Services - Sedation Dentistry: General Anesthesia & IV Sedation

General Anesthesia

Nowadays, general anesthesia in adults (being put to sleep) is a treatment of last resort. For most adults, sedation works perfectly acceptably. If sedation fails then GA can be provided. Also, there are exceptional circumstances under which general anesthesia is recommended. But find out more below!

What are General Anesthesia and Deep Sedation?
General anesthesia (GA) is when you are totally unconscious. In this state, you can't feel any pain, even without local anesthesia. You can't reliably breathe on your own, so for more complex procedures (such as fillings - these are actually more complex than extractions under GA!) and procedures of longer duration you need to having a "breathing tube" inserted.

Deep sedation is a state of depressed consciousness, where you may lose the ability to breathe independently and you can't respond to verbal commands. However, you can still feel noxious stimuli like pain, so local anesthesia is necessary.

In contrast, what is usually called "IV sedation" (or, in advertisements, "twilight sleep") in dentistry is conscious sedation. Conscious sedation is a minimally depressed level of consciousness during which the patient is able to breathe independently and/or respond purposely to verbal command

Why is General Anesthesia not used very much for dental work?
General anesthesia is a procedure which is never without risk (including the risk of death). As a result, the General Dental Council in the UK recommends that "the decision to refer a patient for treatment under general anesthesia should not be taken lightly." "In assessing the needs of an individual patient, due regard should be given to all aspects of behavioral management and anxiety control before deciding to treat or refer for treatment under general anesthesia. General anesthesia for dental treatment should only be administered in a hospital setting with critical care facilities. All dentists involved in arranging or providing treatment under general anesthesia should discuss with the patient advice and treatment options to avoid or reduce future episodes of general anesthesia. A dentist who refers a patient for treatment or carries out treatment on a patient under general anesthesia without ensuring that the relevant conditions ... are met is liable to a charge of serious professional misconduct." (excerpt from "Maintaining Standards", GDC, 1997)

Apart from the risk of death (which, while very small, is still significantly higher than for conscious IV sedation), general anesthesia has a few major disadvantages:

(1) Complications are more likely with GA compared with conscious sedation both during and after the procedure. GA depresses the cardiovascular and respiratory systems. For some groups of medically compromised patients, it is contraindicated for elective procedures.

(2) It's not recommended for routine dental work like fillings. The potential risk involved is too high to warrant the use of GA. For things like fillings, a breathing tube must be inserted, because otherwise, little bits of tooth, other debris or saliva could enter the airway and produce airway obstruction or cause illnesses like pneumonia.

(3) Laboratory tests, chest x-rays and ECG are often required before having GA, because of the greater risks involved.

(4) Very advanced training and an anesthesia team are required, and special equipment and facilities are needed. GA introduces a number of technical problems for the operator (i. e. dentist), especially when a "breathing tube" is involved: the tongue is brought forward more into the dentist's way by the airway tubing, the muscles are paralyzed so the operator is working against a dead weight all the time and there are postural problems because the patient can't be moved about much. The operator can get very tired very quickly when doing a session. It's physically the most demanding kind of dentistry (usually standing, hot lights, compromised patient position).

(5) You can't drink or eat for 6 hours before the procedure (otherwise, vomiting is possible and this would be extremely dangerous during GA).

(6) It's expensive.

(7) GA does nothing to reduce dental anxiety. The next time you need any work, or even a routine check-up, you'll most likely be as afraid as ever. This may not be applicable to all situations - as mentioned below, GA can be useful or even indicated for certain situations.

As a means of anxiety management however, GA is next to useless. Anecdotal evidence suggests that people who have treatment done under GA as a means of anxiety-control are less likely return for regular check-ups and cleanings which are necessary to maintain dental health. Obviously, there may be exceptions.

Are there any circumstances under which general anesthesia should be used?
Exceptional circumstances include treatment for certain groups of special needs patients, procedures which would be very unpleasant if you were conscious (such as very complex extractions of bony impacted wisdom teeth), certain other types of oral surgery, and people with an extreme anxiety of dental procedures for whom conscious IV sedation isn't enough (although IV sedation works fine for about 97% of people with a high anxiety of dental procedures).

If it's extractions that really terrify you, it may be possible to be put to sleep for the extractions and then have fillings etc. done under conscious sedation with local anesthetic. However, general anesthesia is not widely on offer, and must be carried out in a hospital, in the UK at least.

How is it administered?
GA is usually started off with an injection in the hand or arm. It can be supplemented by a face mask but if a face mask is used you probably won't remember it.

If post-op pain is expected, the normal practice is to inject a long acting local anesthetic during the GA, so that when you wake up everything is nice and numb for a good few hours (say 6 hours?) afterwards, which should give you time to take some painkillers and allow them to kick in. It's much better to pre-emptively stop pain than it is to try to deal with it once it has started.  
 

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