My 22 month old son needs to have crowns placed on his top two incisors. Because of the lack of cooperation at his age level the Dentist wants do the procedure under general anesthesia in a surgery center. There is another dentist an hour away who will do the procedure in his office under a "conscious sleep" without intubation. Are there risks/benefits of one type of anesthesia over the other? My son also has a lipoma on his abdomen. Our general surgeon said it is very unlikely to be anything of concern, but if my son is going to be put to sleep anyway, he would like to remove it at the same time. Any information you can pass along regarding the anesthesia would be greatly appreciated. 

ﾠThank you for your interesting question. I am not familiar with the term "conscious sleep" but "conscious sedation" is a term commonly applied in the community. The correct medical terms however are "mild", "moderate" or "deep sedation", and general anesthesia. It is not clear from your description what method of sedation your dentist would use. 

Enteral sedation is the use of oral medications. No IV is used. There are pros and cons to this approach - e.g. the onset is slower but also less predictable. 

Another technique is the use of nitrous oxide breathed in by mask. 

General anesthesia for dental procedures will normally require intubation and an IV. 

Oral sedation does not mean that less monitoring is required and this approach has even been associated with deaths, usually from respiratory (breathing) problems. Although anesthesia is safer than ever before, the current high levels of safety were achieved through the development and consistent application of safety standards, including the use of certain types of monitoring, coupled with improvement in the skills of anesthesia providers, and were achieved in operating room settings, not offices. That is not to say that sedation in a properly equipped and staffed dentist's office isn't safe, it's just that we don't have as much published data to prove it. 

Notoriously, a study in Florida some years ago found a 10-fold higher rate of serious problems including death in adult patients undergoing office-based cosmetic surgery. Hospitals and surgery centers have to undergo rigorous accreditation inspections, that include safety, whereas doctors offices do not, although you can be sure that legislation will pretty soon catch up with this in the United States. 

If your dentist is offering sedation to your 22 month child you might want to ask about the extent of his/her experience with children so young; outcomes including complication rates; levels of staffing, personnel and their skills; the type of sedation technique used; monitoring equipment; recovery and resuscitation protocols and resources. 

Research has shown that the drugs used, the route of administration and the type of patient are less important to morbidity and mortality than the monitoring and resuscitation skills of the providers. So that is of cardinal importance. 

Your selected provider should be using standard monitors like pulse oximetry and ideally capnometry (carbon dioxide monitoring). 

Intuitively, having a dedicated anesthesia provider is preferable than assigning the task to someone whose primary role is dentist, or scrub nurse, or something else. 

The recovery phase is just as important as the procedure itself. All anesthetics and sedatives take time to wear off. During recovery are there adequate personnel and equipment for monitoring? Can those personnel make good judgments about impending problems, or about when patients are fit to be discharged? In case of problems, is a hospital nearby? Does that hospital have an agreement to take patients who need help? 

In addition there are issues of cost and convenience to be put into the equation. General anesthesia in a hospital or surgery center will certainly cost more. 

Recently after a hernia surgery I experienced lots of pain on my tongue. I noticed a day after the surgery that my tooth (#3 upper) was missing except for a point on the end which was cutting my tongue. This is the same tooth that I has a root canal and endo fill done 15 months before the surgery. It was causing me no problems and was not loose. The hospital is claiming that it could not have happen during my surgery. What do you think? My dentist says it will need to be extracted and a bridge put on. I feel the tooth was knocked out during surgery. What is your professional opinion? Thank You. 

Tooth injuries certainly can happen during, and after, surgery. When a breathing tube, also called an endotracheal tube, is inserted, a metal instrument, called a laryngoscope, is used. The laryngoscope allows the anesthesiologist to see down your throat and visualize the vocal cords. The breathing tube is placed through the cords. This instrument may chip or even break a tooth, particularly if the space is narrow, or the structures don't line up, making the procedure of intubation more difficult and therefore requiring more pressure to be applied to the laryngoscope. The teeth most commonly affected are the upper central teeth on the right hand side - the incisors and canines (teeth #8-11). Tooth #3 is a premolar on the left and not likely to be affected by laryngoscopy. Tooth injuries can also occur at other times, for example if the patient actively bites down. This happens fairly commonly at the end of the surgery when the person is waking up. If enough force is applied during a bite on a fragile tooth or dental prosthesis, an injury may result. Tooth injuries can also occur during the recovery period, after transfer from the operating room, under similar circumstances. Because the person is still recovering from the effects of the anesthetic she may be unaware of the bite, nor may she notice that the tooth has been damaged at that time. The fact that your tooth was apparently normal when you went in to the hospital, and is now damaged may suggest that the hospital and its staff were responsible. However, in a dispute it may be difficult to prove either way. The hospital might say there is no evidence you had a normal tooth when you were admitted, and you had work done on it previously. Your tooth may not have been in the good condition you think it was, so a small amount of pressure might have injured it. In our hospital we try to make a point of taking a proper dental history, and documenting it. This is so that we can take extra care to avoid damaging fragile teeth (occasionally this is impossible), make alternate plans that avoid intubation entirely, or even postpone procedures in order to take care of a severe dental problem first. We have even, on occasion, called our dental colleagues in to do a procedure immediately before, during, or after the planned surgical procedure. When dental injuries do occur in our practice, we refer our patients to a trusted, expert, university-based dentist for diagnosis and treatment and try to come to a reasonable arrangement. As a matter of routine, I warn my patients about the possibility of dental injury during anesthesia, as unfortunately it may be considered one of the "normal" risks of general anesthesia. 

Method of administration anesthesia drugs for sedation in dental procedure 

Sedation for dental procedures is often administered intravenously (IV). A small intravenous line is placed in your hand or arm before the procedure begins. The IV remains in place until the end of the procedure. Usually you will also be given oxygen and possibly nitrous oxide (`laughing gas`) through a nasal mask. The medications used are short acting to enable rapid recovery.