Chapter 3: Anesthesia and Sedation in OMS¶

Office-based anesthesia, local anesthesia techniques, IV sedation, general anesthesia, airway management, monitoring standards, and emergency protocols for the oral and maxillofacial surgeon.

3.1 Introduction¶

Oral and maxillofacial surgeons occupy a unique position in medicine: they are one of the few specialties that administer their own anesthesia while simultaneously performing surgery. This dual-provider model, with a dedicated anesthesia team member (typically a surgical assistant trained in anesthesia monitoring), has an outstanding safety record. The AAOMS Office Anesthesia Evaluation (OAE) program has documented a mortality rate of approximately 1:365,000 for office-based anesthesia in OMS practices (Perrott et al., J Oral Maxillofac Surg 2003;61:983-995), which compares favorably with hospital-based general anesthesia.

This chapter covers the full spectrum of anesthesia and sedation techniques employed in OMS practice, from local anesthesia through deep sedation/general anesthesia, with emphasis on airway management, monitoring standards, and emergency preparedness.

3.2 Local Anesthesia¶

3.2.1 Pharmacology of Local Anesthetics¶

Local anesthetics block voltage-gated sodium channels, preventing action potential propagation along nerve fibers. They consist of three components: an aromatic lipophilic group, an intermediate chain (ester or amide linkage), and a hydrophilic amino group.

Classification:

Property	Amides	Esters
Examples	Lidocaine, mepivacaine, bupivacaine, articaine, prilocaine	Procaine, tetracaine, benzocaine
Metabolism	Hepatic (CYP enzymes)	Plasma cholinesterase (pseudocholinesterase)
Allergy	Extremely rare	More common (PABA metabolite)
Clinical use in OMS	Primary agents for all procedures	Topical (benzocaine); rarely injected

Agent profiles:

Agent	Onset	Duration (with epi)	Max Dose	Notes
Lidocaine 2% (1:100,000 epi)	2-3 min	60-90 min (pulpal) / 3-5 hr (soft tissue)	7.0 mg/kg (with epi)	Gold standard; most widely used
Articaine 4% (1:100,000 or 1:200,000 epi)	1-2 min	60-90 min (pulpal)	7.0 mg/kg	Superior bone penetration (thiophene ring); higher paresthesia risk with IAN block (see below)
Mepivacaine 3% (no vasoconstrictor)	1.5-2 min	20-40 min (pulpal)	6.6 mg/kg	Useful when vasoconstrictor is contraindicated or short procedures
Bupivacaine 0.5% (1:200,000 epi)	6-10 min	4-8 hr (pulpal) / 8-12 hr (soft tissue)	1.3 mg/kg	Long-duration; excellent for postoperative pain control; cardiotoxic at high doses

Critical Safety

Local anesthetic systemic toxicity (LAST) occurs when plasma levels exceed the toxic threshold (CNS symptoms: tinnitus, circumoral numbness, seizures; cardiovascular: arrhythmias, cardiovascular collapse). The ASRA (American Society of Regional Anesthesia) guidelines recommend having 20% intralipid (lipid emulsion) available in every office that administers local anesthetics. Dosing for LAST: 1.5 mL/kg bolus IV, followed by 0.25 mL/kg/min infusion. Maximum total dose: 12 mL/kg (Neal et al., Reg Anesth Pain Med 2018;43:113-123).

3.2.2 Nerve Block Techniques¶

Inferior Alveolar Nerve Block (IANB)¶

The most common injection in OMS practice. Technique (Halsted approach):

Palpate the coronoid notch and pterygomandibular raphe
Identify the injection target: the medial aspect of the ramus at the level of the mandibular foramen, approximately 1 cm above the occlusal plane
Insert the needle from the contralateral premolar region, with the barrel over the contralateral premolars
Advance to bone (approximately 20-25 mm depth), withdraw 1-2 mm, aspirate (positive aspiration rate: 10-15% -- highest of any dental injection)
Deposit 1.5-1.8 mL of anesthetic solution

Success rate: 80-85% for the standard Halsted technique. Failure is commonly due to anatomical variation (bifid mandibular canals, accessory foramina) or infection (pH shift reduces un-ionized base).

Alternative techniques for IANB failure:

Gow-Gates technique: Higher injection site targeting the condylar neck; 97% success rate; lower positive aspiration rate (2%) (Gow-Gates, Anesth Prog 1973;20:36-39)
Vazirani-Akinosi (closed-mouth) technique: Indicated for patients with limited opening (trismus); needle inserted medial to the ramus at the level of the mucogingival junction of the maxillary third molar region, parallel to the occlusal plane

Long Buccal Nerve Block¶

Supplements the IANB for mandibular molar procedures. The needle is inserted distal and buccal to the most posterior molar, targeting the buccal mucosa overlying the external oblique ridge.

Posterior Superior Alveolar (PSA) Nerve Block¶

Targets V2 branches on the posterior maxilla. The needle is inserted at the height of the mucobuccal fold above the maxillary second molar, directed posteriorly, superiorly, and medially (45 degrees to the occlusal plane in each direction). Depth: approximately 16 mm. Risk: pterygoid venous plexus hematoma if the needle is advanced too far posteriorly.

Infraorbital Nerve Block (Extraoral and Intraoral)¶

Blocks V2 as it exits the infraorbital foramen, providing anesthesia to the ipsilateral upper lip, lateral nose, and lower eyelid. Intraoral approach: Needle inserted at the mucobuccal fold above the maxillary first premolar, directed toward the infraorbital foramen (palpated extraorally). Extraoral approach: Direct injection at the foramen.

Greater Palatine Nerve Block¶

Blocks the greater palatine nerve at the greater palatine foramen (approximately 1 cm palatal to the second/third molar, at the junction of the hard palate and alveolar process). Provides palatal anesthesia from the third molar to the canine region.

Mental/Incisive Nerve Block¶

Blocks the mental nerve at the mental foramen (below and between the premolar apices). Provides anesthesia to the lower lip, chin, and labial mucosa/gingiva of the premolars, canine, and incisors.

Surgical Caution

Articaine and IAN blocks: A meta-analysis by Yapp et al. (J Am Dent Assoc 2011;142:531-539) and Garisto et al. (J Am Dent Assoc 2010;141:836-844) demonstrated a statistically higher incidence of paresthesia with articaine 4% IAN blocks compared to lidocaine 2% (approximately 3.6x relative risk). While the absolute risk remains low, many practitioners restrict articaine to infiltration techniques and use lidocaine or mepivacaine for IAN blocks. Articaine's superiority for buccal infiltration in the mandible (even for molars) may reduce the need for IAN blocks in many cases (Robertson et al., J Endod 2007;33:11-14).

3.2.3 Vasoconstrictors¶

Epinephrine (1:100,000 or 1:200,000) is the most common vasoconstrictor added to local anesthetics. Benefits include:

Prolonged duration of anesthesia
Reduced bleeding at the surgical site
Decreased systemic absorption (slower onset of peak plasma levels)
Increased maximum safe dose

Cardiovascular considerations: The maximum recommended dose of epinephrine in healthy patients is 0.2 mg (equivalent to approximately 11 cartridges of 1:100,000 epinephrine). In patients with significant cardiovascular disease, the AAOMS and AHA recommend limiting epinephrine to 0.04 mg (approximately 2 cartridges of 1:100,000). However, the endogenous catecholamine release from pain and anxiety typically far exceeds this amount, making adequate anesthesia more important than strict epinephrine limitation (Becker & Reed, Anesth Prog 2006;53:98-108).

3.3 Sedation Continuum¶

The ASA defines four levels of sedation:

Level	Definition	Airway	Response	Cardiovascular
Minimal sedation (anxiolysis)	Drug-induced state; patient responds normally to verbal commands	Unaffected	Normal	Unaffected
Moderate sedation (conscious sedation)	Depressed consciousness; purposeful response to verbal or light tactile stimulation	No intervention required	Purposeful	Usually maintained
Deep sedation	Depressed consciousness; purposeful response to repeated or painful stimulation	Intervention may be required	Purposeful after repeated/painful stimulation	Usually maintained
General anesthesia	Drug-induced loss of consciousness; not arousable	Intervention often required	No response	May be impaired

Clinical Pearl

The OMS office-based anesthesia model typically targets deep sedation rather than true general anesthesia, maintaining spontaneous ventilation while achieving surgical-depth amnesia and analgesia. The key advantage of the OMS-administered anesthesia model is the surgeon's ability to titrate to the exact level needed, adjusting depth in real time during the procedure.

3.4 Intravenous Sedation¶

3.4.1 Agents¶

Benzodiazepines¶

Agent	Onset (IV)	Duration	Dose	Notes
Midazolam	1-2 min	45-60 min	0.5-2 mg titrated; max 5-10 mg	Most common benzodiazepine in OMS; excellent amnesia; water-soluble (less painful on injection)
Diazepam	1-3 min	60-90 min	2.5-5 mg titrated	Longer duration; active metabolite (desmethyldiazepam, t½ ~100 hr)
Triazolam (oral)	15-30 min	60-90 min	0.125-0.5 mg PO	Oral anxiolysis preoperatively

Reversal: Flumazenil (Romazicon) 0.2 mg IV q1min, max 1 mg. Re-sedation can occur because flumazenil's duration (45-60 min) may be shorter than the benzodiazepine's.

Opioids¶

Agent	Onset (IV)	Duration	Dose	Notes
Fentanyl	1-2 min	30-45 min	25-100 mcg titrated	Most common opioid in OMS sedation; minimal histamine release; potent respiratory depressant
Alfentanil	1 min	15-20 min	5-20 mcg/kg	Ultrashort-acting; useful for brief procedures
Remifentanil	30-60 sec	3-5 min	0.05-0.1 mcg/kg/min infusion	Context-sensitive half-life of 3-4 min regardless of infusion duration; requires infusion pump

Reversal: Naloxone (Narcan) 0.04-0.4 mg IV q2-3min. Duration of naloxone may be shorter than the opioid (particularly for fentanyl), requiring re-dosing.

Critical Safety

Opioid-benzodiazepine synergy: The combination of fentanyl and midazolam produces synergistic respiratory depression that is far greater than either agent alone. This synergy is the most common cause of respiratory depression events in OMS sedation. Doses of each agent must be reduced by 30-50% when used in combination, and the opioid should typically be administered before the benzodiazepine to allow assessment of the opioid effect before adding the sedative component.

Propofol¶

Classification: Alkylphenol hypnotic-sedative (not an analgesic)
Onset: 15-30 seconds
Duration: 5-10 minutes (redistribution)
Dose: 0.5-1 mg/kg induction; 25-100 mcg/kg/min infusion for maintenance
Advantages: Rapid onset and recovery; antiemetic properties; easily titratable infusion
Risks: Dose-dependent respiratory depression and apnea; hypotension (vasodilation, negative inotropy); no reversal agent; painful on injection (mitigated by co-administration of lidocaine)
Use in OMS: Propofol has become a cornerstone of office-based deep sedation/GA in OMS. Its use requires training in airway management and the ability to rescue from general anesthesia. CDT D9223 (deep sedation/general anesthesia -- each subsequent 15-minute increment).

Ketamine¶

Classification: NMDA receptor antagonist (dissociative anesthetic)
Dose: 0.5-2 mg/kg IV (anesthetic dose); 0.1-0.5 mg/kg IV (sub-dissociative analgesic dose)
Advantages: Preserves airway reflexes and spontaneous ventilation (at analgesic doses); bronchodilator; provides analgesia and amnesia; positive hemodynamic effects (sympathomimetic)
Risks: Emergence reactions (dysphoria, hallucinations -- mitigated by co-administration of midazolam); increased salivation (mitigated by glycopyrrolate); laryngospasm (rare); increased intracranial pressure (relative contraindication in head injury)
Use in OMS: Increasingly used as an adjunct for multimodal analgesia and as a primary agent for pediatric sedation

Dexmedetomidine¶

Classification: Alpha-2 adrenergic agonist
Dose: 0.5-1 mcg/kg loading over 10 min, then 0.2-0.7 mcg/kg/hr infusion
Advantages: Sedation without respiratory depression; anxiolysis; analgesia; reduced opioid requirements; cooperative sedation (patient arousable)
Risks: Bradycardia (may be profound); hypotension; slow onset
Use in OMS: Growing role as an adjunct to reduce propofol and opioid requirements; useful in patients with OSA

3.4.2 Standard Sedation Protocols¶

Protocol 1: Moderate Sedation (most common for third molar surgery)

Preoperative assessment: ASA classification, Mallampati score, NPO status (2 hr clear liquids, 6 hr light meal, 8 hr full meal per ASA guidelines)
Establish IV access
Apply monitors (see Section 3.6)
Administer O2 via nasal cannula/hood (4-6 L/min)
Midazolam 1-2 mg IV
Fentanyl 50-100 mcg IV (titrate to effect)
± Propofol 20-40 mg boluses or low-dose infusion (25-50 mcg/kg/min) for deeper sedation
Local anesthesia administered after adequate sedation
Monitor and titrate throughout procedure
Recovery: patient meets discharge criteria (modified Aldrete score >= 9)

Protocol 2: Deep Sedation/General Anesthesia (complex cases)

Steps 1-4 above
Midazolam 1-2 mg IV (anxiolysis)
Fentanyl 50-100 mcg IV
Propofol 1-2 mg/kg IV bolus (to loss of consciousness)
Propofol infusion 75-150 mcg/kg/min
Nasal intubation or nasal airway/LMA if needed
Local anesthesia for surgical analgesia and hemostasis
Supplemental fentanyl or ketorolac for analgesia
Discontinue propofol 5-10 min before end of procedure
Recovery and discharge as above

3.4.3 CDT and CPT Codes for Anesthesia¶

Code	Description
D9222	Deep sedation/general anesthesia -- first 15 minutes
D9223	Deep sedation/general anesthesia -- each subsequent 15-minute increment
D9239	IV moderate sedation/analgesia -- first 15 minutes
D9243	IV moderate sedation/analgesia -- each subsequent 15-minute increment
D9248	Non-intravenous conscious sedation
CPT 00170	Anesthesia for intraoral procedures (including biopsy)
CPT 00100	Anesthesia for procedures on salivary glands, with biopsy

3.5 General Anesthesia¶

3.5.1 Office-Based vs. Hospital-Based GA¶

OMS surgeons are uniquely trained (during a 4-6 year residency that includes 4-6 months of medical anesthesia rotations) to administer GA in the office setting. The AAOMS Parameters of Care (ParCare) and state dental board regulations govern office-based GA.

Requirements for office-based GA (varies by state):

Current ACLS (Advanced Cardiovascular Life Support) certification
PALS (Pediatric Advanced Life Support) certification (if treating pediatric patients)
State anesthesia permit (most states require a separate permit for deep sedation/GA beyond the dental license)
Office inspection and equipment standards (AAOMS OAE or state equivalent)
Trained and certified anesthesia assistants
Emergency drugs, equipment, and defibrillator available
Transfer agreement with a hospital or ambulatory surgery center (required in some states)

3.5.2 Inhalation Agents¶

Nitrous oxide (N2O):

Provides anxiolysis and mild analgesia at concentrations of 30-50%
Rapid onset and offset (virtually no metabolism)
Must be delivered with at least 30% O2 (never below 30%)
CDT D9230 (inhalation of nitrous oxide/anxiolysis)
Scavenging system required (occupational exposure limit: 25 ppm per NIOSH)
Contraindications: middle ear surgery, pneumothorax, bowel obstruction, first trimester of pregnancy (relative)

Sevoflurane (less commonly used in OMS office setting):

Provides smooth mask induction, particularly in pediatric patients
MAC: 2.0% (adults), 2.5% (children)
Minimal airway irritation
Requires calibrated vaporizer and scavenging system
Rarely used in OMS offices due to equipment requirements; more common in ambulatory surgery centers and ORs

3.6 Monitoring Standards¶

The AAOMS monitoring standards (aligned with ASA standards) require the following for moderate and deep sedation/GA:

3.6.1 Required Monitoring¶

Parameter	Device	Frequency
Oxygenation	Pulse oximetry (SpO2)	Continuous
Ventilation	Capnography (ETCO2) -- pretracheal or nasal	Continuous
Circulation	ECG (at least 3-lead)	Continuous
Blood pressure	NIBP (non-invasive blood pressure)	Every 5 minutes
Heart rate	From SpO2 or ECG	Continuous
Temperature	If GA >30 min	Intermittent/continuous
Level of consciousness	Clinical assessment (response to command)	Continuous

Clinical Pearl

Capnography (ETCO2) is the single most important monitor for detecting respiratory depression during sedation. It detects hypoventilation (rising ETCO2), apnea (absent waveform), and airway obstruction (abnormal waveform morphology) before SpO2 desaturation occurs (typically 30-60 seconds earlier), providing a critical early warning. The ASA mandated capnography for moderate sedation in 2011, and the AAOMS has adopted this standard. CDT code D9222/D9223 documentation should include ETCO2 values.

3.6.2 Documentation¶

A time-based anesthesia record documenting the following at 5-minute intervals is the standard of care:

Vital signs (HR, BP, SpO2, ETCO2, RR)
Medications administered (drug, dose, time, route)
IV fluids (type, volume)
Airway management interventions
Level of sedation/consciousness
Significant events

3.7 Airway Management¶

3.7.1 Preoperative Airway Assessment¶

Every patient receiving sedation or anesthesia must undergo a focused airway assessment:

Mallampati classification: Class I (full visibility of tonsils, uvula, soft palate) to Class IV (hard palate only). Class III/IV predicts difficult intubation.
Thyromental distance: <6 cm suggests potential difficulty
Mouth opening: <3 cm (inter-incisor distance) limits laryngoscopy access
Neck mobility: Limited extension (cervical disease, prior fusion) complicates intubation
Body habitus: BMI >35, short thick neck, OSA increase difficulty
Dentition: Prominent upper incisors, loose teeth, dental prostheses

flowchart TD
    A[Preoperative Airway Assessment] --> B{Predicted Difficult Airway?}
    B -->|No| C[Standard Sedation/GA Protocol]
    B -->|Yes| D[Difficult Airway Plan]
    D --> E[Awake Fiberoptic Intubation]
    D --> F[Supraglottic Airway Device]
    D --> G[Surgical Airway Prepared]
    C --> H[Standard Nasal Intubation or Sedation with Natural Airway]

3.7.2 Airway Management Techniques¶

Basic maneuvers:

Head tilt-chin lift: Extends the neck and lifts the mandible, opening the airway
Jaw thrust: Forward displacement of the mandible -- particularly useful when cervical spine injury is suspected (avoids neck extension)
Nasal airway (nasopharyngeal airway, NPA): Soft rubber tube inserted through the naris. Maintains airway patency during sedation. Well-tolerated in sedated patients. The most commonly used airway adjunct in OMS sedation.
Oral airway (oropharyngeal airway, OPA): Rigid device inserted into the mouth. Not tolerated in conscious/lightly sedated patients (gag reflex). Less useful in OMS due to oral surgical field.

Advanced airways:

Nasal intubation: The standard for OMS procedures requiring GA with controlled airway. Nasotracheal intubation provides oral access while securing the airway. Performed via direct laryngoscopy, video laryngoscopy (GlideScope, McGrath), or fiberoptic guidance.

Surgical Caution

Nasal intubation contraindications: Basal skull fracture (risk of intracranial placement), coagulopathy, nasal obstruction/polyps, and severe midface fractures. In these situations, oral intubation with a retromolar tube or submental intubation should be considered.

Supraglottic airway devices (SGAs): Laryngeal mask airway (LMA) and similar devices. Useful as a rescue airway and increasingly for elective OMS cases where nasal intubation is not needed (e.g., biopsy, I&D). Flexible LMAs allow sharing the airway with the surgical field.
Surgical airway (cricothyrotomy): The emergency "can't intubate, can't ventilate" (CICV) rescue. The cricothyroid membrane (between the thyroid and cricoid cartilages) is incised and a small (5.0-6.0 mm) tracheostomy or endotracheal tube is inserted. CPT 31605 (emergency tracheostomy). Every OMS office must have a surgical airway kit immediately available.

3.7.3 The Difficult Airway Algorithm¶

The ASA Difficult Airway Algorithm (2022 update) and the AAOMS adaptation should be posted in every operatory:

Assess the airway preoperatively
Plan for difficulty (have backup devices available)
If unable to intubate: attempt SGA (LMA)
If unable to ventilate with SGA: return to bag-mask ventilation
If "can't intubate, can't oxygenate" (CICO): surgical airway immediately

Critical Safety

The OMS surgeon must practice the CICO scenario regularly. Simulation training (mannequin-based or cadaveric) at least annually is recommended. The time from recognition of CICO to knife-on-skin for cricothyrotomy should be under 30 seconds. Delay in surgical airway is the leading cause of anesthesia-related death in the CICO scenario (Cook et al., NAP4 Report, Royal College of Anaesthetists, 2011).

3.8 Emergency Protocols¶

3.8.1 Office Emergency Drugs¶

The following medications should be immediately available in every OMS office performing sedation or GA:

Drug	Indication	Dose (Adult)
Epinephrine (1:1000)	Anaphylaxis, severe bronchospasm	0.3-0.5 mg IM (anterolateral thigh)
Epinephrine (1:10,000)	Cardiac arrest (ACLS)	1 mg IV q3-5 min
Atropine	Symptomatic bradycardia	0.5 mg IV q3-5 min (max 3 mg)
Flumazenil	Benzodiazepine reversal	0.2 mg IV q1 min (max 1 mg)
Naloxone	Opioid reversal	0.04-0.4 mg IV q2-3 min
Succinylcholine	Laryngospasm, CICO requiring paralysis for intubation	0.5-1 mg/kg IV; 4 mg/kg IM if no IV
Diphenhydramine	Allergic reaction (adjunct)	25-50 mg IV/IM
Hydrocortisone	Anaphylaxis (adjunct), adrenal crisis	100-200 mg IV
Dextrose 50%	Hypoglycemia	25-50 mL IV (12.5-25 g)
Nitroglycerin	Acute coronary syndrome	0.4 mg sublingual q5 min x 3
Albuterol	Bronchospasm	2.5 mg nebulized or 2 puffs MDI
20% Intralipid	LAST (local anesthetic systemic toxicity)	1.5 mL/kg bolus IV
Amiodarone	Ventricular fibrillation/pulseless VT (ACLS)	300 mg IV bolus
Aspirin	Acute coronary syndrome	325 mg PO (chewed)

3.8.2 Common Emergencies in OMS Sedation¶

Laryngospasm¶

Definition: Involuntary reflex closure of the vocal cords, preventing ventilation.

Triggers: Airway irritation (secretions, blood, surgical debris), light anesthesia plane, painful stimulus during light sedation.

Management:

Remove the stimulus (suction, stop surgery)
Apply continuous positive airway pressure (CPAP) with jaw thrust and 100% O2
If not resolving: deepening anesthesia with propofol 0.5 mg/kg IV
If persistent: succinylcholine 0.5-1 mg/kg IV (or 4 mg/kg IM if no IV access) -- provides rapid neuromuscular blockade to break the spasm
Prepare for intubation after succinylcholine administration

Bronchospasm¶

Triggers: Reactive airway disease (asthma), airway manipulation, allergic reaction, aspiration.

Management:

100% O2
Albuterol 2.5 mg nebulized (or MDI via circuit)
Deepening anesthesia (propofol, sevoflurane)
Epinephrine 0.01 mg IV (10 mcg) for severe bronchospasm
Hydrocortisone 100 mg IV (delayed effect)

Anaphylaxis¶

Triggers: Latex, antibiotics, NSAIDs, chlorhexidine, muscle relaxants.

Management (immediate):

Remove the offending agent
Epinephrine 0.3-0.5 mg IM (anterolateral thigh) -- THE definitive treatment. Repeat q5-15 min as needed
100% O2, airway management
IV fluid bolus (1-2 L NS)
Diphenhydramine 50 mg IV, ranitidine 50 mg IV
Hydrocortisone 200 mg IV
Prepare for intubation/surgical airway if airway edema progresses
Activate EMS if in office setting

Malignant Hyperthermia¶

A rare but life-threatening hypermetabolic crisis triggered by volatile anesthetic agents (sevoflurane, desflurane) and succinylcholine in genetically susceptible individuals (RYR1 mutation).

Signs: Rising ETCO2, tachycardia, muscle rigidity, hyperthermia (late sign), dark blood in surgical field.

Management:

Stop all triggering agents immediately
Hyperventilate with 100% O2 (non-rebreathing circuit)
Dantrolene 2.5 mg/kg IV (mix with sterile water), repeat q5 min until response (max 10 mg/kg)
Active cooling (ice packs to axillae, groin; cold IV fluids)
Treat hyperkalemia (calcium chloride, insulin/dextrose, bicarbonate)
Monitor urine output (>2 mL/kg/hr to prevent myoglobin nephropathy)
Transfer to ICU

Surgical Caution

While malignant hyperthermia is rare in OMS office practice (succinylcholine is the most common trigger in the OMS setting, as volatile agents are infrequently used), dantrolene must be available in any office that stocks succinylcholine. The AAOMS OAE inspection verifies dantrolene availability. Some OMS practices have elected to remove succinylcholine from their offices entirely, using rocuronium (with sugammadex for reversal) as an alternative for emergency neuromuscular blockade.

3.9 Pediatric Sedation¶

3.9.1 Unique Considerations¶

Pediatric patients present specific anesthesia challenges:

Airway: Relatively large tongue, anterior/cephalad larynx, narrow subglottic space (cricoid ring is the narrowest point in children <8 years)
Physiology: Higher metabolic rate, lower FRC (faster desaturation), higher vagal tone (bradycardia is the most common arrhythmia)
Pharmacology: Higher volume of distribution for water-soluble drugs; immature hepatic metabolism in neonates/infants
Psychology: Separation anxiety, inability to cooperate, need for premedication or parental presence during induction

3.9.2 Sedation Options for Pediatric OMS¶

Technique	Age Range	Indication	Notes
Oral midazolam (0.5 mg/kg PO, max 20 mg)	2-12 years	Anxiolysis for minor procedures or pre-sedation	Bitter taste; mix with acetaminophen elixir or clear juice
Intranasal midazolam (0.2-0.3 mg/kg)	1-6 years	Rapid anxiolysis when oral route refused	Stinging; use mucosal atomization device
Ketamine (1-2 mg/kg IV or 4-6 mg/kg IM)	Any age	Dissociative sedation for brief procedures	Co-administer glycopyrrolate (5 mcg/kg) and midazolam (0.05 mg/kg)
Propofol + fentanyl IV	>3 years (typically)	Deep sedation/GA for longer procedures	Standard OMS office protocol adapted for weight-based dosing
Sevoflurane mask induction	Any age	Inhalation induction when IV access is difficult	Requires OR or ASC with vaporizer; smooth induction; IV started after induction

3.9.3 PALS Considerations¶

Bradycardia algorithm: If HR <60 with poor perfusion despite oxygenation and ventilation: epinephrine 0.01 mg/kg IV (0.1 mL/kg of 1:10,000)
Weight-based dosing: Use Broselow tape or pre-calculated weight-based drug doses posted in operatory
NPO guidelines for children: Same as adults (2/4/6/8 rule): clear liquids 2 hr, breast milk 4 hr, formula/light meal 6 hr, full meal 8 hr

3.10 State Permit Requirements¶

OMS anesthesia practice is governed by state dental board regulations, which vary significantly:

Most states: Require a separate anesthesia permit for moderate sedation, deep sedation, and/or general anesthesia, beyond the dental license
Permit levels (typical state classification):
- Level 1: Local anesthesia and nitrous oxide only
- Level 2: Moderate (conscious) sedation
- Level 3: Deep sedation/general anesthesia
Inspection requirements: Most states require periodic (annual or biennial) office inspection by the state dental board or a board-approved entity (AAOMS OAE program satisfies this requirement in most states)
ACLS/BLS/PALS: Current certification is universally required
Team training: Some states require documented training and certification of all anesthesia assistants (e.g., DAANCE -- Dental Anesthesia Assistant National Certification Examination)
Morbidity/mortality reporting: Several states require reporting of anesthesia-related adverse events to the dental board

Clinical Pearl

The AAOMS Office Anesthesia Evaluation (OAE) program is accepted by most state dental boards as fulfilling office inspection requirements. The OAE evaluator (an OMS peer) inspects equipment, drugs, monitoring, emergency preparedness, staff training, and documentation. Participating in the OAE program also provides peer review feedback that is invaluable for quality improvement.

3.11 Risk Management and Quality Improvement¶

3.11.1 Simulation Training¶

The AAOMS recommends regular (at least annual) simulation-based training for OMS teams covering:

Airway emergencies (laryngospasm, CICO, difficult intubation)
Cardiovascular emergencies (cardiac arrest, anaphylaxis, acute coronary syndrome)
Respiratory emergencies (bronchospasm, aspiration, pneumothorax)
Malignant hyperthermia
Pediatric emergencies
Team communication and crisis resource management (CRM)

3.11.2 Closed Claims Analysis¶

The OMS anesthesia closed claims literature identifies the most common adverse events:

Respiratory depression/hypoxia (most common cause of morbidity/mortality)
Difficult airway/failed intubation
Drug errors (wrong drug, wrong dose, wrong route)
Inadequate monitoring (particularly failure to use capnography)
Aspiration

3.12 Summary¶

The OMS surgeon's ability to safely administer a full spectrum of anesthesia -- from local anesthesia through office-based general anesthesia -- is a defining competency of the specialty. This capability rests on rigorous training in pharmacology, airway management, physiologic monitoring, and emergency preparedness. Adherence to AAOMS monitoring standards, participation in the OAE program, and regular simulation training form the pillars of safe anesthesia practice in oral and maxillofacial surgery.

References¶

AAOMS. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare 6^th Edition). 2017.
AAOMS. Office Anesthesia Evaluation Manual. Updated 2023.
ASA. Practice guidelines for moderate procedural sedation and analgesia. Anesthesiology. 2018;128(3):72-104.
ASA. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022;136(1):31-81.
Becker DE, Reed KL. Essentials of local anesthetic pharmacology. Anesth Prog. 2006;53(3):98-108.
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