Working with a Dentist Anesthesiologist
WORKING WITH A DENTIST ANESTHESIOLOGIST
Kenneth Reed, Amanda Okundaye
Staying in the dental office versus going to a hospital operating room is much more convenient for both dentists and patients. Anesthesia and dental services may be delivered in a dental office for significantly less health care dollars that would be required in the hospital operating room. With health care dollars at a premium, healthcare “reform” well on its way in the United States and more and more people paying out of pocket for dental services, utilization on the hospital operating rooms may decline in the future for otherwise healthy pediatric dental patients. There now is a trend toward in office deep sedation and general anesthetics in some geographical regions (Olabi et al.2012) hence, the focus of this chapter is to discuss why and how to work with a dentist anesthesiologist.
As has been described elsewhere in this text, the levels of sedation to anesthesia within medicine and dentistry are: minimal sedation, moderate sedation, deep sedation andgeneral anesthesia. Both minimal sedation and moderate sedation are “conscious” techniques. A hallmark of a conscious technique is that the patient responds to verbal command or light tactile stimulation. In the case of minimal sedation, the description is the patient responds normally to verbal command or light tactile stimulation. In the case of moderate sedation, the description is the patient responds purposefully to verbal command or light tactile stimulation. If minimal to moderate sedation fails, the next level is deep sedation or general anesthesia.
For these levels, the pediatric dentist has to consider whether the patient will be treated in the dental office or in the hospital. What are the educational requirements for a dentist anesthesiologist? Many years ago, there were no formal requirements for dentists to be able to administer any form of
sedation or anesthesia. Likewise there were no guidelines for dentists in the area of sedation and anesthesia. The first “guidelines for teaching the comprehensive control of pain and anxiety in dentistry” were published in 1972 (Am Dent Assoc.) In the 1985 update of the “guidelines for teaching the comprehensive control of pain and anxiety in dentistry,” the concept of “deep sedation” was introduced and training required to perform this level of anesthesia was deemed to be the same as for general anesthesia (Peskin 1993). These documents have been updated many times since the original version and will continue to be updated as needed.
The training to be licensed and permitted to administer minimal to moderate oral sedation may be obtained in almost all pediatric dental residencies or through a variety of continuing education courses. To be licensed and permitted to administer deep sedation or general anesthesia, the training may only be obtained in specific residencies today. The training requirements for deep sedation and anesthesia are the same.
For dentists in the U.S., the completion of a dental anesthesiology or oral and maxillofacial surgery residency is required in order to obtain a permit to administer general anesthesia. It is not possible to obtain training to administer deep sedation or general anesthesia in a continuing education course. Several pediatric dentists have also completed dental anesthesiology residencies, but the overwhelming majority of pediatric dentists have been trained only to the level of either minimal or moderate oral sedation. Deep sedation and general anesthesia can be thought of as equivalent. Both deep sedation and general anesthesia are “unconscious” techniques where the patient does not respond to verbal command or light tactile stimulation. The technical difference is only that in deep sedation the patient does respond purposefully following repeated or painful stimulation whereas in general anesthesia the patient is not arousable, even following painful stimulation.
Often pediatric dental patients have local anesthesia administered in addition to deep sedation or general anesthesia which muddies the difference between deep sedation and general anesthesia so it is easiest to simply consider deep sedation to be equivalent to general anesthesia.
HOSPITAL BASED VERSUS OFFICE BASED TREATMENT
When minimal to moderate oral sedation fails in the pediatric dental office,
anesthesia may be indicated. For these patients,
many pediatric denti
e their patients
. Consequently, patients
productive time in the office. In
for a typical one
hour dental case
based anesthesia versus hospital
. In early 1990s dollars, he
found the hospital fee approximated
$1,900 while the office
based case would typically cost $150. As of 2009, office
anesthesia remained less than 10%
of the cost of hospital
nesthesia for dental
The spread between hospital
based anesthesia pric
still exists today.
Rashewsky and colleagues
determined that hospital operating
room expense for a pediatric dental patient was 13.2 times the expense of office
anesthesia. At Stony Brook Medicine, dental patients requiring treatment with general
anesthesia receive dental care in either an ou
tpatient facility at the Stony Brook School of
Dental Medicine or in the Stony Brook University Hospital ambulato
the time and cost for ambulatory American Society of
Anesthesiologists (ASA) Class I pediatric patients receivi
rehabilitation using general anesthesia in those two locations
reviewed 96 patient
patients that were ASA I and aged 36
60 months. There were significant
differences in cost, total anesthesia time, and recovery room
time. The average total time
(anesthesia end time minus anesthesia start time) to treat a child at Stony Brook
University Hospital under general anesthesia was 222 +/
62.7 minutes, and recovery
time (time of discharge minus anesthesia end time) was 157
97.2 minutes; the
average total cost was $7,303. At the Stony Brook School of Dental Medicine, the
average total time was 175 +/
36.8 minutes, and recovery time was 25 +/
the average total cost was $414. This study provides evidenc
e that ASA I pediatric
patients can receive full
mouth dental rehabilitation utilizing general anesthesia under the
direction of dentist anesthesiologists in an office
based dental setting more quickly and at
a lower cost than in a hospital based operating
room setting. This is very promising for
patients with the least access to care, including patients with spec
ial needs and lack of
insurance (Rahewsky 2012).
To some extent, the economic barrier is lowered.
So what are other
advantages and disadvantage
s of treating pediatric dental patients in the
hospital operating room versus the dental office? Having provided ane
sthesia services in
, the a
uthors of this chapter
know both systems we
. To begin, there is a
need for both
office and in
choice is determined
by what is available to the practitioner
how the practitioner was
originally trained. Many pediatric dentists, especially those tr
ained some time ago only
the hospital operating room option.
While the hospital operating room is safe, it is often not th
e most ideal place to treat
pediatric dental p
atients. It is a
burden for the pediatric dentist to bring all of the
supplies and equipment th
In some cases,
s charge a facility fee and it is illegal for
s to bring any
nto the operating room.
Hospitals may not have a wide variety of
instruments and dental su
The dentist has to use what is available.
also can be inefficient.
Dental cases are
s in a
medical setting so
it is not
unusual for a dental case to be
“bumped” in order to place a
higher, emergent medical case in the operating room where the dental case was
a novel finding of
emale board certified pediatric
dentists were more likely to employ a dentist ane
sthesiologist than male members.
Based on the data of the foregoing study, it is apparent that dentist anesthesiologist
availability is a main impediment
to increasing the n
umber of deep sedation a
in dental office
. To understand
the problem, some understanding of the
history is needed.
It was realized
the 1950s that a specialty of anesthesia in dentistry
would benefit the profession
department of dental anesthesiology at
the Tokyo Medical and Dental University
was created by Dr. Tadashi Ueno (Matsuura
1993). In 1953,
the American Dental Society of Anesthesiol
ogy (ADSA) was formed
(Peskin 1993). T
he first application for specialt
y status was submitted to the American
Dental Association (ADA) during this time
Unfortunately for dentistry,
and more importantly dental pa
tients, this application was unsuccessful
The next major event
affecting the administration of
anesthesia by dentists was in the
hysicians ‘drew a line in the sand.’
s a portion of a policy statement in
The American Society of Anesthesiologists (ASA) wrote “anesthesia care is the
practice of medicine.”
As a consequence
ts administering anesthesia could be
accused by state medical boards of practicing medicine without a license. Fortunately, by
1987 the ASA had published a more reasonable statement: “The ASA recognizes the
right of qualified dentists as defined by the Am
erican Dental Association to administer
conscious sedation, deep sedation and general anesthesia to patients
procedures only” (ASA 1987).
The ASA recognition has allowed a maturing of the anesthesia specialty. In
Commission on Dent
al Accreditation (CODA) published a
Standards document entitled
“Advanced Dental Education Programs in Dental Anesthes
iology.” Hence, s
now exist for dental anesthesia residencies to be accredited.
a minimum of 500 deep sedations/general anesthetics, 200 of
which must be intubated general anesthetics, and at least 50 must be nasotracheal
cases must incorporate advanced airway techniques such as fiber
tion or lary
ngeal mask airway
. A minimum of 10
0 cases must be for children
age 6 years
or younger and 50 cases must be for special
According to an editorial
by Dr. Joel Weaver (
three major benefits to the
will be derived from
the accreditation of dentist anesthesiologist residency
1. Since there is a huge increased need and demand for dentists to provide advanced sedation and
anesthesia services for other dentists, accreditation should provide increased
to support more residents and residency programs to meet that need and demand.
2. Accreditation by dentistry helps cement anesthesia at its highest level as being within the scope
of dental education and within the scope of the clini
cal practice of dentists.
3. Finally, accreditation keeps the highest level of anesthesia education within the control of
dentistry and maintains our ability to control the quality of anesthesia training that dentist
anesthesiologists receive to protect t
he safety of the public that we serve.
State dental boards now have an appropriate measuring stick to judge the adequacy of
anesthesia training for dentist anesthesiologists. They should now recognize that future
dentist anesthesiologists must be graduat
es of CODA
accredited training programs to be
eligible for anesthesia permits (with, of course, traditional grandfathering for those who
completed training prior to accreditation.)
Accreditation helped to
more residents and residency
meet the need and demand
. In 2007, there were roughly 200 dentist
anesthesiologists in the Un
ited States. There were
five dental anesthesia training
programs in North America that were graduating a combined nine residents in dental
anesthesia per year. In 2
013 there are approximately
300 dentist anesthesiologists in the
, the number of
dental anesthesia training programs in North America
CLINIC USE OF A DENTIST ANESTHESIOLOGIST
Dentist anesthesiologists can help pediatric dentists
with their more troublesome patients
by allowing dentistry to be done safely, efficiently and in a cost effective manner in the
pediatric dental office.
ost dentist anesthesiologists
in the United States
that is, they bring all of their drugs, supplies and equipment with them
when they travel
to a pediatric dental office to provide anesthesia services. Figure 1 demonstrates a
“mobile” setup of a dentist anesthesiologist.
Figure 2 shows the dentist anesthesiologist’s
drugs, supplies and equipment in a dental office, pr
oviding general anesthesia for a
pediatric dental patient.
The usual procedure for involving a dentist anesthesiologist is as follows. T
a day for the dentist anesthesiologist to be in the office
cases are scheduled
to make the day more efficient for both doctors.
the treatment day, the pediatric dental office provid
es a copy of the schedule with patient
data to the dentist anesthesiologis
The dentist anesthesiologis
t typically reviews the
medical history as collected by the pediatric dentist
and talks to the parent or
caregiver one or more days prior to the anesthetic. Further que
history of the child
at that time
t information for physicians or other health
care providers may be obtained if consultation with the patient’s physician is indicated.
Financial arrangements are discussed with the parent. During the pre
call, NPO (
nihil per os
; nothing b
y mouth) requirements are relayed as well as any other
operative instructions such as which medications to take and which to withhold. The
dentist anesthesiologist explains to the parent what to expect. For pre
pediatric patients or uncoo
perative patients with special needs, it is especially important
to inform the parent or caregiver the method of induction of general anesthesia and what
is expected of the parent or caregiver.
CHOICE OF DEEP SEDATION OR GENERAL ANESTHESIA:
It is a moot
whether deep sedation or general anesthesia are chosen as the technique for a particular
case. The dentist anesthesiologist is trained in both techniques and there is enough gray
area, overlap and continuum of spectrum between deep sedation and gene
that teasing out the exact definition during a given case is an academic exercise only.
PREMEDICATION BEFORE DEEP SEDATION OR GENERAL ANESTHESIA:
before general anesthesia
in the pediatric patient is generally not
unless the pre medication/pre induction is given in the office by the
minutes to an hour before planned anesthetic.
the biggest contribution to the anxiety of the child.
premedication is chosen, the oral route is by far the most common. Further, a
benzodiazepine is the most commonly chosen class of drug for orally administered
premedication prior to deep sedation or general anesthesia and the specific
ne is most often midazolam. This drug i
s chosen as it provides some d
is an anxiolytic agent and has a very shallow dose response curve which
translates to a very wide margin of safety.
DEEP SEDATION OR
An IV induction is
the safest and most effective method of inducing
deep sedation or
the patient will allow an IV to be started, that is idea
l. Some older children and
functioning patients with
special needs will allow it
If a lack of cooperation precludes
starting an IV, there are two primary methods of inducing
deep sedation or
. Some dentist anesthesiologists prefer an induction with intramus
drugs. Most often the IM drug of choice
with or without midazolam
without glycopyrrolate. The other primary method of inducing general anesthesia to an
uncooperative dental patient is a “mask” induction
. This technique utilizes
volatile general anesthetic gas, most of
Sevoflurane really isn’t used to
induce deep sedation, only general anesthesia.
Some dentist anesthesiologists have both
sevoflurane and ketamine available and use each technique for different situations
nique over the other.
hat prefer a mask induction generally agree
saves the patient the
ring the IM induction hold
that pediatric patients get
inoculations on a regular basis and this is simply one more “shot” and they
more in the future. Those that criticize mask inductions say that holding a child down
and forcing a mask on them, especially in a claustrop
hobic patient is less than ideal.
Others will point out that in the more cooperati
ve pediatric dental patient, who
in holding the mask, the
n be stress free
Based on personal
there is no right or wrong way to induce
general anesthesia in the pediatric
deep sedation or
general anesthesia is induced, the vast majority of dentist
anesthesiologists will establish IV access.
Having an IV allows administration of
, if needed and
rovides an immediate access
should emergency drug
administration become necessary.
Open airway is defined as an airway that is not intubated or secured wi
th an airway
adjunct such as a nasoendotracheal tube or l
aryngeal mask airway.
anesthesia is performed daily for all levels of anesthesia and has been performed safely
for many years and taught in many pediatric dental residency programs in the US.
literature does not provide a sufficient reaso
n for open airway v
instead it is left up to the individual providing the anesthetic, their training,
comfort level, and case selection.
Any level of sedation being administered should utilize
a throat pack or oral partition.
It is our recommendation that during open airway cases
water if it is required
at all and
rubber dam to
decrease the amount of debris that goes in the throat pack or oropharynx.
The throat pack
is placed in the oropharynx to protect contents from going down the airway and causing
possible complications such as a laryngospasm.
a pediatric dental
type of airway is often
prefer an “open airway” for all procedures, feeling the patient can be kept at a lighter
plane of anesthesia than with adv
anced airway manipulation.
They contend that
induction and recovery is faster
in short cases with an open airway.
However with an
open airway case in a pediatric patient, a patent airway must be maintained at all times
and often either the pediatric dentist, dentist anesthesiologi
st or dental assistant will end
up manipulating the airway for at least a portion of the procedural time. Fewer supplies
and equipment are also necessary in an open airway case than one where there is more
aggressive airway manipulation.
Both deep sedati
on and general anesthesia may be
accomplished with open airway techniques.
Other dentist anesthesiologists prefer a more secure airway even though it requires a
deeper level of anesthesia. Nasotracheally
intubated general anesthesia is considered by
some to be the “gold standard’ for
but a few seconds to a couple of minutes longer than an open airway
. An advantage is that with t
e secure airway, mandible position and the use of
spray are no concern
. Also, with endotracheal intubation, laryngospasm
during the case
is not an issue:
the incidence of laryngospasm is
very low upon either induction or
emergence in an intubat
al anesthesia case
If an endotracheal tube is used, the
resultant anesthetic is always general anesthesia, not deep sedation.
If the plan is to
maintain the anesthetic on a volatile agent such as sevoflurane, some type of advanced
airway will be
necessary. For a dental procedure in which some degree of airway
protection is desired, other than an endotracheal tube, a flexible laryngeal mask airway
(LMA) may be chosen. The LMA offers a more protected airway than a simple throat
partition as used in
an open airway technique but it does not offer the same level of
protection as an endotracheal tube. Additionally, occlusion may be checked and a variety
of other dental manipulations done in cases of an open airway or nasoendotracheal tube
where these s
ame things may not easily be accomplished under LMA general anesthesia.
deep sedation may be utilized with an LMA while practically
resultant level if an LMA is used will
always be true general anesthesia.
OF GENERAL ANESTHESIA
Once the patient is
the airway of choice
is established, the next decision is determining how
general anesthesia. Again
there are two main options. One is to maintain
general anesthesia with IV drugs and the other is to maintain general anesthesia with
inhaled general anesthetic gas. Maintaining with IV agents has a number of advantages.
There is no concern of “gas hygi
ene” and pollution of the dental operatory with waste
anesthetic gases. The equipment used to administer the IV medications is typically a
small, lightweight infusion pump. The drugs used most often
are propofol with
or alfentanil. Each of
have a very short clinical duration of
action and therefore rapid emergence from general anesthesia. Propofol is also a great
antiemetic agent while it is exerting its effects so post
operative nausea and vomiting are
extremely rare. Other ag
ents may be administered through the IV regardless of whet
IV or gas maintenance is desired. Various anti
emetics are sometimes administered,
If an inhalational maintenance is desired with either an LMA
or endotracheal tube in
place, most often that gas is sevoflurane although occasionally isoflurane or desflurane
are chosen for specific reasons. Sevoflurane is a good all around inhalational general
anesthetic. It is the most desirable for an inhalation
al induction as it is least irritating to
the pulmonary system and
has an inoffensive
odor. It works rapidly and has a relatively
Another benefit of the inhalational anesthetics is that they have generally not been in a
nor have prices escalated as they have with most IV drugs. In 2013,
every drug used in anesthesia for dentistry has been in short supply or on back order at
least once and the price of most IV drugs used in anesthesia for dentistry has increa
fold over a four year period. I
nhalational general anesthetics
relatively price stable
At the conclusion of the procedure for the pediatric dental patient, the drugs
are turned off, the patient allowed to breathe 100% oxygen
. The pediatric patient is
allowed to regain consciousness and recover completely. For the patient that had an open
airway deep sedation or general anesthetic, the throat partition is simply removed and
oxygen continued most often via nasal cannula.
here are different schools of thought on the proper time to extubate those patients that
were intubated. Deep
extubation has merit as does
awake extubation and each may be
used on different patient populations or for different
during emergence when the child is deeply anesthetized and will not respond to the
endotracheal tube being removed.
Awake extubation is when the endotracheal tube is
removed once a patient has opened their eyes, lifted their head for five seconds,
pontaneously breathing with no residual muscle relaxant on board.
It is still debated
whether deep extubation v
awake extubation is the preferred technique to reduce the
incidence of emergencies on emergence from anesthesia.
Whether the patient is
deep or awake the overall incidence of adverse events have not been shown to
Once the patient has regained consciousness, they are observed for a period of time until
they may be safely dismissed. For some patients and some deep
sedation techniques for
pediatric dental patients, that may be as short a time period as ten minutes and for other
pediatric dental patients and general anesthesia techniques the recovery time may exceed
one hour. Pediatric dental patients usually recover
fairly quickly from deep sedation or
general anesthesia in the dental office and they recover without significant upset or
discomfort in the majority of cases. These patients have complete amnesia from shortly
after the IM injection or mask induction thr
ough part of the recovery period. They
generally experience no trauma directly related to the anesthesia.
Dentist anesthesiologists are trained to handle
rgencies in the dental setting
virtue of their
training and by involving the office staff at each individual office
they administer anesthesia. It is the anesthesia provider
s responsibility for ensuring the
meets appropriate standards. Each state law also mandates minimum levels of
ipment and facilities
The anesthesia provider must ensure immediate per
to emergency drugs and
equipment and always ensure the office staff can provide basic
life support and activate EMS.
Every patient is monitored as if the patient was in
is always used and blood pressure, heart rate, respiratory rate
oxygen saturation is also always used.
Depending on the practitioner, procedure and
type of airway chosen, end tidal carbon dioxide and/or a precordial stethos
cope may be
Emergency back up lighting, oxygen, suctioning and monitoring is brought to
each facility with the anesthesia provider or already fixed in each facility.
There are a variety of locations that deep sedation and general anesth
esia may be safely
performed for pediatric dental patients. Each has
benefits and drawbacks.
It is up to the
pediatric dentists to make the choice. This chapter was intended to provide background
information to facilitate
that choice. It has emphasized
of both operati
ng room time and
mobile dentist anesthesiologists. There are
different techniques for inducing and maintaining deep sedation and general anesthesia,
different airway adjuncts that may be chosen, di
fferent drugs that may be used for
maintaining deep sedation and general anesthesia and different ways of recovering the
pediatric dental patient from deep sedation or general anesthesia. The bottom line is, all
options are correct. The important thing i
s not who administers the anesthetic or where,
but that there remains the availability of obtaining anesthesia services for pediatric dental
patients that have such an important need for it.
Albany Medical Center, St. Peter’s Hospital, Albany,
The Future of Dental Education.
American Dental Associat
ion Council on Dental Education (1972)
teaching the comprehensive control of pain and anxiety in dentistry.
American Society of Anest
hesiologists House of Delegates (1982)
the administration of anesthes
ia by dentists. October 26
ty of Dentist Anesthesiologists (2010)
The necessity for advanced
for dental care. Available at
American Society of Anesthesiologists Board of Directors: Statement
supporting the right
of qualified dentists as defined by the American Dental Association to utilize anesthesia
for the management of dental patients. August 22, 1987.
Parenteral Sedation Education. New York State Dental
Modern History of Dental Anesthesia in Japan Anesth
et al. (2012)
The Use of Office
and General Anesthesia by Board Certified Pediatric Dentists Practicing in the United
Dentists and Anesthesia: Historical and Contemporary Perspectives.
, et al. (2012)
Time and Cost Analysis:
Pediatric Dental Rehabilitation with General Anesthesia in the Office and the Hospital