Volume 77 Number 3

A Day in the Life of a Dental Anesthesiology Resident

Anesthesia in Modern Dentistry

General anesthesia plays a crucial role in dentistry—particularly when treating children, individuals with special needs, or patients requiring extensive dental procedures. Despite dentistry’s growing demand for general anesthesia services, dentists across the nation struggle to secure block time in operating rooms. Subsequently, the demand for general anesthesia in office-based settings is growing rapidly.

In fact,  anesthesiology residency programs have been training dentist anesthesiologists to help meet this demand since the mid 20th century. Currently, dental anesthesiology training requires a dentist to complete a dedicated three-year residency. During this period, residents must complete at least 800 cases of deep sedation or general anesthesia. Additional requirements include a minimum of:

• 50 nasal intubations;
• 125 pediatric general anesthetics for patients age 7 or younger;
• 75 anesthetics for patients with special needs; and
• 100 anesthetics specifically for outpatient dental procedures.

While a substantial  portion of dental anesthesiology training resembles that of physician anesthesiology residents (e.g., hospital-based anesthesia for general surgery, ENT surgery, neurosurgery, orthopedic surgery, vascular surgery etc.), here’s a glimpse into what my day looks like providing general anesthesia as a resident in a private dental office.

Anesthesia in Dentistry: Where the Partnership Began
Since the mid 1800s, when Morton and Wells began experimenting with inhaled agents, dentistry has maintained a close relationship with the delivery of anesthesia. Over the next century, physicians and dentists worked side by side advancing the field of anesthesiology. Many hospitals relied on dentists to help staff and lead their anesthesiology departments.

A notable example is Jay Heidbrink DDS, Chief Anesthetist at Minneapolis General Hospital, who in 1909 hired Arthur Guedel MD as an intern. Guedel served as an anesthesiologist at multiple hospitals until 1917, when he was called to provide anesthesia to the soldiers during WW1.  Indeed, the delivery of general anesthesia by dentists is a time-honored practice.

Dental Anesthesia: My Typical Day

Advance Planning with my Attending
Prior to administering anesthesia in a private office, the attending has evaluated the office to ensure it meets space requirements for safe anesthesia delivery and will allow access for emergency transport.

As a resident, the night prior to the anesthetic I call my attending to discuss the patient’s health history and anesthesia plan. My attending pre-screens all patients to ensure they are appropriate candidates for office-based anesthesia.

1. Planning and Setup

On anesthesia day, I either carpool with my attending or meet them at the dental office. We travel with all the necessary supplies to provide a safe general anesthetic. This includes such equipment as:

• an anesthesia machine
• monitors
• medications
• syringes and needles
• endotracheal tubes
• supraglottic airways
• laryngoscopes
• breathing circuits
• infusion pumps
• all necessary emergency equipment

We frequently do not have a ventilator available, so we must select our patients and plan our anesthetics accordingly.

“Screening the dental operatory entails determining an ideal layout for our equipment and supplies. It’s a bit reminiscent of playing a game of Tetris.” ~ Eddie Starr DDS

Upon arrival at the office, we screen and set up the operatory using the same “MSMAID” approach we take in the hospital operating room (Machine, Suction, Monitors, Airway, IV, Drugs). Once the patient arrives, we perform a preoperative evaluation, review NPO status, perform a focused physical examination, record baseline vitals, obtain informed consent, and discuss a disposition plan.

2. Induction and Maintenance

We escort the patient back to the operatory and prepare for induction of general anesthesia. Various methods of induction (IV, inhalational, and IM) may be employed depending on the clinical situation. Most cases involve nasal intubation following induction of general anesthesia; however, certain cases may be completed with a natural airway.

Anesthesia is typically maintained with either volatile agents or a combination of propofol and remifentanil. The patient is continuously monitored during the procedure using standard ASA monitors. Upon completion of the procedure, the patient is extubated following emergence from anesthesia.

3. Recovery and Discharge

Unlike the hospital setting, a dental office does not have a dedicated post anesthesia care unit (PACU) staffed with nurses. The responsibility of recovering our patients and discharging them falls on us. Once the patient has reached a modified Aldrete score of 9, we frequently transfer patients to another dental operatory that is outfitted with additional monitors, an oxygen source, and suction to facilitate the recovery process.

While I recover the patient, my attending prepares the primary operatory for the next patient. We may treat anywhere from one to ten patients per day, depending on the length of the planned procedures.

One Resident’s Opinion: The Value of Office-Based Anesthesia Training

Exposure to office-based anesthesia during residency is invaluable, as most dentist anesthesiologists practice in this setting upon completion of their training. Our residency emphasizes the full spectrum of perioperative patient management—from preoperative evaluation to intraoperative and postoperative care. And while the dental office may be considered a relatively low-resource setting compared to a hospital operating room, we nonetheless ensure that we have the essential items and personnel to provide a safe anesthetic.

Our training helps us become more comfortable and efficient in this unique clinical setting. I am incredibly grateful for the opportunity to learn the art and science of delivering general anesthesia to a patient population that is incredibly underserved.