidine, or a combination, is commonly given disguised in juice or given in a syringe to a willing patient. An alternative is intranasal midazolam or intramuscular ketamine. Both of these can be traumatizing to the patient and require a risk assessment before administration. Despite the use of pre-medication as a chemical restraint, the additional judicial use of physical restraint (clinical holding) may be necessary to keep the patient and the team safe during induction.^16,17 Clinical holding may be categorized according to level of intervention, number of people involved or site of hold. The use of clinical holding should be documented, including the justification and details of the process.

All cases described here were compliant with the latest BSSCD clinical guideline on the use of general anaesthetic in special care dentistry.¹³ Basic periodontal examination was recorded as part of comprehensive dental assessment and radiographs were taken under GA and reported on, and were then used to guide treatment decisions. The intra-operative use of digital radiography for anaesthetized patients has revolutionized diagnostic imaging under GA by enhancing efficiency and quality; however, challenges remain in cases of narrow arch, dental crowding, restricted mouth opening or when nasal intubation is not feasible due to the rigidity of the digital X-ray plate, the minimum film size and the presence of a throat pack. Treatment planning in special care dentistry where the patients lack capacity involves two experienced members of the special care dental team discussing findings and making decisions in a patient's best interest. Where unexpected findings are encountered, one of the clinicians may liaise with a relevant specialist or have a best-interest discussion with the family or carer, while the other continues to provide care; however, this must be weighed up against the availability of resources and the risk of prolonging the patient's anaesthetic time. It is not common to provide advanced dentistry for special care patients under GA owing to the risk of complications and difficulty with maintenance afterwards. The risk of using local anaesthetic under GA on special care patients is similar to that for paediatric patients, with conflicting views on its advantages and disadvantages.¹⁸ However, in all these cases, across three trusts, routinely used local anaesthetic lidocaine and articaine were used for haemostatic and pain control purposes when extractions were carried out, and carers were advised to monitor for lip and cheek biting post-operatively. It is routine practice to place resorbable suture over extraction sockets to aid haemostasis because special care patients often lack the compliance to bite down on gauze or the co-operation for suturing when they are awake. It is advisable for carers to administer regular analgesics to patients for the first 3–5 days post-extraction, and to modify the patient's diet to soft food only.

Many hospital trusts have started incorporating team huddle and debrief into their WHO surgical checklist routine, which provides an opportunity for the whole team to come together to reflect and share their thoughts on what went well and what could be improved or carried out differently.¹⁹ This helps to promote safety culture, enhance teamworking and improve patient experience and quality of care. It is recommended practice for patients to be followed up the next day or a few days following their general anaesthetic admission. This also allows carers or family members to ask questions and discuss any concerns they may have. Reports from any investigations carried out under general anaesthetic to support the wider team should be sent to the respective requesting clinician, and a copy should be attached for the GMP. Following completion of comprehensive care under general anaesthetic, patients are discharged back to the care of their dental referrer in primary care; in the case where patient was referred from their GP, a new referral to the local community dental service was completed to ensure follow up and continuation of care, as well as for reinforcement of preventive advice.

Summary

The case series shows that patient needs are individual and complex. The series also shows the importance of reasonable adjustments to facilitate care and to break down barriers and support an individual patient's journey to achieve optimal oral and general health.²⁰ The general concepts and considerations in preparation and execution of each case are similar across different hospital settings, prioritizing safety, efficiency and person-centred care. A general anaesthetic provision in special care dentistry aims to address any clinical concerns or suspicions, stabilize the dentition and reduce disease burden, while providing holistic care and ease the patient's journey as much as possible. While the last may not always be possible in special care dentistry, a co-ordinated team-based approach is crucial for a successful general anaesthetic outcome and a positive experience for the patient.