About 75 years ago, a rather infamous, flashy American dentist advertised himself as ‘Painless Parker.’ He had a thriving practice removing teeth using nitrous oxide or his own local anesthetic, a cocaine-laced mixture for freezing.
Today, the Yellow Pages contain many ads about dental care given while patients are asleep or sedated. Although we think of ourselves as very modern and informed in the 21st century, our search for painless dentistry continues.
Choosing a qualified dental surgeon can be tricky. We want to know that the person delivering pain relief is properly trained, with up-to-date, modern equipment and facilities. Most of all, the facility must provide safe care, meeting or exceeding safety standards.
In Canada, provincial laws control and regulate the practices of medicine and dentistry. Each province has similar rules meant to protect the patient. Although the information here relates mainly to Alberta, dental licensing authorities in each province can provide information specific to that location.
Your local dental society may have a list of care providers to help you to select a surgeon. Failing that, word of mouth from a satisfied friend or co-worker is usually a good place to start.
Two main types of analgesia exist. In conscious sedation, the patient is sedated only to the point of not remembering the effects of the procedure. With general anesthesia, the patient is ‘put to sleep’ or made unconscious. More invasive types of surgery are done with general anesthesia. It is often used in a day surgery clinic, where patients are admitted and discharged on the same day. General anesthesia may also be done in a hospital and involve an overnight stay.
With either type, the patient’s vital functions require careful monitoring and support. This is especially important during general anesthesia.
Three main ways of delivering sedation are used: oral medication (swallowing), intravenous medication (injecting into a vein with a needle) and inhalation (breathing a gas through a mask controlled by a machine).
Oral medication might consist of nothing more than taking a non-steroidal anti-inflammatory drug before surgery. This will help block pain and swelling afterward. Stronger medication can also be taken shortly before surgery. Adults can be given a mild or moderate oral form of sedation. However, the effects of oral medication in children are much less predictable.
Oral sedatives are not always the best choice. It is hard to predict exactly how such a drug will work the first time someone takes it. People react in a variety of ways to a specific drug. The type of food and amount of water in the body influence how well the drug works. The same person can even have problems with the same drug given on a different day.
What’s more, changing or reversing the effect of a drug can be awkward. An intravenous line (IV) might be used and a reversal drug given. Pumping the stomach is another alternative. Such actions take time and can be stressful for both care providers and patients.
Still, routine oral medication for dental surgery for adults can be a safe, less expensive and acceptable way to sedate or control anxiety.
Intravenous drug administration is much more predictable. The drug can be given in a very small but increasing dose. As well, trained care providers use high-tech monitoring devices to check the patient. Such devices monitor vital signs such as blood pressure, heart rate and oxygen levels in the patient’s blood.
If the drug must be reversed, another drug can be used in the same IV to stop or change the effect of the first. In an emergency, fast-acting drugs can be supplied immediately through the IV. Such drugs could improve blood pressure or affect heart rate and the force of heart contractions.
Historically, general anesthesia was received by breathing nitrous oxide, ether or chloroform gas through a gauze mask held over the nose and mouth. At that time, all patients passed through an ‘excitement’ phase, where they might cry out or try to escape before sedation took effect. As a result, strong male attendants were the norm in operating rooms a hundred years ago!
Today’s anesthetic gases are more sophisticated than the old reliable nitrous oxide. It was standard in dental and medical operating rooms for many years as it is easy to use with few side effects. However, as it was given in 100 per cent concentration, lack of appropriate oxygen level for the patient was an ever present safety concern.
Today’s modern anesthetic machines allow nitrous oxide to be mixed with no less than 50 per cent oxygen. As well, more sophisticated devices now monitor the patient’s wellbeing. Thanks to these advances, many dental offices use nitrous oxide with a high degree of safety. Stronger anesthetic gases are used in surgical suites, with trained people delivering the gas and monitoring the patient.
If you are in hospital for major surgery, a combination of anesthesia methods may be used for the same surgical procedure. Dental offices or day surgery suites may also combine methods.
In some cases, anticipated surgical difficulty or recovery from anesthetic drugs make a procedure better suited to an overnight hospital stay. Thankfully for most people, dental procedures can be readily completed with the use of IV or gas anesthesia alone or together. Even wisdom teeth are often removed in this way in “day surgery suites” or specially equipped dental office surgical suites.
The routine use of local anesthetic is required or encouraged for nearly all surgical dental procedures. So, expect to be ‘frozen’ after your wisdom teeth are removed, even if you are sedated for their removal.
Dental surgery utilizing sedation usually comes with extra cost. Find out in advance what to expect in terms of expenses. Ask about the portion your provincial health plan and/or private insurance will cover. In most provinces, the public health care system does not cover routine dental surgery services. Patients and dental insurance plans must cover costs. Unfortunately for those without insurance, dental health care in Canada is usually self-funded.
Selecting a qualified surgeon and facility can be intimidating. As a starting point, check with your local dental society for a list of practitioners or ask friends for referrals.
Most dental specialty offices require a consultation appointment before your surgery date. Use this time to discuss your needs and concerns. During the consultation, the steps and risks involved in your particular procedure will be discussed. If another care provider has referred you, a letter and your X-rays may be sent ahead. If not, bring them with you. Prepare a list of questions so you will not forget something in the hustle of meeting new people and being shown around.
Do not be shy about asking about qualifications. In Alberta, for instance, dentists who administer IV sedation and other forms of ‘sleep dentistry’ must have a certificate ensuring proper training.
You can also ask about the facility’s inspection report, where provincial law requires one. Most facilities offering general anesthesia must pass a strict inspection. This ensures that basic safety features and monitoring equipment meet requirements. It is fair to ask about procedures that ensure a properly equipped facility and sterilized instruments. Most office staff are proud of their surgical facilities. They will be pleased to show you around and answer your questions.
Finally, but perhaps most important, find out who will be looking after you. A trained individual must monitor you, as the surgery may require all of the surgeon’s attention. Many facilities have specially trained professionals on staff. An anesthesiologist may be part of the team, as may a registered nurse skilled in managing ‘day surgery’ patients.
Dental office or day surgery suites provide an experience similar to that received in a hospital. You will be moved to a recovery room after surgery to allow your body to adjust and recover before being sent home.
If you have been unconscious, or given a hypnotic or narcotic drug, you must be taken home. Ask a friend or family member for help in advance. Driving or even taking the bus in a confused state is not a good idea.
Ask beforehand about follow-up for any problems after surgery. You will need both verbal and written instructions on what to expect after surgery and whom to call if you have problems.
Perhaps the best advice is to prepare by doing your homework. Every day, thousands of Canadians have successful, pain-free dental surgery in dental offices and surgical facilities. By choosing carefully you can be one of them.