Providing deep sedation and general anesthesia for patients with special needs in the dental office-based setting
by Anthony Charles Caputo, DDS, FACD, FICD, Diplomat, American Dental Board of Anesthesiology; Diplomat, National Dental Board of Anesthesiology; Dentist Anesthesiologist and President, Southwest Dental Anesthesia Services, Assistant Program Director, Lutheran Medical Center, Advanced Education in General Dentistry Program, Tucson, Arizona Corresponding author e-mail: firstname.lastname@example.org, Spec Care Dentist 29(1): 26-30, 2009
This article discusses the issues of morbidity and mortality associated with deep sedation and general anesthesia specifically in the dental office-based setting for patients with special needs (PSN). A focused review of a particular environment and patient population was challenging as it was difficult to identify articles that discuss the unique scope of this subject. During the review of the literature, no article was identified that discussed this exact topic. There were articles that discussed the delivery of general anesthesia for PSN in an outpatient setting and associated issues of morbidity and mortality.There were also articles and sources of information that discussed the delivery of general anesthesia for other patient populations in the office-based setting. In an effort to support the scope of this article, some of these articles are discussed as they pertain to the subject of this article.
In addition, an analysis of the author’s practice over a 4-year period is discussed in an effort to present relevant data per the scope of this article. After reviewing the literature and the author’s clinical practice, it appears that the incidence of mortality for PSN in the dental office-based setting is minimal and the incidence of morbidity for this same population is limited to relatively minor events. Ultimately, it was concluded that the delivery of general anesthesia for PSN in the dental office-based setting can be considered a very safe and successful procedure.
KEY WORDS: sedation, general anesthesia, dental anesthesiologist, out-patient sedation, out-patient anesthesia
For the purposes of this article, the following definitions will apply:
- Patients with special needs: It includes patients with physical and/or mental conditions such as cerebral palsy, autism, and down syndrome. This definition also encompasses the above patient population with coexisting conditions such as maladaptive behavior, seizure disorders, and obesity.
- Special patient populations: It describes those patients who are outside of the description of an average, healthy child or adult. and includes individuals with significant medical and psychologically conditions and those who are fearful or phobic and elderly patients.
- Office-based setting: It refers strictly to the dental office and includes the provision of anesthesia via fixed or transported equipment. As such, this does not include outpatient facilities at hospitals or ambulatory surgery centers.
- General anesthesia/deep sedation: Any level of anesthesia where the ability to arouse the patient is either difficult or impossible and the protective laryngeal reflexes are partially or completely obtunded.
One of the main purposes of providing anesthesia for patients with special needs (PSN) is to establish and maintain a state of cooperation where the patient is able to receive dental assessment and treatment safely and successfully. Essentially, the approach with anesthesia is to provide pharmacologic behavior management for patients who are mentally incapacitated and unable to communicate effectively due to their disability. For those PSN, it becomes necessary to provide an effective management approach. Otherwise, these patients can be extremely difficult or impossible to treat.
The ability to provide deep sedation and general anesthesia in the office-based setting allows for many positive outcomes. These include comfort and convenience for the patient as well as the dentist, ease of scheduling as compared to a hospital-based or outpatient setting and often a significant cost savings for the patient as well as cost efficiency for the dentist. This treatment approach should never be looked at as a negative experience for the patient. Too often, it is assumed that the provision of general anesthesia must be provided in the hospital or outpatient setting. In addition, it is sometimes mischaracterized as an excessive treatment approach. This is just not true and has the potential to prevent the delivery of dental services for this fragile and vulnerable patient population. In fact, the delivery of safe, effective anesthesia for patients receiving treatment in the office-based setting has been provided for decades and has a very strong record of safety and success.
In reviewing the literature with regard to the treatment of PSN in the office-based setting, there were little data or information identified. As such, it was decided to expand the scope of the review to include other outpatient settings as well as other patient populations. There were few references to the treatment of PSN in the outpatient setting and, interestingly, there was one reference that indicated that the method of choice for treating PSN was the outpatient setting which was identified as a designated day facility in a hospital. In terms of treating other patient populations, the vast majority of articles discussed the treatment of the pediatric patient in the office-based setting. There were also articles that discussed the provision of general anesthesia for the patient requiring oral surgery in the office-based setting. Collectively, this information provides a reasonable foundation from which to discuss the safe and effective treatment of PSN in the office-based setting.
In an effort to present relevant data given the scope of this article, a comprehensive analysis was completed of the author’s clinical practice, which is limited to the provision of office-based anesthesia for dental patients among all patient populations including PSN. This analysis will provide specific data with regard to PSN and associated incidents of morbidity and mortality. This information provides clinically useful data about PSN treated with deep sedation and general anesthesia in the office-based setting. Though this treatment approach is considered to be a safe and effective service provision in the office-based setting, there is the need to collect, review, and analyze more data for PSN treated in this environment to both verify and confirm the safety and efficacy for this procedure.
An editorial article written by Dr. Joel Weaver discusses the evolution of office¬-based anesthesia in dental and medical offices over the past 30 years.1 Since the early 1970s, we have seen a significant shift from providing anesthesia in the hospital to outpatient settings including the office-based setting. This shift was the result of many factors such as advances in procedural technology and in response to rising health care costs. With a larger and larger number of procedures being performed outside of the hospital, there was an increased concern with safety from both a surgical and anesthesia perspective.
As has often been the case with the provision of anesthesia, dentistry has been ahead of our medical colleagues in developing safe and effective standards for the treatment of patients in the office-based environment. In fact, Weaver indicates that the very medical establishment that in the past criticized the dental profession for its provision of anesthesia in the office-based setting has come full circle with the recognition of providing office-based anesthesia safely and effectively. There has even been the development of guidelines and rules for office anesthesia by the medical profession.1 It has also been accepted that regardless of how anesthesia services are provided, whether all equipment and supplies are located at the office or transported to the office by a mobile anesthesia provider, office-based anesthesia is very safe and cost-effective as long as appropriate guidelines are followed.2
In 2007, the American Dental Association (ADA) adopted several documents related to the use of sedation and anesthesia by dentists. The Policy Statement on the Use of Sedation and General Anesthesia by Dentists emphasizes that these modalities are safe and effective when properly administered by trained individuals. In addition, in 2007, the ADA also adopted revised Guidelines for the Use of Sedation and General Anesthesia by Dentists and Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. All of these documents emphasize the fact that the provision of anesthesia in dentistry by appropriately and properly trained dentists has an exemplary safety record. 3-5
Reviewing the incidence of morbidity and mortality over the past 40 years, there are several articles that indicate very little risk associated with office-based anesthesia. In 1966, Driscoll presented the results of a survey for over 1,000 Oral and Maxillofacial Surgeons which identified five fatalities resulting from 1,575,000 general anesthetics or an incidence of mortality of 1:315,000. 6 In 1974, Driscoll again presented the results of survey for 1,507 Oral and Maxillofacial Surgeons that identified seven fatalities resulting from 2,445,853 general anesthetics or an incidence of mortality of 1:349,408.7 In 1980, Lytle and Yoon presented the results of a survey for 153 Oral and Maxillofacial Surgeons that identified no fatalities for 1,285,000 general anesthetics administered over a 5-year period.8 In 1997, Hunter and Molinaro reported on a retrospective analysis of patients treated in an Oral and Maxillofacial Surgery program over a 4-year period. During that time, over 1,000 general anesthetics were performed with no deaths and a 2.3% incidence of morbidity involving no postoperative sequelae.
The most common complication reported was laryngospasm (0.8%).9 In 1999, D’Eramo performed a similar study where the incidence of morbidity was reviewed over a 1-year period and the incidence of mortality over a 4-year period. This was a review of private practice Oral and Maxillofacial Surgeons with no reported deaths in approximately 1.5 million procedures and the most commonly reported morbidity was syncope in relation to the administration of local anesthesia.10 In 2000, Enever et al., reported on postoperative morbidity of pediatric patients with and without disabilities. The study reviewed 55 cases over a 1-year period for patients aged 3-17 years old. There was a reported incidence of 44% morbidity involving postoperative nausea and vomiting (PONV), unexpected drowsiness and the need for pain relief.11 In 2001, Yagic1a reported that mortality and serious morbidity are exceedingly rare in modern practice.12 Finally, Perrott et al., reported no fatalities in 34,391 procedures involving deep sedation/general anesthesia (71.9%), conscious sedation (15.5%), and local anesthesia only (12.6%) over a 1-year period though there were two incidents which required hospitalization.13 One hospitalization was the result of an allergic reaction to an administered antibiotic and the other resulted from aspiration.
An underlying theme to these articles was that the low incidence of morbidity and mortality was directly related to proper patient and procedure selection including appropriate preoperative preparation, use of appropriate perioperative monitoring, use of improved anesthetic drugs allowing for faster recovery and fewer side effects, and the effective and judicious application of pain management. Additionally, over time, there was a decrease in the mortality rate associated with deep sedation/general anesthesia, which very likely is associated with many of the factors previously identified.
Clinical Practice Analysis
In an attempt to provide meaningful data for this article, the author performed a retrospective analysis of his clinical practice in a manner similar to previously discussed articles. This review involved patients seen over a 4-year period of time from January 2002 to December 2005. During this time 5,650 patients were seen in the office-based setting and received general anesthesia for areas of dentistry including simple and complex restorative, prosthodontic procedures, implant placement, periodontal therapy involving sealing and root planning as well as periodontal surgery, simple and complex exodontia, and pediatric dentistry. Offices included both general dentistry and specialty practices. Patients treated included PSN as well as special patient populations with patients ranging in age from 11 months old to 97 years old.
Of the total patients seen, it was estimated that 791 were PSN or 14% of the total. This number can only be identified as an estimate due to the practice method of accounting for this patient population. The accounting of patients seen in this practice is done by the treating office/location or the source of reimbursement for services rendered. As such, 451 patients were identified by a specific treatment location (Arizona Training Center-Coolidge) and by a specific reimbursement source (Department of Developmental Disabilities). Knowing that PSN are seen at other offices/locations and reimbursement is from other sources, a more accurate number was extrapolated through review of the daily schedule.
The office protocol includes a follow-up with patients to determine their postoperative course. Issues covered with the patient, the patient’s parent, or guardian include the incidence of postoperative nausea and vomiting (PONV), activity, intake of fluids and food, temperature elevation as well as discomfort and pain. The presence of issues outside of the focused questions are also elicited such as bruising at injection site(s), general response to recovery, and other concerns raised by the patient, parents or caregivers.
For the 2002-2005 period, follow-up was accomplished with 4,477 of the 5,650 patients seen for a 79% reported follow-up rate. Of this group the following incidents were reported:
Postoperative nausea and vomiting (PONV)
Elevation of temperature
In 2005, information was collected for 1,631 patients and identified seven patients who went to urgent care, experienced a post treatment seizure, or experienced a poor recovery. Patients who went to urgent care went for the purpose of receiving IV fluids due to a prolonged period of no fluid intake (typically this was at least 6 hours post discharge). This decision was typically made by the parent or caregiver following a discussion of alternative options including continuing to wait for recovery and/or administering an antiemetic medication. Patients who experienced poor outcomes were identified as having a poor response to the recovery from the anesthetic medications involving agitation, confusion, fear, or dysphoria.
Patients who sought treatment at urgent care: 3
Patients who experienced a poor outcome: 3
Posttreatment seizure: 1
There were no reported incidents of hospitalization for any patients seen during the 2002-2005 time period. Since starting this practice in 1997 and treating nearly 14,000 patients through 2007, there have been no incidents of mortality as a result of the provision of deep sedation and general anesthesia.
The goal of any anesthetic procedure regardless of where it is administered is to provide anesthesia in a safe and effective manner without any related complication. Obviously, the challenge for any anesthesia provider is to limit or eliminate the risks associated with pro-viding anesthesia to any patient seeking and/or requiring this service. It is well understood and accepted among the anesthesia community of dentists, physicians, and nurses that the most effective way to approach the risks involved with anesthesia provision is through preparation and prevention. This involves thorough preparation of the patient for the procedure and prevention of untoward events before, during, and after any procedure.
In the case of PSN, the challenge often involves the ability to appropriately and properly prepare the patients for the planned procedure. This challenge is often due to the inability to assess PSN as a result of their inability and/or unwillingness to cooperate. With the continued shift of dental and medical treatment from the hospital to the outpatient and office-based settings, there is the concurrent increase in the number of PSN seeking care in these settings. As a result, there is an increased demand on the private practitioner to provide for the health care needs of this patient population.
It has been estimated that approximately 15% of the United States population has some form of disabling condition.14 Given the time that this figure was reported it can be projected that this number has increased. The result is that there is a larger number of PSN seeking care in the office-based setting with greater frequency. This situation is contrasted with the continued stigma associated with treating PSN. It has been reported that dentists have fears and discomfort with approaching and treating PSN. Unfortunately, many dentists are not accustomed to dealing with this patient population and are unsure how they or other patients will respond to them.15 This creates its own barrier with access to care for PSN. As a profession, we need to work together more closely as well as with our medical colleagues to develop effective and efficient pathways for the care of PSN with an emphasis on minimizing barriers. The development of an effective interdisciplinary team or network of caregivers can be a strong step in the right direction. This will also significantly improve the ability to plan and prepare for PSN to be treated in the office-based setting.
Utilizing a network of caregivers that are involved with the ongoing care of PSN provides a tremendous advantage in accessing relevant medical information as well as behavioral information about the patient. Gathering this information prior to seeing the patient allows the dentist to make decisions about the approach to care. This has proven to be significantly beneficial in my clinical practice.
My office has developed a system of care that encompasses all parties involved with the care of PSN. The dental offices that provide care for these patients know that accurate information must be gathered when preparing for treatment. For example, in one practice where I provide anesthesia services, the dentist has PSN come to the office for a “get acquainted” visit. At this visit, the patient is assessed with the involvement of the caregiver(s) in an effort to determine the best approach to caring for the patient. This simple visit provides significant insight into the treatment approach for PSN. From the first visit until the next appointment with deep sedation/general anesthesia, information is gathered to ensure that the patient as well as the team is prepared to provide safe and effective care for the patient. This approach has proven to be incredibly successful for preparing and planning to care for PSN.
Another important component to the care of PSN is the assessment and approach to behavioral challenges. The inability to communicate as well as being with an unfamiliar person can potentiate a challenging, if not dangerous, interaction. As such, great care is given to assessing the involvement of the support network for PSN. The attempt is to create and provide a supportive and non-threatening environment for the patient given the circumstances surrounding the interaction. I have found that involving those persons who have the greatest connection with the patient has proven to be extremely beneficial for the successful treatment of the patient.
Given that I provide office-based anesthesia services, I travel to the dental offices where I treat patients. I have developed a practice that utilizes techniques that incorporate oral, inhalational, and parenteral routes of administration. Typically, anesthesia is induced parenterally by either the intra-muscular (IM) or intravenous (IV) route. With the involvement of others close to the patient as well as attention to making the experience as nonthreatening as possible, there has been tremendous success gaining initial IV access and inducing the patient via this route. In fact, my practice has over a 90% success rate initially establishing an IV with PSN. This is accomplished without any other adjuncts such as applying local anesthetic cream or injecting a skin wheal of local anesthetic or other solution prior to the IV insertion. Though not necessarily significant with regard to morbidity and mortality with this patient population, it has proven to improve overall case flow as well as patient outcomes in terms of recovery response and resultant discharge from the office.
The anesthesia technique consists of the administration of ketamine, midazolam, and propofol. To counter the increased salivary effects of ketamine, glycopyrrolate is administered. On occasion, additional drugs are administered which include diazepam and fentanyl. If an IM approach is required, ketamine (1.0-1.5 mg/kg) and midazolam (0.75-1.0 mg/kg) are administered. Knowing that an IM injection will be needed, arrangement for the location of the injection is made based on the best outcome for the patient and others involved with the procedure. This procedure has been done in cars, the parking lot, on the floor as well as with and without the assistance of family and/or caregivers. There have also been occasions where the administration of nitrous oxide-oxygen (N2O-O2) prior to the IM injection is accomplished for the preservation of an atraumatic experience. The onset of action following IM administration is commonly 4 to 6 minutes. This typically allows for the patient to be in a more cooperative state so that IV access can be established. On occasion, N2O-O2 is administered to deepen the anesthesia effect as the IM injection was identified to not satisfactorily anesthetize the patient to achieve IV access. The intent of the IM injection is not to achieve a deeper level of anesthesia given the different locations this is administered. Once the patient is transferred to the dental operatory, IV access is established, oxygen via nasal cannula is administered, monitors are placed on the patient (blood pressure, electrocardiograph, pulse oximeter) and a propofol infusion is started. Typically, a bolus of propofol (20-30 mg) is administered prior to the start of the infusion. With the ability to start an IV directly, midazolam (2-3 mg), ketamine (20-30 mg), and propofol (20-50 mg) are administered by bolus and then the propofol infusion is started.
Looking at the data from the various articles reviewed and the outcomes reported from my clinical practice, it is possible to conclude that the provision of office-based anesthesia for PSN is very successful with a low incidence of morbidity and mortality. To this end, it is absolutely essential to conduct more research as well as practice reviews of this area of treatment and service provision for PSN. With the increased reporting of treatment of PSN under anesthesia in the dental office-based setting, it will be possible to establish verifiable and conformational data about the safety and efficacy of this treatment approach.
When providing treatment of PSN under anesthesia, it is important to have an established protocol in place that is well understood and followed. To ensure a high level of success when providing office-based anesthesia, I would make the following recommendations.
1. Develop and maintain an interdisciplinary team of providers and support staff including family when possible. This includes identifying who has legal guardianship for the patient and able to make decisions and provide consent.
2. Plan and prepare as much preoperatively for the patient as possible including:
- Obtain current medication and medical history.
- Know the direct person(s) responsible for the general care of the patient and how to contact them-parent, sibling, caregiver (they are often different than the person who has legal guardianship for the patient).
- Obtain medical consultations as needed or indicated.
- Attempt to schedule the patient according to their specific needs as much as possible. If a morning appointment would be better for the patient, try to schedule them accordingly.
- Create and maintain a supportive environment for induction. This will greatly support approaching PSN in a positive manner.
3. Establish discharge criteria that allow for the effective assessment of PSN. When possible, involve the same resources utilized for the preoperative assessment.
4. Have necessary equipment and supplies for the delivery of general anesthesia including emergency equipment and supplies which can be fixed or transported to the dental office.
5. The delivery of deep sedation and general anesthesia must be by a trained anesthesia provider and consistent with the current ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists.
1. Weaver JM. The safety of both fixed and transportable office-based anesthesia for denistry. Anesth Prog 1999;46:1-2.
2. Weaver JM. Incorporating new ADA sedation-anesthesia practice guidelines into state dental board regulations. Anesth Prog 1998;45:131-3.
3. American Dental Association. Policy statement; the use of sedation and general Anesthesia by dentists. ADA House of Delegates. Adopted October 2007.
4. American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. ADA House of Delegates. Adopted October 2007.
5. American Dental Association. Guidelines teaching pain control and sedation to dentists and dental students. ADA House of Delegates. Adopted October 2007.
6. Driscoll EJ. Proceedings of the Conference on Anesthesia for Ambulatory Patient ASOS 48th Annual Meeting, Pre-Meeting Conference. ASOS Annual Meeting September 19. 1966:48-54.
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