The increasing number of reports in recent years about patients in dental practices who have not woken up after dental treatment under general anesthesia give the topic a sad topicality and place it in a greater public focus. Questions about the justification of general anaesthesia in the dental context and possible risks must be carefully weighed. In addition, it must be clarified whether general anaesthesia is really the right solution for anxiety patients.
The ZWP editorial staff spoke with Prof. Dr. Grietje Beck, Director of the Clinic for Anaesthesia, Rescue Medicine and Pain Therapy at HELIOS Dr. Horst Schmidt Kliniken Wiesbaden and co-chair of the Interdisciplinary Working Group on Dental Anaesthesia (IAZA).
Prof. Beck, when in your opinion is a general anaesthetic really justified for dental treatment?
There are indications for general anaesthesia on the operation side and on the patient side. On the operation side, general anaesthesia is given if the planned treatment poses a general risk of aspiration or if it is not possible to secure the respiratory tract or eliminate pain locally and if local anaesthesia or sedation does not provide optimal working conditions for the doctor. In addition, a necessary extremely long operation time under local anaesthesia is often unreasonable. On the patient side, difficult respiratory tract patients, allergy sufferers or patients with many relevant concomitant diseases can indicate general anesthesia.
A general anaesthetic, even if it is called twilight sleep in some places, is a complete elimination of consciousness. What are the risks and side effects?
In anaesthesiological parlance, twilight sleep means sedation. Sedation describes a state caused by a sedative with a damping effect on the central nervous system. If this is combined with a painkiller, it is called analgesia. The choice of medication and its dosage depend on any previous illnesses of the patients as well as the expected pain intensity. To be able to perform a safe analgosedation, the practitioner must be competent, including, among other things, securing the respiratory tract. If, for example, overdoses occur, the patient can slide into a deeper sedation stage fluently and without warning. This then means respiratory arrest and elimination of the reflexes and can only be properly answered by a general anaesthetic with intubation.
Topic: Anxiety patients: Should general anesthesia be used to overcome dental anxiety?
Dental anxiety is common, and unlike phobia, “fear of the dentist” has no disease value of its own. There is no indication for uncritically prescribed general anaesthesia, especially with a large number of other effective therapeutic measures. The situation is different for patients who suffer from dental phobia. For these patients an anesthesiological assistance with general anesthesia is often of great importance for dental therapy, as otherwise serious dental diseases with a possible worsening of the mental disorder are to be expected through avoidance behaviour. Thus, the insurance companies only pay for anaesthesia services for dental treatments for patients with dental anxiety if there is a specialist confirmation of a mental or psychiatric illness. From the point of view of the IAZA, the treatment by a dentist under general anaesthesia, which is often banalised for reasons of comfort, should also be assessed very critically. A general anaesthetic is not suitable for reducing anxiety during dental treatment and also carries the risk of serious complications.
What precautions must be taken for general anaesthesia in the dental treatment context? Which information for the patient and which reinsurance on the part of the practice are important and necessary?
The responsibilities between dentist and anaesthetist are to be clearly regulated according to the agreement between the professional societies DGZMK (Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde) and DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin). The premises must be designed in such a way that unrestricted access to the patient is possible even with a fixed dentist’s chair. The equipment requirements must be made available to adults and children in accordance with the published minimum requirements. Dental anaesthesia places special requirements on the position of the dental chair in a horizontal, head-down or semi-seated position.
Salmon gas sedation is increasingly establishing itself in German dental practices as a particularly gentle and risk-free form of anaesthesia. Anxiety patients as well as children are thus put into a relaxed state, which in turn enables safe and stress-free treatment for practitioners and patients. To what extent do you estimate the potential of this form of sedation? Could salmon gas sedation possibly replace (general) anaesthesia if it were used nationwide – as has long been the case in the USA?
The use of nitrous oxide, even by non-anaesthetists, is only suitable for minimal sedation during dental procedures, especially anxiolysis. Painful procedures require the additional administration of potent analgesics or local anesthesia due to the very minimal analgesia of nitrous oxide. In addition to the indications, a number of contraindications as well as organisational and personnel requirements must also be considered. Laughing gas is a drug and, in addition to its sedative effect, also has side effects such as nausea, vomiting or increased sweating. Laughing gas alone can therefore in no case replace an anaesthetic if it is indicated.
What is the focus of your work as an Interdisciplinary Working Group on Dental Anesthesia? And what exactly is the cooperation between the DGZMK and the DGAI?
The work of the IAZA is to promote dental anaesthesia in science and practice. For both professional societies, this means addressing and answering practical and current questions on this topic, initiating and supporting projects, and offering training courses and congresses. The focus is thus on promoting cooperation between dentists and anaesthetists, emergency medical training for dentists and the entire practice team, evaluation of pain elimination with sedation or anaesthesia as part of dental treatment and treatment management for high-risk patients. Both sides work together on guidelines, recommendations and scientific and popular scientific publications.