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A brief history of British ‘chair’ dental anaesthesia
International Congress Series 1242 (2002) 405 – 408
A brief history of British ‘chair’ dental anaesthesia Adrian Padfield* Royal Hallamshire Hospital, Glossop Road, Sheffield S10, 2GF, UK
Traditional UK general anaesthetics (GAs) for patients in dental surgeries/offices will stop at the end of 2001 by government decree. For 133 years, they have continued in a similar way to Colton’s administration of nitrous oxide to Horace Wells for a dental extraction in 1844. Dentists have had a long involvement with general anaesthesia in Britain, and some unkindly refer to anaesthetists as a junior speciality. A dentist, James Robinson, gave the first GA in the UK in 1846 on 19 December for a dental extraction using ether, but it was not really a suitable or convenient agent for dentistry. Colton reinstated nitrous oxide for dentistry in 1862 – 1863 and is said to have given 27,000 GAs by 1868 when T.W. Evans, an American dentist in Paris, came to London to demonstrate Colton’s method of using nitrous oxide for dental extractions. Doctors, dentists and even lay people took up the method, so it spread rapidly around Britain. Nitrous oxide became popular for dental extractions because chloroform was dangerous and ether was difficult. Both Clover and Coleman, dentists, used nasal masks and designed mouth gags, essential for rapid dental extraction. The Barth & Coxeter companies of London liquefied nitrous oxide in cylinders and these were widely available by mid-1870s. There was little clinical investigation, however, until in 1892, Hewitt published his results and urged mixing with oxygen: advocated by Andrews of Chicago in 1868. Hewitt had designed a suitable portable machine in 1887 (by which date Colton said he had given 150,000 nitrous oxide GAs with no fatalities). There was opposition: many dentists and doctors continued to use 100% nitrous oxide into the late 20th century despite McKesson’s intermittent flow machine in 1910 (emulated by the Walton in 1925) and the availability of modern volatile agents. Rivalry between dentists and doctors about who were the best anaesthetists has always been present in Britain, sometimes breaking out in public. In 1899, a dentist, Marston, said that dentists were better because they did more. He condemned operator/anaesthetists but the practice was only prohibited in 1983 by the UK General Dental Council (GDC). The question is: why did this archaic practice of ‘chair’ GAs survive for so long and was it dangerous? In the UK, dentistry has always been a separate profession but until the
*
Fax: +44-1142664532. E-mail address: [email protected] (A. Padfield).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 7 8 0 - X
406
A. Padfield / International Congress Series 1242 (2002) 405–408
GDC and registration was introduced by Parliament in 1921, it was not properly regulated. Many dentists trained by apprenticeship before this date. When the NHS was introduced in 1948, dentists were paid by item of service fees rather than a salaried service as in the rest of the Health Service. This was a stimulus for speedy treatment; it was quicker to extract teeth under GA rather than local, especially in children. Approximately 70 million chair dental GAs have been given since the start of the NHS in 1948 with a low mortality. The Dental Practice Board (DPB) (formerly Dental Estimates Board) supplied figures of GAs paid for in general dental practice (GDP) since 1948, but for England and Wales alone and Scottish figures go back only to 1968. The author has collected the numbers of GAs in UK dental schools since 1970. Dr. Victor Goldman, who is probably the most famous British dental anaesthetist after Sir Frederick Hewitt, estimated, in a 1958 paper [1], that 7.7 million GAs had been given for dentistry between 1952 –1955. At a meeting in 1960 of the British Dental Association (BDA) in Edinburgh, Scotland, he calculated that there had been nearly 22 million dental GAs given in 7 years, 1952 –1958 = 3.5 million/year (Table 1). He may have overestimated ‘additional cases’ compared to the previous paper, but neither included Scottish dental GAs. In both papers, he calculated the mortality rate— 1:137,500 (1958) and 1:219,000 (1960)—but his motive for his 1960 paper was to show that intravenous GA was more dangerous. It was published in the British Dental Journal (BDJ) [2], including the interesting discussion, and it was followed by robust correspondence including a certain Dr. Coplans. Much controversy but not many facts were generated over the next few years. Useful data were provided by a Report of a Joint Sub-Committee on Dental Anaesthesia [3] in 1967, but a few months later, at a special BDA Conference, it was generally denigrated [4]. There, Coplans pleaded for accurate statistics. In 1973, he and Curson wrote a letter to the British Medical Journal entitled Deaths associated with General Dental Anaesthesia [5]. They pointed out errors in the Registrar General’s category, ‘deaths associated with dentistry’, and also that place of death (usually hospital) was not the same as place of collapse (often the dental surgery). This was important because again it was being suggested by dentists that they were safer than doctors. In October 1969, Coplans and Curson decided to make their own study of the available data and Deaths Associated with Dentistry was published in BDJ [6] in 1982. This was a thorough and detailed analysis of the decade 1970– 1979. The overall mortality rate was 1:267,000, but 1:1.37 million for nitrous oxide alone! The next decade (1980 – 1989) is covered by their 1993 paper Deaths associated with dentistry and dental disease [7]. It included deaths with LA, sedation and various medical conditions, accounting for almost half the total. The paper is shorter but as rigorous as the previous one.
Table 1 Dental cases under general anaesthesia 1952 – 1958 National Health Service cases School Dental Service Additional cases (estimated) [with the help of the Ministry of Health] Approximate total for 7 years Taken from Goldman, 1960 [2].
12,447,140 4,549,769 4,900,000 21,896,909
A. Padfield / International Congress Series 1242 (2002) 405–408
407
Fig. 1. Lower line: annual number of GAs paid for by DPB to dentists in England and Wales. Upper line: author’s extrapolation to include other dental chair GAs. .: Dinsdale and Dixon’s estimate of GAs in dentistry in England and Wales 1976 [8].
Fig. 2. Annual number of deaths attributed to chair dental GAs. Stippled columns from Registrar General.
408
A. Padfield / International Congress Series 1242 (2002) 405–408
The author has collected the numbers of GAs paid for by the DPB (formerly DEB) by courtesy of that organisation, but the DPB numbers of GAs for England and Wales are purely for fees paid to NHS dental practitioners (Fig. 1). The numbers from 1948 to 1950 are omitted because they do not cover 12-month periods. Following and modifying figures in Goldman’s 1960 paper and using what has been the only statistically accurate survey of GAs in dental practice by Dinsdale and Dixon in 1976 (BDJ 1978 [8]), the graph has been extrapolated to allow for GAs in dental schools, school dental or community clinics, general hospitals and Scotland. The deaths shown (Fig. 2) are from the Registrar General’s figures (stippled), from Coplans and Curson (1970 – 1989) and in the last decade, derived from other sources such as media reports, personal communications and A Conscious Decision [9]. It was in this publication that the archaic practice of GA in dental surgeries was condemned even though the death rate over 50 years has been less than 1:235,000.
References [1] V. Goldman, Deaths under anaesthesia in the dental surgery, Br. Dent. J. 105 (1958) 160 – 163. [2] V. Goldman, Halothane in the dental surgery, Br. Dent. J. 109 (1960) 259 – 263. [3] Central Health Services Council, Ministry of Health: Report of a Joint Sub-Committee on Dental Anaesthesia, HM Stationary Office, London, 1967. [4] Conference on general anaesthesia in dentistry, Br. Dent. J. 120 (1967) 1 – 16, Supplement. [5] M.P. Coplans, I. Curson, Deaths associated with general dental anaesthesia, Br. Med. J. i (1973) 109 – 110. [6] M.P. Coplans, I. Curson, Deaths associated with dentistry, Br. Dent. J. 153 (1982) 357 – 362. [7] M.P. Coplans, I. Curson, Deaths associated with dentistry and dental disease, Anaesthesia 48 (1993) 435 – 438. [8] R.C.W. Dinsdale, R.A. Dixon, Anaesthetic services to dental patients, Br. Dent. J. 144 (1978) 271 – 279. [9] A Conscious Decision. A Review of the Use of General Anaesthesia and Conscious Sedation in Primary Dental Care, Department of Health, London, July 2000.
A brief history of British ‘chair’ dental anaesthesia Adrian Padfield* Royal Hallamshire Hospital, Glossop Road, Sheffield S10, 2GF, UK
Traditional UK general anaesthetics (GAs) for patients in dental surgeries/offices will stop at the end of 2001 by government decree. For 133 years, they have continued in a similar way to Colton’s administration of nitrous oxide to Horace Wells for a dental extraction in 1844. Dentists have had a long involvement with general anaesthesia in Britain, and some unkindly refer to anaesthetists as a junior speciality. A dentist, James Robinson, gave the first GA in the UK in 1846 on 19 December for a dental extraction using ether, but it was not really a suitable or convenient agent for dentistry. Colton reinstated nitrous oxide for dentistry in 1862 – 1863 and is said to have given 27,000 GAs by 1868 when T.W. Evans, an American dentist in Paris, came to London to demonstrate Colton’s method of using nitrous oxide for dental extractions. Doctors, dentists and even lay people took up the method, so it spread rapidly around Britain. Nitrous oxide became popular for dental extractions because chloroform was dangerous and ether was difficult. Both Clover and Coleman, dentists, used nasal masks and designed mouth gags, essential for rapid dental extraction. The Barth & Coxeter companies of London liquefied nitrous oxide in cylinders and these were widely available by mid-1870s. There was little clinical investigation, however, until in 1892, Hewitt published his results and urged mixing with oxygen: advocated by Andrews of Chicago in 1868. Hewitt had designed a suitable portable machine in 1887 (by which date Colton said he had given 150,000 nitrous oxide GAs with no fatalities). There was opposition: many dentists and doctors continued to use 100% nitrous oxide into the late 20th century despite McKesson’s intermittent flow machine in 1910 (emulated by the Walton in 1925) and the availability of modern volatile agents. Rivalry between dentists and doctors about who were the best anaesthetists has always been present in Britain, sometimes breaking out in public. In 1899, a dentist, Marston, said that dentists were better because they did more. He condemned operator/anaesthetists but the practice was only prohibited in 1983 by the UK General Dental Council (GDC). The question is: why did this archaic practice of ‘chair’ GAs survive for so long and was it dangerous? In the UK, dentistry has always been a separate profession but until the
*
Fax: +44-1142664532. E-mail address: [email protected] (A. Padfield).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 7 8 0 - X
406
A. Padfield / International Congress Series 1242 (2002) 405–408
GDC and registration was introduced by Parliament in 1921, it was not properly regulated. Many dentists trained by apprenticeship before this date. When the NHS was introduced in 1948, dentists were paid by item of service fees rather than a salaried service as in the rest of the Health Service. This was a stimulus for speedy treatment; it was quicker to extract teeth under GA rather than local, especially in children. Approximately 70 million chair dental GAs have been given since the start of the NHS in 1948 with a low mortality. The Dental Practice Board (DPB) (formerly Dental Estimates Board) supplied figures of GAs paid for in general dental practice (GDP) since 1948, but for England and Wales alone and Scottish figures go back only to 1968. The author has collected the numbers of GAs in UK dental schools since 1970. Dr. Victor Goldman, who is probably the most famous British dental anaesthetist after Sir Frederick Hewitt, estimated, in a 1958 paper [1], that 7.7 million GAs had been given for dentistry between 1952 –1955. At a meeting in 1960 of the British Dental Association (BDA) in Edinburgh, Scotland, he calculated that there had been nearly 22 million dental GAs given in 7 years, 1952 –1958 = 3.5 million/year (Table 1). He may have overestimated ‘additional cases’ compared to the previous paper, but neither included Scottish dental GAs. In both papers, he calculated the mortality rate— 1:137,500 (1958) and 1:219,000 (1960)—but his motive for his 1960 paper was to show that intravenous GA was more dangerous. It was published in the British Dental Journal (BDJ) [2], including the interesting discussion, and it was followed by robust correspondence including a certain Dr. Coplans. Much controversy but not many facts were generated over the next few years. Useful data were provided by a Report of a Joint Sub-Committee on Dental Anaesthesia [3] in 1967, but a few months later, at a special BDA Conference, it was generally denigrated [4]. There, Coplans pleaded for accurate statistics. In 1973, he and Curson wrote a letter to the British Medical Journal entitled Deaths associated with General Dental Anaesthesia [5]. They pointed out errors in the Registrar General’s category, ‘deaths associated with dentistry’, and also that place of death (usually hospital) was not the same as place of collapse (often the dental surgery). This was important because again it was being suggested by dentists that they were safer than doctors. In October 1969, Coplans and Curson decided to make their own study of the available data and Deaths Associated with Dentistry was published in BDJ [6] in 1982. This was a thorough and detailed analysis of the decade 1970– 1979. The overall mortality rate was 1:267,000, but 1:1.37 million for nitrous oxide alone! The next decade (1980 – 1989) is covered by their 1993 paper Deaths associated with dentistry and dental disease [7]. It included deaths with LA, sedation and various medical conditions, accounting for almost half the total. The paper is shorter but as rigorous as the previous one.
Table 1 Dental cases under general anaesthesia 1952 – 1958 National Health Service cases School Dental Service Additional cases (estimated) [with the help of the Ministry of Health] Approximate total for 7 years Taken from Goldman, 1960 [2].
12,447,140 4,549,769 4,900,000 21,896,909
A. Padfield / International Congress Series 1242 (2002) 405–408
407
Fig. 1. Lower line: annual number of GAs paid for by DPB to dentists in England and Wales. Upper line: author’s extrapolation to include other dental chair GAs. .: Dinsdale and Dixon’s estimate of GAs in dentistry in England and Wales 1976 [8].
Fig. 2. Annual number of deaths attributed to chair dental GAs. Stippled columns from Registrar General.
408
A. Padfield / International Congress Series 1242 (2002) 405–408
The author has collected the numbers of GAs paid for by the DPB (formerly DEB) by courtesy of that organisation, but the DPB numbers of GAs for England and Wales are purely for fees paid to NHS dental practitioners (Fig. 1). The numbers from 1948 to 1950 are omitted because they do not cover 12-month periods. Following and modifying figures in Goldman’s 1960 paper and using what has been the only statistically accurate survey of GAs in dental practice by Dinsdale and Dixon in 1976 (BDJ 1978 [8]), the graph has been extrapolated to allow for GAs in dental schools, school dental or community clinics, general hospitals and Scotland. The deaths shown (Fig. 2) are from the Registrar General’s figures (stippled), from Coplans and Curson (1970 – 1989) and in the last decade, derived from other sources such as media reports, personal communications and A Conscious Decision [9]. It was in this publication that the archaic practice of GA in dental surgeries was condemned even though the death rate over 50 years has been less than 1:235,000.
References [1] V. Goldman, Deaths under anaesthesia in the dental surgery, Br. Dent. J. 105 (1958) 160 – 163. [2] V. Goldman, Halothane in the dental surgery, Br. Dent. J. 109 (1960) 259 – 263. [3] Central Health Services Council, Ministry of Health: Report of a Joint Sub-Committee on Dental Anaesthesia, HM Stationary Office, London, 1967. [4] Conference on general anaesthesia in dentistry, Br. Dent. J. 120 (1967) 1 – 16, Supplement. [5] M.P. Coplans, I. Curson, Deaths associated with general dental anaesthesia, Br. Med. J. i (1973) 109 – 110. [6] M.P. Coplans, I. Curson, Deaths associated with dentistry, Br. Dent. J. 153 (1982) 357 – 362. [7] M.P. Coplans, I. Curson, Deaths associated with dentistry and dental disease, Anaesthesia 48 (1993) 435 – 438. [8] R.C.W. Dinsdale, R.A. Dixon, Anaesthetic services to dental patients, Br. Dent. J. 144 (1978) 271 – 279. [9] A Conscious Decision. A Review of the Use of General Anaesthesia and Conscious Sedation in Primary Dental Care, Department of Health, London, July 2000.