Anesthesiology and oral and maxillofacial surgery

Abstract

One of the most important skills possessed by oral and maxillofacial surgeons (OMFSs) is the ability to provide high-quality pain and anxiety control for their patients. For most office patients, this means either deep sedation or general anesthesia. Before the introduction of the benzodiazepines in the early 1970s, the primary method of anxiety control was through the administration of an ambulatory general anesthetic by means of the ultra–short-acting barbiturates, a skill possessed primarily by OMFSs. After the introduction of benzodiazepines, dentists other than OMFSs began using sedation to provide anxiety control. (Today, several other dental specialties actually require that resident trainees be given instruction in sedation). In response, many OMFSs became defensive. Many believed that the ability to control pain and anxiety was an important, if not the only, advantage OMFSs had over competing dental specialists. Thus, the attempt by other dental groups to become as well trained in sedation and general anesthesia as OMFSs was viewed as a threat to their practices. At about this time, the dental anesthesiologist had an increasing presence. These specialists had a clearly defined 2-year training program, which made them expert in outpatient sedation and anesthesia. Because their services are not provided for hospitalized patients, but rather for ambulatory patients, dental anesthesiologists usually see patients in the office of the individual surgeon or dentist. This has led to the derogatory term “itinerant anesthesiologist.” Dental anesthesiologists are highly skilled and trained. They use the most modern equipment and the newest and best drugs to achieve the desired goal, and they have high-level skills in the management of the medically compromised patient. When they are allowed to practice as they are qualified to do, their schedules quickly fill up and the waiting time for a patient to be seen by them might be weeks. Why does this happen? The answer is that the demand for the services of a dental anesthesiologist outstrips the availability of the dental anesthesiologists. The primary dental groups that use dental anesthesiologists are (in rank order) OMFSs, pediatric dentists, periodontists, endodontists, and a few general dentists. Oral surgeons and pediatric dentists account for about 65% to 75% of the total caseloads of dental anesthesiologists. OMFSs use anesthesiologists for osteotomies, bone grafts, and other procedures that are commonly per- formed in the hospital operating room but that do not require the patients to be hospitalized. In today’s world, many procedures cannot be performed in the hospital setting because of limitations set by insurance companies and HMOs. But these procedures become affordable if done in the office setting rather than in the hospital. Oral surgeons also enlist the dental anesthesiologist’s assistance in the management of patients who are severely medically compromised. Pediatric dentists benefit from the services of dental anesthesiologists for children with severe behavior problems on whom they perform complete mouth rehabilitation in a single appointment in an outpatient setting. This is especially important in the case of a patient for whom management in a hospital setting is not available. Periodontists employ dental anesthesiologists to help with sedation in long periodontal surgical procedures or in patients whose anxiety is so great as to prevent the procedure from being accomplished without sedation. Dentists who enlist the aid of a dental anesthesiologist usually do not expand the scope of the surgical procedure just because the patient is asleep. The ultimate benefactor in these situations is the patient. Dental anesthesiologists understand outpatient ambulatory anesthesia. At the end of the procedure, the patient awakens quickly and is safely discharged early. This is because the dental anesthesiologist uses contemporary drugs such as sevoflurane, remifentanil, and propofol with skill and finesse, as well as with an eye toward rapid recovery. Office patients can be discharged in about the same time, or less, it takes for hospital patients to be discharged from the recovery room to go to their hospital rooms. OMFSs need ambulatory anesthesia that is effective, efficient, and safe. Highly trained and skilled dental anesthesiologists can provide this service in the areas where they practice. The only real problem is that there are too few of them in only a handful of communities in the United States. With an eye to the future, we in organized oral and maxillofacial surgery should embrace dental anesthesiology and foster training programs so as to increase the number of trained personnel available to us and our patients. Additionally, OMFSs should use their influence to encourage state dental boards to write rules and regulations that will foster the development of an active group of dental anesthesiologists. Anesthesiology is truly a part of dentistry. No one will help us maintain its rightful position in dentistry more than dental anesthesiologists.