Over 92 million Americans are fearful of seeing a dentist. Thanks to sedation dentistry, more than 20 million of these patients have overcome their hesitancy and received safe, pain-free, oral health treatments without incident.
On each of five successive days, we will be publishing a new informative article to reinforce your sedation dentistry skills and review procedures designed to protect the health and safety of your patients. Your entire team will benefit from these five special articles.
Dr. Michael Silverman, a globally recognized lecturer, educator, author and patients’ rights advocate, is founder and national chairman of Sedation Safety Week. He is also co-founder and president of DOCS Education, the world’s leading educator of sedation dentists, which annually hosts Sedation Safety Week.
Check back here every day to find out what 2020's Sedation Safety Week has in store
How important is sedation dentistry? According to the “Guidelines for the Use of Sedation and General Anesthesia by Dentists” adopted by the American Dental Association (ADA) House of Delegates in October 2016, the “administration of local anesthesia, sedation, and general anesthesia is an integral part of dental practice.”
The 2016 ADA Guidelines tasked state dental boards with re-evaluating their sedation regulations, and some boards are now requiring IV Sedation permits to continue to provide even oral sedation. It’s already happened in several states—Louisiana, Rhode Island, Utah and soon, Virginia—and others, like Arizona and Washington, are reviewing their sedation permitting.
Despite this, in many areas, sedation dentistry services are in short supply, partly due to the need for more trained sedation dentists (geographic underservice), and partly because patients with economic and/or anxiety-based limitations cannot afford or avoid treatment (economic underservice).
When asked about sedation dentistry, a majority of dental patients indicate that they are interested in receiving sedation treatment. Hassan M. Yehia, et al. cite a number of studies in Journal of Dental Education.
63% of subjects in a study by Taani preferred local anesthesia to avoid pain, and 14% preferred general anesthesia. Chanpong et al.’s study found that 12.4% of patients were “definitely interested” in sedation or general anesthesia and 42.3% were interested dependent upon cost. These percentages were even higher when patients with high dental fear were surveyed. Considering that 35% of patients in a study by Wong and Lytle categorized root canal therapy as the most unpleasant treatment and named it in the high anxiety category, it is not surprising that Huh et al. found that over half of the patients who presented to a Graduate Endodontic Clinic for an endodontic consultation would have elected to receive intravenous (IV) sedation for their endodontic treatment if the option was available. This service is even more advantageous for certain groups of patients such as those with high dental fear and/or a history of a bad dental experience, patients with special medical considerations or mental and developmental conditions, and patients with reflex difficulties. Ultimately, IV-sedation might result in even more patients seeking and accepting dental and endodontic treatment. [Emphasis ours.]
While patient demand for sedation dentistry is high, in many areas, access to treatment is low, whether due to scarcity of providers, economic limitations or both; dental anxiety also presents a psychological barrier causing an estimate 10-20% of the US population to avoid care (Nelson, Travis M, and Zheng Xu). It is clear that sedation dentistry training (particularly IV sedation) is critically needed to qualify more sedation dentists to fill the gaps.
According to the Yehia study, “Should Endodontic Residents Be Educated About IV-Sedation? Endodontics Program Directors’ and Endodontists’ Perspectives”:
Most of the endodontists disagreed/disagreed strongly that they had received adequate training in IV-sedation in their postgraduate program (87%) and were not satisfied with their IV-sedation training (71%); half (51%) reported not feeling competent answering patients’ questions about IV-sedation. While most of the endodontists were dissatisfied with their IV-sedation related postgraduate education, most of the program directors did not offer IV-sedation education in their programs. A discussion of the need to educate future endodontists about IV-sedation is needed.
A 2017 report by Catherine H. Bersell, RDH, BASDH in The Journal of Dental Hygiene, “Access to Oral Health Care: A National Crisis and Call for Reform,” highlights the barriers to accessing dental care, including:
Low socioeconomic status; the shortage and maldistribution of dentists; a lack of professional training regarding current evidence-based oral health guidelines; deficient continuity of care due to inadequate interdisciplinary collaboration; low oral health literacy; and patient perceptions and misconceptions about preventive dental care…There are also internal barriers to oral health care related to low oral health literacy; fear and anxiety associated with dental care; and perceptions and misconceptions about preventive oral health care. [Emphasis ours.]
Fortunately, a number of dental practitioners and educators are actively involved in providing solutions.
In recognition of the shortage of care available to underserved and anxious patients, a number of dentists, practices and organizations around the country are providing free sedation care events. Here are just a few examples:
Nearly every month, the Happy Smiles Dentistry program sets aside three days to provide FREE consultation, x-ray services and dental treatment (cleaning, filling, extractions) to community members with financial need or anxiety issues. Dental treatment is supervised by the dentists of Dental Wellness of Lexington, and provided by licensed practitioners offering charitable services to our community.
The Happy Smiles philosophy is, “Not everyone can afford to have dentistry done, but everybody deserves a happy smile!”
According to Patient Care Coordinator, Carol Wilson, DMD, “Many people in our community don't have the financial means to seek dental treatment, or have avoided it due to anxiety. Happy Smiles is a great opportunity for us to share our time and resources and give back to the community.”
Founded by Dr. Vincent J. Monticciolo 17 years ago, Dentistry From The Heart (DFTH) is a worldwide nonprofit organization dedicated to providing free dental care to those in need. Since its creation, the dentistry profession has reached out and shown the world the giving spirit of the dental care industry. With over 300 events per year, DFTH has been able to help thousands of patients and give millions of dollars worth of free dentistry. Every year, thousands individual dentists, hygienists, volunteers, and hundreds of practices across the world donate their time and resources to host their own DFTH events, providing free extractions, fillings and cleanings.
Give Kids A Smile (GKAS) is a not-for-profit 501(c)3 organization working to eliminate the silent epidemic of dental disease for underserved children who cannot sleep, eat properly, pay attention in school or simply smile. GKAS brings caring dental professionals, volunteers and organizations together for the purpose of delivering free, quality dental services and oral health education to children. The organization’s commitment is to the underserved and their goal is to help improve kids’ smile. GKAS provides quality, full-service dentistry free of charge to children 12 months to 14 years old (8th grade max) with inadequate access to dental care due to the lack of insurance or financial hardship.
On the continuing education side, check out the Dr. Robert C. Fazio Memorial Grant, launched in the late doctor’s name to help dentists in underserved areas receive the sedation training they need.
Speaking of continuing education, it isn't a stretch to say it can save a life. Read how one dentist used her training to save a life when a serious auto accident happened outside her Burke, Virginia practice.
Bersell, Catherine H. “Access to oral health care: A national crisis and call to reform.” The Journal of Dental Hygiene 2017: Vol. 91 No. 1.
Chanpong B, Haas DA, Locker D. “Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population.” Anesth Prog 2005; 52 (1): 3–11.
Dionne RA, Gordon SM, McCullagh LM, Phero JC. “Assessing the need for anesthesia and sedation in the general population.” J Am Dent Assoc 1998; 129 (2): 167–73.
Huh YK, Montagnese TA, Harding J, et al. “Assessment of patients’ awareness and factors influencing patients’ demands for sedation in endodontics.” J Endod 2015; 41 (2): 182–9.
Montagnese TA. “Why intravenous moderate sedation should be taught in graduate endodontic programs.” J Dent Educ 2012; 76 (3): 288–90.
Nelson, Travis M, and Zheng Xu. “Pediatric dental sedation: challenges and opportunities.” Clinical, cosmetic and investigational dentistry vol. 7 97-106. 26 Aug. 2015, doi:10.2147/CCIDE.S64250.
Taani DSQ. “Dental fear among a young adult Saudian population.” Int Dent J 2001; 51 (2): 62–6.
Yehia, Hassan, M., et al. “Should Endodontic Residents Be Educated About IV-Sedation? Endodontics Program Directors’ and Endodontists’ Perspectives.” Journal of Dental Education Aug 2018, 82 (8) 828 838; DOI: 10.21815 JDE.018.077.
During Sedation Safety week, we thought it apropos to address the biggest safety concern in the news worldwide: the novel coronavirus, COVID-19. So we’re sharing a recent update from Dr. Leslie Fang, who is one of the nation’s top physicians and actively involved in sedation dentistry continuing education.
As of this writing, the situation of the coronavirus in the United States remains in a state of rapid flux. It is clear that there is community-transmission of the virus and death of affected patients in the United States, but it is also clear that aggressive steps at containment are in play, hoping to limit the scope of COVID-19.
Recommendations are added or updated based on new information that arises daily and you should be mindful of the situation in your local community and the continuing evolution of the disease globally.
COVID-19, the disease caused by SARS-CoV-2, is now known to be highly contagious with a rapid velocity of transmission. The disease appears to have a fatality rate that is lower than its predecessors, SARS-CoV-1 and MERS-CoV-2, and the majority of the fatality is in elderly patients and in patients with pre-existing underlying chronic diseases, such as cardiovascular disease, diabetes mellitus and chronic obstructive pulmonary disease. However, there are anecdotes of young and healthy patients succumbing to the disease, heightening the fear toward it.
In 80% of the cases, COVID-19—particularly in young, healthy patients—is mild and those affected would have symptoms similar to that of a cold or flu. In 15% of the cases, development of progressive respiratory symptoms may necessitate hospitalization. In 5% of the cases, the patients are critically ill and would require intensive care unit support. The overall fatality is estimated to be about 3%.
Editor’s note: Since the writing of this article, vaccines are currently being tested in the U.S. and China, with some amounts possibly becoming available soon. “According to our estimates, we are hopeful that in April some of the vaccines will enter clinical research or be of use in emergency situations,” Zheng Zhongwei, China’s director of the National Health Commission’s Science and Technology has said.
Clinical trials with antiviral agents such as Remdesivir, chloroquine, and others are in place and would hopefully help with development of effective therapeutic agents.
Obviously, if COVID-19 does not take hold in your community, you should be able to conduct business as usual, but I would still caution you to be vigilant because of the highly contagious nature of this disease and the rapid spread of the infection.
As of now, the best protection for the dental professional is a heightened sense of awareness, avoiding unnecessary contact with patients that may have coronavirus, use of appropriate personal protective equipment, and increased attention to personal hygiene.
We are aware of the risk to healthcare workers from the data coming out of Wuhan. Of the initial 44,672 cases, 3,019 (6.75%) were health workers and 7 have died as of February 11, 2012. With increasing awareness and the uniform adoption of personal protective equipment, the risk has decreased progressively in Hubei.
The dental professional is particularly at risk if one is working on an infected patient, because of the close contact with the patient and the risk of blood, saliva and droplet exposure.
The CDC Recommendations are designed for all health workers. Because of the unique situation the dental professional is in, I have made modifications to tailor the recommendations to the dental professional.
The most important difference between the medical and the dental professional in this situation is that a great deal of the dentistry can be deferred to a later time, whereas the medical professional is obligated to see the patients when they are sick.
The modifications to the recommendations have been made to minimize the likelihood of contact with an infected patient.
The CDC has recommended attention be paid to:
We have made modifications to reflect the circumstances unique to dentistry.
It is important to stress that even with all these precautions, an infected patient might still slip through. It is therefore all the more important to take every precaution one can to protect oneself.
The hope is to be able to optimize ventilation in the operatory. Ideally, air exchange of the operatory 6 times an hour during operating hours would minimize issues with undue exposure.
This may not be practical in your given set of circumstances, but the ventilation system should be optimized inasmuch as is possible.
Because the coronavirus can stay alive on surfaces for 24 hours+, it is important to keep all surfaces clean and sanitized. While this pertains to the waiting room, the bathroom and the front desk, it is particularly important to disinfect the operatory as frequently as is feasible.
Common cleaners such as 0.1% sodium hypochlorite, 0.5% hydrogen peroxide or 62-71% ethanol have all been shown to be effective.
Special attention should be paid to good hand hygiene:
Dental professionals are used to working with a mask, gown and gloves on. Because the coronavirus is an airborne virus, conventional surgical masks would not be adequate. Depending upon the potential exposure, the dental professional and the staff should consider:
Full contact and respiratory precautions should be in place including deployment of:
The recommendations outlined are obviously subject to change as the clinical scenario evolves. However, they are certainly reasonable cornerstones to help the dental professionals navigate these troubled times.
Good luck and take good care of yourself and your patients.
Dr. Leslie Shu-Tung Fang is the John R. Gallagher III and Katherine A. Gallagher Endowed Chair in Clinical Excellence at Massachusetts General Hospital and Harvard Medical School.
He is a world-renowned physician, educator, businessman and speaker. He received his PhD in Physiology and Biophysics from the University of Illinois and his Doctorate of Medicine from Harvard Medical School. He is board certified in both Nephrology and Internal Medicine and has been repeatedly honored as one of “America’s Top Doctors” and “The Best Doctors of Boston.”
The ADA Council on Scientific Affairs has created new antibiotic guidelines, in large part to join global efforts to prevent overuse of antibiotics, which can increase microbial resistance and reduce effectiveness of antibiotics. Since dentists are the third-highest prescribers of antibiotics in all outpatient settings in the United States, keeping up with these regulatory developments is a top priority.
The new guidelines were enacted as part of a larger effort which the Centers for Disease Control (CDC) launched in 2018, called the Antimicrobial Resistance (AMR) Challenge: “A yearlong effort to accelerate the fight against antimicrobial resistance across the globe,” according to the CDC. “The AMR Challenge is a way for governments, private companies, and non-governmental organizations worldwide to make formal commitments that further the progress against antimicrobial resistance.”
Dr. Peter B. Lockhart, Chair of the panel [convened by the ADA Council on Scientific Affairs] that developed the ADA guidelines, says that, “Dental treatment without antibiotics is often sufficient to manage a dental infection, but when it is not available and the patient has signs and symptoms such as fever or swollen lymph nodes, antibiotics may need to be prescribed.” But Dr. Lockhart adds that, “in most cases when adults have a toothache and access to dental treatment, antibiotics may actually do more harm than good."
The new ADA Guidelines focus on localized infection, with a little time on spreading infections. They were predicated on a multidisciplinary evaluation of risk benefit ratio of antibiotics and evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling.
According to the ADA’s November issue of The Journal of the American Dental Association, antibiotics are not needed to manage most dental pain and intraoral swelling associated with pulpal and periapical infections.
The October 25, 2019 ADA News, further clarifies:
The guideline, “Evidence-Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and Periapical-Related Dental Pain and Intraoral Swelling: A Report from the American Dental Association," advises against using antibiotics for most pulpal and periapical conditions and instead recommends only the use of dental treatment and, if needed, over-the-counter pain relievers such as acetaminophen or ibuprofen.
The article continues that, according to the guidelines, “Dentists should instead prioritize treatments such as pulpotomy, pulpectomy, nonsurgical root canal treatment or incision and drainage for symptomatic irreversible pulpitis, symptomatic apical periodontitis and localized acute apical abscess in adult patients with normal immune systems,” and that, “if a patient's condition progresses to showing signs or symptoms of systemic involvement, such as fever or malaise, then dentists should [then] prescribe antibiotics.”
Dr. Leslie Fang, MD, PhD, is a world-renowned physician, educator, businessman and speaker who trains and advises thousands of sedation dentists nationwide. In order to clarify and simplify the new ADA guidelines, he has developed a new lecture to help dental professionals understand and put them into practice, including a walk-through of several case studies demonstrating which antibiotic(s) to use in various scenarios. His lecture answers other important questions as well, such as:
This lecture, “Master the New ADA Antibiotic Guidelines,” is part of Dr. Fang’s immensely popular Ultimate Cheat Sheets The Practical Guide for Dentists (2020 Edition).
In addition to the lecture, Dr. Fang has created a 2-page Cheat Sheet which covers the ADA’s guidelines and how to how to comply when prescribing antibiotics going forward, as well as adding this information to an app for the Ultimate Cheat Sheets. This three-pronged approach ensures easy understanding and access to sedation dentists everywhere.
Some friendships last a lifetime, then leave an enduring legacy in their wake. Such was the bond between Robert C. Fazio, DMD and Dr. Leslie Fang, whose close friendship began in Harvard Medical School, decades ago.
Dr. Fazio, a former faculty member with DOCS Education, was an outstanding clinician, educator, author, and public speaker. Dr. Fazio regularly lectured on topics including: Oral Sedation Dentistry; Antibiotics in Dentistry; Periodontitis & Peri-Implantitis; and Medicine, Dentistry and Drugs.
Attending one of his courses was to witness an instructor who was at once a master of pedagogy and an eloquent presenter who charmed professional audiences around the world with his genuine warmth and dedication. Sadly, Dr. Fazio was taken from us on April 29th of 2018, at the age of 68.
“It is difficult to envision that my lifelong friend and collaborator, Bob Fazio, has had an early and untimely death,” wrote Dr. Fang. “This is clearly a great loss to friends and family, to dental education, and to the dental profession; it is also an immense personal loss to me.” You can read his personal eulogy to his friend here.
Dr. Fazio was a warm, engaging, generous man who truly cared about others. He had a passion for imparting his considerable knowledge to aspiring dental professionals. That profound legacy lives on in the Robert C. Fazio Memorial Grant, which will provide ten full-tuition grants for an oral sedation class to eligible dentists who provide free and/or reduced-cost care to underserved populations.
The purpose of this annual Grant is to give humanitarian leaders the opportunity to safely treat their patients with Sedation Dentistry while helping shoulder the financial contribution required to serve society’s most disadvantaged.
“Bob was acutely aware of the way that he was improving patient welfare in the day-to-day practice of the dental professional,” according to Dr. Fang.
We are delighted to honor the late Dr. Fazio and continue his mission to positively impact the lives of others—from individuals to whole communities—through sedation dentistry.
We know Robert would have been extremely pleased to know such a grant would one day continue his life’s work and his legacy.
For more information on the Robert C. Fazio grant, or to apply, visit SedationCare.com
We conclude our 12th Annual Sedation Safety Week on a high note by sharing our 2020 Safe Sedation Dentist of the Year. Selecting just one dentist among so many notable and dedicated professionals is no small order. However, a Virginia dentist rose among the ranks, in part due to her extraordinary story of putting her training into action to save the life of an automobile crash victim outside her office (read the full story here).
Dr. Pamela Marzban is a sedation dentist in Burke, Virginia providing a wide range of family and cosmetic dentistry services to patients throughout several Northern Virginia communities. She is a firm believer in the adage, “Every smile has a story,” and she strives to change the lives of her patients by delivering a beautiful smile that restores confidence and maintains optimal levels of oral health for years to come. In order to provide her patients with the best possible treatments, she believes it’s important to continue studying with the finest dentists in the country throughout her career.
“Right now is a perfect example of understanding that fear is not logical,” Dr. Marzban told us in a March 19 interview. “Sedation dentistry has made a huge impact because a lot of patients come in terrified, but also embarrassed about their fear; often they have a tangible reason for their anxiety, like past trauma.”
Sedation dentistry opens up a whole range of possibilities for helping people with understanding and compassion.
“Sedation dentistry opens up a whole range of possibilities for helping anxious people with understanding and compassion,” she added. “With the various options, including oral sedation and IV sedation, we can help people take that step and come to understand there is a better way.”
Dr. Marzban has been practicing dentistry for over 20 years, including about 14 as a sedation dentist. “Sedation dentistry been a big help to our practice,” she says. “It has been so effective in producing a great experience that we have even seen formerly anxious patients return and decide they don’t need the sedation anymore to feel at ease!”
Dr. Marzban believes her success comes with a responsibility to the profession. To help other dentists achieve the level of success she has enjoyed, she created a speaking and consulting service that helps dentists unlock their potential to realize success.
Among other topics, she teaches and speaks about sedation for cosmetic work, which often entails 3-5 hours in the chair—an uncomfortable experience even without underlying anxiety issues. “Sedation allows our patients to be more comfortable during long treatments, and helps mitigate stress that could lead to post-operative discomfort.”
After graduating with honors from the Medical College of Virginia, she pursued a rigorous post-graduate training program at the Las Vegas Institute for Advanced Dental Studies (LVI), the leading school for cosmetic and neuromuscular dentistry in the nation. Upon completion of this program, she graduated as an LVI Fellow, only awarded to a select few dentists who have demonstrated mastery of the entire LVI program that includes a minimum 278 hours of dental training in advanced aesthetics and neuromuscular science.
In addition, Dr. Marzban has earned several other prestigious accolades as part of her continued post-graduate training:
Dr. Marzban’s work has been published, awarded and internationally recognized and she is known as one of the top cosmetic dentists in Northern Virginia by patients and peers alike. She has earned the following honors:
Over the years, Dr. Marzban has had the opportunity to serve the dental profession in many capacities. She is very active in the dental community as a teacher and a volunteer:
Dr. Marzban and her staff have taken an ACLS Recertification course offered by DOCS Education five times. Many of her team members have been working with her for over five years, and their passion for sedation dentistry matches her own.
Her experience saving a crash victim’s life was a watershed moment for Dr. Marzban and her team.
“I speak on the business side of dentistry about hiring the right people, training them and reducing turnover,” she says. “When we were called on to help the victim of an accident outside our office, my team knew exactly what to do, thanks to their training. That’s how I explain to people the relevancy of our training and the importance of our profession.”