General Anesthesia in Dentistry

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In the field of dentistry, the uses of methods involving sedation, for the treatment of patients are often used. It is however crucial that these methods and techniques are safe and help in making the procedure more effective while reducing the pain of patients undergoing dental procedures. A commonly used technique for dentistry procedures is General Anaesthesia. The safety of the technique of general anesthesia has been of constant concern to the anesthesia regulatory bodies and there are several guidelines and standards for its use in the medical field. The Royal College of Anaesthetists (RCA), has concerns regarding the increasing number of general anesthetics being used for dentistry (1,2) and that these anesthetics may not always be necessary, as such patients face the unnecessary risk, sometimes even resulting in the death of healthy patients, due to the use of these anesthetics (3).

The use of general anesthesia has been associated with certain levels of risks and it has been widely accepted that dentistry procedures must be performed by using local anesthetic measures where ever [possible. In cases of patients with elevated levels of anxiety, it has been proposed that the technique of conscious sedation be used (4). The Royal College of Anaesthetists strictly states that the use of general anesthesia must be limited only to the patients and clinical situations where local anesthesia is not possible. The college maintains that there should be persistent pressure regarding the use of the general anesthesia technique.

The College recommends dentists ensure that very young children must be administered anesthesia only at the hands of pediatric anesthetists who are specialized in the field.

Standards and Guidelines for use of General Anaesthesia Guidelines and training (10, 11)

In most circumstances, sedation is conducted by non-anesthesiologists. To prevent or manage complications during sedation, the practitioner has to follow certain safe practice guidelines. Various professional bodies and organizations, such as the Royal College of Anesthetists, have promulgated guidelines to assist the practitioner in performing sedation safely. These guidelines outline the general principles of safe practice without providing specific details. Individual departments need to build their own practice guidelines based on these principles to cater for variations in patients, procedures, practitioner skills, and physical setting (10, 11).

Doctors and nurses involved with sedation should undergo regular recertification of cardiopulmonary resuscitation skills. Protocols for resuscitation such as the Advanced Cardiac Life Support protocol, and for managing complications such as desaturation, should be adopted in areas where sedation is conducted. The staff involved should also receive training in the use of sedative drugs and in appropriate monitoring of patients (10, 11).

Assessment of patient and discussion

In administering general anesthesia to patients there are a number of standards and guidelines which are necessary to be followed in the practice of dentistry.

It is necessary to perform a screening of the patient by the referring dentist to take into account the full history and inform the patient about the risks involved in the use of general anesthesia, also informing him about the alternative techniques present (4).

Consent form & Medico-legal aspects

General anesthesia is a technique that carries significant risks to the patient. It is necessary to explain all significant risks to the patient and to obtain consent for sedation. It is also important to have another person present during the sedation process to circumvent any potential claims with legal ramifications made by the patient (5).

The consent of the patient is crucial before the use of general anesthesia, the best method of doing so is by signing a consent form. This is important as the patient will be unconscious while the dental procedures are being performed (4, 5).

Staffing

Medical practitioners involved with sedation should have a good knowledge of the physiology/pharmacology of sedation, and be competent in patient monitoring and resuscitation. The anesthesiologist is the ideal person to sedate and monitor the patient.

The RCA recommends the categories of staff for administering dental anesthesia to dental patients. These include trainees working in programs affiliated to the RCA under proper guidance (6) and non-consultant career grade doctors who work under the supervision of named consultant doctors with a membership of a reputable hospital or community trust (7,8).

Monitoring

The performing anesthetists are required to have sincere assistants who have received prior training for the job function. Till the time the unconscious person regains consciousness, careful and accurate monitoring of the patient needs to be done in a setting equipped with adequate recovery facilities (9). The guidelines state that one nurse per patient must be present for monitoring and after-care of unconscious patients.

The Clinical Setting

The clinical setting for the practice of administering general anesthesia to patients must take the ‘worst-case scenario’ into account. Although modern practices of anesthesia do not offer risks and complications, the team performing the procedure must be skilled and efficient, so that the patient is not at any kind or risk of permanent harm to the patient (10). The risk to the life of a patient is greater if the administration of general anesthesia takes place far away from the aid of essential clinical services, thus the administration setting must be close to clinical services which may ensure access to emergency services (10).

Equipment and drugs

The equipment used by the dentist and the anesthetist must be specially designed for use in dental settings and procedures. Besides the equipment and the anesthetic drugs, adequate equipment for monitoring the patient must also be available which also includes the necessary drugs crucial for resuscitation of the patient (10, 12, & 13).

All the equipment and drugs available must be checked by the anesthetist (14) before the conduction of the procedure and special care must be taken to ensure that in case there is the failure of one or more equipment, there is/are substitute equipment and facilities available for immediate use and access. It is also the duty of the anesthetist to ensure that the medical gases which have been supplied and stored are in accordance with the necessary rules and regulations of the medical regulations (15).

The area where sedation is conducted should be supplied with appropriate equipment and drugs required for cardiopulmonary resuscitation, and airway, ventilatory, and circulatory support (13).

Aftercare

The modern dental procedures used for sedation do necessitate prolonged hours of unconsciousness and the patients recover quickly. It is necessary that patients are evaluated, to check their fitness levels before being discharged. Especially in the case of administration of general anesthesia, the patients are required to stay for at least a day, before the effects and hang-over effects of the drug are eliminated (16).

Management of anxious patients using general anesthesia

General anesthesia is not very commonly used for dental procedures, with several modern and effective techniques available to dentists today. However, in the case of extremely phobic patients, general anesthesia may be administered to patients. Since the technique of general anesthesia involves the complete sedation of the patient, all the senses of the patient are de-activated, causing the patient to go into a deep sleep (4).

It is therefore crucial for the anesthetist, to carefully monitor all the physical vital functions of the patient including the heart and pulse rate, blood pressure, and breathing. It is the duty of the functioning anesthetist to carefully monitor and control the amount of anesthesia to the patient to avoid any complications and risks (4).

Effects of General anesthesia

General anesthesia may be used for extremely phobic patients, but the technique is not without any substantial risks. The most immediate effects of general anesthesia are nausea and dizziness. The procedure is more expensive than the other sedation techniques used. According to several researches conducted, anxious children who had been administered general anesthesia for dental procedures, displayed several symptoms of nausea, vomiting, sickness, and prolonged bleeding, following the procedure (17, 18). Some children were even reported having psychological trauma, one month after the procedure had been conducted (17). A few children were reported having nightmares and bad memories while one child experienced depression for several days after being administered general anesthesia for the dental procedure (17). Thus, researchers have concluded that dental procedures and extractions which are conducted using the administration of general anesthesia among young children have several ill effects including morbidity and distress (17).

Researchers have substantially proved that the practice of general anesthesia for extractions and dental procedures in anxious young children does not in any way help to curtail or manage the phobia among children (18). The after-effects are several and commonly include morbidity (19) and distress among anxious patients, with substantial side-effects stretching from a day to several weeks and sometimes even a month after the dental procedure has taken place (17, 18).

It is therefore the duty of the dentist and the anesthetist to inform the parents of the child regarding the side-effects of the administration of general anesthesia for dental procedures (18).

References

Whittle JG, Jones CM, Hannon CP. Trends in the provision of primary care dental general anaesthesia in the North of England, 1991/92-1994/95. British Dental Journal 1998; 184: 230-234. See also: Whittle JG, Hannon CP, Jones CP. Dental general anaesthesia in the North of England 1991/92 to 1996/97. The Dental Public Health Northern Quality Improvement Group. 1998.

Dental Practice Board for England and Wales. Digest of Statistics.

General Dental Council. Maintaining Standards: Guidance to Dentists on Professional and Personal Conduct. 1998.

Association of Anaesthetists of Great Britain and Ireland. Consent for Anaesthesia. (In Press.).

Bachelor P, Sheiham A, Albert D, Cowell C. Department of Dental Public Health, The London Hospital Medical College; January 1994.

The Association of Anaesthetists of Great Britain and Ireland. Non-Consultant Career Grade Anaesthetists. 1998.

Royal College of Anaesthetists. Guidance for the Appointment of the Staff Grade, Associate Specialist and Hospital Practitioner Grade Anaesthetist. 1998.

The Association of Anaesthetists of Great Britain and Ireland. Recommendations for Standards of Monitoring during Anaesthesia and Recovery; Revised. 1994.

Standing Dental Advisory Committee. Report of an expert Working Party (Chairman: Professor D Poswillo). General Anaesthesia, Sedation and Resuscitation in Dentistry. 1990.

Clinical Standards Advisory Group. Dental General Anaesthesia. 1995.

The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland. Good Practice: A Guide for Departments of Anaesthesia. 1998.

Colquhoun MC, Handley AJ, Evans TR (Eds). ABC of Resuscitation, 3rd Edn. London: BMJ Publishing Group; 1995.

The Association of Anaesthetists of Great Britain and Ireland. Checklist for Anaesthetic Apparatus 2. 1997.

European Committee for Standardisation. The European Standard EN 737-4: 1998. Medical Gas Pipeline Systems. 1998.

The Royal College of Surgeons of England Commission on the Provision of Surgical Services. Guidelines for Day Case Surgery. Revised 1992.

Bridgman CM, Ashby D, Holloway PJ. An investigation of the effects on children of tooth extraction under general anaesthesia in general dental practice. Br Dent J 1999; 186: 245–247.

M. T. Hosey, L. M. D. Macpherson, P. Adair, C. Tochel, G. Burnside & C. Pine. Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia. Br Dent J 2006; 200: 39-43.

Arch LM, Humphris GM, Lee GTR. Children choosing between general anaesthesia or inhalation sedation for dental extractions: the effect on dental anxiety. Int J Paed Dent 2000; 11: 41–48.

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