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General Anesthesia in Dentistry R Review Article General anesthesia in dentistry R. Balaji1, M. Dhanraj2*, Arunasree Vadaguru Mallikarjuna2 ABSTRACT Dentistry, in its surgical and restorative aspect, is in majority based on office practice. Limited dentists work routinely in operation theaters. Majority of the dental procedures can be performed under local anesthesia which is inherently safe. Most dentists are skilled in techniques of local anesthetics and nerve blocks. General anesthesia should not be used as a method of anxiety control but for pain control. All general anesthetics are associated with some risk, and modern dentistry is based on the principle that all potentially painful treatment should be performed under local anesthesia, if at all possible. General anesthesia is strictly limited to those patients and clinical situations in which local anesthesia (with or without sedation) is not an option such as children or individuals with learning difficulties. This review elucidates the facts and importance of general anesthesia in dentistry. KEY WORDS: Anesthesia, Complication, Extraction, Sedation INTRODUCTION would otherwise be technically unfeasible. Three broad categories of anesthesia exist: Pain has always been linked to dentistry, representing a • General anesthesia suppresses central nervous persistent challenge to the employment of preventive, system activity and results in unconsciousness and restorative, and surgical dental practice.[1,2] It is total lack of sensation. accepted that various procedures in the dental clinic • Sedation suppresses the central nervous system cause pain such as deep dental fillings, root canal to a lesser degree, inhibiting both anxiety and therapy, tooth extraction and tooth preparation. Even creation of long-term memories without resulting when analgesics are used, painful sensations induced in unconsciousness. by dental procedures often cannot be fully eliminated • Regional and local anesthesia, which block and can contribute to anxiety about further dental transmission of nerve impulses from a specific part therapy, postponed or canceled appointments, and of the body. Depending on the situation, this may impaired quality of life. Anesthesia or anesthesia be used either on its own (in which case the patient (from Greek “without sensation”) is a state of remains conscious) or in combination with general controlled, temporary loss of sensation or awareness anesthesia or sedation. Drugs can be targeted at that is induced for medical purposes. It may include peripheral nerves to anesthetize an isolated part of analgesia (relief from or prevention of pain), paralysis the body only, such as numbing a tooth for dental (muscle relaxation), amnesia (loss of memory), work or using a nerve block to inhibit sensation or unconsciousness. A patient under the effects of in an entire limb. Alternatively, epidural or spinal [3] anesthetic drugs is referred to as being anesthetized. anesthesia can be performed in the region of the central nervous system itself, suppressing all Anesthesia enables the painless performance of incoming sensation from nerves outside the area medical procedures that would otherwise cause severe of the block. or intolerable pain to an unanesthetized patient or HISTORY OF ANESTHESIA Access this article online There is a long historical association between Website: jprsolutions.info ISSN: 0975-7619 anesthesia and dentistry. Some of the initial anesthetics 1Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India, 2Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: M. Dhanraj, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India. Phone: +91-9841504523. E-mail: [email protected] Received on: 18-08-2018; Revised on: 23-10-2018; Accepted on: 22-12-2018 Drug Invention Today | Vol 11 • Issue 3 • 2019 715 R. Balaji, et al. given were for dental extractions.[4,5] The first general Children anesthetic administered was for a dental extraction Majority of outpatient general anesthesia in dentistry and is credited to Horace Wells. Wells, on December is administered to small children who may not 11, 1844, underwent extraction of one of his own tolerate dental surgery under local anesthesia or some wisdom teeth by a colleague while under the influence may be failures of attempts using local anesthesia. of nitrous oxide. In 1846, William Morton, a pupil It is recommended that only specialist pediatric of wells, successfully demonstrated the properties of anesthetists should administer general anesthesia to ether to facilitate dental extraction in Massachusetts. very young children. In the 1970s and 1980s, there were numerous deaths, Mentally Challenged Patients often in healthy children undergoing simple dental Such patients, due to problems related to physical/ procedures under general anesthesia. The reasons were mental disability, are unlikely to allow safe completion multifactorial, including administration of anesthesia of treatment under local anesthesia. in conditions with substandard monitoring, assistance, and resuscitation equipment. Furthermore, patients Dental Phobia [6] were poorly prepared for anesthesia and surgery. Patients in whom long-term dental phobia will be However, currently, there is a worldwide trend that induced or prolonged are administered general an increasing number of children are receiving dental anesthesia in the first sitting. The long-term aim in [7-9] treatment under general anesthesia. such patients should be the graduated introduction of treatment under local anesthesia using, if necessary, GENERAL ANESTHESIA conscious sedation and behavior management techniques. General anesthesia for dentistry is not without risk and should not be undertaken as a first-line means Allergy to Local Anesthetics of anxiety control. Considerations should always be It is rare and is due to the amide group of local given to the possibility of local anesthetic techniques anesthetics. The preservative methylparaben can also with or without conscious sedation. Patients requiring cause allergic reactions. However, allergic reaction general anesthesia for dental work are frequently should be differentiated from vasovagal attacks, children or individuals with learning difficulties. The palpitation, and flushing occurring as a result of standards of general anesthesia for dentistry should be absorption of adrenaline present in local anesthetic the same as those in any other setting. solution. General anesthesia in dentistry covers three main Extensive Dentistry and Faciomaxillary Surgery types of surgical procedures: 1. Dental chair anesthesia: It is outpatient anesthesia, Local anesthesia is unsuitable in an awake patient mainly for simple extraction of teeth, especially in when the dentistry is likely to be extensive. children. 2. Day-care anesthesia: It is for minor oral surgery. CONDUCT OF GENERAL 3. In-patient anesthesia: It is for complicated ANESTHESIA extractions, oral surgical procedures, and maxillofacial surgical procedures.[10] Assessment Patients must be assessed in the usual manner, INDICATIONS particularly regarding their medical, social, and surgical suitability for day-case anesthesia. Given Decisions about general anesthesia can only be made the risks of general anesthesia, the possibility of on an individual patient basis, but its use in dentistry performing the procedure under local anesthesia with should be limited to. or without sedation should always be considered. The risks of general anesthesia should be explained to the Acute Infection patient, and consent obtained. In such clinical situations, it would be impossible to achieve adequate local anesthesia and so complete The Clinical Setting treatment without pain, for example, management of Defining the setting in which a general anesthetic is acute dentoalveolar abscess and severe pulpitis. In administered must take into account the “worst case these conditions, drug therapy or drainage procedures scenario” because the uneventful anesthetic is not with other methods of pain relief are in appropriate the problem. Complications of modern anesthesia or unsuccessful. The local anesthetic may not be are rare, but skilled teamwork is required to prevent effective in such conditions due to local change in pH permanent harm to the patient. The further away from and there is a risk of spreading infection also. the support of other clinical services that an anesthetic 716 Drug Invention Today | Vol 11 • Issue 3 • 2019 R. Balaji, et al. is administered, the greater is the risk of death should Aftercare a complication occur. Ideally, all general anesthetics The brief nature of most dental procedures means for dentistry should be administered within the that the majority of patients may be managed on an administrative aegis of the range of services typically “ambulatory” basis. Modern anesthetic drugs permit provided by. The location of any such facility must rapid recovery of consciousness and early discharge, [11] allow easy access for emergency services. but it should be recognized that it may take >24 h for all traces of the agents to be eliminated. Thus, when, Equipment, Monitors, and Drugs in the opinion of the anesthesiologist, patients are All standard equipment, gadgets, monitors, and drugs ready
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