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Wednesday, December 11, 2013
GA with Intubation for Dental Procedure
My 22 month old son needs to have crowns placed on his top two incisors. Because of the lack of cooperation at his age level the Dentist wants do the procedure under general anesthesia in a surgery center. There is another dentist an hour away who will do the procedure in his office under a "conscious sleep" without intubation. Are there risks/benefits of one type of anesthesia over the other? My son also has a lipoma on his abdomen. Our general surgeon said it is very unlikely to be anything of concern, but if my son is going to be put to sleep anyway, he would like to remove it at the same time. Any information you can pass along regarding the anesthesia would be greatly appreciated.
Thank you for your interesting question.
I am not familiar with the term "conscious sleep" but "conscious sedation" is a term commonly applied in the community. The correct medical terms however are "mild", "moderate" or "deep sedation", and general anesthesia. It is not clear from your description what method of sedation your dentist would use. Enteral sedation is the use of oral medications. No IV is used. There are pros and cons to this approach - e.g. the onset is slower but also less predictable. Another technique is the use of nitrous oxide breathed in by mask. General anesthesia for dental procedures will normally require intubation and an IV. Oral sedation does not mean that less monitoring is required and this approach has even been associated with deaths, usually from respiratory (breathing) problems.
Although anesthesia is safer than ever before, the current high levels of safety were achieved through the development and consistent application of safety standards, including the use of certain types of monitoring, coupled with improvement in the skills of anesthesia providers, and were achieved in operating room settings, not offices. That is not to say that sedation in a properly equipped and staffed dentist's office isn't safe, it's just that we don't have as much published data to prove it. Notoriously, a study in Florida some years ago found a 10-fold higher rate of serious problems including death in adult patients undergoing office-based cosmetic surgery. Hospitals and surgery centers have to undergo rigorous accreditation inspections, that include safety, whereas doctors offices do not, although you can be sure that legislation will pretty soon catch up with this in the United States.
If your dentist is offering sedation to your 22 month child you might want to ask about the extent of his/her experience with children so young; outcomes including complication rates; levels of staffing, personnel and their skills; the type of sedation technique used; monitoring equipment; recovery and resuscitation protocols and resources.
Research has shown that the drugs used, the route of administration and the type of patient are less important to morbidity and mortality than the monitoring and resuscitation skills of the providers. So that is of cardinal importance. Your selected provider should be using standard monitors like pulse oximetry and ideally capnometry (carbon dioxide monitoring). Intuitively, having a dedicated anesthesia provider is preferable than assigning the task to someone whose primary role is dentist, or scrub nurse, or something else.
The recovery phase is just as important as the procedure itself. All anesthetics and sedatives take time to wear off. During recovery are there adequate personnel and equipment for monitoring? Can those personnel make good judgments about impending problems, or about when patients are fit to be discharged? In case of problems, is a hospital nearby? Does that hospital have an agreement to take patients who need help? In addition there are issues of cost and convenience to be put into the equation. General anesthesia in a hospital or surgery center will certainly cost more.
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University