Restorative dentistry under general anesthesia

Anesthesiology Leonard

M. Monhciw,

l?ditok

Restorative dentistry under general anesthesia IZichard

T

J. Lowell,

D.D.S.,

Jumccicn, N. 17.

he use of general anesthesia in dentistry has been common practice for many years, but has been restricted, more or less, to the practice of oral surgery. Most, if not all, types of oral surgical procedure, from simple exodontia to the removal of large cysts and tumors, have been performed under general anesthesia. These operations have taken place in the hospital and in the private dental office. In recent years, as a result of new drugs, new techniques, and improved training in general anesthesia for the oral surgery intern and resident, t,he number of procedures performed under general anesthesia in the private office has increased. The employment of general anesthesia for rest,orative dentistry was a logical consequence of its use in oral surgery. Dentistry has always been primarily concerned with the preservation of teeth since this, in effect, is the real objective of dental practice. It has been recognized, however, that there arc many groups of patients for whom satisfactory restorative dentistry or, for that matt,er, anj restorative dentistry is difficult if not impossible. This group includes the very young, the physically handicapped, and the mentally handicapped. In addition, we find those patients in whose mouths carious activity has progressed so rapidly and extensively that, if teeth are to be saved at all, thorough, exhaustive dental care must be rendered in the shortest possible time under ideal working conditions. In still other cases, restorative dentistry under general anest,hesia can bc used as a stopgap measure to preserve the natural dentition unt.il such time as the patient will cooperatively accept routine dental t,reatment. It was obvious that the use of general anesthesia for restorative dentistr) would present problems unlike those encountered in oral surgery. In manp cases, the duration of the procedure would be prolonged. Restorative dentistry is more time consuming than simple cxodontia, and when numerous teeth are involved this time factor could extend to -1 or I’ hours. The level of anesthesia would have to render the patient quiet and his mouth dry if good fillings were to be placed. Particles of filling material falling into the oral cavity would have t,o be c,on42

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stantly removed. The water spray used in conjunction with high-speed engines would have to be siphoned off. The length of recovery time must be kept to a minimum, even though the operation was prolonged, if the procedure was to be a practical one for the ambulant patient in the dent,al office. Little or no groundwork had been laid for solving these problems; thus, methods, techniques, drugs, and equipment had to be modified or new ones devised so that restorative dentistry under general anesthesia could become a successful modality. Certain .fundamental requirements are essential for positive results. The first of these is proper personnel. There must be an adequate number of people, and these people must be thoroughly trained in their respective duties. The dentist should have a good background in general anesthesia. In my opinion, this involves a training period of about one year in the operating theater of a hospital. This training should be under the supervision of the medical and dental anesthesia staffs and should include both medical and dental cases. The dentist should also have experience operating on anesthetized dental patients who are in both supine and sitting positions. The dental assistants should be well trained in both dental assisting and general nursing care of anesthesia patients. The latter includes the management of emesis, familiarity with anesthesia equipment, recognition of an obstructed airway, and the like. The presence of well-trained assistants is a sine qua non. The operating team should consist of a dentist-anesthesiologist, a dentist treating the patient, and two nursing assistants. It is possible to vary the combination somewhat, but I believe that this is the ideal arrangement for best results. The second fundamental requirement concerns the physical plant and equipment. The dental office should incorporate certain feat,ures of the hospitaloperating rooms, recovery rooms, a central sterilizing room, and a central source for suction, compressed air, and medical gases. The remaining rooms can be left to the discretion of the individual dentist. A detailed description of equipment and supplies is beyond the scope of this article. However, anesthesia machines, suction apparatus, intravenous equipment, operating table, drugs, and the necessary dental items, such as engines, hand instruments, filling materials, etc., are obvious requirements. It is suggested that two anesthesia machines and two suction machines be maintained in the event that one fails to function. Wherever possible, the operating room equipment should be kept off the floor. The use of wall plug-ins for medical gases, suction, and air and overhead mounting of intravenous stands and dental operat,ing lights will permit the floor space to remain unencumbered for easy movement, of personnel. The planning of t,he office and the selection of equipment form an integral part of the entire scheme. If done haphazardly, the result can be very disappointing. Experience and inquiry are valuable aids in planning and should be utilized to the maximum for best results. General anesthesia, although first introduced by a dentist, has grown and developed in the hospital under the aegis of the medical profession. Many drugs have been developed-some to be used and others to be used and later discarded.

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o.s..o.JI.‘!i 0.1’. July, 1964

Varying tcchniqucts have 1~~9 e~~~~,lo~~c~ct-sort~~~cant /)lic4;1lc~l, othc~rs l~c~lati\-c~l> simple. General anesthesiology as practicctl in the motlc~1 hospital is a rcsc*ognizcd specialty of medicine. We in dentistry must look ht~rc~ i’or our inspiration and training, but we must also remain cognizant of the c>sscntial differences between the hospital and the dental office. Ambulation, I*(~lat,ively short procedures, generally good-risk patients, lack of prcoptxrative pat ir:nl supervision, c~lc. force us to modify and adapt medical ant~sthesiologic principles and procrd~es for use in our offices. At, no time must we compromise basic principles. The maintenance of a patent airway, adequate oxygenat.ion, the LUC of' rccaognixcd drugs and tcchniyues, and the like are essential in dental anesthesia. We must strive f’o~ simplicity while obtaining effectiveness. Rapid induction, smooth maint,enanct’, and short, pleasant recoveries-all with a maximum of safety for the paticntshould be our goal. Available and in general anesthcsiologic use in most hospit,als today arc the following drugs and ancsthctic tcchniqnc~s, which I ha\-? (slasxificd alhitrarily for descriptive purposes: 1. lhc,gs

for prcopcraticc ,mcdication Tribromocthanol (Avertin) Ultrashort-acting barbiturates-tlliopental sodium Short-acting barbiturates-socobarbital sodium (Hwonal), pentol,arbital sodium (Nembutal) Narcotics-morphine Synthetic analgesics-meperidine hydrochloride (Demerol), xnileridine (Leritine), alphaprodine hydrochloride (Risentil) Tranquilizers (ataractics)--chlorpromazine (Thorazine), promethazine hydroehloride (Phenergan) , hydroxyzine hydrochloride (htarax) Belladonna derivatives-atropine, scopolamine 2. General anesthetic agents (all types) Ether, vinyl ether, nitrous oxide, ethyl chloride, trichloroethylene, halothane, cy~~lopropane, methoxyflurane (Penthrane), ultrashort-acting barbiturates (sedativehypnotics) such as thiopental sodium and methohexital sodium 3. Nonanesthetic drugs and gases osed in conjunction with arwsthasia Muscle relaxants-succinylcholine chloride (Anectine j , Curare Hympathomimetic drugs-epinephrine (Adrenalin), phenylephrine hydrochlorirlo (Neo-Synephrine), norepinephrine (Levophed) , methoxamine (Vasoxyl) Analeptics-Metrazol, picrotoxin, bemigride Inorganic gases Oxygen, carbon dioxide, helium 4. Anesthetic techniques A. Lnhalation anesthesia-open, semiopen, semiclosed, closer1 B. Intravascular injection for basal narcosis and analgesia C. Bectal anesthesia D. Hegional anest,hesia E. Specialized procedures-pediatric anesthesia, geriatric anesthesia, hypothermia

It is obvious from this brief review that many drugs and techniques arc available to us today. In the dental office, however, we must be particularly concerned with simplicity, effectiveness, and safety. Toward this end, it is advisable to maintain as light a plane of anesthesia as is compatible with good

Restorative

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working conditions. I shall now describe a simple but effective technique that we employ in our office for restorative dentistry under general anest,hesia. Over the years, we have used ether, divinyl ether, meperidine, anileridine, promethazine, and other drugs which ne have since discarded. These agents have been discarded because of flammability OP explosiveness, tendency to increase nausea and vomiting, slow rate of induction, prolongation of recovery period, etc. At present, we limit ourselves to secobarbital sodium, scopolamine, methohexit,al sodium, trichloroethylene, halothane, and nitrous oxide and oxygen. In general, our technique is as follows, A consultation visit is held for the purpose of taking a medical and dental history and evaluating the patient for premeditation dosage and probable duration of t,he treatment visit. A prescription for premeditation and preoperative instructions regarding food ingestion, etc. are given. Premeditation consists of secobarbital (Seconal) and scopolamine, compounded into capsule form by the pharmacist and usually taken orally one hour before the treatment visit. The dose varies from 1 gr. (60 mg.) to 3 gr. (180 mg.) of Seconal and 2300 gr. (0.2 mg.) to $J& gr. (0.4 mg.) of scopolamine. Upon arrival in the ofice, the patient is very drowsy or asleep. Anesthesia is induced in children by means of nitrous oxide-oxygen blown gently over t,he face until unconsciousness is produced, at which time the face mask is lowered to the face. A. soothing, running commentary on inane subjects by the anesthetist accompanies the anesthetic gases, After a suitable interval, trichloroethylene or halothane is introduced into the mixture. An intravenous puncture with a 23 gauge 1 inch needle is made, and small amounts of methohexital sodium (10 to 30 mg.) are slowly injected. The needle is left in the arm and a 5 per cent dextrose-in-water infusion is continued for the duration of the operation. After a satisfactory anesthetic level is attained (very light surgical stage), the face mask is removed and a nasal inhaler is placed in position. This is secured to the nose by four straps of a head harness which attach to a four-pronged hook located just beneath the inhaler’s exhaling valve. The mouth is then opened, a throat partition is positioned, the head is extended to ensure the patency of the airway, and the operative procedure is begun. We try to maintain the status quo from this point on through termination of the procedure. Occasionally, small additional increments of methohexital are given if the situation warrants it. On termination of the procedure, 100 per cent oxygen is administered and the reacted patient is removed to a recovery room, where he remains until ready to go home. Essentially the same technique is used for the adult patient with the exception that anesthesia is usually induced by the intravenous injection of methohexital (40 to 80 mg.) until unconsciousness is attained. The needle size is 20 gauge, I$$ inch, and drug doses vary proportionately. By eliminating intubation, multiple use of drugs, deep levels of anesthesia, etc., we accomplish our objective of simplicity with effectiveness. We obtain a rapid induction, smooth, safe maintenance, and a pleasant, rapid recovery. It is obvious .that in such a brief review as this only the highlights can be stressed. Although the technique is relatively simple and uncomplicated, it

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does, in practice, demand 1-11~ul;ti~osl in attention and ci~t’(’ flown the dental operator and anesthesiologist. Chnstant attention to the airway, assisted respirations, careful placement of the tlwotlt partition, suctioning of the ~31 cavity, and the like are essential for ~UCCCSS. The rewards in t,crms of the patient’s safety, the convenience of operation, and the paticwt’s comfort outweigh the extra burdens placed upon the operating team. It is possible to perform any dtantal procedure under this technique. The placement of fillings, endodontic treatment,, crown and bridge prosthesis, oral surgical procedures, periodontal scaling, and curettage are readily accomplished in the child or adult dentitions. It is possible to do a large qua.ntity of work in a relatively short period of timcb without sacrificing quality. In fact, the quality of treatment is often improved because of the excellent operating conditions which result from the anesthetic. The patient’s response to this combination of dental and anesthetic disciplines is invariably very favorable, and there is rarely any hesitation about undergoing the procedure again. In summary, restorative dentistry under general anesthesia is a necessary and practical modality in modern dental practice. It should bc undert,aken only by trained personnel in a properly equipped environment. In most cases, &is environment can be the dent,al off& . h simplified, effective technique of light anesthesia has been presented. All types of dental treatment, wit,h cscellcnt results, are possible under this technique. 88-15

168th

St.