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Educational Seminars

Chair dental anaesthesia

Mike R Blayney & Andy F Malins

Abstract
Chair dental anaesthesia has remained basically unchanged for over 150 years and in the UK formed the basis of pain and anxiety management for dentistry until the 1960s. Dentists played a significant role in its administration with up to 2 million anaesthetics per annum being given in the 1950s. Recent demand has decreased with improved dental health, increased use of local anaesthetics, fluoridation and the development of sedation techniques. Nevertheless demand for general anaesthesia for dentistry in the UK has remained inappropriately high. A brief history of chair dental anaesthesia is described together with current practice and the development of alternative strategies. Associated mortality remains an important issue. Rigorous standards regarding the control of pain and anxiety, the indications for general anaesthesia, and the conduct of chair dental anaesthesia have now been defined.

Keywords
Anaesthetics, dental, inhalational, mortality, sedation, inhalational, intravenous.

Historical perspective
General anaesthesia and dental surgery have been closely associated for 157 years. Although local anaesthetic techniques were described in dentistry in 1886, general anaesthesia remained the mainstay of pain and anxiety control for dentistry in Britain until the 1960s. Although chair dental anaesthesia has played a significant role in anaesthetic practice in the United Kingdom for many decades (peaking at approximately 2 million anaesthetics per annum), it was uncommon elsewhere in Europe and North America. It was Humphrey Davy who, in 1800 whilst suffering from acute gingivitis, first described the analgesic properties of nitrous oxide as follows, on the day when the inflammation was most troublesome, I breathed three large doses of nitrous oxide. The pain always diminished after the first four or five respirations, and it appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.

It was not until 1844 that the surgical potential of nitrous oxide was realised by Gardner Quincy Colton, and Horace Wells, a dentist. On 10th December 1844, when Colton demonstrated the effects of nitrous oxide in Hartford, Connecticut, Wells noticed that the subject felt no discomfort on injuring his shin whilst under the inf luence of nitrous oxide. Wells proposed that nitrous oxide might have a role for the painless extraction of teeth and on the following day volunteered to have a wisdom tooth extracted under the effects of nitrous oxide administered by Colton. The procedure was a huge success and Wells declared a new era in tooth pulling! Two years later, in December 1846, the first dental anaesthetic was administered in England by James Robinson. Ether was first publicly used in September of that year by William TG Morton, an associate of Horace Wells, to anaesthetise Eben H Frost for a dental extraction. From 1846 ether and later chloroform became the anaesthetics most commonly used for both dental and general surgery. In 1867 Colton, having successfully administered 24,000 dental anaesthetics without fatality, travelled to France where he instructed T W Evans, an American dentist, to administer nitrous oxide. The nitrous oxide was given from an animal bladder through a wooden tube into the mouth, whilst the nostrils were compressed. This technique was described by Gardner as follows: instruct the patient to take full deep and slow inspirations of the gas and hold the lips and nose so as to allow no particle of common air to enter and dilute the gas. By this means anaesthesia will be reached in 45 to 60 seconds. Evans also demonstrated the technique in London in 1868 and inf luenced Joseph Clover, who subsequently adapted his technique using nitrous oxide instead of ether, delivered via a nasal mask of his own design. Improvements in the delivery of nitrous oxide came when the gas became available in cylinders in 1868. Oxygen was first used in Chicago in 1868 by Edmund Andrews to avoid the inevitable asphyxia associated with the

Mike R Blayney FRCA Consultant Anaesthetist Nobles Isle of Man Hospitals Andy F Malins FRCA Consultant Anaesthetist Honorary Senior Clinical Lecturer Birmingham Dental Hospital and School St Chads Queensway Birmingham B4 6NN UK Mike Blayney Qualified in dentistry in 1983 and medicine in 1991. Finally choosing anaesthesia for a career he completed his SpR training in the Birmingham School of Anaesthesia. Recently appointed as a consultant at Nobles Hospital Isle of Man. His career interests are dental anaesthesia and sedation and postgraduate education Andy Malins Consultant Anaesthetist since 1983 trained in Birmingham and the South West Region. Anaesthetist at the Birmingham Dental Hospital. Currently, Deputy Regional Advisor and Programme Director Birmingham School of Anaesthesia Correspondence: M R Blayney Nobles Isle of Man Hospitals Westmoreland Road Douglas Isle of Man IM1 4QA British Isles Tel: 01624 642218 E- mail: Mike.Blayney@btinternet. com

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inhalation of a hypoxic gas mixture. In 1887 Sir Frederick Hewitt designed the first practical apparatus for administering oxygen/nitrous oxide mixtures and in 1926 E.I McKesson designed the first demand-f low apparatus which was later followed by the Walton machine that remained in service until the 1970s. Nitrous oxide anaesthesia was in common use and remained popular for over 100 years. Patients typically passed through the stages of analgesia and excitation until surgical anaesthesia was achieved. Oxygen was then introduced to prevent hypoxia, its concentration carefully regulated as the margin between inadequate anaesthesia and significant hypoxia was known to be narrow. Ether anaesthesia did not have this problem although induction was prolonged and often stormy, and recovery was slow and associated with nausea and vomiting. Ethyl chloride, trichlorethylene and cyclopropane were also used but nitrous oxide anaesthesia alone remained popular until the introduction of halothane in 1956 and methohexitone in 1957. With these agents surgical anaesthesia was now possible without the hypoxia associated with the pure nitrous oxide technique with adequate oxygenation throughout the procedure and better recovery. Although associated with painful injection and excitatory phenomena, methohexitone became a more popular induction agent for chair dental anaesthesia than thiopentone, by virtue of a more rapid induction, shorter duration of action and rapid recovery. In 1965 Drummond Jackson introduced the minimal incremental technique with methohexitone for sedation during dental procedures. However the narrow therapeutic margin between sedation and anaesthesia was of concern when undertaken by the single-handed operator anaesthetist. Methohexitone remained a popular agent with dental anaesthetists until its manufacture ceased in 1998. Both enf lurane and isof lurane supplemented nitrous oxide and oxygen anaesthesia have been used in chair dental anaesthesia. However, halothane remained popular until the introduction of sevof lurane in 1996. Propofol by way of contrast was introduced with some caution because of its propensity to cause hypotension and occasional apnoea.

precludes all but healthy ASA grade I and II patients. It remains essential that dental surgeons have some understanding of the anaesthetic implications of common medical conditions and can exclude patients with significant medical problems and instigate appropriate specialist referral. Clear preoperative instructions detailing recommendations for pre-operative starvation and appropriate instructions for discharge home are essential. Particular attention must be paid to all aspects of good anaesthetic practice, including formal protocols for referral, medical history, records and standards of practice throughout the perioperative period. In the past anaesthetists often worked without skilled assistance, with outdated and often poorly maintained equipment, sub-optimal standards of monitoring and in the absence of adequate recovery and resuscitation facilities. Before 1998, the qualifications and experience of the anaesthetists involved in dental anaesthesia were wide ranging from dental surgeons and general medical practitioners with some anaesthetic experience to consultant anaesthetists with wide specialist expertise in the field.

Anaesthetic Considerations Posture

There has been considerable debate regarding the relative merits of the sitting position versus the supine position. It is important to differentiate between the various positions- the true sitting position (Figure 1) has been abandoned in favour of the semi-reclining position but often referred to as the sitting position. The advantages and disadvantages of the sitting and supine position are outlined in Table 1.

Practical considerations
Traditionally chair dental anaesthesia has been practiced in general dental practice, community dental clinics, dental hospitals and hospital outpatient departments, often in locations remote from immediate medical, diagnostic and critical care facilities. Patients presenting for dental extraction under chair dental anaesthesia can often be casual attendees, only seen by the anaesthetist immediately prior to administration of anaesthesia. The nature of the practice
Figure 1. Dental anaesthesia, December 1938, Great Charles Street, Birmingham.

The sitting position is recognised as a potential cause of mortality in chair dental anaesthesia. The semi reclining position affords some of the advantages of the sitting position and overcomes some of the shortcomings of the supine position.

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Advantages
Sitting Position Gravity reduces the likelihood of passive regurgitation and of gastric contents.

Disadvantages

Reduction in venous return due to pooling, resulting in aspiration decreased cardiac output and cerebral hypoperfusion. Airway maintenance Unrecognised may be marginally vasovagal syncope easier with improved leading to cerebral respiratory mechanics. hypoperfusion and The floor of the hypoxia. mouth angles forward Debris passing over with blood, saliva and the posterior tongue tooth debris gravitating into the oropharynx to the anterior part of may cause the oral cavity. This laryngospasm and facilitates suction aspiration. clearance reducing the possibility of laryngospasm and aspiration. Exodontia with forceps is sometimes easier for dental surgeons as counter pressure can be applied. Compromised respiratory mechanics Fluid and solid debris is more likely to pass into the oropharynx. Passive regurgitation and aspiration may occur.

ventricular arrhythmias.3 In a study comparing halothane and sevof lurane supplemented N2O and O2 anaesthesia the incidence of ventricular extrasystoles and ventricular tachycardia was higher with halothane than with sevof lurane. Only isolated atrial extrasystoles were a feature of sevof lurane anaesthesia. In November 1999 the Committee on Safety of Medicines withdrew the use of halothane outside a hospital setting.

The shared airway

It is of paramount importance that the anaesthetist maintains an adequate airway whilst the dental surgeon extracts the teeth. An oral pack is used for this, protecting the airway from saliva, blood and tooth debris. If placed too far posteriorly airway obstruction will result, too far anteriorly then airway leakage, air entrainment, lightening of anaesthesia and possible aspiration of saliva, blood and tooth debris can occur.

Age of the patient

The majority of patients attending for chair dental anaesthesia are children (median age at the Birmingham Dental Hospital is 6 years). Children have a low incidence of significant co-existing systemic disease but a high incidence of respiratory tract infections, adenotonsillar hypertrophy, and nasal obstruction. Any child should therefore undergo an assessment of nasal airway patency. All anaesthetists practising chair dental anaesthesia need adequate paediatric experience, and the RCA recommends that only appropriately trained paediatric anaesthetists should anaesthetise very young children.

Supine Position Venous return from the lower limbs is unimpeded. Reduced incidence of cerebral hypoperfusion Both operator and anaesthetist can sit

Table 1. Advantages and disadvantages of the sitting and supine positions in chair dental anaesthesia.

Arrhythmias
Cardiac arrhythmias are commonly associated with exodontia and anaesthetic factors such as hypoxia, hypercarbia, light anaesthesia and some inhalational anaesthetic agents, notably halothane. Trigeminal stimulation is a potent cause of arrhythmias, and prior infiltration of the operative site with lignocaine significantly reduces the incidence. Halothane in dental anaesthesia is frequently accompanied by ventricular arrhythmias (>30% incidence) particularly during exodontia and emergence. A causal link between halothane anaesthesia, ventricular arrhythmias and mortality associated with the dental chair has been suggested. In comparison, enf lurane is less likely to cause ventricular arrhythmias but is a more difficult inhalational agent to use. Isof lurane has no association with ventricular arrhythmias but has an unacceptably high incidence of coughing, excessive salivation and laryngospasm.1 Sevof lurane by comparison is a suitable alternative to halothane.2 Its pleasant smell and favourable physical characteristics make it ideal for inhalational induction. It also has no association with

Nitrous oxide exposure

Studies have shown that occupational exposure to N2O in dental anaesthesia can exceed the recommended limits (100 ppm N2O) The use of high fresh gas f low rates, inhalational induction techniques, poor airway seal and recovery in the dental chair contribute to this. Active scavenging and optimal ventilation in the surgery may minimise exposure to N2O, however this can be eliminated if oxygen supplemented sevof lurane anaesthesia is used as routine.

Current Techniques
Inhalational induction remains popular for younger children, whereas the intravenous route is more common for older children. Discussion of alternative methods of pain and anxiety control, where appropriate, is mandatory and is the responsibility of the anaesthetist and the referring and treating dentist. After undertaking a preoperative assessment, obtaining consent, and giving a clear explanation of the

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anaesthetic technique involved, the patient is positioned semi-reclined or supine in the dental chair. The younger child may be sat on a parents lap. The uncooperative and difficult child may benefit from premedication. It is mandatory that all patients must be monitored with an ECG, pulse oximetry and non-invasive blood pressure (in the uncooperative child monitoring may have to be applied during the induction phase). Where an intravenous technique is not used, intravenous access is secured immediately after inhalational induction. Establishing venous access is mandatory even for the briefest procedures. When intravenous induction is the preferred technique, topical anaesthesia is of benefit prior to cannulation particularly in the young child.

Inhalational induction
Anaesthesia is administered via a nasal mask or full facemask and non-rebreathing system with children in the semi-reclining or supine position. Sevof lurane supplementation of 66% nitrous oxide in oxygen is used. Sevof lurane may either be introduced in 2% increments every 2 to 3 breaths to a maximum of 8%, with maintenance of anaesthesia at or around 4%, or it may be introduced at the maximum concentration of 8%, with maintenance at 4%. Induction using 8% sevof lurane does not appear to cause any adverse effects.3 On reaching Stage 3 anaesthesia, a Ferguson gag or McKesson prop (to open the mouth) and oral pack are inserted before dental extractions are commenced (Figure 2). Specially preformed oro-pharyngeal packs (e.g. Dentmed V-pack) are available to protect the airway with advantages over the traditional pack or strip of gauze. Efficient suction is required to remove f luids and debris. Adenotonsillar hypertrophy can compromise the nasal airway and nasopharyngeal airways have been shown to significantly improve airway patency and reduce episodes of airway obstruction.4 Laryngeal masks have been demonstrated to provide better surgical access and easier airway maintenance than nasal mask with nasopharyngeal airway, or nasal mask alone.5 This technique improves airway maintenance and some studies suggest that it avoids the need for a oropharyngeal pack. Scavenging of anaesthetic gases is greatly improved due to an improved airway seal. After the last extraction 100% oxygen is administered until the patient has regained consciousness. Monitoring should be maintained during the initial recovery phase as acute cardiovascular collapse can occur at this stage. The cannula is removed when recovery is complete.

Figure 2. GA dental pack.

thiopentone. Titrated administration is used to induce Stage 1 anaesthesia, to reduce and avoid an apnoeic phase. Thereafter sevof lurane supplementation of 66% nitrous oxide in oxygen is administered, proceeding as for the inhalational induction. Although methohexitone was withdrawn in 1998, there is the possibility that it may be re-introduced in the near future.

Mortality
The safety of general anaesthesia for dentistry has received substantial attention over the last three decades. However, mortality has not fallen despite efforts to improve standards of practice and to discourage use of general anaesthesia in dentistry. The cause of death is usually either respiratory difficulty or sudden cardiovascular collapse. The latter may be due to unrecognised vasovagal syncope or ventricular arrhythmias. The number of general anaesthetics administered and deaths for each decade since 1950 are detailed in Table 2.
Decade DEB/DPB Nos Enhanced Nos Deaths Ratio 1950-9 16.26m 24.39m 134 1:182,000 1960-9 13.96m 20.95m 70 1:299,000 1970-9 10.37m 15.56m 64 1:243,000 1980-9 4.39m 6.58m 20 1:329,000 1990-00 2.06m 3.10m 12 1:258,000 50 year 47.05m 70.58m 300 1:235,000 total Table 2. Number of general anaesthetics administered and deaths each decade since 1950 (by kind permission of Dr Adrian Padfield).6

Intravenous induction
Propofol is suitable for chair dental anaesthesia with recovery times that are significantly less than with

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The total number of anaesthetics according to the Dental Estimates Board and Dental Practice Board (DEB/DPD) are detailed in column 2 with the numbers being enhanced by an estimate of the activity in Scotland in the next column. However the methodology of identifying an accurate mortality ratio may be problematic due to the way in which the data has been recorded. When a fatality occurs it promotes widespread media attention and public concern especially when it involves a fit healthy child for a procedure which is perceived to be of a trivial nature. The steady decrease in numbers of anaesthetics administered over the last 50 years may be due to several factors including improved dental hygiene and the introduction of f luoridated water and toothpaste. The number of dental practices providing a general anaesthetic facility has decreased, and the use of local anaesthetics increased. In addition there has been a development in alternative methods of anxiety control including sedation techniques.

Recommendations
Successive reports from expert groups, professional bodies and the NHS spanning some decades have focused on dental anaesthesia. Of particular note was the abandonment of the single handed operator anaesthetist whilst the key landmark was the Report of an Expert Working Party on General Anaesthesia, Sedation and Resuscitation in Dentistry in 1990, commonly referred to as the Poswillo report. It made the following recommendations: General anaesthesia should be avoided wherever possible. Uniform standards of monitoring and personnel necessary for patient safety should apply, wherever general anaesthetics are administered. Health authorities should review the provision of consultant dental anaesthetic sessions to ensure they are sufficient to meet local needs. Doctors and dentists with knowledge, experience and competence sufficient to satisfy the Royal College of Anaesthetists and Faculty of Dental Surgery should be allowed to continue administering anaesthetics. Despite the adoption of the recommendations and central government funding to change and improve the standards of practice, deaths continued to be reported. In 1995 the Clinical Standards Advisory Group reported on general anaesthesia in dentistry, raising certain issues with regard to the implementation of the Poswillo recommendations. The key areas were the variations in the availability of a general anaesthetic service, the standards of clinical facilities, provision of equipment and drugs and the availability of

appropriately trained anaesthetists. It recognised that a significant number of general anaesthetics were given on patient demand rather than because of clinical need. It was evident that some professionals had failed to recognise fully that general anaesthesia is never without risk. In November 1998 the General Dental Council, in consultation with the Royal College of Anaesthetists (RCA), issued new guidance in respect of general anaesthesia for dentistry. Dental surgeons were made professionally responsible for ensuring their patients receive a clear and thorough explanation of the risks involved in general anaesthesia and informed of alternative methods of pain and anxiety control (i.e. local anaesthesia with or without sedation). Dental practitioners must be able to justify the use of general anaesthesia and ensure that the anaesthetist is appropriately qualified: An anaesthetist on the specialist register of the GMC A trainee working under supervision as part of a RCA-approved training programme; A non-consultant career grade anaesthetist with an NHS appointment working under supervision of a named consultant. Any dental practitioner failing to comply with these recommendations is now liable to a charge of serious professional misconduct. The Royal College of Anaesthetists Standards and Guidelines for general anaesthesia for dentistry, (February 1999), defined the situations where general anaesthesia would be indicated: Clinical situations in which it would be impossible to achieve adequate local anaesthesia and so complete treatment without pain (e.g. acute dento-alveolar abscess) where drug therapy, or drainage procedures with other methods of pain relief, are inappropriate or have been unsuccessful. Patients who, because of problems related to age/immaturity or physical/mental disability, are unlikely to allow the completion of treatment. The RCA recommended that only specialist paediatric anaesthetists administer general anaesthetics to very young children. Patients in whom long term phobia will be induced or prolonged. The long-term aim in such patients should be the gradual introduction of treatment under local anaesthesia using, if necessary, an intermediate stage employing conscious sedation techniques. The Department of Health Report, A Conscious Decision, published in 2000 concluded that despite a large number of expert reports aimed at improving standards, patients remain vulnerable to unexpected death or non-fatal complications occurring outside

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hospital in circumstances which may be avoidable. Standards aimed at protecting patients from the serious complications of general anaesthesia or conscious sedation during dental treatment are not rigorously applied or enforced and it is unlikely that further attempts to refine general anaesthesia in dental practice outside hospitals through guidance, inspection and enforcement will provide sufficient assurance. The experts on the working party recommended that chair dental anaesthetics must be administered in a hospital setting no later than 31st December 2001.

Alternative techniques
Psychological and pharmacological strategies are well established as alternatives to general anaesthesia for anxiety control and management of the dental patient. Relative analgesia with N2O and intravenous sedation with midazolam are commonly employed. With regard to the safety of intravenous sedation the relative risks are unknown. However sedation for endoscopy is not without significant risk. In comparison the dental patient represents a different cohort and it could be assumed that the risks are significantly reduced in this group of relatively fit individuals without concurrent systemic disease. The definition of conscious sedation is clearly stated by the General Dental Council: A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to
References 1. McAteer PM, Carter JA, Cooper GM, et al; Comparison of isof lurane and halothane in outpatient paediatric dental anaesthesia. Br J Anaesth 1986; 58: 390-393. 2. Arrifin SA, Whyte JA, Malins AF, et al; Comparison of induction and recovery between sevof lurane and halothane supplementation of anaesthesia in children undergoing outpatient dental extractions. Br J Anaesth 1997; 78: 157-159. 3. Blayney MR, Malins AF, Cooper GM. Cardiac arrhythmias in children during outpatient general anaesthesia for dentistry: a prospective randomised trial. Lancet 1999; 354: 1864-6.

provide sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely. Recent developments in the field include inhalational sedation with subanaesthetic concentrations of sevof lurane and there are a number of published studies on sedation with target controlled infusions (TCI) of propofol. Adequate sedation can be achieved with propofol at a target concentration of 2 to 2.5 mcg/ml. However, supplementation with other agents such as fentanyl (10 to 25mcg) or midazolam ( 1 to 2 mg) is usual. In the authors experience of using TCI sedation with propofol alone the level of sedation achieved can be variable. Transient apnoea during the initial infusion can occur and in approximately 2 to 3% of cases, a brief period of anaesthesia has occurred even with a target concentration of 1.5mcg/ml. Whilst the dangers of anaesthesia have been identified, the morbidity and mortality associated with sedation is not clearly defined. Thus the development and practice of sedative techniques may not be without risk. A question that cannot as yet be answered is Are the sedative alternatives to general anaesthesia any safer? In the meantime rigorous standards and monitoring must be applied.

Acknowledgement
The photograph published is with the kind written consent of the patient

4.

Bagshaw ON, Southee R, Ruiz K. A comparison of the nasal mask and the nasopharyngeal airway in paediatric chair dental anaesthesia. Anaesthesia. 1997; 52: 786-9.

5.

Woodcock BJ, Michaloudis D, Young TM. Airway management in dental anaesthesia. European Journal of Anaesthesiology. 1994; 11: 397401.

6.

Padfield A. Fifty Years of Dental Anaesthetic Mortality. Proceedings of the Association of Dental Anaesthetists 2000; 18: 28-30.

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