Type of Anesthesia for Dental Implant Surgery?

General anesthesia seems extreme for a single implant. Is the surgeon planning on doing an additional procedure such as a hip or tibial graft? If not, my personal feeling would be to have the case performed under local anesthesia or IV sedation if the patient is very anxious. Think about how you would treat your mother. Would you put her through general anesthesia for a single implant? If so, you must not like your mother.

The question shouldnt be whether you need it the question should be asked to the patient whether he/she needs it. Implant cases can be done from local, oral sedation, moderate IV sedation to general anethesia. It all depends on what the patient wants and should be offered to the patient.

There is a case (a Central)written up here in the UK where only Hypnosis was used , NO local !! and apparently only mild discomfort felt by the patient.Not sure why it was done as local with or without sedation is always workable. GA in Ilaic crest graft and other difficult block graft cases obviously.

I suspect RTKR is not qualified to deliver General Anesthesia and thus spreads fear with his "would you do that to your mother." As someone who has performed general anesthesia on his mother... and wife...... and much of my staff..... You should know the facts. IV Sedation/General Anesthesia always carries some risk.... depending on the study, somewhere in the range of 1 in 600,000 patients experience a "severe complication." With that said, General Anesthesia, if performed by a qualified and licensed doctor is considered very safe and is performed by Oral Surgeons like myself 1800-2000 times a year. Many of my patients opt to do their implants or other oral surgery under local... but more request some form of sedation. That is fine by me. You see, I strive to ensure a positive experience for my patients.... I don't "hope to get them through it" I want a predictable outcome.... everytime. Personally, I don't find invasive bony surgery to be as predictable under local alone. I suspect you have all head a horror story about a patient that had a terrible experience and now hates the dentist. I prefer not to risk that possibility, unless the patient insists. In the end, L. you have choice and should clearly consent to your preference and you surgeon should happily respect your decision.... even if he or she thinks it is unwise. All your surgeon can do is make recommendations based in his or her experience. Because we are all human, you will find some variation in opinions.... properly so. Just make sure you are comfortable with your doctor and you are informed about the facts by a qualified individual.

Sedation or General anesthetic is always a good option when surgery is to be performed. It is safe and predictable and requires extensive training. The risks are minimal and the benefits are great. Local anesthetic works ok and should be done at the patients request, but if I were having a central maxillary incisor implant done, I would like to be sedated and/or asleep.

In my opinion the type of anesthetic used for implant surgery, dental treatment or any other medical procedure is best determined by comparing three factors: patient, provider and procedure. If a patient is anxious or hypertensive, some form of supplemental anesthesia may be beneficial; if emphysema, CVA or dementia exist local anesthesia or minimal sedation are better for patient safety and comfort. If a provider is comfortable removing extensive bone, lifting a sinus, sectioning teeth and controlling bleeding with local anesthesia alone this may be reasonable. For many others including me these are more comfortable in my hands under some form of anesthesia. If a procedure is of short duration and minimal difficulty local anesthesia may be appropriate. For more lengthy procedures sedation or general anesthesia may be best. Ultimately the decision must be agreed by patient and provider. If the patient wants local anesthesia the provider can choose to refer the patient if he or she is uncomfortable. When patient comfort and provider compassion meet a successful outcome is likely. Ultimately the provider will develop a level of comfort beyond which his or her reputation will be adversely affected. Reputation is built over time either positively or negatively. If we think first of our patients and then of our abilities we will likely succeed.

Just my usual questions: Why take the extra risk of general or even Oral Conscious sedation for a 20 minute procedure? Is it for patient management? (difficult patient ) Schedule management? (have the patient ready when the doctor is?) Is this implant placement complicated by block grafting, graft harvesting, PRP (platelet rich plasma) preparation, sinus lift, soft tissue grafts or something else? Best bet, ask YOUR doctor why he recommends general anesthesia! Don't be afraid to ask more questions, then come back and ask better questions. #9 is central to the aesthetic zone, give Dr. time to do it right, if he needs it. Best of luck.

If the only tool in your tool box is a hammer......... Every problem begins to look like a nail! If your surgeon can provide IV sedation or General Anesthesia, I my opinion, he or she should offer it as an option, or even a recommedation in my case. Yes, you must always weight risks vs. benefits... and if your surgeon is a good one, he or she will guide you through it easily and comfortably. But a "Why bother" approach sounds like someone not used to seeing the positive effects and experieences on their patients.

I am qualified to do light, moderate and deep sedation on my patients. I have placed at least 4000 implants with just a local. Unless the patient request General Anesthesia/Sedation there is no reason to use it for a single implant.

Wow..... "No reason" ..... strong uncompromising words without respect for the subtle art of patient care. Not what I would expect from such an experienced surgeon. I try to seek out and find the wisdom in everyone's view point, that is why I read this Blog and occasionally post what I hope is a balanced comment. My apologies if my post seemed cut and dry as I find very little about taking care of people is that easy.

Hypnosis............O.K. Local workd just fine in the vast majority of cases. I have done ramus frames and subperiosteal implants with local and it's just fine. You can premedicate with ultracet to take the edge off of the procedures.

I have spent three months doing GA in the OR of the hospital including intubation etc.If you are very apprehensive or the procedure will include harvesting bone from other extra oral source then GA or IV sedation may be helpful .If the procedure is only intra oral then local anesthesia with mild oral sedation should be adequate. Most anesthesiologist will tell you that an intubated patient with secured airway and established IV line is safer then a patient going into deep sedation without intubation.Intubation is when a endo tracheal tube (plastic air tube) is placed in the air way. Considering the risk it is always preferable to pick a safer option. Thanks

It seems like the decision to use GA or local has a lot to do with doctors' preference rather than patients. Dr. Levitt prefers to do it with local and Dr. Emprical Medicine has a strong opinion towards GA. If Dr. Emprical Formula does 2000 GA/year, he must do about 10/day, or most of his work under GA. Just like Dr. MainOralSurgeryMan said, it should be based purely on patient's best interest. I myself never "suggest" or persuade to do a single implant with GA. If the patient wants it, fine. But is there a "need"? I don't think so. I have recently placed 20 implants in a elderly lady, 18 implants on elderly gentleman and they did fine with local. It was a long surgery, but they insisted on local. They even told me they felt fine after they went home. There was also a patient who came in for scaling and root planning and asked my hygienist if he can be put to sleep. He wasn't joking. Single implant takes about 20 - 30 mintutes. Scaling and root planning takes 45 minutes for my hygienist. To tell you the truth single implant surgery is more comfortable procedure compared to many other dental procedures. Well... at least according to my patients. Now Mr. L, you make the decision here now that you've been informed. To give you my two cents, you can totally have a single implant done with out any major discomfort with local. If you want GA, open up your wallet and tell the oral surgeon that's what you want. Besides he should be thanking you for coming in well informed so he doesn't have to spend extra time explaining everything we talked about in this forum. good luck.

I never suggest to do a single implant with GA.less than 10 minutes need for this operation.

Sajjad, compare the morbidity/mortality rate in hospital anesthetics versus office general anesthetics, who do you think has better batting average ? You might say, yeah it is patient selection and healthier patients, but numbers speak louder than words. Securing and airway and use of a paralytic agent and inhaled anesthetic with a ventilator is a nice thing, but luckily I've never run into the nightmare for anesthesiologists---can't intubate---can't ventilate scenario. I"ve been in the room and watched one of those nightmares, luckily I, not the anesthesiologist, jet ventilated (as the sat was 14%--never seen one that low) the patient long enough to secure a formal airway with a tracheotomy. Nice to have to tell the mother of a 17 year old daughter coming in for a BSSO that they needed a trach, but it happens and she lived without consequence except a scar. Anesthesiologists are wonderful, but if they need a surgical airway and they are in a case with an OB/GYN, podiatrist or and ophthamologist and there isn't a general surgeon, ENT, cardiothoracic, or vascular guy or even the lowly oral surgeon around, the products of the terminal end of the colon will certainly hit the fan. For most oral surgeons, deep conscious sedation and general anesthesia is a very predictable procedure. What we do in the office, isn't replicated at all in the hospital. An intravenous sedation in the hospital, call a MAC (monitored anesthetic or anesthesia care) is like 3mg of versed and perhaps 50-100 mics of fentanyl or some other narc like remi. The techniques we do are foreign to them as they do what they do very well (subdurals, epidural, bier blocks, mask GA, LMA GA's and ETT GA's). I can speak from experience as I used to do LMA's with sevo in the office. My number of complications intraoperatively and post-operatively climbed, not dramatically, but climbed. I did feel better with a secured airway, but when I looked at the cost to both myself and to the patients and evaluated its efficacy compared to the "old" intravenous way, I found no added value and safety for my patients and therefore it did not justify the added cost. I found a little ketamine, along with versed and nalbuphine with very small continuous infusion of propofol and sometimes a little nitrous with the O2 keeps patients very smooth, they maintain their own airway and have excellent inspiratory effort with good end tidal CO2 gas sample readings. The propofol followed by decadron also provides a nice anti-emetic profile that is much better than I had with sevoflurane. With LMA's I had some emesis, followed by some laryngospasms, and positive pressure pulmonary edema (heavy coughing on a closed glottis), two of which required overnight stay in the hospital for IV diuretics, steroids and supplemental O2. Never had that with an IV technique. To comment on implants with GA, I pretty much do most with local unless the patient requests otherwise. Some patients come to me because, "no one ain't touchin' me unless I'm asleep" get referred to me on a daily basis. Most of the time the lower posteriors I only use infiltration and forget blocks and nearly everyone does just fine. Deeply impacted wisdom teeth, some large bone graft harvest, nerve repositionings, distraction, minor fractures (that can be managed in the office), rhinoplasties (I've done them with local and no one has fun), genioplasties, other larger cosmetic procedures, and of course patient's interest and needs---sedation or general. For most else, local for me. However, some medically compromised cardiovascularly involved patients, local with IV sedation is usually safer as it manages their catecholamine response which taxes their CV system. One other comment, when I was on general surgery, we had some yahoo come in thinking his appy was going to be done with self hypnosis. We went along with his request. Well we made about a 0.5mm by 2mm deep incision before he called it quits and went to sleep.

One other thing I forgot, I see many fractured teeth lacerated tongues, damage vocal cords (I don't see that, but my ENT buddy across the hall does), chronic hoarseness, torn tonsils, pharyngeal walls, lacerated lips, lacerated soft and hard palates, severe nasal bleeding from turbinate tears from nasal intubations, damaged and degloved septums, degloving of tori all from intubations and many more things that happen from intubations. I'd sure hate to add all those little annoyances to secure an airway that the outcomes data doesn't support its need. They don't happen very frequently, but many of those little mishaps I ended seeing and then testifying as a treating doctor fact witness............

My practice focuses on treating the apprehensive patient and I have offered IV sedation for many years however this patient does not indicate that she is apprehensive. While I can understand that the oral surgeon might be far more comfortable with her being sedated I would think that she could be managed with just local with the understanding that if the case becomes more complex then have an anesthesia option. Of course with good planning this uncertainty might well be avoided.

The Indian press seems to go gaga with this case, but please don't develop any base less fears, as I am posting it here because t is relevant. Child dies after root canal 5-Yr-Old From Dahisar Failed To Come Out Of Anaesthesia TIMES NEWS NETWORK Mumbai: A five-year-old child from Dahisar died during a root canal dental procedure on Friday. While the root canal itself was over, doctors said the girl, Krisha Joshi, suffered a cardiac arrest while her anaesthesia was being reversed and died within two hours of the procedure at Rose and Petal Hospital in Borivli. The Borivli police have registered a case of accidental death. Her uncle, Chirag Trivedi, told TOI, “Going by the credentials of the dentist, we took her to that clinic. As he had just returned from Japan, a dentist from his team checked Krisha and told us that she needed nearly 14 root canals, which could be done in one sitting. We asked for the six major ones to be done first.’’ Krisha had gone to Dr Uday Tamhankar’s clinic on Friday, but as the procedure required general anaesthesia, it was decided that she would undergo the procedure at the nearby hospital. She was taken there thrice before for basic check-ups. On the day of the root canal procedure, Krishna was taken to the hospital around 8 am and was administered with general anaesthesia. As Dr Tamhankar was away, another dentist, Mrunal Kende, performed the procedure, after which the parents were called in and shown her work. Following that, Dr Kende left the clinic, while anaesthetist Dr Prajakta Kulkarni monitored her condition. It was when she took a turn for the worse that the team called other paediatricians and tried to resuscitate her, but in vain. “She had gone for a simple procedure but didn’t gain consciousness for nearly three to four hours. Something obviously had gone wrong and we feel it is negligence,’’ said Trivedi. When contacted, Dr Tamhankar said he had come in only this morning and that the complications did not have anything to do with the dental procedure. “Her teeth were decayed and we decided to conduct the procedure at the earliest as she was in great pain. Her root canal was fine and we even showed the parents, but there were complications during her reversal,’’ said Dr Kende. Calling the incident unfortunate, Dr Kulkarni said Krisha had even come out of the effect of anaesthesia and was trying to breathe. “Only then did we start reversal medicines. As a complication, cardiac arrest occurred with pulmonary edema. We called in other experts and tried to resusicate the child for nearly an hour, but in vain,’’ she said. As it was a medico-legal case, the police were called in before giving out the death certificate. “An autopsy examination has been carried out at the Borivli postmortem centre and the reports are yet to arrive. Only after learning the cause of death and making inquiries with hospital doctors as well as the child’s parents, will we decide on the next course of action,’’ said inspector Annasaheb Rajmane. “It’s too early to say if a case of negligence is made out.’’ Another one you can see here: - Inept dentist led to Krisha's death Anita Aikara Sun Jun 29, 2008 03:15 IST Doctors say five-year-old died, not because of wrongly-administered anaesthesia, but because dentist was not qualified The death of five-year-old Krisha Joshi, who died during a dental procedure on Friday, could not have been caused by medical neglect, doctors say. It has been alleged that the dentist who carried out the root canal operation, was not qualified enough. Dr Mrunal Kende, who carried out the six root canal procedures on Krisha on the same day - the child was scheduled for 14 root canal operations, but her family requested for only six initially - is a Bachelor of Dental Science (BDS), not a periodontist or an endodontist. This was confirmed by Dr Uday Tamhankar, head of Cremaco Clinic, who was earlier supposed to operate on Krisha. It was when Dr Tamhankar went abroad that Dr Kende took over the case. According to the police, Dr Kende is absconding. A BDS may have only five years experience, compared with a periodontist or an endodontist, who must have at least seven years. Dentists say without these qualifications, no doctor should perform multiple root canal procedures in a single sitting. "Handling multiple root canals in a single sitting, that too for a five-year old, requires the skills of at least a periodontist or endodontist," a well-known city dentist says. "If the dentist who conducted the surgery does not have these qualifications, she should not have even attempted such a complex, multiple surgery." Ashok Dhoble, secretary general of the Indian Dental Association, adds, "It is not uncommon for children to be treated for 14 root canals, and that too in a single sitting. Since the cost of anesthesia alone is about Rs2,500-3,000, some people opt for just one sitting. In fact the fewer sittings you put a child through, the better. But such surgeries must be handled only by qualified doctors." Doctors add that had Krisha been administered general rather than local anaesthesia, she might have survived the operation. An Indian Dental Association member, requesting anonymity, says "Reports state that the anaesthetist had not met the child before the procedure. In such cases, you have to bring the child over to the clinic several times before the operation, and help her get accustomed to the surroundings. This would have relaxed her before the procedure." Doctors have also raised questions about the 14 root canals being suggested. "Most children lose their milk teeth by the time they are eight," says dentist E Bhatnagar. "The back teeth come out only when the child turns 11. Since only the back teeth needed to be treated, Krisha would have required less than 14 root canal procedures in any case." Krisha's uncle Amit Trivedi says that they had no idea who would treat her until an hour before the surgery. "We thought it was Dr Tamhankar, and had cancelled a previous appointment because he was not available. It was at the last minute that some junior doctors convinced us to go ahead with the surgery, since Dr Tamhankar was in Japan. They kept reassuring us, saying that since they had trained under Dr Tamhankar, they would do a good job." He adds that the family was not informed even when Krisha was in a critical condition. "It was around 12.15pm, when the doctors began to panic, that we got to know of her situation," Trivedi said. Around 1.15pm, the doctors declared Krisha dead. The family was going to pay Rs25,000 for the treatment. Inspector Annasaheb Rajmane of Borivli police station says, "We are trying to get information about Dr Kende and also waiting for the autopsy results. It's too early to say whether this was a case of medical neglect. We will know once the reports are in." Hospital authorities, however, refused to comment on the incident." end of report. I think the accusations are ridiculous What do you guys have to say?

Mr. L. I agree with Dr. Kim. Now you have been informed as to your options and you can see how our community has various opinions and techniques to ensure your sucess. All based on sound data and good intentions (and often corrupted by Doctors emotions). Good luck.

Dr. SJD, I believe you are witnessing in India, that which occurs in the US every few years. A patient dies or has a serious complication during a dental anesthesia. The last one I remember was child in Chicago died in an unmonitored recovery. I my area, we had a "plastic surgeon" kill 3 patients over a 1 year period before being stopped. Since I wasn't there and I don't rely on our horrific sensational fear mongering media, I can't explain what happened in those cases. I suspect the teams made mistakes... and in the case of the above "pseudo-plastic surgeon" I suspect he was a criminal. 1 in 600,000 means that there is real risk, however, focusing on the risks alone is also unwise. Unfortunately, the thousands of good, qualified, caring providers doing thousands of excellent procedures to happy patients doesn't sell newspapers or ad space.

This patient questions the use of G/A and implys it may not be necessary, and there seems to be no hint of anxiety about the procedure which several friends have undergone using local anasthesia. Local anasthesia seems to me to be the obvious choice unless there is something in the medical history that would be an influencing factor. For a 30 minute procedure in the anterior part of the mouth it seems ludicrous to use G/A when it can be carried out painlessly and safely with L/A. A patient can quickly resume normal daily routines after a local whereas the same cannot be said with a G/A. It seems that those who use G/A or deep sedation as a routine lose the "respect for the subtle art of patient care" and patient management skills needed to perform gentle treatment on a conscious patient.

Empirical Medicine, Actually, I have done quite a bit of general anesthesia and, obviously, it does have its place. However, unless your patient is ASA class 3 or 4 (I personally would not do an implant on an ASA 4 patient), using general anesthesia for a single unit implant case is not justified in my opinion. If you are doing a hip, tibia, or calvarial graft in conjunction with the implant...sure. But for a simple single unit...no. The cost is not justified for said procedure in my opinion. My comment about "mother" had nothing to do with safety. It had to do with putting the patient through an unnecessary procedure. Again, in my professional opinion (and I am a board certified specialist with general anesthesia training), general anesthesia for a single unit implant is not warranted unless the patient has a severe medical condition or additional procedures that require GA are required. Unless a hip or tibia is being taken, I do almost all of my sedation cases with IV sedation (fentanyl + versed). I rarely use oral sedation, but I do offer it to certain patients. Cheers.

As a general rule of thumb, use the same anaesthetic procedure for the placement of an implant(s) as you would for an extraction of a tooth or teeth.

RTKR, Cheers.... and I hope you agree... we are all doing what we think is best for our patients. What I hope come across is that "medical necessity" and cost issues, can at times forget the human, emotional and mental trauma that patients often endure unnecessarily. Many... if not all?...of my patients come to me with some type of emotional trauma from a past surgical or dental experience from good well meaning doctors ( I choose to ignore the monster doctors as there isn't enough time). I believe that those issues can be address in many ways.... Most good doctors get by with a kind bedside manor, but sedation can be more predictable over more broad cases.

My main concern is the comfort of the patient. If the patients feels comfortable having a local then he should be fine. As an OMFS, I see a lot of patients with anxiety, but many patients do not want an IV for implants and they normally do very well with local.

i suspect mr L and empirical med, are patient and doctor

Dr. David Levit said it best..."if the only tool in your toolbox is a hamner, then every problem begins to look like a nail" General anaesthesia for a single implant is definately overkill, and looking for serious problems. Before starting implant therapy, do some other simpler procedure for the patient, even a simple prophy, just to see their level of cooperation,and level of security in the dental chair. Inserting a single dental implant is a simple procedure, and certainly much less painful than an extraction, assuming the receptor site is healthy. If the patient is so sensitive, and so terrified, refer him/her to a collegue you don't particularly care for.....from experience, these hypersensitive,intolerant patients will come back to haunt you, and they are not worth your skills or efforts......say goodbye and good luck....let someone else drive a nail into the coffin. Gerald Rudick DDS Montreal

Is it clinically appropriate to do implant placements on the same visit as bone augmentation procedures.

Great job on some of the comments on this thread (emperical medicine, rtkr etc). Im glad to see we are considering whats best for the patients and looking at what the patient wants, and not what is best for the doctor in this case. After all its about providing the best comprehensive care to our patients, which unfortunately isnt happen in alot of practice in the US since most dentists are more concerned about the patients pocket book then doing what the patients wants, needs, and doing whats BEST for the patient. As part of your informed consent process a patient should be assessed for there level or fear/apprehension. A anesthetic plan should be reviewed with the patient to include, local, oral, inhalation, IV or general sedation. The patient will then be able to make an educated choice. Part of the problem I see with patients is they often aren't explained thier treatment options or given choices by thier dentist. Often treatment options are conveniently left off the table. If we just slow down, dont rush and educate our patient you will be amazed on how smart they are and more importantly you will have a patient for life because they will realize that the care your giving them is truly about thier needs and not about the doctor. Believe me patients can see through the bull.

Mainoralsurgeryman, I too have enjoyed this thread (obviously) and I could not support your above comments more. Some guy, I hope that L. is my patient. It would mean that I have educated them to the fact that they have options and that, if unsure, they should seek out the opinion of other doctors. Empowering a patient like that would be a wonderful success. Dr. Rudick, "Definately overkill and looking for serious problems" and that we should refer those patients away............. I don't know where to begin. 1) Some of us don't have the luxury of referring away those who are difficult. 2) I find very little about caring for people to be so "definative." People are complex, emotional difficult animals that need to be treated thoughtfully on a case by case basis with and open mind and EVERY option on the table. 3) Worrying about a patients clinical experience is NEVER overkill. To all, Finally, I hope we all take a moment to think how this thread might be used by a trial lawyer or confused scared patient. We should all be advocating education, evidence based medicine and the understanding that different doctors treat in slightly different ways while still having the patients best interest at heart. Making blanket statements serves none of those causes.

I have placed implants for over 20 years. Most people do very well with local anesthesia. Some may need oral sedation in addition. Rarely have I found that a patient needs IV sedation. There is one OMFS in the area who always uses IV and bone grafts(socket augmentation or?) with even the simplist extraction--the point is that the patient is charged ~$1K for this and then an implant for $2.5K +sedation. I think this is almost criminal and is definitely in his interest not the patients.

Empirical Medicine, Your most recent comments are much appreciated. Thank you.

Most adult patients know what they can tolerate and when indicated an IV sedation is great for any type of procedure. I detailed hx. and an informed patient usually can make the decision about the type of anesthetic. It is not "overkill" to have an IV sedation for a single implant if that patient has high anxiety, in fact it is warranted. But, I have also performed multiple implants and bone grafts under local. Talk to the patient and make the appropriate decision for each and every patient.

I am L. Thank you all for your input and time. I am just a patient. I was worried so I posted my question. I just had my implant #9, 3 days ago. Just a plain single implant (single stage and immediate loading). I requested local and the doctor accepted my request. I asked for local because I asked a forum and a lot of people said local is enough. I had local and laughing gas and it was fine, no problems. I did good. I normally cooperate very well. He is a very good oral surgeon. My neighbors and dentists told me. I was surprised that it only hurt some for the first few hours. I did not need pain killer medicine the second day. I only took one pill at the doctor's office and one at home. I am taking antibiotics for a week and using the oral rinse 3 times a day. I had the extraction and socket bone graft 3 months ago and it hurt a little for 2 - 3 days. The implant surgery hurt less. Wow. It feels like a natural tooth already. I feel like I have my tooth back. Amazing. I am glad there are implants and doctors. You know, I was afraid and did not have the implant at the extraction time. I was going to have a bridge but I changed to implant because I read more and I am afraid of bone loss and gum recess later with a bridge. I am praying that my implant will be successful. I need to wait at least 6 - 8 weeks. I cannot wait to have my permanent crown (all ceramic). Thank you all.

wow-let's not start judging who charges how much for what procedure and why! let's not go down that road. It is just unprofessional and tacky for the whole profession! At the end of the day it is the patient who has accepted the financial responsability to pay for the service! I don't have the right to put my own values on someone else! Thank God, patients can be their own best advocate and request 2nd, 3rd opinions. We have have at some treat these pts as adults! Peace out- NH

Dear L: Congrats! Most of our implant patients have a similar experience: minimal discomfort followed by something that even "feels like a tooth". I'm glad yours went well, you should be enjoying it for many years to come.

"Unless the patient request General Anesthesia/Sedation there is no reason to use it for a single implant." After 4000 cases, I would expect you to have met patients who don't realise how jumpy they are. Haven't you seen patients who bravely tell you they can take anything and then start yelling when you tap on your osteotome?

thats "NEGATIVE pressure pulmonary edema" jawdude - to imply an anesthesiologist is not the "airway expert" is due only to lack of experience and/or understanding. Who do you think is called to the floor, ER or any difficult airway situation.

I'm just a patient, but... GA seems rather exaggerated. My periodontist suggested (against my intial reluctance) and used nitros-oxide. If yours has it - don't mess around, suck it up it! Believe it or not, it makes the entire experience (mine was an extraction, implantation and grafting) VERY pleasant and stress-free.

i know a guy who does everything under 4 pills of triazolam - conscious sedation. he claims to risks are associated, no contraindications to be concerned about. i have trouble beliving that. any of you guys had trouble with this drug?

I'm just a lowly patient-type guy, but when it comes to anesthesia and undergoing implant surgery, my opinion is thus... WHY SUFFER EVEN MINIMAL PAIN OR STRESS??? Of course you're going to get the local - that's given - but if your periodontist has nitros oxide, suck it up!!! Nitros makes the entire experience downright enjoyable. You're not "out of it" - rather you know what's going on, but have a much more philosophical perspective on it all. I'm sure this makes the doc's job all the easier. Periodontists/surgeons: If it isn't cost-prohibitive to your practice, get and offer the gas for your patients. Your patients will appreciate being offered the option and better yet, they'll tell their friends how their implant surgery at your clinic/office was... dare I say... "fun"???

Tony, I couldn't agree with you more! Due to some awful experiences in the past, I get so anxious about dental work that my dentist gives me nitrous oxide even for routine cleaning. With that, even a deeper poking and prodding doesn't bother me a bit. :-)

I have a root abscess on my central incisor which has a post and crown. The dentist thinks the root may have cracked. What is the likely outcome if I leave it all alone?

I have same problem ( cracked tooth ) with crown and post central incisor confirmed by endodontist. Please advise my options

I would appreciate any advice regarding this problem Thank you

I had a premolar with a crack in the root [also was endodontically treated and crowned] I had an apcoectomy[removed root tip] and also powdered bone placed. That surgery did not work. As it turned out, there was a very large crack on the palatal side that of course wasn't visible. Healing didn't happen and I had to have the tooth removed. You just never know. It is a chance you take. Listen to the advise of your endodontist and make your decision.

pre op my patients get midazolam tablets (Versed in US) I do multiple implants /wisdom teeth and grafting etc under this No problems at all i have the antagonist (Flumazinil) also all patients go on a pulsoximeter I no longer have the need for GA Although GA in the right hands is perfectly ok

It is interesting to see the comments on the need or otherwise of sedation or GA for implant placement. As a practitioner who places implants I want a patient who is comfortable during the procedure and who will allow me to operate in a sterile environment without wanting to scratch their nose or talk or move about because they feel vibrations or hammering when using an osteotome.I have done these procedures on unsedated patients from time to time,and everytime I do I regret having done so. The latest IV sedation procedures are safe, effective and offer quick recovery, and in my opinion this should be the treatment of choice. Research shows clearly the amount of stress patients exhibit prior to undergoing any of these procedures, and there is no doubt in my view that it is safer to perform the procedures under sedation (with a qualified, experienced sedationist) than without, because of the reduction in stress for the patient (and for the operator also).Unfortunately it is sometimes difficult for practitioners to understand the stress patients may experience, even though the planned procedure may appear simple and routine to them.

I had a dental implant three weeks ago (central incisor) and am surprised that dentists feel the need to sedate patients for this procedure. My prosthetist prompted me to do some deep breathing exercises during the procedure and played calming music. A mask was placed over my eyes and I was pre-warned of any odd noises or sensations. A warm blanket was placed over me and I was asked not to move my arms. Overall, it was not a painful or arduous experience.

A very sad case of dental implant failure. After 3 years of pain ,I lost 3 implants one after the other. Now I am told,that there will be no piece until the remaining 6 come out . No real reason is given just bad luck?

I believe we the patient should have the right to refuse general if we have a high stress level. I have been under once before and I could not come out of it..I woke up with the nurses slapping and shaking me and so now tomorrow I go in for 4 implants and i am going to refuse general..hope they agree.I am having it done in Costa Rica.. Still don't get the real reason we have to go under... I had 4 teeth pulled out a week ago and I was fine, My dentist says it is for the sounds of them having to split the bone .. but sounds alone can't hurt so I, she played the card of me having memories and how it sounds could be traumatic ..not sure about that wish me luck.. Aloha

The whole concept of anesthesia and or sedation is to make the patient comfortable, So, what ever the patient needs or desires is ok as long as it is proper for the patient to receive said anesthesia or sedation. Most of the time I use a local anesthetic, sometimes I add valium or ativan po or tramadol po.

I have found that Septocaine is an excellent LA. far superior and reliable than Lidocaine. Also, Prilocaine works very well as does a combo of Carbiocaine and Septocaine or Lidocaine. Also, a combo of Prilocaine and Septocaine.

"I have found that Septocaine is an excellent LA" I thought so too some years ago. Then, I started getting feedback. 1. paresthesia or prolonged numbness lasting up to a day even though it's supposed to be short-acting. 2. ulceration at injection site 3. pain at injection site after anesthesia wears off It happens only in a minority of cases, but in far higher frequency than with Lidocaine. I've switched back to the latter, reserving articaine only for pulp extirpations or areas of infection.

Oral midazolam is often unreliable as one cannot predict the amount of first pass for a particular patient. If Midazolam is used, it is best to titrate to clinical effect through an IV line. Ideally, an anaesthetist should be called in to give propofol. A deep and safe sedation can then be obtained. The patient is often out of the office 15 minutes after the propofol is turned off. Done at the dental office, this costs much less than GA in a surgical facility, but having heard about the ego of Western OMS people, I'm not sure if Western anaesthetists would do any roaming to dental offices equipped with oxygen and pulse oximeters.

I am in the process of having several implants and while waiting for the extraction sites to heal an unrelated but very painful molar reared its ugly head - or should I say crown - and had to be removed.. Because of the severity of the tooth's condition I was given intraoral anesthesia by the performing dentist. The cost for this was enormous - more than for the actual extraction - and I'm wondering what the average charge would usually be for something like this. It took 5 minutes to administer the anesthesia and I was up and out of the office - with one less tooth - in about 45 minutes, start to finish. I want to be fair and pay whatever the going rate is - but I also want to make sure I'm not being overcharged. Thanks for any answers and/or info.

You paid for skill and knowledge. He could of done it the way we use to do it in the old west..ie. without.

Intra-oral? Do you mean an injection to get it numb? Did you mean something else? Perhaps nitrous oxide? Perhaps conscious sedation? Surely, there would be no extra charge for an intra-oral injection.

I'm not disputing the skill and knowledge involved, am glad to pay for it and extremely grateful that I wasn't born in the old pre-anesthetic west. With all due respect, I'm just wondering what it costs when the skilled and knowledgeable extract a tooth that requires the use of an IV anesthesia.

Having IV anesthesia takes a lot of skill and knowledge. Check with local insurance companies [dental] and they should be able to tell you the "reasonable and customary" fee in your area. Hope this helps.

IV sedation not only requires skill and knowledge but results in legal exposure for the dentist doing the sedation. If you don't believe it check out the insurance rate paid by oral surgeons versus general dentists who do not perform IV sedation. Also consider the cost of the monitoring equipment used and the added employee often used to monitor the equipment. If you need to be "asleep" consider the possible complications before you complain about the cost.

In my experience with IV sedation I think I can comfortably say that it'd be enough for getting an implant. Particularly based on what I've read about the length of the procedure. I don't have any yet but I know that day will eventually come. I'm glad to know there are sedation techniques out there to suit extremely anxious patient. Cost is more but I look at it as an investment into having good oral health which results in overall better health, period. A healthy, functioning mouth is worth more than anything you could otherwise spend the money on. :) The exceptions for using GA might be complicated, lengthy procedures. That's probably beyond the scope of my current dentist anyway.

I believe it is the PATIENTS choice not the dentists..as long as the patient is informed of the risks then I think it is their decision how much pain or anxiety they are willing to endure since we are all different and have different levels of pain. I don't understand whats wrong with nitrous oxide...I am having a different problem..I WANT nitrous and my dentist doesn't even offer it as an option so I am now looking for another specialist. Since January (it is now Jun 20th) I have been in the dentists office sometimes 2 times a week getting 4 root canals,4 posts/crowns,fillings,bone graft etc...I am now so freaked out by the dentist,I never even once asked for sedation..my last 2 procedures are tomorrow,1 screw for a dental implant and I need a broken piece of my wisdom tooth removed surgically since it is lodged in the side of my gum..I sincerely can't sit through another appointment and I NEED to be sedated but this dentist offers nothing but novacaine and during some of my longer appointments I was actually told that they gave me the max amount of novacaine allowed,even though it had long since ran out & was no longer numb I white knuckled through it. I decided that it would be inhumane and barbaric to make me go through this awake and out of my mind with anxiety. Don't ever let your dentist talk you into doing either..its up to you,you are paying them. Everyone can come up with a story that a friend of a friend had this or that bad happen or heard something on the news or read it online,surgery happens everyday although I don't think I would want IV sedation for dental work if someone does its their choice. I choose to get nitrous.

Hi. I underwent dental implant surgery with bone grafting 8 days ago for two full size bottom molar implants. I was told that I would be put to sleep, but that didn't happen. Surgeon told me that he required me to be awake in order to place the pins accurately. He said people move in their sleep. It was AWFUL! I could feel the cutting and the suturing. I screamed and cried and pleaded for more freezing. He gave me the freezing, but then didn't wait for the gums to numb up. He said, "Sorry but I don't have the time to wait for your gums to numb up, so just breathe through it." I started violently shaking like a bad seizure which I believed was caused by the torturous pain I endured, except I don't have seizures, and while shaking the surgeon was continuing to suture. Afterwards my resting pulse was 114, 108 and took time to come down. My blood pressure was 189/83. I remember everything! and honestly it was a torturous and cruel experience that I never want to repeat ever again. I will remember two words next time, if there is a next time - "GENERAL ANESTHETIC." Actually, the suffering has continued post surgery with severe pain as of Day 8 post surgery is very bad pain, as bad as it was on Day 2. The bruising left me with a rather larger black/reddish mark on my jaw and numbness in parts of my lip, chin and face that isn't going away, plus a lot of swelling. I also have a small bruise in the center of my neck where I felt the surgeon's thumb pinning me down when I started violently shaking. I was given only 10 (1 mg hydromorphone pills for post surgical pain, which prescribed as "Take 2 every 4 to 6 hours" only last into the second day, and I was in agony -- very bad pain 8/10. Actually, I feel so assaulted that I don't want to go back for Stage 2 of the surgery. I don't think general anesthetic is the worse; I think being in pain during the surgery and not having adequate pain control is extremely cruel and unconscionable! I don't know why I wasn't frozen up enough? I don't get it? All I know is that no one should ever have to suffer like that. And, the worse is that the surgeon promised me he would put me to sleep, then the day of the surgery while I was in the chair all prepped, he told me, "I have some bad news and can't put you to sleep anymore because I need you to be awake and cooperative for placement of the pins, so you are going to feel pain." I had discussed with the surgeon in my consultation that I did not want to feel any pain during the surgery, and he told me they would give me an IV and put me to sleep, then changed his mind the day of the surgery." Patients need to be properly informed and again I still don't know why I wasn't frozen up enough? An extremely CRUEL experience to say the least! Also the surgeon wasn't going to insert the two full sized pins anymore the day of the surgery because he then said he thought he had left me too long and I was told now I might not have enough bone, so changed the plan to one implant and a cantilever without ever discussing it with me first. I was very upset and reminded him what we had discussed. The positive is that I got the two full sized implants that we had discussed, so that could have gone much worse. However, I am very upset and afraid to go for Stage 2 of the surgery. I don't know what to do. Has anyone else had an experience like this? I feel like I was tortured! and yes I'm absolutely terrified now to go back to surgeon or even talk to him about what I'm going through.

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I have myasthenia gravis (3 decades) and numerous problems with medications. I cannot have either GA or IV. I've had all dental work (a lot of it!) with only a local because of MG. Not pleasant but have had an understanding dentist. I now have to go to an oral surgeon for major work - implants, etc. As my local dentist recommends him highly, I'm hoping at our consultation appt he agrees to work with me. If not, I'll be doctor hunting. I appreciate the information on this site about whether or not what work can be done, how and when. I'm adding it to my research so I know what questions to ask at the appt.