Since Horace Wells’ early use of nitrous oxide analgesia in the 1840s, the dental profession has been at the forefront of the delivery of anesthesia for the relief of anxiety and pain control for patients undergoing dental treatment. Today, effective training of anesthesia and pain control for dental patients have been carefully codified by the Commission on Dental Accreditation of the American Dental Association.1 Under the auspices of numerous dental schools, undergraduate and continuing education programs are administered for basic airway management and enteral sedation as well as parenteral mild to moderate sedation. Nitrous oxide analgesia courses are popular in both the undergraduate and postgraduate setting. Deep sedation and general anesthesia techniques are part of the comprehensive training programs for oral and maxillofacial surgeons and dentists who desire the concentration of their practice on anesthesia and pain control. Frequently, these dental practitioners will sedate or anesthetize patients in office-based, dental clinic-based or other ambulatory settings. Special-needs patients who require routine dental care are frequently sedated or undergo general anesthesia in the ambulatory or office-based environment. Treating these patients requires special attention to the details of transitioning the patient from the transport vehicle through recovery. Skills in basic and advanced life support are usually requisites for attending courses in analgesia, anxiety and pain control. Despite the rare adverse outcome, dentists have an enviable record of patient safety with respect to anesthesia and pain control.2,3
The “alphabet soup” of dental societies and specialties involved in sedation, anxiety and pain control as well as anesthesia may be confusing. In the list below, the abbreviations are elaborated for greater understanding.
AAOMS – American Association of Oral and Maxillofacial Surgeons: Oral surgeons with no less than four months of formal anesthesiology training on the hospital anesthesiology service.
ADSA – American Dental Society of Anesthesiology: Dentists with an abiding interest in anesthesiology and pain control for dental patients. No formal training is required for membership. However, most members have extensive training, continuing education and clinical experience.
ASDA – American Society of Dentist Anesthesiologists: Dentists with no less than one year of exclusive and formal anesthesia and pain control training. Many have two to three years of exclusive training. Many teach anesthesia and pain control in dental schools or provide moderate or deep sedation for dental patients in the office-based setting as well as dental clinics.
AAPD – American Academy of Pediatric Dentistry: Pediatric dentists have a minimum one-month rotation for exclusive anesthesia and pain control treatment. Their specialty regulations are in virtual “lock step” with the American Academy of Pediatrics position on airway management, procedural sedation and pain control.4
Recent safety initiatives include mandates for capnography in the oral and maxillofacial surgeons’ offices effective January 1, 2014. The board of directors mandated this change in 2012 and may be found in the latest (8th) edition of the AAOMS Office Anesthesia Evaluation Manual, which was published in 2012.5 Also, there is a mandate for additional and specific training by their residents for one month of pediatric anesthesia training, including sedation and general anesthesia effective in 2013.6 Oral and maxillofacial surgeons are rigorously trained in anesthesiology along with their medical anesthesia counterparts. More than one-half of the 102 training programs are combined in a six-year M.D./oral surgery program.6 Many of these residents come to the anesthesiology service during their residency program having spent months of rotations on internal medicine, general and subspecialty surgery, pediatrics, critical care and emergency medicine. The consecutive time spent on the anesthesiology rotation varies depending upon the jigsaw puzzle of mandated rotations, clinical service mandates and workforce needs in their specialty.
There are a number of organizations in dentistry that have an active interest in anesthesia and pain control. The largest groups of practitioners are members of the ADSA.7 This organization of more than 5,000 members has an open membership to any dentist who has an interest in anesthesia and pain control. The greatest proportion of members is oral and maxillofacial surgeons. The second largest group are those who solely practice anesthesia and pain control for dental patients in the ambulatory setting. Many of these second group of practitioners are also members of the ASDA. This group of approximately 300 dentists has been trained in a hospital and dental school setting. Rotations often take place in the operating room environment to master skills in general anesthesia for oral and maxillofacial surgery as well as other dental care. There are accreditation standards for such training under the Advanced General Dentistry Education Programs in General Anesthesia. These programs are at least 24 months in duration. Starting in 2015, the program must be at least 36 months in duration. The training programs specify a carefully planned didactic as well as clinical program. Specific case requirements include intubated and non-intubated patients and pediatric and adult case mix, as well as rotations in internal medicine, pediatrics, emergency medicine and others. Advanced airway techniques, including the use of rigid and flexible videolaryngoscopy, are required. The training occurs in hospital operating rooms, dental schools and hospital dental clinics. At the time of this writing, there are nine programs in the United States and one in Canada that teach anesthesia for dental trainees.1 Prior to 1993, these programs were one year in length. From 1993 through the present, two years of formal training were mandated.
Simulation is now a mainstay of anesthesia and pain control in dentistry. The ADA, ADSA, ASDA, AAPD and AAOMS have active simulation programs for office-based anesthesia emergency treatment and airway task trainers. Each of these organizations has invested many hours to have quality and effective teaching programs. Dental anesthesia providers are co-leaders and authors with contributions to position papers in simulation in health care.8,9
A new program for patient safety in the dental office taught by dentists with extensive anesthesia and pain control interest has achieved national recognition. It is called “10 Minutes Can Save a Life” and is sponsored by the ADSA Foundation. It teaches advanced life support using ACLS methodology and medication. The program creates an organized approach to airway management, medication support and is taught based upon the skills and anesthesia credentials of the dentist.10
Most of the dental societies that have anesthesia and pain control focus utilize ASA practice guidelines wherever possible, including ASA’s Management of the Difficult Airway. From a regulatory perspective, virtually all states require both practitioner and facility permits for use of nitrous oxide and other forms of sedation and anesthesia. Several states have proscribed specific numbers of continuing education credits for maintenance of certification; many of these requirements are mandated to be no less than biannually. Florida and New Jersey have rigorous regulatory oversight.11 The dental profession has made educational efforts to improve anesthesia safety and pain control in the office-based environment.
Dental patients with multiple medical, psychological or physical challenges were frequently treated in the hospital environment in the past. Unfortunately, insurance issues have made the hospital environment a difficult or costly option. Consequently, most dental care for these individuals is provided in the office or dental clinic environment. These patients present challenges for sedation or general anesthesia in the office-based or dental clinic environment. The dental practitioners who practice sedation, anxiety and pain control are skillful and competent in adapting to the care of these technically chal-lenging patients. In a larger sense, our dental colleagues have safely advanced sedation, anxiety and pain control in the off-site environment. Their ongoing educational initiatives will continue to improve patient safety for those who require sedation, anxiety and pain control.
Andrew Herlich, D.M.D., M.D., FAAP is Professor and Vice-Chair for Faculty Development, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. His is an MHAUS Hotline consultant.