INTRODUCTIONThe association between anaesthesia anddentistry: Horace Wells (Dec. 1844): N2O; Failed Demo. WTG Morton: “Inventor of Anaesthesia” GQ Colton: Reintroduced N2OThereafter for almost 100 years GA was a normfor Dental procedures Decline in popularity of General AnaesthesiaLocal Analgesia and Sedation emerged as achoice for Outpatient Dental Anaesthesia
INTRODUCTION (Cont) Although low Mortality (1 in 226000- 300000)1,2 Mortality or morbidity in a young fit patient coming for a brief and trivial procedures is a major concern Anaesthesia is conducted by an unqualified person (the surgeon himself or a non- Anaesthetist) in a poorly equipped setup1.Coplans MP, Curson I. Deaths associated with dentistry. British Dental Journal 1982; 153: 357-62.2.Tomlin P. Deaths associated with dentistry, British dental anaesthetic practice. Anaesthesia. 1974; 29: 551-70.
INTRODUCTION (Cont) Efforts to address these ethical, moral & economical issues: The Poswillo Report (1990)3 , Department of Health, UK This was revised in 19984 and amended again in 19995 and from USA in 199963.Poswillo D. General Anaesthesia, sedation and resuscitation in dentistry: Report of an expert working party. London: Department of Health, 1990.4.General Dental council. General Dental council: Maintaining standards: Guidance to dentists on professional and personal conduct: Amendments: General Anaesthesia and Resuscitation. London: General Dental council, 1998.5.General Dental council. General Dental council: Maintaining standards: Guidance to dentists on professional and personal conduct: Amendments: Pain & Anxiety control. London: General Dental council, 1999.6.Silker ES. Office based anaesthesia (ASA OBA Guidelines- ASA Guidelines- ASA House of delegates): New Orleans: 1999.
Aims & Objectives (Goals of learning) Understanding basic fundamentals Getting to know available guidelines Actual existing circumstances in India & our own experience Recommendations
Understanding Basics fundamentalsI. Out patient Dentistry includes: Conservative dentistry Single or multiple simple tooth extraction Impacted Molar Extraction Simple, short duration orthognathic procedures Incision and drainage, ennucleation of cyst/other soft tissue surgeries of short duration
Understanding Basics fundamentals (Cont)II. Indications of outpatient dental anaesthesia include: Children Anxious/apprehensive patients Mentally retarded Patients with allergic to local Anaesthetics or failure of L A
Understanding Basics fundamentals (Cont)III. Sedation for outpatient dentistry:Conscious sedation is a carefully controlled technique in which a single intravenous drug or combination of oxygen and nitrous oxide is used to reinforce hypnotic suggestion and reassurance in a way which allows dental treatment to be performed with minimal physiological and psychological stress, but allows verbal contact with patients to be maintained at all times
Indications for Sedation:Patients with simple, genuine fear or phobiaof dental treatmentYoung uncooperative childrenPatients with mild systemic disorders i.e.controlled hypertension, angina or asthma.Patients with neuromuscular disorders, i.e.Spasticity, Parkinsonism
Contraindications:Only ASA I & II are fit for SedationContraindicated in: Significant Cardio-Respiratory Disease Neuromuscular weakness Severe psychiatric disorder Pregnancy/ Lactation Un-cooperative, unwilling, unaccompanied patients Prolonged dental procedures Inexperienced Dentist/ Assistant Lack of appropriate equipmental resources
In 1st plane there is moderate sedation and analgesia. In 2nd plane sedation is dissociative withgreater element of Analgesia. In 3rd plane there is total analgesia precedingloss of consciousness. Local analgesics should be used along withnitrous oxide
Contraindications (Cons):Inadequate nasal breathingImproper fitting of mask due to facialabnormalitiesDeaf patientSevere respiratory disease Surgery of front teeth
Getting to know available guidelinesIn UK and some other countries inMarch 1990, a far reaching document:The Poswillo Report3:In March 1990, chaired by Professor DEPoswillo published the report of a workingparty on general anaesthesia, sedation andresuscitation in dentistry3.Poswillo D. General Anaesthesia, sedation and resuscitation in dentistry: Report of an expert working party. London: Department of Health, 1990.
“A carefully controlled technique in which a singleintravenous drug or a combination of oxygen andnitrous oxide is used to reinforce hypnoticsedation and reassurance in a way which allowsdental treatment to be performed with minimalphysiological and psychological stress, but whichallows verbal contact with the patient to bemaintained at all times. The technique must carrya margin of safety wide enough to renderunintended loss of consciousness unlikely. Inaddition, any technique of sedation other than asdefined above, be regarded as coming within themeaning of dental general anaesthesia”
RecommendationsAnaesthetic training should include specificexperience in dental anaesthesiaDental undergraduates should be taughtprinciples of Physiology and clinical practice ofanaesthesiaDental anaesthesia itself should be regardedas a postgraduate subject
Recommendations (Cont)Wherever possible, the use of generalanaesthetics should be avoided , if required alldental anaesthesia be given by accreditedanaesthetistsFacilities: multipara monitors, DC defibs,capnograph, adequate suction and operating light& other equipments“Single handed” operator/anaesthetist” -discontinuedSupine position for patient undergoing generalanaesthesia
Recommendations (Cont)Intensive courses on intravenous sedationAppropriate refresher courses‘British Standard’ relative analgesia machinesSkill and competence must be obtained bydentists in resuscitation & BLS skills
Because of elaborateness of the report -- lot of hue and cryWarning that: Demise of ‘GA in Dentistry is for sure’, were proven wrong! Revised and amended by General Dental Council Approved by Leo Strunnin, President, Royal College of Anaesthetists88. Woodman R. Dental council aims to cut anaesthetic rate. BMJ 1998; 317: 1407.
The Atmosphere of Pessimism, due tothese in-depth and very stringent guidelinesPersonnel related Only Anaesthetists on GMC Specialist register or Trainee Anaesthetists in approved training programs or Non consultant career grade Anaesthetists working under the supervision of consultant Anaesthesiologist
Specified equipment related Anaesthesia is to be administered using nasal inhaler Cuffed nasal airways Monitoring very high standardSurgical equipment related Mouth packs are essential Dental surgery should be practiced mainly as inpatient rather than outpatient
Getting to know available guidelines (contd.)While in USA, workshop “ASA, OBA guidelines-ASA House delegates” (New Orleans, October1999)6 - the problems raised & discussed: Problems associated with Resources Backup support system Professional liability of individual. Insurance coverage Special drugs e.g. :- Dantrolene sodium for malignant hyperthermia patients.6. Silker ES. Office based anaesthesia (ASA OBA Guidelines- ASA Guidelines- ASA House of delegates): New Orleans: 1999.
Problems associated with venueAvailability of reliable unending medical gasesboth oxygen as well as nitrous oxide.Electrical generator backup.Sophisticated equipment: monitors, infusionpumps, wall suction, alternative electrical suctionAvailability of support personnel: trained nursingstaff, O.R. personnel.Availability of additional anaesthetic personnel
Essential equipment:Anaesthesia machine is desirable but notessential, provided a self inflating resuscitationbag and equipment for securing airway isavailable.Equipment like D.C defibrillator is considered asessentialTrainingTrained anesthesiologist is the central figure.ACLS certification is must.Ongoing and continuous updating is needed.
MiscellaneousDesigning/ construction of such a facility toconduct these procedures requires seriousplanning.Financial implications.Guidelines by American Dental Society ofAnaesthesiology (ADSA) are more liberalUnlike in UK, In USA, there is a 1 year Fellowship inGeneral Anaesthesia equivalent to residency inanaesthesia and dental surgeons are permitted .
Actual Existing Circumstances in India and Our own experienceGrowing interest in Dental Anaesthesia“ Literacy, awareness , access to internet andincreased demand about “Pain & anxietyFree Dentistry”So..Newer Anaesthesiologist ask about: Setting up the service Understanding the pros and cons about it Most important :- the medico legal implications
Actual Existing Circumstances in India and Our own experience (Cont) No guidelines prescribed in our country Western practice set up - two diagonally opposing sets of guidelines existing on the two sides of Atlantic (UK Vs. US) Under the given dilemmatic circumstances, one is fraught with ambiguity Our efforts to Amalgamate both the philosophies and tailoring it to suit the current practices in our country
Actual Existing Circumstances in India and Our own experience (Cont) THE SET UP In our dental college in the department of Paedodontics - Dental Outpatient Anaesthesia Room (DOAR). Typical Dental Chair with all the paraphernalia suiting requirements for all the dental outpatient procedures. Cases of OMF/ Paedodontics procedures are also performed here
Actual Existing Circumstances in India and Our own experience (Cont) INFRA STRUCTUREEquipment Anaesthesia machine All other safety features No central O2 or N2O pipe line, so we have kept gas cylinders A working set of resuscitation equipment Oxygen delivery devices
Stand alone electrical working suctionAdditional equipments like, syringe pump, IVfluid giving stand etcRefrigeratorDrugs and ConsumablesIntravenous Anaesthetic agents, mainlyPropofol & MidazolamMonitoring equipments
Other drugs of resuscitation and support.Anticholinergics like atropine &glycopyrrolateIV Cannulas, Syringes, Three ways etc.Recovery RoomPersonnel
Effect ofPropofol, Midazolam & their Combination in day carepatients undergoing Oral and Maxillofacial Surgical Procedures
MODIFIED HAMILTON ANXIETY RATING SCALE (M-HAM-A)1. Anxious mood2. Tension3. Fears4. Insomnia MODIFIED HAM-( A ) score5. Difficulties in concentration and for level of anxiety : memory6. Depressed mood <17 : mild7. General somatic symptoms:8. General somatic symptoms: 18 – 24: mild to moderate Sensory9. Cardiovascular symptoms 25 – 30: moderate to severe10. Respiratory symptoms11. Gastro-intestinal symptoms12. Other autonomic symptoms13. Behavior during interview
METHODOLOGYInclusion criteria Exclusion criteria Availability of informed consent. Patient unwilling or hesitant for the procedure Known history of egg allergy Age between 18-50 years. History of adverse reaction or allergy to any ASA Physical status Class I & II. drug used during anesthesia Patients with systemic disease… Hemodynamically stable patient Pregnancy. with all routine investigations Known alcoholic. within normal limit. Anticipated prolonged surgery Patients with full stomach with chances of Elective surgery aspiration Duration of surgery between 30- Patients requiring emergency procedure Patients with compromised airway 150 minutes. Recent administration of CNS depressant drugs
METHODOLOGY (Cont)To compare and assess the clinical efficiency of sedation….Prospective, randomized, double blind, controlled study60 subjects of either sex, randomly allocated Propofol Midazolam & Propofol- Midazolam CombinationGroup A: Propofol Group B: Group C: Inductionbolus & Midazolam bolus & by Propofol &continuously continuously continuouslymaintained by maintained by maintained byinfusion of infusion of infusion ofPropofol. Midazolam. Midazolam.
METHODOLOGY (Cont)INJ. PROPOFOL & INJ. MIDAZOLAMBolus: Inj. Propofol 1 mg/ Kg IVMaintenance: Inj. Midazolam in a dose of 0.03-0.2 mg/Kg/hr.Permitted range of Midazolam formaintenance: 1.5 mg-10 mg/ hr.Average: 5 mg diluted in 25-30 ml/hr.
METHODOLOGY (Cont)Ten minutes after the infusion of sedativeagents, the local anesthetic is allowed tobe injected (comprising 2% lignocainehydrochloride with 1:100,000adrenaline).
METHODOLOGY (Cont) Patients verbal response is continuously monitored during the procedureWarning signs : Patient is apprehensive/anxious/uncomfortable Persistent closing of mouth Spontaneous mouth breathing Responds sluggishly to command Patient becomes uncooperative Patient has uncoordinated movements Patient talks incoherently
METHODOLOGY (Cont)The drug administration was stoppedAfter surgery sent to the recovery room &monitored for 2 hours.IV access was maintained for at least for 2hours and until discharge criteria are met Discharge instructions were reviewed
METHOD OF STATISTICAL ANALYSISAnalysis of variance (ANOVA) to test thehypothesis of the significance difference amongthe groups.Chi-square Test of association to determine theassociation between the categorical variables.Student’s t – test to test the hypothesis ofsignificant difference for inter-comparisons ofgroups
Comparison of Age factor among the groups 35.00 31.40 30.00 27.95 27.30 Absolute Value 25.00 20.00 15.00 10.00 8.78 8.38 5.67 5.00 0.00 Group A Group B Group C Groups Mean Standard DeviationResult: There is no significant difference in Age among the groups. The age of patients is equally distributed among the groups.
Comparison of Weight among the groups 70.00 60.00 57.70 54.00 50.95 50.00Absolute value 40.00 30.00 20.00 11.06 10.00 7.04 7.69 0.00 Group A Group B Group C Groups Mean Standard DeviationResult: there is no significant difference in weight among the groups. The weight of patients is equally distributed among the groups.
Comparison of Hamilton - Anxiety Score among the groups 25.00 22.80 23.00 21.50 20.00Absolute value 15.00 10.00 5.00 2.48 2.80 1.03 0.00 Group A Group B Group C Groups Mean Standard Deviation Result: As p value = 0.07 > 0.05 implies that, there is no significant difference in Hamilton anxiety score among the groups i.e. the anxiety level among all the three groups was same.
Distribution ASA grading among the patients 18 16 (80%) 16 14 12 (60%) 12Absolute count 11 (55%) 10 9 (45%) 8 (40%) 8 6 4 (20%) 4 2 0 Group A Group B Group C ASA - Grading Grade - I Grade - IIResult: There is no significant association between ASA grading & groups. Itimplies ASA grading within each group is equally distributed.
Comparison of Duration of surgery among the groups 60.00 52.50 50.00 39.00 40.00Absolute value 34.50 32.10 30.00 20.00 18.04 15.04 10.00 0.00 Group A Group B Group C Groups Mean Standard Deviation Result: There is no significant difference in average duration of surgery among the groups.
Comparison of Sedation score among the groups 16 14 14 12 12 10 9 8Absolute count 7 7 6 4 4 2 2 2 2 1 0 0 0 Fully Awake & oriented Drowsy Eye open Drowsy Eye Closed but rousable Deep ,Eye closed rousable on mild stimulation Sedation Scale Group A Group B Group C Result: The proportion of Deep, Eye closed, rousable on mild stimulation was more in Group C as compared to Group A & Group B.
Operating Condition among Groups 18 17 16 14 12 12 10Absolute Count 10 9 8 7 6 4 3 2 1 1 0 0 Good Fair Poor OC Levels Group A Group B Group C Result :Operating condition score was good in Group A when compared between Group B & Group C.
Distribution of Amnesic patients among the groups 18 16 16 14 14 13 12 Absolute count 10 8 7 6 6 4 4 2 0 Group A Group b Group C Groups Partially Amnesic Totally AmnesicResult: There is statistically highly significant association between degree ofamnesia & groups. It implies that proportions of totally amnesic patients arestatistically more in Group C than other groups.
Distribution of Incidence of Side Effects 20 19 18 18 16 14 12 12Absolute Count 10 8 8 6 4 4 2 1 0 Group A Group B Group C Groups Yes No Result: There is statistically highly significant association between incidence of side effects & groups. It implies that proportion of incidence of side effects is less in Group A than other groups.
Comparison of Discharge Score among the groups 10.00 9.30 9.00 8.30 8.00 8.00 7.00 6.00Absolute Value 5.00 4.00 3.00 2.00 1.00 0.57 0.47 0.00 0.00 Group A Group B Group C Groups Mean Standard Deviation Result: There is statistically highly significant association between Discharge Score & groups. It implies that proportion of Discharge Score Average is more in Group A than other groups.
BASE OPERATIVE VITALS:Pre-operative Procedure (T0) Pulse RateAt Induction (T1) SPO2 Systolic Blood PressureAt LA Administration (T2) Diastolic Blood PressureAt the beginning of Surgical Procedure (T3)At the end of surgical procedure (T21)At the recovery room at the time of discharge
Comparison of Pulse Rate between the Groups at all Time Points 80. 78. 76 74 72Mean Pulse 70 68Rate 66 64 62 60 T0 T1 T2 T3 T4 T5 T6 T7 T19 T20 T21 Group A 77.85 70.25 74.00 72.55 72.15 72.40 71.74 70.92 70.30 71.20 72.20 Group B 78.45 69.50 74.20 72.25 70.80 69.95 69.54 69.11 68.55 69.15 70.30 Group C 78.80 69.70 73.90 70.30 68.70 67.89 67.54 68.00 68.10 69.80 71.90 Time Point Group A Group B Group c Pulse Rate is better in Group A when compared with other groups
Comparison of SPO2 among the Groups at all time points 100.00 97.50Mean SPO2 95.00 92.50 T0 T1 T2 T3 T4 T5 T6 T7 T19 T20 T21 Group A 98.50 97.95 97.75 97.65 97.80 97.90 97.67 97.58 98.05 98.50 98.55 Group B 98.40 97.60 97.50 97.15 97.05 96.79 96.23 95.78 96.85 97.40 98.20 Group c 99.00 98.00 98.00 97.60 97.40 97.37 97.86 97.67 97.55 97.95 98.50 Time Point Group A Group B Group c SPO2 is better in Group A & Group C when compared with Group B
Comparison of Systolic BP among the groups at all points 130. 125.Mean Systolic BP 120. 115 110 105 100 T0 T1 T2 T3 T4 T5 T6 T7 T19 T20 T21 Group A 124.50 120.50 125.30 124.10 124.20 124.10 123.11 122.77 121.80 123.40 123.90 Group B 123.50 119.10 123.90 122.55 120.70 119.33 119.69 119.00 118.70 119.85 121.00 Group c 120.70 116.30 119.20 117.40 116.10 115.05 115.57 115.56 115.70 117.10 118.90 Time point Group A Group B Group c Systolic BP better in Group A when compared with other groups
Comparison of Diastolic BP among the Groups at all Time 85. pointsMean Diastolic BP 80 75. 70 65 T0 T1 T2 T3 T4 T5 T6 T7 T19 T20 T21 Group A 84.00 80.50 84.80 84.15 83.90 83.60 82.33 81.33 81.40 82.40 83.30 Group B 83.30 79.70 84.00 82.50 80.90 80.11 79.69 78.80 78.80 79.60 81.00 Group c 80.40 77.20 79.20 76.80 75.80 74.95 75.00 75.11 75.50 76.65 78.80 Time Point Group A Group B Group cDiastolic BP better in Group A when compared with other groups
SUMMARY & CONCLUSIONIn the present study we conclude that ….• Propofol Bolus dose: 1mg/kg and Maintenance dose: 0.5mg-0.6mg/Kg/hr is better than• Midazolam Bolus dose: 0.03mg-0.3 mg/kg & Maintenance dose:0.03-0.2mg/kg/hr and• Combination with (induction by Propofol 1mg/Kg + Maintenance by Midazolam)
SUMMARY & CONCLUSION (Cont)Group A (PROPOFOL 1%) is better when compared with other Groups: Sedation level is optimum The operating condition were ideal. Fluctuations in the hemodynamic profile, but there were no incidence of deviation from expected pattern. Recovery is very rapid and uneventful Partial amnesia Discharge criteria were successfully fulfilled and the scoring was high Patient’s satisfaction were highest with the use of Propofol
RECOMMENDATIONSGeneral Anaesthesia or its variants in association withdental outpatient practice have very specificindicationsThe conduct of Anaesthesia is not with specificproblemThe ease of local analgesia is very appealing, but if thepatient demand GA, or there are specific indications,then it justifies the troubles of giving GAAs a new developing, challenging field this can be veryusefulThe setup is very important, so initial investment has tobe considered.
IN CONCLUSIONDental Chair Anaesthesia is steadily gaining popularitychallenging, new, unexplored but promising territoryBalancing of ‘Pros & Cons’ for: conscious sedation,relative analgesia or Actual GAdispute in prescribing the guidelinesSetting up the services is as such not easy, cheap,or frivolous and simpleMust be done by trained qualified anaesthesiologistsProper homework, preparation and execution areabsolutely essential
Unforgettable Principle!“There is absolutely no justification inexposing the patient to any danger resulting inany morbidity & mortality especially when thepatient has come to get treated for a verytrivial, superficial and absolutely noninvasivesurgery.”“However if it is deemed necessary to ventureupon this , then Proper Homework,Preparation and execution : essential.