Role of the Dentist Anesthesiologist in the Community Alvin L. Solomon, D.D.S., M.S. Private Practice, Bayside, New York

Currently, training in requires 2 1. To provide and , where re- years of advanced education beyond the un- quired, in the private dental office. dergraduate level, including one year of anesthesiol- 2. To provide anesthesia and be part of a teaching ogy. In the future, it is probable that this requirement program in a hospital-based dental service, and will be raised to three years of advanced education. to provide anesthesia when called upon as an There may also be required postgraduate anesthesia adjunct to the department of anesthesiology. programs as opposed to today's salaried resident 3. To provide service within a dental school. programs. Add to this the high cost of receiving an 4. To be part of continuing education programs undergraduate dental education, of setting up a prac- sponsored by local or state dental societies or by tice, and of malpractice insurance rates for dentists hospitals. using anesthesia and sedation. Therefore, before a 5. To be certified instructors in basic life support dentist decides to undertake this kind of advanced and in advanced cardiac life support. training, he must be very sure that there will be a 6. To represent dental anesthesia before gov- definite need for this type of service in . ernmental and regulatory agencies expressing Is there such a need in this area? The answer is concerned interest in this area. yes. There is a large segment of the public which for years has been neglected with respect to the main- tainance of their dentition. This includes individuals Anesthesia Services In Private Practice who avoid dental treatment out of fear. It is estimated The first area is delivery of anesthesia services in a by the ADA that upward of 15 million people fall into solo practice, or as an anesthesiologist providing this category. Dentists trained in the art and science various services in the multiple dentist office. In most of anesthesiology can provide a valuable service to communities, there exist numerous patients who, for these people. In recent years, we have seen an in- various reasons, cannot undergo dental procedures creased interest in, and use of, anxiety-reducing without the use of some form of sedation or general techniques in dentistry. Newer and sometimes better anesthesia. These individuals include dental drugs that can be used for the management of anxi- phobics, the mentally handicapped, those with cer- ety and pain control are constantly being developed. tain physical handicaps, the highly anxious, phobic Changes in drugs also create changes in delivery gaggers, those who cannot receive local anesthetics, systems or in the techniques of administration. The those with various temporomandibular joint dysfunc- dentist anesthesiologist keeps abreast of these tions, and finally, numerous young pediatric patients. changes and is able to provide the best type of care Treating patients in these categories often requires for the dental patient. sedation and anesthesia skills possessed only by a Dentist anesthesiologists are true anesthesiology dentist with a formal residency training in anes- professionals and continually interact with their col- thesiology. The patient must be managed during cer- leagues in medical anesthesia departments to tain procedures by a separate dentist who is able to examine such questions as: (1) Is it always neces- both provide a proper, quiet, environment for the sary to intubate patients for so-called longer proce- operating dentist, and ensure the patient's welfare. It dures? (2) What are the advantages of newer drugs? has been generally accepted that if the management (3) When is hospitalization necessary? (4) Are of the procedure requires deep or general anes- anesthetic considerations altered by the age of the thesia, it necessitates the use of a three-person patient? (5) Is there a place in dentistry for the use of team. One of these must be qualified to administer agonist-antagonist combinations? (6) What are the and monitor the anesthesia from the preoperative minimum types of facilities and equipment, including period to the intraoperative period, and then finally to those used for , required to insure patient supervise the postoperative period. This individual safety? (7) What additional help or assistance is re- evaluates all patients who are candidates for such quired for a given type of anesthesia procedure? management as to their ability to tolerate a sedation Regarding the role of dentist anesthesiologist, or general anesthetic procedure, and would deter- much is yet to be finalized and accepted by both the mine the technique best suited based on the patient dental profession and the public. I will outline what I history and on the dental treatment anticipated. The believe to be the numerous reasons that the dentist dentist anesthesiologist is capable of selecting vari- anesthesiologist is needed, and how his or her skills ous methods of management with single or multiple can best be utilized. There are six major areas in this drug regimens and is proficient in either intubation or respect: in nonintubation techniques. In a busy multiple den-

JULY/AUGUST 1986 191 tist practice he or she could also supervise all con- relationship with the anesthesia department, and the scious sedation procedures so as to decrease the demands made upon him by the department of den- responsibility of the operating dentist during treat- tistry. Dentistry desires to train its dentists in anes- ment. This person is responsible for establishing a thesia to be used toward advancing dental care. proper facility to manage these patients and for in- Their utilization by other departments on a selective suring their safety in the event of untoward reactions. or continual basis is usually agreed upon between Along this line, he or she is responsible for maintain- that dentist and the department of anesthesia or the ing the emergency drugs and equipment. The anes- hospital. The dentist anesthesiologist can also play thesiologist also instructs other office personnel in an important role in a pain center team, evaluating the recognition of early signs of adverse reactions, for chronic pain syndromes that are associated with example respiration and pulse changes, and assists temporomandibular joint dysfunction and other facial in emergency care. pathologies. Where a residency in anesthesia with dentist participation exists, the dentist trained in anesthesia plays an important role in the training of Dental Anesthesia in a Hospital-based these dentists on both an inpatient and an ambula- Dental Service tory basis. The second major area of involvement for dentists trained in anesthesia is providing anesthesia, and Dental Anesthesia in the Dental School being part of a teaching program, in the hospital- The third major area of involvement is in the dental based dental service, providing liaison with the de- school. The dentist anesthesiologist is an important partment of anesthesia, and playing a role in any addition to any dental school. His value extends from overlapping areas of pain and anesthesia that both the predoctoral level to the postgraduate and con- the dental and anesthesia departments deem impor- tinuing education levels. The involvement of such a tant. Primarily, they provide and supervise the vari- person increases the available information for the ous sedation and anesthesia services for the de- student. Most dental schools need upgrading in the partment of dentistry. This is primarily an ambulatory areas of pain and anxiety control. The dentist anes- type service, but can also include day surgery in thesiologist's responsibility includes developing didac- which the patient is admitted to the hospital in the tic and clinical instruction in the various conscious morning, has the procedure done, and is discharged sedation techniques. The dentist trained in anes- sometime the same day. Finally, it also includes in- thesia can also serve as a source person for clinical patient anesthesia for the patient requiring more than pharmacology and physiology in the dental school. same day services. Anesthesia or sedation is pro- He has the ability to evaluate problematic patient vided for all phases of dentistry that are required, not histories and to plan appropriate treatment. He can only surgery. They are responsible for the teaching also work closely with the basic science department programs in pain control, sedation and anesthesia, in evaluating drug reactions in dental patients while and basic and advanced cardiac life support within under treatment. the residency programs: oral and maxillofacial sur- gery, general practice, and other specialties. The dentist anesthesiologist is also the liaison be- Continuing Education Programs in tween the hospital anesthesiology department and Dental Anesthesia the department of dentistry. In the most desirous The fourth area of involvement for the dentist anes- situation for training dentists, he is responsible for the thesiologist is conducting continuing education anesthetic management of all dental-related cases courses. These can be sponsored by the local dental which are performed in the operating room. He is also society, the state society, the dental school, or the responsible for the instruction of residents when they hospital. The use of a dentist anesthesiologist in the rotate through anesthesia. If hospital policy does not area of continuing education would fall into three permit a dentist anesthesiologist's use in the operat- basic categories. For previously trained dentists thi- ing room, and this varies with hospitals, then he could includes refresher courses in established proced4ures be responsible for all the outpatient dental anes- in anesthesia or sedation, or instruction in new tech- thesia and the instruction of the residents in this niques. For minimally or nontrained dentists, this program. A dentist having had a residency program includes instruction in certain conscious sedation in anesthesia is fully trained in all aspects of the art techniques, such as seaation. The third and science of anesthesiology. He is therefore also area for continuing education is the teaching of basic capable of providing anesthesia services for other life support and advanced cardiac life support. This is than dental procedures. an area where the dentist anesthesiologist can be of The utilization of a dentist anesthesiologist's ex- service to his total community. He can easily certify pertise in an anesthesia department will vary apprec- as an instructor in basic life support and advanced iably from hospital to hospital. Determination of how cardiac life support, and can be a part of a community his services are utilized will be dependent upon many program to teach these life-saving procedures to the factors. These may include the community need, his laity and to other professionals. This clinical skill al-

192 ANESTHESIA PROGRESS lows him to impart additional depth to any course he dures can be extremely costly in terms of settlement participates in. He has knowledge of emergency drug awards, and have begun to require high premiums of administration, intubation, the use and interpretation the professional who uses general anesthesia, and in of cardiac monitors, and use of the defibrillator. some cases, any form of conscious sedation. In a period of such change, it is incumbent upon the den- tist trained in anesthesiology to speak out in support Continuing Education Programs in CPR of the need for safe sedation and anesthesia, and in and ACLS support of the competency of individuals who have The dentist anesthesiologist can also contribute received such intensive training. This would include services to community emergency medical efforts. A development of local and state groups who could willingness to be on call with the municipal services present testimony before agencies interested in this and to respond when needed will give additional area. Examples of this would be testimony given expertise to the on-the-spot personnel. These types before city and state agencies exploring possible of services are immensely appreciated by the com- regulation of sedation and anesthesia in the dental munity. office, testimony before state agencies concerned with proposed increases in malpractice insurance Representatives of Dental Anesthesia premiums, and serving as consultants to third party Dentist anesthesiologists can represent dental insurance carriers to encourage a fair reimbursement anesthesia before government and regulatory to the participant. bodies. As I stated in my opening remarks, we prac- In conclusion, there definitely is an important place tice today in a litigious society, and with pressure for the dentist anesthesiologist in the community. As for governmental agencies to regulate the ways se- a true dental health professional, he is able to provide dation and general anesthesia are administered to a much needed service in a safe and effective man- the public. Already 30 states have passed laws reg- ner, and to inspire public confidence in dental seda- ulating the type of training required of dentists using tion and anesthesia. Through his efforts, dentistry will sedation and anesthesia. In addition, malpractice in- continue to be able to utilize these effective pain and surance carriers have discovered that these proce- anxiety control techniques.

Current and Future Research in Dental Sedation and Anesthesia 0. Ross Beirne, D.M.D., Ph.D. University of Washington, Seattle, Washington

In 1844, Horace Wells, a dentist, recognized that have been synthesized since the discovery of pro- nitrous oxide might be used as a general anesthe- caine.4 has replaced because of tic.1'2 After attending a public demonstration of the its anesthetic efficacy, and low allergic potential and gas, he had his own decayed molar removed pain- long-acting local anesthetics such as lessly using nitrous oxide. Another dentist, William and etiodocaine are used for complex and prolonged Morton, using ether, successfully anesthetized a pa- dental procedures that cause significant post- tient having a mass removed from his neck in 1846.3 operative discomfort.46 After the discovery of nitrous oxide and ether, den- Even though relieves the pain of tists quickly began to use these anesthetics to relieve dental treatment, a large number of patients continue the pain associated with extracting decayed and to avoid dental care because of fear and anxiety. This abscessed teeth. fear and anxiety can be relieved with general The synthesis of the procaine in anesthetics or with recently developed sedatives that 1905 revolutionized the practice of dentistry.2'4 Pro- decrease anxiety without producing unconscious- caine could be safely used to block conduction in ness.7 peripheral nerves relieving pain in the conscious pa- Many drugs have been developed and are being tient without suppressing the central nervous system used for general anesthesia and conscious sedation, with general anesthetics. Many local anesthetics but the safety and efficacy of these drugs have not

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