Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Deepak Krishnan, who is here to discuss OMS expertise through training to safely administer anesthesia. Dr. Krishnan, great to see you.

Deepak Krishnan: Thank you, Bill. Great to see you, too.

Bill Klaproth (host): Absolutely. Thank you so much for being here. So, this is a topic I think that a lot of people probably ask about when they come to see an OMS. One of the big questions they probably have is about anesthesia. So, I think this is going to be a great topic. So, can you explain the training an OMS undergoes in regards to learning anesthesia administration?

Deepak Krishnan: Indeed. So, we should always acknowledge the fact that anesthesia kind of started in dentistry. So, persons that were instrumental in developing the entire specialty of anesthesia all started with somebody having a toothache and how do I get rid of this toothache? Well, let's get to numb it up, right? And then, it went to, well, going to the dentist was always like this anxiety-inducing, huge endeavor and you slug a lot of whiskey or you smoke a lot of something else or do something. And then, you go into the old age dentist and then you get the tooth pulled, right? So, this is always a traumatic experience for human race. So, where do we fix that? So, anxiolysis comes to play.

And as we adapted from dentistry to major surgery, it became very apparent that in order to practice our craft well, we must have our patients very comfortable. And that comfort comes from the time that they come in and hear about the procedure, through the procedure and then later after the procedure. All of this is anesthesia. There's anxiolysis, there's patient preparation, patient assessment, the actual procedure and then postoperative care.

And so for us to provide that care, we must do it in a setup which is not particularly traditional in the healthcare scenario, because our offices are often sequestered away from a large medical center. Our patients come to us for a one-time event, you know, have one procedure done. So, how do we adapt medical anesthesiology into our practice? And so, that becomes important. And so, when we started looking at how do we train our residents, our surgeons to the next level of provision of anesthesia, it became apparent that we must have a very structured curriculum. And that structured curriculum is incorporated into current day training. This is unique in North America. This is in fact very unique in the United States. Even in other North American countries, people don’t necessarily have the ability to provide ambulatory anesthesia care in the outpatient setting.

Bill Klaproth (host): Wow. That’s really interesting.

Deepak Krishnan: Yes. So, the rest of the world still depends–

Bill Klaproth (host): Whiskey and smoking something. No, they’re probably a little more advanced than that at this point.

Deepak Krishnan: They’re probably a little bit more advanced than that, indeed. But the ability for us to provide anesthesia beyond just local anesthesia or numbing them up is very unique to United States. And that’s why the training is unique as well.

Bill Klaproth (host): I’m happy to live here then.

Deepak Krishnan: Yes. Among other things, right?

Bill Klaproth (host): That’s very good, among other things. Absolutely. So then, what are the different types of anesthesia we should know about?

Deepak Krishnan: Yeah. So, you know, you can have procedures of all sorts of things done in your head and neck area. And depending on the complexity of that, they might be very simple procedures that can be performed under local anesthesia, which traditionally is just numbing you up with a medication that makes that area go numb, and there's no pain related to the procedure. Then, there's procedures that are a little bit more complex than that, and that takes it to other levels.

Bill Klaproth (host): Okay. And that's called minimal sedation. Is that right?

Deepak Krishnan: Yeah. It's this concept of sedation is a continuum.

Bill Klaproth (host): Okay. There's different levels of sedation. So, I have here in my notes, there's minimal, there's moderate, there's deep. And then, we often hear general anesthesia. So, I'm wondering if you could just go in depth on each of these. If I ask you more about each of these, is that okay?

Deepak Krishnan: Yeah.

Bill Klaproth (host): Okay. So, local anesthesia, you said that's kind of a specific area, is that right? Can you tell us more about that?

Deepak Krishnan: Yeah. So, local anesthetic medications don't render you unconscious. They just render the area without sensation. So, if you give a small injection to your lip or your teeth in the area or your jaw on that spot, all of those can be made numb. And then, the patient does not feel anything after that. Now, that's very straightforward.

Bill Klaproth (host): Right. And then, there's minimal, which is you said it's a continuum. So, minimal is a little bit more. Can you tell us about that?

Deepak Krishnan: Yeah. So, if you gather a bunch of your friends and you go to a bar on Bourbon Street, there are people who are cheap drunks. You know, one beer and they're out. And then, there are those that go on to having – So, this is that continuum we are talking about, right? So, every human being has a different threshold, depending on the medications that they're given as to how unconscious or conscious they may be, you know, during that procedure.

So, minimal sedation, for instance, is something where you use something like nitrous oxide or, you know, the laughing gas. You get that going and it kind of tingles you up. It kind of gives you a little bit of a euphoric sense and has a very potent ability to knock pain away. So then, it becomes easier for you to just start a small IV or give you some numbing medicine, and that's minimal anesthesia.

Bill Klaproth (host): So, minimal, is this when someone goes in to have their wisdom teeth pulled, if you will, extract it? Is that generally the level of sedation? No.

Deepak Krishnan: No. So, wisdom teeth surgery is actually rather involved and because these teeth are all the way in the back of your mouth often covered with bone significantly. It involves removing a lot of bone and then making sure that the nerves and the other structures in the area are protected. Making sure that the jaw does not break during the procedure. So, it's a little bit more complex.

Bill Klaproth (host): Okay. So, that would be moderate then?

Deepak Krishnan: That would be potentially moderate, but more than likely deep sedation or general anesthetics.

Bill Klaproth (host): So, moderate is deeper than minimal. And then, next is deep. So, someone with a wisdom teeth that were severely impacted, like you said, could use deep. So, it could be a continuum then?

Deepak Krishnan: That is correct.

Bill Klaproth (host): And then, there's general. What is that?

Deepak Krishnan: So general anesthesia, it depends on what kind of medications you are receiving. So, there are medications that put you into a class of moderate sedation. But there are also medications that put you into a class of general anesthetic. It's harder to wake up if you have those medications. It's harder to control your secretions. It's harder to control your reflexes if you're receiving those medications. Depending on what we give you, you fall into these. Depending on your response to what we give you, you fall into this. So, this is why training is very important. It's not about pick drug A, pick patient X, give patient X drug A and you will get – that's not how it goes. You need to be able to meander through all of this and then put the patient in the comfort zone where you're comfortable managing that patient and that patient's comfortable from your management. And that's where balanced anesthesia comes in.

Bill Klaproth (host): So, you mentioned training. Can you talk about the training that an OMS receives to be able to administer anesthesia?

Deepak Krishnan: Indeed. So, the training of anesthesia is incorporated throughout the training process of an oral maxillofacial surgery resident. Somebody walks in from dental school, they are well-trained as a dentist. Now, we are deviating from that path to train them further. In many aspects of surgery, medicine and anesthesia. And anesthesia itself is kind of interspersed throughout the training process of a resident, whether you are fresh out of dental school or you're six or four years into training, it doesn't matter. You have gradations of training. Within that training, there's structured time that is spent on the anesthesia service. As an anesthesiology resident, training just like any other anesthesia resident, you're taking care of cardiothoracic cases, you're taking care of orthopedic injuries, taking care of patients that are going into labor, you're taking care of any patient that you want to put to sleep as an anesthesia resident. So, what that does is it exposes and trains our residents in all aspects of anxiolysis, pain management and anesthesia.

Bill Klaproth (host): It seems like that would be very beneficial for the different sizes and types of people. Is that right? Is that a good way to look at it?

Deepak Krishnan: That's correct. That's absolutely right. Yes. So, most of all, training, regardless of what specialty you are in, you tend to overtrain and then practice a little below that.

Bill Klaproth (host): I love that.

Deepak Krishnan: And the intent is always that you have been trained to the maximum. Should something deviate and go up to the maximum, you know what to do, you'll recognize what needs to be done, and then you handle it appropriately. But you don't want to do that every day.

Bill Klaproth (host): Right. And having that exposure to a variety of people makes you capable of handling different situations that arise then.

Deepak Krishnan: Indeed.

Bill Klaproth (host): So, what should a patient expect then when receiving anesthesia?

Deepak Krishnan: The first thing that they should accept is the fact that, you know, not everybody might be a candidate for what they decide to be. You know, I have patients that walk in, that sometimes don't walk in because they cannot walk and then they have a very minor procedure that needs to be done. And then, they'll immediately tell us, "Well, I need to be asleep for this." My usual rule of thumb was you are coming to me unconscious, and I would have to give you medications to get you unconscious, we don't get you asleep for it. We don't stop breathing when we sleep.

Bill Klaproth (host): Right.

Deepak Krishnan: So, we need to make sure that you are a good candidate for surgery. So, setting that expectation is the first thing. So, if you are a good candidate for surgery and anesthesia in the office, then we start with going over the preparations that you must come in with. So, we need to make sure that you're here with a responsible escort that will drive you back home that day and stay with you for 24 hours. I need to make sure you properly follow what we call the NPO guidelines. Don't eat or drink anything past midnight. You know, and that includes coffee, that includes your big breakfast platter and things like that. You know, kids don't consider, you know, Doritos as breakfast. But you know, sometimes they say, "Why are you eating Doritos before dinner?" "Well, it's not dinner." "Well, okay. Maybe I can have Doritos, right?" So, nothing to eat or drink before the procedure. Don't wear a lot of jewelry. Don't wear makeup. We often require access to intravenous medications through an IV. So, don't wear full sleeves. Loose clothing that is comfortable. It's okay to bring your music, so you can listen to it. So, when you're waking up, you're listening to your music. Be prepared mentally to expect to some – you know, there's no surgery without discomfort. So, we go over these things with the patients.

Bill Klaproth (host): Right. So, you mentioned wear loose clothing because sometimes you have to administer an IV. An OMS can administer anesthesia in a variety of ways. So that's IV, you mentioned laughing gas before. There's different ways of administering anesthesia. Can you just touch on that?

Deepak Krishnan: So, laughing gas is certainly one definite way that most people start off things. It actually makes the placement of the IV more comfortable, you don't even feel that. Once you get the IV, you know, then we can go from there. Real smaller children that may be uncooperative for an IV, for instance, there are other techniques that we can encourage and give them a little bit deeper anesthetic through blowing into a mask. You know, we have a little game that we play with them saying, "This is a little space suit," a pilot's mask or a race car thing. And then, they will take a couple of gaps of this gas and then they fall asleep and we can start the IV from there. Sometimes we can give medications as a jab, intramuscular medications. So, those are the things that we would do.

Bill Klaproth (host): So, depending on the level of sedation or the size of the person, you'll determine how you will administer it. Is that right?

Deepak Krishnan: Yes, those are factors. Also, another factor is what's the type of surgery that you're going to do. Do you just need to stun them for a minute or two to take a simple tooth out, or is this something that's going to take three or four hours in the office? So, what's the kind of anesthetic that you're going to consider? All of these patient factors, surgical factors, all contribute towards what we need to do.

Bill Klaproth (host): Is anesthesia one of the biggest challenges you face when working with patients or the biggest questions you get about that? Because people are like, "Oh, I don't know if I want to go under. I'm bringing my son or daughter in for their wisdom teeth. I'm scared of the anesthesia." Is that a proper perception?

Deepak Krishnan: It's not unusual to get that question. The opposite is also true. The opposite is often true where they come to us because they are aware of the fact that they can have the anesthetic available as an option. "I could have my dentist do this, but he said you could get me asleep in order for me to go through this. Hence, I am here." But when patients do bring up their apprehensions and their trepidations about having anesthetic care, we walk them through the process. We have an impeccable safety record as a specialty in this nation. We have records and data that suggest that our training helps us and that our ability to provide safe anesthesia care in the circumstances that we are in, which is uniquely different from a medical anesthetic situation, in a healthy patient that is otherwise a good candidate for this kind of anesthetic is very good. So, when you tell parents that, you know, it's a powerful motivator.

Bill Klaproth (host): Well, I would think an OMS with the training that you have to go through would put a parent or anyone at ease, knowing that you're an expert in administering anesthesia.

Deepak Krishnan: Indeed. You know, I mean, parents are well-versed these days. They have looked you up beforehand. They've understood what's happening in the anesthesia regimen that we are going to give them. They know what to expect. Oftentimes they tell us that, "Oh, aren't you going to do this. Are you not going to do that?" So, it's usually useful.

Bill Klaproth (host): They come in well-prepared. "Can I have the laughing gas? Give me the laughing gas," right? Well, Dr. Krishnan, this has been fascinating and very educational and informative. Thank you so much for your time.

Deepak Krishnan: Thanks, Bill.

Bill Klaproth (host): Yeah. Once again, that is Dr. Deepak Krishnan. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.