Until the advent of local anesthetics, surgery was a very traumatic and painful experience. The very best surgeons were by no means the gentlest; they were the fastest. General “ether” anesthetics helped alleviate pain, but were very dangerous to administer and unpredictable in the dosing. The advent of local anesthetics truly revolutionized in-the-office surgery, particularly in the dental profession. Our understanding of the anatomy of the head and neck and the efficacy of local anesthetic nerve block has enabled dentistry to be routinely and painlessly performed in an office setting. The advent of safe intravenous sedation and deep sedation/general anesthetic techniques have enabled the oral and maxillofacial surgeon to perform complicated oral and facial surgery procedures in the comfort and convenience of the office surgical suite, thus allowing the patient to return home that day. Intravenous anesthetics in use today are rapid in onset, very potent, and rapid in elimination. This assures that the patient is completely relaxed and unaware for the surgical procedures and allows for a rapid recovery and the ability of the patient to be discharged home.
Our knowledge of local anesthetic techniques coupled with our training in intravenous sedation/deep sedation/general anesthetic techniques allows us to perform procedures of a complexity that too often is taken for granted. The removal of impacted wisdom teeth, for example, is usually more difficult than the removal of tonsils, but due to the fact that it is most often performed in an office surgical suite instead of a hospital, it is deemed by patients and oftentimes referring clinicians to not truly be “surgery”. In fact, many procedures performed in the hospital under general anesthetic could be much more easily, economically, and conveniently performed in an office surgical setting if the physician were trained in local anesthetic and intravenous general anesthetic techniques. Due to the general lack of training among physicians in these techniques, procedures such as the placement of ear tubes in children, digital and extremity amputations, and soft tissue facial plastic procedures requires the use of an anesthesiologist and a general anesthetic or block local anesthetic and, therefore, are performed in a hospital setting.
In the everyday practice of dentistry, extractions are performed. While many of these extractions are simple and can be accomplished with minimal manipulation and quite comfortably under a local anesthetic, a surgical extraction requiring the use of a handpiece and adequate visualization are much more easily accomplished under a monitored deep sedation. Such a sedation produces amnesia for the event, enables the patient to be completely relaxed, not only emotionally, but also from a musculoskeletal standpoint, and allows the safe completion of the procedure. By performing procedures under deep sedations, the procedures are almost always shorter, are almost always performed more gently due to improved access and visualization, and produce a much quicker recovery than when the patient is awake during the procedure and involuntarily tensing and tightening cervical and facial muscles. Briefer procedures produce less postoperative swelling and discomfort and a lower incidence of infection.
These considerations might be kept in mind in evaluating a patient for a potential oral surgical procedure. In private practice, I have rarely had a patient say to me after a surgical procedure that they wished they had been awake for it, but I have had a few wish they had been sedated. Certainly, treating a patient in a fashion in which they are completely relaxed, comfortable, and have an uneventful recovery promotes a happier patient for both the surgeon and the referring clinician.