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COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY

Year 2023, Volume: 32 Issue: Ek Sayı, 1 - 7, 25.12.2023
https://doi.org/10.34108/eujhs.1292148

Abstract

The Total Airway Score, determined by eight bedside tests during the preoperative period, and the Intubation Difficulty Scale, assigned during intubation, are both used to describe and predict difficult intubation. The aim of this study is to investigate the correlation between the Total Airway Score and the Intubation Difficulty Scale.Two hundred,American Society of Anesthesiologists ASA 1-3 patients elective dental treatment, maxillofacial surgery under general anesthesia were included in the study. Airway evaluation was performed preoperatively by total airway score which were; Mallampati classification, thyromental and sternomental distance measurement, head and neck mobility,body mass index (BMI), presence of buck teeth, inter incisors gap, upper lip bite test. After endotracheal intubation, the patients were divided into two groups as a healthy group (intubation difficulty scale (IDS)<4) and difficult intubation (IDS ≥4) according to their estimated difficult intubation scores with seven variables and compared with patients with total airway score > 3 in two groups. In this study, total airway score (> 3), thyromental distance (<6cm), upper lip bite test (class III), mallampati classification (≥ class III), inter incisors gap (<3 cm) and buck teeth (> 0.5) respectively 49.45 (95% CI = 4.75-515.45, P <0.05) 7.72 (95% CI = 1.81-32.9, P <0.05), 21.12 (95% CI = 2.31-192.27, P <0.05), 1.92 (CI 95% = 0.51-7.22), 3.54 (95% CI-) 2.31 (95% CI = 0.49-10.78) was detected.It is concluded that total airway score (> 3), upper lip bite test (class III),thyromental distance measurement (<6 cm), which we use in predicting difficult intubation are the most useful preoperative evaluation factors.

References

  • Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429-34. doı: 10.1007/BF03011357
  • Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087-110. doı: 10.1097/00000542-199112000-00021
  • Seo SH, Lee JG, Yu SB, et al. Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factors. KJA 2012; 63(6): 491-97.PMID: 23277808.doı: 10.4097/kjae.2012.63.6.491.
  • Roth D, Pace NL, Lee A, et al. Bedside tests for predicting difficult airways: an abridged Cochrane diagnostic test accuracy systematic review. Anaesthesia 2019; 74(7): 915-28. PMID: 30843190 doı: 10.1111/anae.14608
  • Tuzuner-Oncul AM, Kucukyavuz Z. Prevalence and prediction of difficult intubation in maxillofacial surgery patients. J Oral Maxillofac 2008: 66(8): 1652-1658. PMID: 18634954 doı: 10.1016/j.joms.2008.01.062
  • Practice guidelines for management of the difficult airway. A report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology 1993; 78: 597- 602. PMID: 8457062
  • Adnet F, Borron SW, Racine SX, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997; 87: 1290-7. PMID: 9416711 doı: 10.1097/00000542-199712000-00005
  • Inal MT, Memiş D, Sahin SH, Gunday I. Comparison of different tests to determine difficult intubation in pediatric patients. BJAN (English Edition) 2017; 64(6): 391-394. PMID: 25437694 doı: 10.1016/j.bjan.2014.02.001
  • Tokmakoğlu M, Çağlar S, Ünlü S. Çocuklarda Entübasyon ÖngörülmesindeMallampati Testinin Cormack-Lehane Testi Ile Karşılaştırılması. Turkiye Klinikleri J Med Sci 2002; 22(5): 284-6.
  • Mathew P, Ashok V, Siraj MM, et al. Validation of age and height based formulae to predict paediatric airway distances–a prospective observational study. J Postgrad Med 2019; 65(3): 164-168. PMID: 31169136 doı: 10.4103/jpgm.JPGM_545_18
  • Lee SM, Kim DS, Ryu SJ, et al. The evaluation of predictability of difficult intubation using upper lip bite test. KJA 2005; 49: 287-92. doı: 10.4097/kjae.2005.49.3.287
  • Lee A, Fan LT, Gin T, et al. A systematicreview (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesth Analg 2006; 102: 1867-78. PMID: 16717341 doı: 10.1213/01.ane.0000217211.12232.55
  • Ezri T, Warters RD, Szmuk P, et al. The incidence of class "zero" airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg 2001; 93:1073-1075. PMID: 11574386 doı: 10.1097/00000539-200110000-00055
  • Butler PJ, Dhara SS. Prediction of difficult laryngoscopy: an assessment of the thyromental distance and Mallampati predictive tests. Anaesth Intensive Care 1992; 20:139-142. PMID: 1595845 doı: 10.1177/0310057X9202000202
  • Janssens M, Hartstein G. Management of difficult intubation. Eur J Anaesthesiol 2001; 18:3-12. PMID: 11270007 doı: 10.1046/j.0265-0215.2000.00777.x
  • Yıldırım İ, İnal MT, Memiş D, Turan FN. (2017). Determining the efficiency of different preoperative difficult intubation tests on patients undergoing caesarean section. Balkan Med J 2017; 34(5): 436-43. PMID: 28443579 doı: 10.4274/balkanmedj.2016.0877
  • Qudaisat IY, Al-Ghanem SM. Short thyromental distance is a surrogate for inadequatehead extension, rather than small submandibular space, when indicating possible difficult direct laryngoscopy. Eur J Anaesthesiol 2011; 28:600-606. PMID: 21610502 doı: 10.1097/EJA.0b013e328347cdd9
  • Siriussawakul A, Maboonyanon P, Kueprakone S, et al. Predictive performance of a multivariable difficult intubation model for obese patients. PLoS One.2018; 13(8): e0203142. PMID: 30161197 DOI: 10.1371/journal.pone.0203142
  • Pearce A. Evaluation of the airway and preparation for difficulty. Best Pract Res Clin Anaesthesiol.2005; 19(4): 559-579. PMID: 16408534 DOI: 10.1016/j.bpa.2005.07.004
  • Mashour GA, Stallmer ML, Kheterpal S, Shanks A. Predictors of difficult intubation in patients with cervical spine limitations. J Neurosurg Anesthesiol 2008; 20:110 -5. PMID: 18362772 doı: 10.1097/ANA.0b013e318166dd00
  • Rao KVN, Dhatchinamoorthi D, Nandhakumar A, et al. Validity of thyromental height test as a predictor of difficult laryngoscopy: A prospective evaluation comparing modified Mallampati score, interincisor gap, thyromental distance, neck circumference, and neck extension. Indian J Anaesth. 2018;62(8):603-608. doi:10.4103/ija.IJA_162_18
  • Eberhart LH, Arndt C, Cierpka T, et al. The reliability and validity of the upper lip bite test compared with the Mallampati classification to predict difficult laryngoscopy: an external prospective evaluation. Anesth Analg 2005; 101:284-289. PMID: 15976247 doı: 10.1213/01.ANE.0000154535.33429.36
  • Khan ZH, Mohammadi M, Rasouli MR, et al. The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Anesth Analg 2009; 109:822 -824. PMID: 19690252 doı: 10.1213/ane.0b013e3181af7f0d
  • Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J Anaesth 2013; 60:1119-38. PMID: 24132408 doı: 10.1007/s12630-013-0020-x
  • Lundstrøm LH, Møller AM, Rosenstock C, et al. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology 2009; 110:266-74. PMID: 19194154 doı: 10.1097/ALN.0b013e318194cac8
  • Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114(1):34-41. doi:10.1097/ALN.0b013e3182023eb7
  • Baillard C, Boubaya M, Statescu E, et al. Incidence and risk factors of hypoxaemia after preoxygenation at induction of anaesthesia. Br J Anaesth.2019; 122(3): 388-394. PMID: 30770057 doı: 10.1016/j.bja.2018.11.022
  • Robertshaw HJ, Hall GM. Diabetes mellitus: anaesthetic management. Anaesthesia 2006; 61(12): 1187-1190. PMID: 17090240 doı: 10.1111/j.1365-2044.2006.04834.x
  • George R, Menon VP, Edathadathil F, et al. Myocardial injury after noncardiac surgery—incidence and predictors from a prospective observational cohort study at an Indian tertiary care centre. Medicine 2018; 97(19): e0402-09. PMID: 29742684 DOI: 10.1097/MD.0000000000010402
  • Akpinar H. Evaluation of general anesthesia and sedation during dental treatment in patients with special needs: A retrospective study. J Dent Anesth Pain Med. 2019; 19(4): 191-199. PMID: 31501777 doı: 10.17245/jdapm.2019.19.4.191

GENEL ANESTEZİ ALTINDA YAPILAN DENTAL İŞLEMLERDE; ENTÜBASYON ZORLUK SKORU İLE TOPLAM HAVAYOLU SKORUNUN KARŞILAŞTIRILMASI: RETROSPEKTİF ÇALIŞMA

Year 2023, Volume: 32 Issue: Ek Sayı, 1 - 7, 25.12.2023
https://doi.org/10.34108/eujhs.1292148

Abstract

Toplam hava yolu skoru, preoperatif muayene sırasında 8 yatak başı testi ile belirlendi. Entübasyon sırasında, Entübasyon Zorluk Ölçeği ile zor entübasyon puanı belirlendi. Her iki değer birbiri ile karşılaştırıldı. Bu çalışma toplam hava yolu skoru ile zor entübasyon uyumuna bakmak amacıyla yapıldı.Çalışmaya genel anestezi altında elektif diş tedavisi, maksillofasiyal cerrahi olan 200Amerikan Anestezistler Derneği(ASA) 1-3 hasta dahil edildi. Hava yolu değerlendirmesi ameliyat öncesi toplam hava yolu skoru; Mallampati sınıflaması, tiromental ve sternomental mesafe ölçümü, baş ve boyun mobilitesi, vücut kitle indeksi (VKİ), tavşan dişlerin varlığı, kesici dişler arası boşluk, üst dudak ısırma testleri ile belirlendi. Endotrakeal entübasyon sonrası hastalar yedi değişkenli tahmini zor entübasyon skorlarına göre sağlıklı grup (entübasyon zorluk skoru (IDS)<4) ve zor entübasyon (IDS ≥4) olmak üzere iki gruba ayrıldı ve her iki grup toplam hava yolu skoru > 3 olan hastalarla karşılaştırıldı. Bu çalışmada toplam hava yolu skoru (> 3), tiromental mesafe (<6cm), üst dudak ısırma testi (sınıf III), mallampati sınıflaması (≥ sınıf III), kesici dişler aralığı (<3 cm) ve tavşan dişlerin öne protrüzyonu ( > 0.5cm) olması zor entübasyon lehine değerlendirildi. İstatistiksel olarak sırasıyla 49.45 (%95 GA = 4.75-515.45, P <0.05) 7.72 (%95 CI = 1.81-32.9, P <0.05), 21.12 (%95 CI = 2.31-192.27, P <0.05), 1.92 ( CI %95 = 0.51-7.22), 3.54 (%95 CI-) 2.31 (%95 CI = 0.49-10.78) saptandı.Zor entübasyonu öngörmede kullandığımız total hava yolu skoru (> 3), üst dudak ısırma testi (sınıf III), tiromental mesafe ölçümünün (<6 cm) en yararlı preoperatif değerlendirme faktörleri olduğu sonucuna varıldı.

References

  • Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429-34. doı: 10.1007/BF03011357
  • Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087-110. doı: 10.1097/00000542-199112000-00021
  • Seo SH, Lee JG, Yu SB, et al. Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factors. KJA 2012; 63(6): 491-97.PMID: 23277808.doı: 10.4097/kjae.2012.63.6.491.
  • Roth D, Pace NL, Lee A, et al. Bedside tests for predicting difficult airways: an abridged Cochrane diagnostic test accuracy systematic review. Anaesthesia 2019; 74(7): 915-28. PMID: 30843190 doı: 10.1111/anae.14608
  • Tuzuner-Oncul AM, Kucukyavuz Z. Prevalence and prediction of difficult intubation in maxillofacial surgery patients. J Oral Maxillofac 2008: 66(8): 1652-1658. PMID: 18634954 doı: 10.1016/j.joms.2008.01.062
  • Practice guidelines for management of the difficult airway. A report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology 1993; 78: 597- 602. PMID: 8457062
  • Adnet F, Borron SW, Racine SX, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997; 87: 1290-7. PMID: 9416711 doı: 10.1097/00000542-199712000-00005
  • Inal MT, Memiş D, Sahin SH, Gunday I. Comparison of different tests to determine difficult intubation in pediatric patients. BJAN (English Edition) 2017; 64(6): 391-394. PMID: 25437694 doı: 10.1016/j.bjan.2014.02.001
  • Tokmakoğlu M, Çağlar S, Ünlü S. Çocuklarda Entübasyon ÖngörülmesindeMallampati Testinin Cormack-Lehane Testi Ile Karşılaştırılması. Turkiye Klinikleri J Med Sci 2002; 22(5): 284-6.
  • Mathew P, Ashok V, Siraj MM, et al. Validation of age and height based formulae to predict paediatric airway distances–a prospective observational study. J Postgrad Med 2019; 65(3): 164-168. PMID: 31169136 doı: 10.4103/jpgm.JPGM_545_18
  • Lee SM, Kim DS, Ryu SJ, et al. The evaluation of predictability of difficult intubation using upper lip bite test. KJA 2005; 49: 287-92. doı: 10.4097/kjae.2005.49.3.287
  • Lee A, Fan LT, Gin T, et al. A systematicreview (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesth Analg 2006; 102: 1867-78. PMID: 16717341 doı: 10.1213/01.ane.0000217211.12232.55
  • Ezri T, Warters RD, Szmuk P, et al. The incidence of class "zero" airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg 2001; 93:1073-1075. PMID: 11574386 doı: 10.1097/00000539-200110000-00055
  • Butler PJ, Dhara SS. Prediction of difficult laryngoscopy: an assessment of the thyromental distance and Mallampati predictive tests. Anaesth Intensive Care 1992; 20:139-142. PMID: 1595845 doı: 10.1177/0310057X9202000202
  • Janssens M, Hartstein G. Management of difficult intubation. Eur J Anaesthesiol 2001; 18:3-12. PMID: 11270007 doı: 10.1046/j.0265-0215.2000.00777.x
  • Yıldırım İ, İnal MT, Memiş D, Turan FN. (2017). Determining the efficiency of different preoperative difficult intubation tests on patients undergoing caesarean section. Balkan Med J 2017; 34(5): 436-43. PMID: 28443579 doı: 10.4274/balkanmedj.2016.0877
  • Qudaisat IY, Al-Ghanem SM. Short thyromental distance is a surrogate for inadequatehead extension, rather than small submandibular space, when indicating possible difficult direct laryngoscopy. Eur J Anaesthesiol 2011; 28:600-606. PMID: 21610502 doı: 10.1097/EJA.0b013e328347cdd9
  • Siriussawakul A, Maboonyanon P, Kueprakone S, et al. Predictive performance of a multivariable difficult intubation model for obese patients. PLoS One.2018; 13(8): e0203142. PMID: 30161197 DOI: 10.1371/journal.pone.0203142
  • Pearce A. Evaluation of the airway and preparation for difficulty. Best Pract Res Clin Anaesthesiol.2005; 19(4): 559-579. PMID: 16408534 DOI: 10.1016/j.bpa.2005.07.004
  • Mashour GA, Stallmer ML, Kheterpal S, Shanks A. Predictors of difficult intubation in patients with cervical spine limitations. J Neurosurg Anesthesiol 2008; 20:110 -5. PMID: 18362772 doı: 10.1097/ANA.0b013e318166dd00
  • Rao KVN, Dhatchinamoorthi D, Nandhakumar A, et al. Validity of thyromental height test as a predictor of difficult laryngoscopy: A prospective evaluation comparing modified Mallampati score, interincisor gap, thyromental distance, neck circumference, and neck extension. Indian J Anaesth. 2018;62(8):603-608. doi:10.4103/ija.IJA_162_18
  • Eberhart LH, Arndt C, Cierpka T, et al. The reliability and validity of the upper lip bite test compared with the Mallampati classification to predict difficult laryngoscopy: an external prospective evaluation. Anesth Analg 2005; 101:284-289. PMID: 15976247 doı: 10.1213/01.ANE.0000154535.33429.36
  • Khan ZH, Mohammadi M, Rasouli MR, et al. The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Anesth Analg 2009; 109:822 -824. PMID: 19690252 doı: 10.1213/ane.0b013e3181af7f0d
  • Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J Anaesth 2013; 60:1119-38. PMID: 24132408 doı: 10.1007/s12630-013-0020-x
  • Lundstrøm LH, Møller AM, Rosenstock C, et al. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology 2009; 110:266-74. PMID: 19194154 doı: 10.1097/ALN.0b013e318194cac8
  • Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114(1):34-41. doi:10.1097/ALN.0b013e3182023eb7
  • Baillard C, Boubaya M, Statescu E, et al. Incidence and risk factors of hypoxaemia after preoxygenation at induction of anaesthesia. Br J Anaesth.2019; 122(3): 388-394. PMID: 30770057 doı: 10.1016/j.bja.2018.11.022
  • Robertshaw HJ, Hall GM. Diabetes mellitus: anaesthetic management. Anaesthesia 2006; 61(12): 1187-1190. PMID: 17090240 doı: 10.1111/j.1365-2044.2006.04834.x
  • George R, Menon VP, Edathadathil F, et al. Myocardial injury after noncardiac surgery—incidence and predictors from a prospective observational cohort study at an Indian tertiary care centre. Medicine 2018; 97(19): e0402-09. PMID: 29742684 DOI: 10.1097/MD.0000000000010402
  • Akpinar H. Evaluation of general anesthesia and sedation during dental treatment in patients with special needs: A retrospective study. J Dent Anesth Pain Med. 2019; 19(4): 191-199. PMID: 31501777 doı: 10.17245/jdapm.2019.19.4.191
There are 30 citations in total.

Details

Primary Language English
Subjects Dentistry
Journal Section Research Article
Authors

Hatice Akpınar 0000-0001-9422-7879

Müge Çına 0000-0003-2005-3153

Berfin Öykü Erdoğan 0000-0002-3444-5281

Early Pub Date December 25, 2023
Publication Date December 25, 2023
Submission Date May 3, 2023
Published in Issue Year 2023 Volume: 32 Issue: Ek Sayı

Cite

APA Akpınar, H., Çına, M., & Erdoğan, B. Ö. (2023). COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY. Sağlık Bilimleri Dergisi, 32(Ek Sayı), 1-7. https://doi.org/10.34108/eujhs.1292148
AMA Akpınar H, Çına M, Erdoğan BÖ. COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY. JHS. December 2023;32(Ek Sayı):1-7. doi:10.34108/eujhs.1292148
Chicago Akpınar, Hatice, Müge Çına, and Berfin Öykü Erdoğan. “COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY”. Sağlık Bilimleri Dergisi 32, no. Ek Sayı (December 2023): 1-7. https://doi.org/10.34108/eujhs.1292148.
EndNote Akpınar H, Çına M, Erdoğan BÖ (December 1, 2023) COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY. Sağlık Bilimleri Dergisi 32 Ek Sayı 1–7.
IEEE H. Akpınar, M. Çına, and B. Ö. Erdoğan, “COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY”, JHS, vol. 32, no. Ek Sayı, pp. 1–7, 2023, doi: 10.34108/eujhs.1292148.
ISNAD Akpınar, Hatice et al. “COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY”. Sağlık Bilimleri Dergisi 32/Ek Sayı (December 2023), 1-7. https://doi.org/10.34108/eujhs.1292148.
JAMA Akpınar H, Çına M, Erdoğan BÖ. COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY. JHS. 2023;32:1–7.
MLA Akpınar, Hatice et al. “COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY”. Sağlık Bilimleri Dergisi, vol. 32, no. Ek Sayı, 2023, pp. 1-7, doi:10.34108/eujhs.1292148.
Vancouver Akpınar H, Çına M, Erdoğan BÖ. COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY. JHS. 2023;32(Ek Sayı):1-7.