This is the second post in a four part series about Autism and Dental Surgery. Please check out Part 1 – Getting Started for more information about preparing for dental surgery and resource links. This is helpful information for any child, but especially helpful if you have a child with autism.
In this post, I’m going to discuss (some of) the specific medications used during dental surgery. Please note that this is for informational purposes only. I thought it would be helpful to share what I decided was right for my son Christopher, who has severe autism, when he needed dental surgery. This should in no way be taken as medical advice or replace the advice of your doctor/dentist. Every child is different and just because my child is sensitive to a medication does not mean your child will be.
It is possible that your dentist will suggest an antibiotic be taken prior to surgery. Many children with autism do not do well on antibiotics. Most of them have disrupted intestinal flora, which antibiotics exacerbate. Given the side effects and there being little evidence of the effectiveness of prophylactic antibiotic therapy, you may opt not to give antibiotics preventatively. We chose to use Colloidal Silver, which is a potent natural antibacterial agent, for a few days prior to surgery.
Just as it is very important to make sure you and your child’s dentist are on the same page, it is equally important to speak with the anesthesiologist prior to the surgery. The best thing to do is to explain your child’s issues and your concerns, and ask to know everything the anesthesiologist plans to use. Make sure to let the anesthesiologist know all of your child’s allergies and sensitivities, even if you’ve already told the dentist and the hospital. For example, my son has a B-12 deficiency, mitochondrial disorder, and multiple food allergies.
Typically for children with autism, the process begins with the child being sedated with a gas mask and then an IV is inserted. The anesthesia and other medication is administered through the IV and sedation is maintained through the gas mask. The anesthesia is typically delivered at a high flow rate. You can discuss the possibility of lowering the flow rate to low or minimal, which can prevent heat loss during the procedure and shivering after surgery. If your child is used to IVs from frequent IV medication or blood draws, you also can discuss the possibility of starting the IV without using anesthetic gas to induce the anesthesia.
When I was researching this, the most comprehensive information I found was provided by Sym C. Rankin, RN, CRNA so I would definitely recommend reviewing her article Anesthesia and the Autistic Child.
Below is not an exhaustive list, but includes medications that the anesthesiologist will typically be using.
This is given to the child, typically orally, shortly before surgery. This might be Versed (or Midazolam). It is important that you ask how this will be given. We initially okayed this with the anesthesiologist because it is not heavily metabolized. I had a lot of new information and this was our first experience with dental surgery, so I just assumed this was put in the IV. However, when we got to the hospital, this was handed to us in a red drink. I explained that his chart clearly said he could not have corn (I’m sure it was loaded with corn syrup) or red dye. The nurse who brought it kept saying, “But you okayed this medication.” Luckily another nurse stepped in and helped us out.
This is a very important issue to discuss. While less anesthesiologists are using nitrous oxide, many still use it in combination with other gases. Nitrous oxide can be problematic for children with autism and patients with MTHFR gene polymorphisms (which are common in individuals with autism). In very simple non-scientific terms, nitrous messes with the enzymes in the methylation cycle, and B12 and folate get all screwed up (and our kids typically already have methylation issues). If you want documentation to back you up, here is a good article from the New England Journal of Medicine. Better safe than sorry!
Ketamine is sometimes given because it’s easy to use and can be administered in many different ways. But it is a hallucinogenic, so I wanted to make sure that Christopher would not be having this.
Sevoflurane is probably the safest choice for our kids. It has a low solubility so it doesn’t stay in the body very long and it is not heavily metabolized. This is what we used – and NOT in combination with any other anesthetic gas.
Analgesics are pain-killers and both narcotic and non-narcotic analgesics may be put in the IV.
Narcotic analgesics are opiates which work by binding to opioid receptors and block pain signals from the brain. These would include Fentanyl, Morphine, and Dilaudid. In my initial conversation with the anesthesiologist, I told her that I didn’t want to use any narcotics. She insisted that she would reserve the right to administer narcotic pain relief if she thought it was necessary. I was very concerned this – and it ended up not happening – but decided that if it was absolutely necessary, it would have to be Fentanyl because that is short-acting and only a small percent is metabolized.
Non – Narcotic Analgesics
Non-Narcotic Analgesics are anti-inflammatories that work in the body (instead of the brain) and affect the chemicals at the site of the pain. Typically, Acetaminphen is given, but this is not a good choice for children with autism because it depletes glutathione (which most are already low in). The only IV pain medication that I did allow was Toradol (or Acular or Ketarolac), which does have side effects. But, I didn’t want him not to have any pain relief at all (I don’t think the anesthesiologist would have agreed with that anyway) and this seemed to be the safest choice.
An amnestic agent might be used during the surgery to maintain sedation. This is usually Propofol (or Diprivan). If your child has mitochondrial issues, s/he won’t be able to break down the phospholipids in Propofol. It will be important to let the anesthesiologist know this, allowing a better understanding of why you won’t want to use this. Propofol also contains eggs and soybean oil (which is important if you child has food allergies).
Other Medications and Considerations
None of the following were used during our surgery, but these are commonly given during surgery so they should be considered and discussed with the anesthesiologist as well.
A muscle relaxant like Rocuronium might be used to keep the body still during surgery. We requested not to use this – it increases the heart rate and my son has a heart murmur.
An anti-nausea medicine like Zofran, which works by blocking serotonin, might also be administered. This medicine may contain inactive ingredients that can be problematic for children with allergies, so we requested not to use this either.
This is a solution that is sometimes put in the IV to replace fluid. It contains lactate, which my son can’t have because of his dairy allergy. When I asked the anesthesiologist for the list of medications she planned to use, this was not on the list. But I wanted to discuss it anyway just to make sure that only saline would be used for fluid replacement.
To sum it up, the meds we agreed to were Versed (but not in a red corn-syrupy drink), Sevoflurane, Toradol, and Fentanyl (only if completely necessary). We ended up only using Sevoflurane and Toradol in the IV.
Your dentist may recommend pain medication following surgery. I opted to try to use homeopathy only for Christopher’s post -op recovery, which I will cover in the next segment – What to Expect the Day of Surgery. Also, please check out the final post in this series, Follow-Up Prevention and Care.