Death in the dental chair.

Abstract

The title of your recent editorial (Anaesthesia 1999; 54: 105–7) was calculated to both shock and imply that dental chair anaesthesia is the main contributory factor in deaths associated with dentistry. This is plainly a too economical dealing of the truth since about half of the deaths [1, 2] occurred in hospital and involved anaesthetists of consultant grade: presumably, these are operating table deaths. The amended guidance on general anaesthesia issued by the General Dental Council (GDC) in November 1998 [3] applies to all dentists registered in the UK, including those in hospital practice, but the GDC puts the burden of responsibility on the dentist for ensuring that proper systems, equipment and processes are in place and that the anaesthetists and supporting staff are properly trained and accredited. There may be ambiguity in the field of oral and maxillofacial surgery where the surgeon is both medically and dentally qualified, who might not be necessarily registered with the GDC but with the General Medical Council, yet delegate dental operative procedures under general anaesthesia to junior staff who are singly qualified, registered with the GDC and would therefore need to fully comply with its guidance. The issue of whether general anaesthesia is always appropriate is an important one. As a dentist with long-standing experience with children and adults with special needs, I see many patients for whom general anaesthesia is the only option. Many children have already experienced dentistry in general practice and are referred in for general anaesthesia as a last resort because of a history of poor co-operation and acute anxiety. Many children require multiple extractions which may not be achievable under local anaesthesia even with inhalation sedation: they may be cajoled to accept one treatment under local anaesthesia, but subsequently become impossible to manage. There is also a question of economics. In previous years, where dental payments were for each treatment item, there was a financial incentive for the general dental practitioner to carry out as much treatment as required in practice. Under the capitation arrangements for children introduced in 1990, this financial incentive was removed (apart from certain exceptions) and there was a tendency for dental caries in primary teeth to be left untreated until symptoms occur whereupon a referral for extractions is made. Fee per item has currently been reinstated so that more treatment of the primary dentitions is now being carried out in general dental practice. This change in funding obviously influences treatment and referral practices. The difficulties inherent in treating deciduous teeth inevitably means that many children will require multiple extractions and that general anaesthesia will remain as a appropriate option. If the referral is made to a centre or hospital where the only treatments available are extractions under general anaesthesia, then the decision becomes polarised towards exodontia under general anaesthesia. In the Community Dental Service, where resources and Service Specifications allow, patients can be given treatment which is most appropriate: this could include preventive treatment, conservation or extractions under local anaesthesia, sedation or general anaesthesia. In the General Dental Service, item of service payments remain for adults; however, the fee for general anaesthesia is likely to be removed shortly. There are, at present, far fewer general anaesthetics carried out in general dental practice funded from National Health Service monies. The majority of all anaesthetics are now administered either in hospitals or on Community Dental Service premises, where patients can be monitored. It is accepted that some premises, even hospitals, may not be ideal. Health Authorities need to work in partnership with provider Trusts to ensure that general anaesthetics are available, where appropriate, on premises which are entirely satisfactory in every respect for the safe administration of anaesthesia, as well as the delivery of operative dentistry, by accredited and trained staff. Equally high standards are de rigueur for recovery facilities. The General Dental Council's intention was not to confine all general anaesthetics to the district general hospital but to highlight the responsibility of dentists in appropriate treatment decisions and for ensuring that appropriate facilities and staff are used. This was re-stated by Dame Margaret Seward, President of the General Dental Council, in answer to questions at the British Association for the Study of Community Dentistry conference in December 1998. General anaesthetics are generally safe but are never without risk, whether they are administered for dental surgery or general surgery. We need to ensure that, wherever the anaesthetic is given, risks are minimised, not only by close co-operation between anaesthetists and dentists, but by health service managers, planners and commissioners.