Prof. mridul M. panditrao, discusses the fundamental aspects of Problems of Dental Chair anesthesia, conscious sedation, The management and his own experience

2. DR. MRIDUL M. PANDITRAO
CONSULTANT
DEPARTMENT OF ANESTHESIOLOGY
& INTENSIVE CARE
PUBLIC HOSPITAL AUTHORITY’S
RAND MEMORIAL HOSPITAL
FREEPORT,
THE BAHAMAS

3. DENTAL CHAIR
ANAESTHESIA
PROS & CONS

4. INTRODUCTION
The association between anaesthesia and
dentistry:
Horace Wells (Dec. 1844): N2O; Failed Demo.
WTG Morton: “Inventor of Anaesthesia”
GQ Colton: Reintroduced N2O
Thereafter for almost 100 years GA was a norm
for Dental procedures
Decline in popularity of General Anaesthesia
Local Analgesia and Sedation emerged as a
choice for Outpatient Dental Anaesthesia

5. 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 setup
1.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.

6. 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 19996
3.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.

7. Aims & Objectives (Goals of learning)
Understanding basic fundamentals
Getting to know available guidelines
Actual existing circumstances in India &
our own experience
Recommendations

8. Understanding Basics fundamentals
I. 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

9. 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

10. 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

11. Indications for Sedation:
Patients with simple, genuine fear or phobia
of dental treatment
Young uncooperative children
Patients with mild systemic disorders i.e.
controlled hypertension, angina or asthma.
Patients with neuromuscular disorders, i.e.
Spasticity, Parkinsonism

12. Contraindications:
Only ASA I & II are fit for Sedation
Contraindicated 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

13. Relative Analgesia (Langer 1976)7
Concept – to divide 1st stage of Guidel’s
Classification into 3 planes:
1st & 2nd plane - Relative Analgesia
3rd plane - Complete Analgesia
15 – 30 % Nitrous Oxide → 1st plane
30 – 55 % Nitrous Oxide → 2nd plane
55 % + Nitrous Oxide → 3rd plane
7.Launger H. Relative Analgesia in dental practice; WB Saunders. Philadelphia: 1076.

14. In 1st plane there is moderate sedation and
analgesia.
In 2nd plane sedation is dissociative with
greater element of Analgesia.
In 3rd plane there is total analgesia preceding
loss of consciousness.
Local analgesics should be used along with
nitrous oxide

15. Contraindications (Cons):
Inadequate nasal breathing
Improper fitting of mask due to facial
abnormalities
Deaf patient
Severe respiratory disease
Surgery of front teeth

16. Getting to know available
guidelines
In UK and some other countries in
March 1990, a far reaching document:
The Poswillo Report3:
In March 1990, chaired by Professor DE
Poswillo published the report of a working
party on general anaesthesia, sedation and
resuscitation in dentistry
3.Poswillo D. General Anaesthesia, sedation and resuscitation in dentistry: Report of an expert working party. London:
Department of Health, 1990.

17. “A carefully controlled technique in which a single
intravenous drug or a combination of oxygen and
nitrous oxide is used to reinforce hypnotic
sedation and reassurance in a way which allows
dental treatment to be performed with minimal
physiological and psychological stress, but which
allows verbal contact with the patient to be
maintained at all times. The technique must carry
a margin of safety wide enough to render
unintended loss of consciousness unlikely. In
addition, any technique of sedation other than as
defined above, be regarded as coming within the
meaning of dental general anaesthesia”

18. Recommendations
Anaesthetic training should include specific
experience in dental anaesthesia
Dental undergraduates should be taught
principles of Physiology and clinical practice of
anaesthesia
Dental anaesthesia itself should be regarded
as a postgraduate subject

19. Recommendations (Cont)
Wherever possible, the use of general
anaesthetics should be avoided , if required all
dental anaesthesia be given by accredited
anaesthetists
Facilities: multipara monitors, DC defibs,
capnograph, adequate suction and operating light
& other equipments
“Single handed” operator/anaesthetist” -
discontinued
Supine position for patient undergoing general
anaesthesia

20. Recommendations (Cont)
Intensive courses on intravenous sedation
Appropriate refresher courses
‘British Standard’ relative analgesia machines
Skill and competence must be obtained by
dentists in resuscitation & BLS skills

21. Because of elaborateness of the report --
lot of hue and cry
Warning 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 Anaesthetists8
8. Woodman R. Dental council aims to cut anaesthetic rate. BMJ 1998; 317: 1407.

22. The Atmosphere of Pessimism, due to
these in-depth and very stringent guidelines
Personnel 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

23. Specified equipment related
Anaesthesia is to be administered using nasal
inhaler
Cuffed nasal airways
Monitoring very high standard
Surgical equipment related
Mouth packs are essential
Dental surgery should be practiced mainly as
inpatient rather than outpatient

24. Getting to know available
guidelines (contd.)
While in USA, workshop “ASA, OBA guidelines-
ASA House delegates” (New Orleans, October
1999)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.

25. Problems associated with venue
Availability of reliable unending medical gases
both oxygen as well as nitrous oxide.
Electrical generator backup.
Sophisticated equipment: monitors, infusion
pumps, wall suction, alternative electrical suction
Availability of support personnel: trained nursing
staff, O.R. personnel.
Availability of additional anaesthetic personnel

26. Essential equipment:
Anaesthesia machine is desirable but not
essential, provided a self inflating resuscitation
bag and equipment for securing airway is
available.
Equipment like D.C defibrillator is considered as
essential
Training
Trained anesthesiologist is the central figure.
ACLS certification is must.
Ongoing and continuous updating is needed.

27. Miscellaneous
Designing/ construction of such a facility to
conduct these procedures requires serious
planning.
Financial implications.
Guidelines by American Dental Society of
Anaesthesiology (ADSA) are more liberal
Unlike in UK, In USA, there is a 1 year Fellowship in
General Anaesthesia equivalent to residency in
anaesthesia and dental surgeons are permitted .

28. Actual Existing Circumstances in India
and Our own experience
Growing interest in Dental Anaesthesia
“ Literacy, awareness , access to internet and
increased demand about “Pain & anxiety
Free Dentistry”
So..Newer Anaesthesiologist ask about:
Setting up the service
Understanding the pros and cons about it
Most important :- the medico legal
implications

29. 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

30. 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

31. Actual Existing Circumstances in India
and Our own experience (Cont)
INFRA STRUCTURE
Equipment
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

32. Stand alone electrical working suction
Additional equipments like, syringe pump, IV
fluid giving stand etc
Refrigerator
Drugs and Consumables
Intravenous Anaesthetic agents, mainly
Propofol & Midazolam
Monitoring equipments

33. Other drugs of resuscitation and support.
Anticholinergics like atropine &
glycopyrrolate
IV Cannulas, Syringes, Three ways etc.
Recovery Room
Personnel

34. DOAR

36. MATERIALS USED

39. Effect of
Propofol, Midazolam & their
Combination in day care
patients undergoing Oral and
Maxillofacial Surgical
Procedures

40. MODIFIED HAMILTON ANXIETY RATING SCALE
(M-HAM-A)
1. Anxious mood
2. Tension
3. Fears
4. Insomnia
MODIFIED HAM-( A ) score
5. Difficulties in concentration and for level of anxiety :
memory
6. Depressed mood <17 : mild
7. General somatic symptoms:
8. General somatic symptoms: 18 – 24: mild to moderate
Sensory
9. Cardiovascular symptoms 25 – 30: moderate to severe
10. Respiratory symptoms
11. Gastro-intestinal symptoms
12. Other autonomic symptoms
13. Behavior during interview

41. METHODOLOGY
Inclusion 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

42. METHODOLOGY (Cont)
To compare and assess the clinical efficiency of sedation….
Prospective, randomized, double blind, controlled study
60 subjects of either sex, randomly allocated
Propofol
Midazolam &
Propofol- Midazolam Combination
Group A: Propofol Group B: Group C: Induction
bolus & Midazolam bolus & by Propofol &
continuously continuously continuously
maintained by maintained by maintained by
infusion of infusion of infusion of
Propofol. Midazolam. Midazolam.

43. METHODOLOGY (Cont)
INJ. PROPOFOL
Bolus: 1 mg/ Kg IV
Maintenance dose: 0.5-0.6 mg/ Kg/ hr
Average: 25-30 mg/hr.

44. METHODOLOGY (Cont)
INJ. MIDAZOLAM
Bolus: 0.03 mg- 0.3 mg/Kg
Maintenance: 0.03-0.2mg/Kg/hr.
Permitted range: 1.5 mg- 10 mg/hr.
Average: 5 mg diluted in 25-30 ml/hr.

45. METHODOLOGY (Cont)
INJ. PROPOFOL & INJ. MIDAZOLAM
Bolus: Inj. Propofol 1 mg/ Kg IV
Maintenance: Inj. Midazolam in a dose of
0.03-0.2 mg/Kg/hr.
Permitted range of Midazolam for
maintenance: 1.5 mg-10 mg/ hr.
Average: 5 mg diluted in 25-30 ml/hr.

46. METHODOLOGY (Cont)
Ten minutes after the infusion of sedative
agents, the local anesthetic is allowed to
be injected (comprising 2% lignocaine
hydrochloride with 1:100,000
adrenaline).

47. METHODOLOGY (Cont)
Patient's verbal response is continuously
monitored during the procedure
Warning 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

48. METHODOLOGY (Cont)
The drug administration was stopped
After surgery sent to the recovery room &
monitored for 2 hours.
IV access was maintained for at least for 2
hours and until discharge criteria are met
Discharge instructions were reviewed

49. METHOD OF STATISTICAL ANALYSIS
Analysis of variance (ANOVA) to test the
hypothesis of the significance difference among
the groups.
Chi-square Test of association to determine the
association between the categorical variables.
Student’s t – test to test the hypothesis of
significant difference for inter-comparisons of
groups

50. 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 Deviation
Result: There is no significant difference in Age among the groups.
The age of patients is equally distributed among the groups.

51. Comparison of Weight among the groups
70.00
60.00 57.70
54.00
50.95
50.00
Absolute 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 Deviation
Result: there is no significant difference in weight among the groups.
The weight of patients is equally distributed among the groups.

52. Comparison of Hamilton - Anxiety Score among the groups
25.00
22.80 23.00
21.50
20.00
Absolute 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.

53. Distribution ASA grading among the patients
18
16 (80%)
16
14
12 (60%)
12
Absolute 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 - II
Result: There is no significant association between ASA grading & groups. It
implies ASA grading within each group is equally distributed.

54. Comparison of Duration of surgery among the groups
60.00
52.50
50.00
39.00
40.00
Absolute 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.

55. Comparison of Sedation score among the groups
16
14
14
12
12
10
9
8
Absolute 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.

56. Operating Condition among Groups
18
17
16
14
12
12
10
Absolute 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.

57. 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 Amnesic
Result: There is statistically highly significant association between degree of
amnesia & groups. It implies that proportions of totally amnesic patients are
statistically more in Group C than other groups.

58. Distribution of Incidence of Side Effects
20 19
18
18
16
14
12
12
Absolute 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.

59. Comparison of Discharge Score among the groups
10.00
9.30
9.00
8.30
8.00
8.00
7.00
6.00
Absolute 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.

60. BASE OPERATIVE VITALS:
Pre-operative Procedure (T0)
 Pulse Rate
At Induction (T1)  SPO2
 Systolic Blood Pressure
At LA Administration (T2)  Diastolic Blood Pressure
At the beginning of Surgical Procedure (T3)
At the end of surgical procedure (T21)
At the recovery room at the time of discharge

61. Comparison of Pulse Rate between the Groups at all Time Points
80.
78.
76
74
72
Mean Pulse
70
68
Rate
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

62. Comparison of SPO2 among the Groups at all time points
100.00
97.50
Mean 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

63. 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

64. Comparison of Diastolic BP among the Groups at all Time
85. points
Mean 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 c
Diastolic BP better in Group A when compared with other groups

65. SUMMARY & CONCLUSION
In 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)

66. 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

67. RECOMMENDATIONS
General Anaesthesia or its variants in association with
dental outpatient practice have very specific
indications
The conduct of Anaesthesia is not with specific
problem
The ease of local analgesia is very appealing, but if the
patient demand GA, or there are specific indications,
then it justifies the troubles of giving GA
As a new developing, challenging field this can be very
useful
The setup is very important, so initial investment has to
be considered.

68. IN CONCLUSION
Dental Chair Anaesthesia is steadily gaining popularity
challenging, new, unexplored but promising territory
Balancing of ‘Pros & Cons’ for: conscious sedation,
relative analgesia or Actual GA
dispute in prescribing the guidelines
Setting up the services is as such not easy, cheap,
or frivolous and simple
Must be done by trained qualified anaesthesiologists
Proper homework, preparation and execution are
absolutely essential

69. Unforgettable Principle!
“There is absolutely no justification in
exposing the patient to any danger resulting in
any morbidity & mortality especially when the
patient has come to get treated for a very
trivial, superficial and absolutely noninvasive
surgery.”
“However if it is deemed necessary to venture
upon this , then Proper Homework,
Preparation and execution : essential.