Chapter 126

CHAPTER 126 ■ Dental Procedures: Anesthetic Considerations 2081
fractures, and distraction osteogenesis of the jaw are commonly
performed by oral and maxillofacial surgeons. Lastly, cleft palate
repair, craniofacial anomaly reconstruction, facial plastic surgery,
tracheotomy, temporomandibular joint (TMJ) surgery (at times
with costochondral bone graft), jaw reconstructive surgery, usually
in conjunction with cleft palate deformities or trauma and with
iliac crest bone graft, are provided. Many of these latter procedures
require overnight admission.
In many situations, therefore, regional anesthesia is either
ineffective or not possible. Oral sedation, intravenous sedation
and general anesthesia are all used by dentists in a variety of
settings to complete surgical goals.
TRAINING OF DENTISTS IN SEDATION
AND GENERAL ANESTHESIA
Many dentists, through additional postgraduate residencies, are
trained to provide sedation as well as general anesthesia. To ensure
adequate training and competence, a dentist must legally posses a
special permit from the state/provincial dental board to provide
intravenous sedation or deep sedation/general anesthesia. Many
states now require a special permit for pediatric or adult oral
moderate sedation as well. No permit is generally required for
minimal sedation or nitrous oxide–oxygen sedation. The postgraduate
residencies that require extensive sedation or general
anesthesia experience include pediatric dentistry, oral and maxillofacial
surgery, and dental anesthesiology. Oral surgeons have
consistently been in the forefront of office-based deep sedation/
general anesthesia. However, with the elimination of operator–
anesthetist deep sedation and general anesthesia in medicine, as
well as the limitation of the oral surgeon to providing only
extractions for dental concerns, specific residencies in anesthesiology
for dentists were developed. The training and scope of
practice of dentists involved in pediatric sedation and general
anesthesia are described below.
Pediatric Dentists
U.S. training programs require a minimum of 20 cases of dental
treatment under general anesthesia in the operating room and an
additional one month rotation on the anesthesiology service itself
to familiarize residents with the provision of general anesthesia
and airway management. 5 Pediatric dentists are trained in oral
moderate sedation and/or nitrous oxide–oxygen sedation for
children that might have limited dental treatment needs and have
some capability to cooperate but are anxious for care in the dental
office. The most common oral sedation medications include
midazolam or chloral hydrate with hydroxyzine but many
different medications and combinations are used. There is an
increasing use of general anesthesia for precooperative or uncooperative
children, especially those with more than one, or
possibly two, required short dental treatments. 6 Additionally,
pediatric dentists are frequently called upon to treat adult mentally
or physically challenged patients in the operating room.
Oral and Maxillofacial Surgeons
In the United States and Canada, oral surgeons must complete a
4-month rotation on the anesthesia service and provide 90 deep
sedations and 10 general anesthetics for clinic oral surgery patients
as part of their program’s requirements. There is no specific
requirement for anesthetizing children, defined as less than
13 years old, except that the resident must be trained in the unique
anatomic/pharmacologic/physiologic variations of the pediatric
anesthesia patient. 7 Many U.S. and Canadian oral surgeons provide
deep sedation for older teenaged pediatric patients with a limited
number intravenously sedating preadolescent children in the
dental office and rarely children younger than 6 years old. In this
last remaining operator–anesthetist model, the oral surgeon
provides both the deep sedation and the surgery in conjunction
with a surgical dental assistant and another dental assistant to
monitor the patient and provide airway support. In the United
Kingdom, single drug intravenous moderate sedation is the only
I.V. sedation regimen administered by dentists and may not be
practical, especially for many younger pediatric patients. 8
Dentist Anesthesiologists
Dentist anesthesiologists are dentists in the United States and
Canada who have completed 2 to 3 years of accredited training in
anesthesiology, with a minimum of 1 year of operating room
general anesthesia for all types of surgical procedures and additional
specialized rotations in office-based anesthesia for dental,
oral, and maxillofacial surgery. They provide the full range of
anesthesia services for patients of all ages and medical complexity,
from moderate sedation to intubated general anesthesia, for
dental, oral, and maxillofacial procedures in hospitals, ambulatory
surgery centers, and office settings. 9 Dentist anesthesiologists in
the United States almost exclusively provide anesthesia services
only. Most administer anesthesia in dental offices where they
generally provide all required monitors, anesthetic drugs, and
emergency drugs/equipment for the provision of safe anesthesia
care while the dentist or oral surgeon operates. With the advent of
newer, shorter-acting anesthetic agents and improved monitoring
techniques, there is an increasing use of the office-based setting
for general anesthesia for all types of procedures, medical or
dental, particularly in North America. 10
PREANESTHETIC ASSESSMENT
Dental and oral surgery is frequently needed over a patient’s
lifetime. This has particular implications for the mentally and
physically challenged patient who may require general anesthesia
every 1 to 3 years for routine dental care. Furthermore, as dental
and minor oral surgery carries very low surgical risk, the administration
of anesthesia may potentially be the most hazardous
component of the perioperative experience. Therefore, the preanesthetic
evaluation takes on increased importance.
The vast majority of dental or oral surgical procedures are
performed on an ambulatory, outpatient basis. The abbreviated
time to complete the admission process poses issues common to
all same-day surgical care, such as ensuring that patients receive
complete preoperative medical evaluation and continue appropriate
medications on the day of surgery. This is further complicated
by the fact that pediatric dentists can not complete their own
history and physical within 7 days of surgery, a Joint Commission
requirement in the United States. This means that the history and
physical must be performed by the patient’s pediatrician a few days
before the procedure and forwarded to the anesthesia department
for review. When this information is not available, the case must