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DEATH FOR ANAESTHESIA IN THE GENERAL AND COMMUNITY DENTAL SERVICE?
" / would have everie man write what he knowes and no
BRITISH
JOURNAL
OF
more."—MONTAIGNE
ANAESTHESIA APRIL 1986
VOLUME 58, No.4
EDITORIAL DEATH FOR ANAESTHESIA IN THE GENERAL AND COMMUNITY DENTAL SERVICE?
140 i 130 120 110 100 90 80 7060 5040 ' 30 • 20 • 10 •
0
FIG. 1. Number of anaesthetics administered in general dental practice (black areas), and the community dental service (open columns) in Scotland 1978-1984.
over the past 7 years and a similar trend extends back over a much longer period both in Scotland, and in England and Wales. In England and Wales for example, the total number of anaesthetics given in the general dental service decreased from 1138320 in 1974 to 792660 in 1978, then to 408960 in 1984. To assess whether the trend is likely to continue, the underlying causes must be considered. A major factor is the current decrease in the incidence of dental caries, which has declined by 35-50 % over the past 10-15 years in most industrialized countries (Jenkins, 1985). The main factor is, probably, the use offluoridetoothpaste. Currently, this decrease in the incidence of caries is continuing and may accelerate in the U.K. now that the Bill to authorize fluoridation of water supplies has been approved. This decrease in incidence has led to a commensurate reduction in the numbers of teeth extracted, but the effect on the numbers of anaesthetics is even greater than might be anticipated, as multiple extractions are now becoming less common and dentists find that local analgesia will often suffice for the extraction of the single tooth. A second factor leading to a reduction in the use of anaesthesia in dental practice lies in the recommendations of the General Dental Council. In November, 1981 the Council recommended in a notice for the guidance of dentists that "neither general anaesthesia nor sedation should be employed unless proper equipment for their administration and adequate facilities for the resuscitation of the patient are readily available with both the operator and his staff trained in their use". In addition, the Council recommended that a second person, a dental or medical practitioner appropriately trained, should be present to
Downloaded from http://bja.oxfordjournals.org/ at New York University on June 11, 2015
There have been several reviews of the risk of death to patients receiving anaesthesia in the dental chair (Coplans and Curson, 1973, 1982; Tomlin, 1974). Although the overall risk is very small—perhaps one in 248000 anaesthetics for the general and community dental service (Coplans and Curson, 1982)—such accidents are particularly tragic, as most patients are young and fit. Facilities for resuscitation and recovery have been inadequate in many dental surgeries (Dinsdale and Dixon, 1978) and so improvements in this field might reduce the risk. However, the title identifies a different problem for the dental anaesthetist, which is shown graphically, using Scotland as an example in figure 1. The histogram indicates the combined total of anaesthetics given in general dental service and community dental service over the years 1978-1984. The numbers have decreased steadily
370
BRITISH JOURNAL OF ANAESTHESIA
Downloaded from http://bja.oxfordjournals.org/ at New York University on June 11, 2015
administer (or supervise a trainee administering) an anaesthetic. Possession of a dental degree alone does not meet the requirement to be "appropriately trained". Although the 1985 Council recommendations concerning the dental curriculum indicate that students should have practical experience in i.v. and inhalation sedation techniques and in general anaesthesia and resuscitation, the recommendations add "that students should qualify with full recognition of their limitations in these aspects of pain control which must be recognised as subjects for postgraduate study". To meet the General Dental Council recommen83 80 dations and those of the Spence Report (1981) a period of 3 months' full-time training in dental anaesthesia has been offered for several years by FIG. 2. Number of anaesthetics administered in Dental Hospitals in Scotland 1978-1984. the West of Scotland Postgraduate Committee. No Scottish applicants have been received and it appears that few newly-qualified dentists now previously, the number of patients treated has wish to embark on a postgraduate study of been maintained. There will always be some anaesthesia. As dentally qualified anaesthetists patients requiring outpatient or day-case anaesbecome less readily available, many dentists thesia for dental treatment, but by the early 1990's transfer to techniques which avoid the need for I would anticipate the numbers will be so small anaesthesia. that all such patients can be referred to dental A final factor which is causing the decrease in schools or major hospitals. the use of dental anaesthesia is the increasing use G. D. Parbrook of the alternative technique of local anaesthesia with sedation. "Relative Analgesia" or sedation with low percentages of nitrous oxide has a good ACKNOWLEDGEMENTS record of safety, while sedation by i.v. agents such I am grateful to Mr J. W. Shoolbread of the Scottish Dental as diazepam is also proving popular. Midazolam Estimates Board and Mr D. Loeb of the Common Services provides a promising alternative and several Agency, for details of the number of anaesthetics given in the papers on the benzodiazepines are included in the General and Community Services in Scotland, and to Mr R. Elwis of the Dental Estimates Board, for the figures for present issue of this journal. Dental students now N. England and Wales. Details of the anaesthetics given in see sedation techniques in regular use in their Glasgow, Edinburgh and Dundee Dental Schools were kindly training, and postgraduate courses in sedation are provided by Dr D. P. Braid, Dr D. MacLachlan and by Miss well subscribed. These techniques now attract a J. M. Stonier. stated fee per item in the general dental service, so this factor, too, may encourage their use in future. REFERENCES All three factors described (the decrease in Coplans, M. P., and Curson, I. (1973). Deaths associated with dental caries, better standards for dental anaesgeneral dental anaesthesia. Br. Med. J., 1, 109. thesia and the increasing use of sedation techniques) (1982). Deaths associated with dentistry. Br. Dent. J., 1S3, 357. continue to apply, so I would predict death for anaesthesia in the general and community dental Dinsdale, R. C. W., and Dixon, R. A. (1978). Anaesthetic services to dental patients: England and Wales 1976. practice within 10 years. For Scotland the final Br.Dait.J., 144,271. demise could be as early as 1992. Jenkins, G. N. (1985). Recent changes in dental caries. Br. Med. J., 4, 1297. To conclude with a cheering note for those anaesthetists with an interest in dental outpatient The Spence Report (1981). Report of a Joint Working Party on anaesthesia in general dental practice. Br. Dent. J., 151, anaesthesia, figure 2 details the number of dental 392. anaesthetics given in Scottish dental schools. In Tomlin, P. J. (1974). Death in outpatient dental practice. contrast to the figures for Dental Practice shown Anaesthesia, 29, 551.
BRITISH
JOURNAL
OF
more."—MONTAIGNE
ANAESTHESIA APRIL 1986
VOLUME 58, No.4
EDITORIAL DEATH FOR ANAESTHESIA IN THE GENERAL AND COMMUNITY DENTAL SERVICE?
140 i 130 120 110 100 90 80 7060 5040 ' 30 • 20 • 10 •
0
FIG. 1. Number of anaesthetics administered in general dental practice (black areas), and the community dental service (open columns) in Scotland 1978-1984.
over the past 7 years and a similar trend extends back over a much longer period both in Scotland, and in England and Wales. In England and Wales for example, the total number of anaesthetics given in the general dental service decreased from 1138320 in 1974 to 792660 in 1978, then to 408960 in 1984. To assess whether the trend is likely to continue, the underlying causes must be considered. A major factor is the current decrease in the incidence of dental caries, which has declined by 35-50 % over the past 10-15 years in most industrialized countries (Jenkins, 1985). The main factor is, probably, the use offluoridetoothpaste. Currently, this decrease in the incidence of caries is continuing and may accelerate in the U.K. now that the Bill to authorize fluoridation of water supplies has been approved. This decrease in incidence has led to a commensurate reduction in the numbers of teeth extracted, but the effect on the numbers of anaesthetics is even greater than might be anticipated, as multiple extractions are now becoming less common and dentists find that local analgesia will often suffice for the extraction of the single tooth. A second factor leading to a reduction in the use of anaesthesia in dental practice lies in the recommendations of the General Dental Council. In November, 1981 the Council recommended in a notice for the guidance of dentists that "neither general anaesthesia nor sedation should be employed unless proper equipment for their administration and adequate facilities for the resuscitation of the patient are readily available with both the operator and his staff trained in their use". In addition, the Council recommended that a second person, a dental or medical practitioner appropriately trained, should be present to
Downloaded from http://bja.oxfordjournals.org/ at New York University on June 11, 2015
There have been several reviews of the risk of death to patients receiving anaesthesia in the dental chair (Coplans and Curson, 1973, 1982; Tomlin, 1974). Although the overall risk is very small—perhaps one in 248000 anaesthetics for the general and community dental service (Coplans and Curson, 1982)—such accidents are particularly tragic, as most patients are young and fit. Facilities for resuscitation and recovery have been inadequate in many dental surgeries (Dinsdale and Dixon, 1978) and so improvements in this field might reduce the risk. However, the title identifies a different problem for the dental anaesthetist, which is shown graphically, using Scotland as an example in figure 1. The histogram indicates the combined total of anaesthetics given in general dental service and community dental service over the years 1978-1984. The numbers have decreased steadily
370
BRITISH JOURNAL OF ANAESTHESIA
Downloaded from http://bja.oxfordjournals.org/ at New York University on June 11, 2015
administer (or supervise a trainee administering) an anaesthetic. Possession of a dental degree alone does not meet the requirement to be "appropriately trained". Although the 1985 Council recommendations concerning the dental curriculum indicate that students should have practical experience in i.v. and inhalation sedation techniques and in general anaesthesia and resuscitation, the recommendations add "that students should qualify with full recognition of their limitations in these aspects of pain control which must be recognised as subjects for postgraduate study". To meet the General Dental Council recommen83 80 dations and those of the Spence Report (1981) a period of 3 months' full-time training in dental anaesthesia has been offered for several years by FIG. 2. Number of anaesthetics administered in Dental Hospitals in Scotland 1978-1984. the West of Scotland Postgraduate Committee. No Scottish applicants have been received and it appears that few newly-qualified dentists now previously, the number of patients treated has wish to embark on a postgraduate study of been maintained. There will always be some anaesthesia. As dentally qualified anaesthetists patients requiring outpatient or day-case anaesbecome less readily available, many dentists thesia for dental treatment, but by the early 1990's transfer to techniques which avoid the need for I would anticipate the numbers will be so small anaesthesia. that all such patients can be referred to dental A final factor which is causing the decrease in schools or major hospitals. the use of dental anaesthesia is the increasing use G. D. Parbrook of the alternative technique of local anaesthesia with sedation. "Relative Analgesia" or sedation with low percentages of nitrous oxide has a good ACKNOWLEDGEMENTS record of safety, while sedation by i.v. agents such I am grateful to Mr J. W. Shoolbread of the Scottish Dental as diazepam is also proving popular. Midazolam Estimates Board and Mr D. Loeb of the Common Services provides a promising alternative and several Agency, for details of the number of anaesthetics given in the papers on the benzodiazepines are included in the General and Community Services in Scotland, and to Mr R. Elwis of the Dental Estimates Board, for the figures for present issue of this journal. Dental students now N. England and Wales. Details of the anaesthetics given in see sedation techniques in regular use in their Glasgow, Edinburgh and Dundee Dental Schools were kindly training, and postgraduate courses in sedation are provided by Dr D. P. Braid, Dr D. MacLachlan and by Miss well subscribed. These techniques now attract a J. M. Stonier. stated fee per item in the general dental service, so this factor, too, may encourage their use in future. REFERENCES All three factors described (the decrease in Coplans, M. P., and Curson, I. (1973). Deaths associated with dental caries, better standards for dental anaesgeneral dental anaesthesia. Br. Med. J., 1, 109. thesia and the increasing use of sedation techniques) (1982). Deaths associated with dentistry. Br. Dent. J., 1S3, 357. continue to apply, so I would predict death for anaesthesia in the general and community dental Dinsdale, R. C. W., and Dixon, R. A. (1978). Anaesthetic services to dental patients: England and Wales 1976. practice within 10 years. For Scotland the final Br.Dait.J., 144,271. demise could be as early as 1992. Jenkins, G. N. (1985). Recent changes in dental caries. Br. Med. J., 4, 1297. To conclude with a cheering note for those anaesthetists with an interest in dental outpatient The Spence Report (1981). Report of a Joint Working Party on anaesthesia in general dental practice. Br. Dent. J., 151, anaesthesia, figure 2 details the number of dental 392. anaesthetics given in Scottish dental schools. In Tomlin, P. J. (1974). Death in outpatient dental practice. contrast to the figures for Dental Practice shown Anaesthesia, 29, 551.