Dr. Richard B Liposky Copyright © 2015
“Need to” vs. “Want to”
It’s not unusual for a patient to request general anesthesia for their dental treatment. “I have to be put to sleep for my dental treatment.” The question that must be answered is “do they need to or do they want to” be put to sleep.
“Need to” implies that the treatment cannot be performed safely for the patient unless they are asleep. Any anesthesia risks are outweighed by the need for the surgery.
“Want to” implies that the treatment can be performed safely and comfortably for the patient, but the patient’s desire to be asleep outweighs the risks of being put to sleep.
Sleep Dentistry is a word that has crept into our dental marketing vernacular. One or two day courses arm the clinician with the credential to advertise “Sleep Dentistry” for his or her practice. But is it the same sleep as the patient might understand, or is it simply a pill to allay dental anxiety?
If it is a pill, then advertising “sleep dentistry” is simply a way to get patients into the office and is misleading to the patient. If it is truly a general anesthesia (sleep) protocol, then a one or two day course will not qualify the practitioner to provide the service. An anesthesia team must support the service.
Types of Anesthesia
The drugs used in anesthesia have two basic functions: Stop the transmission (nerve blocks) of the pain stimulus or stop the interpretation/response to the pain stimulus by the brain (general anesthesia).
Local anesthesia means that the drug (benzocaine or novacaine) blocks the feeling and the brain does not know that something is painful. This is a nerve block. Example: Benzocaine on sunburn skin or an injection by the dentist resulting in a numb lip.
Regional anesthesia means that the nerve block will block sensation for a large area. Example: spinal block anesthesia which can block the lower extremities.
General anesthesia means that the drugs affect the brain’s ability to recognize, interpret and respond to painful stimuli. Deeper general anesthesia may block muscle movement and the ability of the brain to monitor and respond to changes in the body’s vital functions…heart rate and breathing. The deeper the general anesthesia, the greater the risk to the patient.
Walk in General Anesthesia
Walk in sedation/anesthesia means that the patient is put to sleep on their first visit. They walk into the office, they request general anesthesia and they get it. Even though we know it is practiced in certain areas, walk in general anesthesia is not recommended. The risk is substantial to the patient and practice.
A thorough pre-op evaluation is mandatory. The physical and mental status of the patient, medical and medication history as well as the response to previous anesthesia/surgery must be evaluated. The patient must have a complete understanding of the anticipated anesthesia and surgery. It’s like the preflight checklist used by the pilot. You only get one shot at a perfect landing. Every other landing is less than perfect and the worst landing may be a crash. We do not want crash landings in anesthesia.
Questions for the surgeon
- Can you perform this surgery safely and comfortably without putting me to sleep? Most surgeons can.
- Why do you recommend general/IV deep sedation?
- Do you consider this the safest way for me to have the surgery?
- Will you be doing both the anesthesia and surgery? Surgeons should not do both the surgery and IV or general anesthesia.
- How many people on your team have ACLS certification? Should be at least two members of the anesthesia/surgical team.
- Do you have emergency backup support for your anesthesia service?
Who should be put to sleep? When the pre anesthetic evaluation reports a low risk, when the surgical procedure requires general anesthesia, and when the patient is fully informed as to the indications and contra indications of the anesthesia procedure, then a safe general anesthesia/IV deep sedation is expected and can be performed. This is still a decision made between the surgeon and patient.
Even though general anesthesia/IV deep sedation is an accepted service, it does come with certain risks to the patient. Even with well-trained and highly skilled clinicians, anesthesia complications can occur. The successful management of these complications will depend on that training. You want an anesthesia team that can prevent, recognize and manage anesthesia complications…thus provide a safe anesthesia experience.