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From 1 January 2002, a healthy child in the UK who requires the simplest of dental extractions under general anaesthesia will have to be treated in a hospital with ready access to intensive care. However, an adult with significant concomitant disease will still be able to undergo total hip replacement, laparotomy or any number of other major surgical procedures in a medical facility without such resources. That this anomalous situation has arisen at all provides an interesting example of how even individuals trained in scientific method may be incapable of separating emotion and evidence. Out-patient or ‘chair dental’ anaesthesia has always had the capacity to polarize opinion amongst anaesthetists, between those who believe it to be barbarous and lethal, and others – mainly its practitioners – who believe it to be a high art form. Yet the evolution of anaesthesia itself does have its humble origins in dentistry, with the first authenticated general anaesthetic in England taking place in London in 1846, with the use of ether for dental extraction. In the UK, if not elsewhere, a longstanding cultural acceptance has characterized this form of anaesthesia, particularly in areas of socio-economic deprivation with high rates of dental caries, so that even 150 yr later, inhalational anaesthesia for simple exodontia still takes place. The reasons are not hard to find: the pain of toothache is severe, universal, and cured easily by extraction. That was true in 1846 and it is true today, which is why during any year in the 1950s there were upwards of 3.5 million dental anaesthetics given in the UK. Many combining influences have ensured that numbers have declined steadily from that peak, but even during the 1990s, there were still over 300 000 cases performed annually. One such influence was the perception that chair dental anaesthesia is uniquely dangerous, and indeed it was a cluster of fatalities in children in the late 1990s in the UK that precipitated a dramatic change in the regulations. What is the evidence on which this perception is based? In respect of all hospital anaesthetics, the early landmark report of Lunn and Mushin in 1982 [1] produced pessimistic figures of one death per 10 000 anaesthetics. However, the first Report of the Confidential Enquiry into Perioperative Deaths (CEPOD) by Buck and colleagues in 1987 [2] quoted mortality rates solely associated with anaesthesia at a more realistic 1 : 185 000 administrations. Coplans and Curson examined deaths associated specifically with dental anaesthesia over 20 yr from 1970 to 1989 in studies that identified 54 deaths in the first decade and 18 in the second [3,4]. There were 119 fatalities overall, 60% of which occurred outside hospital and 29% of which involved children. In the first decade, denominator data allowed these authors to establish a mortality rate of 1 : 230 000. Total general anaesthetic numbers were not available for the second decade, but best estimates suggest that the mortality rate was equally low. Meanwhile, figures issued by the UK Department of Health (DoH) show that over the past 30 yr there have been 147 deaths with a child-to-adult ratio of 1 : 2 [5]. Despite the alleged perils of chair dental anaesthesia, therefore, it would seem that these statistics confirm that there is no safer form of general anaesthesia. Other investigators had also looked at dental anaesthetic deaths, with Tomlin in 1974 [6] quoting an even lower mortality rate of 1 : 274 000, in spite of anaesthetic practices such as this: ‘Anaesthesia was induced with 100% N2O which was gradually reduced to 90% and then to 80% while unknown concentrations of halothane and trichloroethylene were administered.’ This adult suffered a fatal cardiac arrest, which is perhaps no great surprise, yet it is certainly possible that such techniques were widespread. What may have protected most patients from disaster is that out-patient dental anaesthesia typically has always been very swift. In one series of 12 000 cases, the mean time from the start of induction until eye opening on command was 251 s in children and 307 s in adults (S. R. W. Bricker, personal data), which confirms the transient nature of this form of anaesthesia. It is likely that this brevity has Correspondence to: Simon Bricker, Department of Anaesthesiology, The Countess of Chester Hospital, Chester, CH2 1UL, UK. E-mail: bricker@ globalnet.co.uk; Tel: 1 44 (0)1244 365461; Fax: 1 44 (0)1244 365435

Oasis or mirage? The safety of outpatient dental anaesthesia in hospital