Anesthesia is defined as, “insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs before surgical operations”.
Several methods of anesthesia are available. The method of anesthesia that is chosen for or by a patient depends upon the nature of the surgical procedure and the patient’s level of apprehension.
The following table illustrates the choices of anesthesia, a description of the anesthetic technique, and the usual indications for that technique.
MethodTypes of AnesthesiaDescription of TechniqueUsual Indications
Method Local AnestheticDescription of Technique The patient remains totally conscious throughout the procedure. Local anesthetic is administered in the area where the surgery is to be performed. Local anesthetic will control pain, but it will not eliminate noise, pressure and vibration commonly associated with surgical procedures. Local anesthesia used in conjunction with the other methods of anesthesia in all oral surgery procedures.Usual Indications Simple oral surgery procedures such as minor soft tissue procedures and simple tooth extractions.
Method Nitrous Oxide Sedation with Local AnestheticDescription of Technique A mixture of nitrous oxide (laughing gas) and oxygen is administered through a nasal breathing apparatus. The patient remains conscious in a relaxed condition. Nitrous oxide has a limited sedative and analgesic (pain- controlling) effect.Usual Indications Simple oral surgery procedures to more involved procedures such as removal of wisdom teeth and placement of dental implants.
Method Office Based General Anesthesia with Local Anesthetic*Description of Technique Medications are administered through an intravenous line (I.V.). The patient falls asleep and is completely unaware of the procedure being performed. Medications most commonly used are Fentanyl (opiate), Versed (benzodiazepine), Ketamine, and Diprivan (Propofol). Supplemental oxygen is delivered through a nasal breathing apparatus and the patient’s vital signs are closely monitored.Usual Indications General anesthesia is available for all types of oral surgery. A patient may choose general anesthesia for simple procedures depending on their level of anxiety. Most people having their wisdom teeth removed or having a dental implant placed will choose general anesthesia. General anesthesia may be necessary if local anesthesia fails to anesthetize the surgical site which often occurs in the presence of infection.
Method Hospital or Surgery Center Based General AnesthesiaDescription of Technique A patient is admitted to a hospital or surgery center where anesthesia is administered by an anesthesiologist.Usual Indications Indicated for patients undergoing extensive procedures such as face and jaw reconstruction and TMJ surgery. Also indicated for patients with medical conditions such as heart disease or lung disease who require general anesthesia.
To administer general anesthesia in the office, an oral surgeon must have completed at least three months of hospital based anesthesia training. Qualified applicants then undergo an in office evaluation by a state dental board appointed examiner. The examiner observes an actual surgical procedure during which general anesthesia is administered to the patient. The examiner also inspects all monitoring devices and emergency equipment and tests the doctor and the surgical staff on anesthesia related emergencies. If the examiner reports successful completion of the evaluation process, the state dental board will issue the doctor a license to perform general anesthesia. The license is renewable every two years if the doctor maintains the required amount of continuing education units related to anesthesia. Dr. Stewart and Dr. Michael along with their certified anesthesia assistants (DAANCE), have undergone the office evaluation procedure and are certified to administer office-based general anesthetics.
Our first priority is your comfort and safety. If you have any concerns regarding the type of anesthesia that will be administered during your oral surgery procedure, please do not hesitate to discuss your concerns with the staff or doctor at the time of your consultation. Whole
Intravenous Sedation (“Twilight Sedation”)
Our office offers our patients the option of Intravenous Sedation , commonly called “Twilight Sedation” or Twilight Sleep” for oral surgical treatment. Intravenous Sedation helps you to be comfortable and calm when undergoing dental procedures. With this type of sedation, patients will commonly report that they heard noises and conversation, but were calm and relaxed. Intravenous sedation or “IV sedation” (twilight sedation) is designed to better enable you to undergo your dental procedures while you are very relaxed; it will enable you to tolerate, as well as not remember, the procedure. IV sedation will essentially help alleviate the anxiety associated with your treatment. You may not always be asleep but you will be comfortable, calm and relaxed, drifting in and out of sleep: a “twilight sleep”. This technique works very well for our older patients who may have some physical or medical limitations on general anesthesia.
If you choose the option of intravenous sedation, your IV sedation/anesthesia is administered and monitored by the doctor therefore eliminating the costly expense of having your treatment carried out in an operating room or same day surgical facility.
How is the IV sedation administered?
A thin catheter will be introduced into a vein in your arm or hand. The catheter will be attached to an intravenous tube through which medication will be given to help you relax and feel comfortable. Some patients may be asleep while others will “slip in and out of sleep”, this will depend upon the anesthesia technique you choose. Some patients with medical conditions and/or on specific drug regimens may only be lightly sedated and may not “sleep” at all.
The goal any office based sedation is to use as little medication as possible in order to safely complete treatment. Did you know that IV anesthesia is safe? Even much safer than oral sedation! How is that possible? With IV sedation a constant “drip” is maintained via the intravenous tube and you are only given as much anesthesia as is necessary to achieve the desired effect. At any time an antidote can be administered to reverse the effects of the medications, if necessary. With oral sedation medications given preoperatively, they are limited to specific dosage strength of the pill which may or may not be sufficient for you. It is impossible to predict the level of sedation that a patient will achieve with a pill. Many factors can modify the patient’s response to oral sedation premedication including: length of time since the patient had anything to eat, the patient’s other medications, the patient’s anxiety level. Some doctors utilize a “stacked dosing’ approach to oral sedation. We DO NOT advocate this approach! While Dr. Michael and Dr. Stewart will sometimes prescribe an oral sedation premedication to relax you, it is not the preferred choice for an office based “anesthesia”. There are much better alternatives, please ask!
Nitrous Oxide (Laughing Gas)
Nitrous Oxide is a sweet smelling, non irritating, colorless gas you can breathe through a nasal cannula. Nitrous Oxide has been the primary means of sedation in dentistry for many years. Patients are able to breathe on their own and remain in control of all bodily functions. The patient may experience mild amnesia and may not remember what happened during their appointment.
Reasons to Not use Nitrous Oxide
Though there are no major contraindications to using nitrous oxide, you may not want to use it if you have emphysema, significant lung problems, M.S., a cold or other difficulties with breathing. Laughing gas has some significant limitations as to its sedating effect, and Dr. Michael and Dr. Stewart feel that there are much better anesthetic options than nitrous oxide (laughing gas).
FAQ’S Regarding IV General Anesthesia
1. Other than “not being aware of the procedure”, what benefit exists from sedation/anesthesia?
The benefits of office-based anesthesia are numerous for both oral surgeons and patients alike.
As mentioned above, the elimination of patient anxiety with oral surgery procedures is the most significant benefit. But there are other, less obvious benefits.
Keeps you motionless during surgery
In many instances surgical procedures require delicate instrumentation and manipulation of bone and tissue and sudden movement (usually unintentional) can negatively impact the outcome. Adequate sedation/anesthesia will allow a patient to remain very still during surgery.
Makes procedure seem like it lasts for 2 seconds
Some surgical procedures can be lengthy, and it is difficult for anyone to remain calm and still for a prolonged period. This is not an issue when a patient is under sedation/anesthesia.
Even when you are numb, you still feel pressure
Local anesthesia (numbing medicine) does not eliminate noises, feelings of pressure, or vibration during a procedure, and this is not an issue with sedation/anesthesia.
2. How will the anesthesia affect my body?
Anesthesia has wide ranging effects on different people.
Most patients emerge from sedation and feel a little groggy for several hours.
On occasion, patients may emerge from sedation feeling disoriented, possibly nauseous, fatigued or confused. It is usually impossible to know how you will feel when emerging. Fortunately, the side effects of anesthesia are well known and precautions are taken to prevent the most common ones.
Just because it took your sister 6 hours to be able to dance, doesn’t mean it will take you that long
Recovery periods differ for each patient, and how you feel in the 24 hours after your surgery will depend on how your body metabolizes the anesthetic drugs.
Medications, medical conditions, age, sex, etc. can affect the length of recovery from anesthesia.
The best predictor of how you will respond is a previous experience with anesthesia; if this is your first time with office-based anesthesia, then you should understand that your recovery length may be unpredictable.
You’re constantly and thoroughly monitored while sedated
Many people have a conscious anxiety or fear of anesthesia: usually associated with the “loss of control”. Know that while you are sedated, your heart electrical activity (EKG), heart rate, blood oxygen saturation (pulse oximetry), blood pressure, respiratory rate, and end-expiratory carbon dioxide level are being constantly monitored by our team.
For the science nerds like us: the carbon dioxide levels measured at the end of an exhaled breath (called ETCO2 or End Tidal CO2) provides critical information that can tell us if your breaths are too deep or shallow (tidal volume) or too rapid or slow (tachypnea or bradypnea).
We use state of the art monitoring equipment and are very strict about performing frequent monitor checks and calibrations.
Our assistants of are DAANCE (Dental Anesthesia Assistant National Certifying Exam) certified.
Dr Stewart and Dr Michael are BLS, ACLS, and PALS certified. In fact, Dr Michael is a BLS instructor!
3. What happens if there is a complication with the sedation?
The key is keeping calm
The great thing about office-based sedation/anesthesia is that complications are very rare when appropriate training is in place and precautions are taken (as is the case in our office).
Nevertheless, some things are beyond our control and the best policy is to make sure that we are prepared to handle any possible situation that may arise.
We maintain state of the art emergency equipment and emergency medications on hand.
We-as a team-undergo frequent training drills where we practice our roles in various emergency scenarios. While we always hope that urgency or emergency scenarios do not arise, we are proud of the fact that we place so much emphasis on being well-prepared in case such a situation occurs.
4. What kind of training is involved to be able to perform office-based general anesthesia?
Oral and Maxillofacial Surgeons are unique
If you’re receiving office-based sedation/general anesthesia for an oral surgery procedure by an Oral and Maxillofacial Surgeon, know that it’s being delivered by a highly qualified individual.
In the U.S., Oral and Maxillofacial Surgeons are required to undergo intensive general anesthesia training in a hospital-based residency training program working alongside Anesthesiology residents and being trained by Anesthesiologists. Oral surgeons can provide IV general anesthesia (this is different than a simple IV sedation or conscious sedation) that can assure your adequate level of anxiolysis and comfort. A simple IV sedation (which requires significantly less training and expertise) is usually not optimal for patients undergoing most oral surgical procedures.
In order to be allowed to perform IV general anesthesia, Oral and Maxillofacial Surgeons in Texas must undergo a rigorous anesthesia evaluation of their office (including office layout, equipment, medications, and surgeon knowledge) by a peer from the Texas Society of Oral and Maxillofacial Surgeons.
Make sure your Oral Surgeon is Board Certified
Board Certification (American Board of Oral and Maxillofacial Surgery) is important to consider when evaluating the training of the individual administering your anesthesia. Oral and Maxillofacial Surgeons undergo a very rigorous written and oral exam to become Board Certified, and anesthesiology is a large part of that exam. You can be assured that a Board Certified Oral and Maxillofacial Surgeon has proven adequate training and knowledge in anesthesiology.
Don’t be afraid to ask questions!
The more you know….
If you’ve scheduled an oral surgery procedure and are feeling uneasy about it, never be afraid to speak with the oral surgeon or staff. Asking questions about the procedure, including the anesthesia, is all part of the process and could provide you the comfort and peace of mind you need. Coordinating with a friend or family member to care for you, having trust in your oral surgeon, and understanding the nature of office-based anesthesia are all important.
If you have any questions about anesthesia, we encourage you to contact our experienced oral surgery team at the Texas Oral Surgery Group.