Frances Woolley, one of my favorite Canadian observers of
the world, reflects on what is not just a Canadian issue but perhaps a worldwide
one, namely the expanding procedures in the world of dental care[1].
She opines on the use of general anesthesia for extractions. I most heartily
agree with her conclusion but for a different reason. A general anesthesia, a “General”,
is always a high risk procedure. However it does allow the practitioner to add
to the fee charged for a nominal increase in costs, namely what may be
administered. A local such as lidocaine or a related anesthetic numbs the pain,
yet the patient does endure the procedure.
However as an old rule of thumb, a patient
takes one month’s time to recover from a one hour General. That means that for
a thirty minute extraction under a General you are not quite yourself for two
weeks or more. For a Local you are back somewhat in 24 hours of less. The Local
allows you to experience the process and putatively experience it and expunge
it. The General is a suppressed experience that somehow requires a longer
psychological recovery. That is why people who have a four hour General for say
a prostatectomy take a long period to “feel themselves” again. Just what the
process is I have no idea.
Now for dentists in general. Often one heard in Medical
School that you can examine any part of the patient’s body except the teeth!
There are people who handle that and in almost all cases they are dentists. A
physician can do eyes, brains, toes, skin, intestines and the list goes on, but
“no teeth”. I often wondered why? The answer in my humble opinion is that the
handling of teeth is still somewhat stuck in the late Middle Ages. It is a
craft, and part art.
You see, when God made man, or woman for that matter, but
with women he corrected for a few mistakes in the first model, they live
longer, but God assumed that these creatures would not live that longer than
the first few batches out the gate. Thus God designed teeth to last say 30 to
at most 40 years, slowly falling out along the way. Then along came physicians
extending life spans, despite attempts to keep it low by using tobacco and the
like. God’s current plan on shortening life span seems to be obesity so we will
have to see how that plays out. But back to teeth. They were poorly designed.
Like a 1957 Chevy chrome front bumper. Good to look at in the showroom but by
the second or third year rotting away! Then along came the dentists, tear out
the old bumper and attach a new one. Then keep that process up a bit but as
anyone remembers the 57 Chevy lasted no more than 5 years because the engine or
floor boars went as well.
Now back to Frances. She observes:
And if it makes having
a tooth extracted less unpleasant, what's the harm? Well, the harm may be to
your brain. General anesthesia may increase the chance of post-operative
cognitive decline. This article using Taiwanese administrative data found a
link between dementia and a history of surgery under general anesthetic. On the
other hand, this study found no differences between patients receiving a
general anesthetic and those receiving epidurals in terms of cognitive
functioning three months post-surgery - although patients receiving an epidural
had better surgical, as well as better short-term cognitive, outcomes. Many
surgical procedures can be performed either with an epidural or under a general
anesthetic. It is hard to find any study suggesting that general anesthesia
produces superior results in cases where local anesthetic is a viable option.
This study finds that general and local anesthetics produces similar outcomes,
but local is cheaper. This one found that epidurals produced better patient
outcomes than general anesthetics, and this one also comes down in favour of the
local option. This leaves aside the 40 percent risk of post-operative nausea
and vomiting after having a general anesthetic. Perhaps one day we'll see the
Canadian dental association issuing guidelines on the use of general
anesthesia. Insurance companies might step up and only reimburse the cost of
general anesthesia in exceptional circumstances.
I think that she may be understating the issue. I would
avoid a General at all costs. Last time I remember was when I had my tonsils
out. They used ether, yes I am that old. Then after they ripped out the little
lymph organs from the back of your mouth, pumped your lungs with ether, and
some ended up in your stomach, you awake and have emesis emptying the last of
your stomach contents past the now ripped out organ! Thank God medicine has advanced.
But dentists using a General should really be extremely cautious. It must be a
last resort in my opinion and done only when emergency facilities are
proximate.
The same risks apply for example to colonoscopies. One can
use a General or a more controlled use of fentanyl and versed. Even that has
risks and requires a good backup plan. Thus the general use of a General is in
my opinion highly unadvisable and Frances makes a compelling argument worth
note to all.
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