Sedation Safety: Where We’ve Come and Where We Still Must Go
Welcome to our 10th Annual Sedation Safety Week – five days earmarked to remind oral health professionals and members of the public that Priority #1 for all dentists is the safety of each and every one of our patients.
No patient, ever, should have to accept less than 100% of our best, fully qualified efforts to safely protect and restore their oral health.
“All dentists who provide their patients with this immensely popular form of pain-free, anxiety-free dental treatment are invited and encouraged to use this annual week to review and freshen their safety training,” says Dr. Michael Silverman, founder and national chairman of Sedation Safety Week (SSW)
Oral sedation dentistry has made great strides over the past decade in battling oral health diseases, which leave many people in perpetual pain, shy about smiling, and often unable to even chew and enjoy their food.
Science has also linked poor oral health to increased risk for a wide variety of serious illnesses, including coronary disease, cancer, diabetes, stroke, osteoporosis, and rheumatoid arthritis.
The theme of this 10th Anniversary Sedation Safety Week is “Awareness,” because even after a decade of promoting safe sedation dentistry – and all of its health and lifestyle benefits – tens of millions of Americans remain unaware of the ready availability of sedation dentistry
We also selected “Awareness” as our theme, because many dentists themselves – especially those who have graduated dental school only recently – do not realize that the patients they see represent only a fraction of the patients who need to be seen, but are too afraid to seek out dental care.
General dentists who fail to obtain the special training necessary to safely administer oral sedation – typically taught in a single three-day weekend course – are missing the opportunity to serve a much wider population of patients in need.
A Wake-Up Call
We also hope to use this year’s Sedation Safety Week to raise awareness of the barriers to care – especially financial – that contribute to the reluctance of so many Americans to see a dentist on a regular basis. A leading culprit is unnecessary new regulations that are raising the cost of quality sedation dental care and also reducing the number of general dentists who are licensed to provide it.
Safety is never something we can take for granted. It requires dentists and their team members to follow a daily routine of taking all the steps, and following all the best protocols, that dentistry has to offer. That is even truer of sedation dentistry – which has helped tens of millions of patients without incident – but which nevertheless always must be administered with the utmost safety in mind.
Here is a surprising fact. Since we launched Sedation Safety Week in March 2009, we have not identified a single instance nationwide where a patient – adult or child – was harmed by a qualified sedation dentist, when the patient was screened, sedated, and monitored following the highest safety protocols, and the guidelines set forth by the American Dental Association.
Yet, a very small number of dentists don’t pay close enough attention to safety, and sometimes their patients do suffer because of it. Some patients, tragically, even die.
Sedation Safety Week is, and has been since Day One, a wake-up call to all dentists to be ever-vigilant of the need to protect our patients, and to the many state-of-the-art tools and continuing-education training opportunities available to help guarantee patient safety.
(Be sure to review our Sedation Safety Week 7-Step Sedation Safety Checklist.)
An Expanding Universe of Patients
The first lesson every sedation dentist must learn and absorb is that not every patient is well-suited to in-office oral sedation. Proper patient screening and selection is paramount.
Fortunately, the universe of patients who can safely and successfully be treated by general dentists using oral sedation has grown over the past decade.
Patients with a variety of complex medical conditions, who were routinely referred out when we began Sedation Safety Week in 2009, increasingly are being safely, comfortably, and effectively treated in-office by general dentists who’ve completed advanced oral sedation courses.
Due to complex medical or psychological conditions, there remain some patients who should never be treated by general dentists, and must instead be treated in a hospital setting, or by dentists specifically trained and licensed to administer IV sedation.
A broader discussion of the expanding role that oral sedation is playing in oral health will be the Tuesday focus of Sedation Safety Week.
On Wednesday, we’ll open a window on a unique dental safety resource, the EliteDOCS forum, that regularly provides 24/7 peer-to-peer and faculty responses to some of the knottiest and esoteric questions that dentists face when it comes to sedation and safety.
Normally, the EliteDOCS forum is restricted to members in good standing of DOCS Education, a community of professionals who are dedicated to providing the safest, state-of-the-art, dental services. (DOCS Education is the host and founding sponsor of Sedation Safety Week.)
But for this year’s Sedation Safety Week, any dentist – whether a member of DOCS Education or not – will be able to email sedation safety-related questions to be shared with EliteDOCS forum members, including the continuing dental education faculty who regularly respond to requests for advice and support.
Opening the Forum Archives
In addition, on Wednesday, we’ll dig into our EliteDOCS archives to revisit some of the more interesting questions we've received over the years – on pharmacology, protocols, equipment, and drugs – and share the answers that were posted.
For Thursday of Sedation Safety Week, the topic will be the regulatory landscape and what dentists need to know about the evolving guidelines and regulations that govern the use of oral sedation.
Even dentists who have been safely providing oral sedation to their patients for years, without incident, remain at risk of losing their sedation privileges due to overzealous regulators and – truth be told – a small but powerful group of dentists acting out of self-interest, not public interest.
Where does your state stand in the regulatory merry-go-round and what can you do to help ensure the widespread availability of safe sedation dentistry? We’ll have some answers for you on Thursday.
Previous Sedation Safety Dentists of the Year Honorees
On Friday, as we do each year, we’ll announce the Safe Sedation Dentist of the Year honoree. These dedicated men and women, selected by a jury of their peers, represent the finest examples of oral health professionals who elevate our profession and its commitment to safe, effective, comfortable, sedation dentistry.
Ten years ago, Dr. Silverman, chairman and founder of Sedation Safety Week, recognized the need to remind dentists each and every spring of the importance of reviewing their safety protocols and equipment, just as each year it has become customary for people around the country to check their smoke detectors as daylight saving time arrives.
A decade later, Dr. Silverman reflects:
“We are proud of what we’ve accomplished and of the lives that Sedation Safety Week assuredly has saved. At the same time, as we look ahead, we see that tens of millions of patients, and thousands upon thousands of general dentists, have yet to recognize the many benefits of safe oral sedation dentistry. We enter our second decade more committed than ever to the goal of making every week in America, a safe sedation week.”
Inclusion: Safely Serving Greater Numbers of Sedation Patients
(EDITOR’S NOTE: The theme of this year’s 10th Annual Sedation Safety Week is “Awareness.” Many dental patients remain unaware of the safe, in-office sedation options available to them, and as a result, let go of their oral health when faced with a major illness. Both patients and physicians can benefit from speaking with a qualified advanced oral sedation dentist about the opportunity for medically-complex individuals to receive in-office oral sedation.)
The fear and anxiety that most patients experience when going to the dentist are uncomfortable, sometimes even paralyzing, but the emotions aren’t, in and of themselves, dangerous.
That's not true of patients who are already medically compromised, battling life-threating illnesses such as coronary disease and cancer, where the stress of a dental visit alone poses an additional health risk.
Other fearful patients, those with disorders of the nervous system or severe psychological conditions, not only may pose a threat to themselves during dental visits, but on occasion, they also become disruptive and threaten the well-being of the dental team trying to care for them.
Historically, there were few options for patients such as these other than to be seen in a hospital setting where they would be treated under general anesthesia. Such procedures – especially for more-or-less routine dental care – were very expensive for the patient, difficult to schedule, and required patients to accept the ever-present risks associated with general anesthesia for non-life-threatening treatments, including fillings and cleanings.
Advanced oral sedation dentistry has changed the dynamics of caring for medically-complex patients, allowing large numbers of those suffering from chronic medical and psychological problems to be seen and safely treated in-office by a qualified general dentist.
Advanced Oral Sedation Pioneers
The result: millions of men and women with an ASA III+ classification can now join with the tens of millions of other fearful and anxious adults who’ve benefited from seeing a dentist trained to provide oral sedation.
Drs. Leslie Shu-Tung Fang and Anthony S. Feck
Although many dedicated dentists deserve a share of the credit for advancing the state of oral sedation training to include patients classified by the American Society of Anesthesiologists as ASA III+, two educators, in particular, have been instrumental in establishing the necessary screening and treatment protocols.
Anthony S. Feck, DMD, and Leslie Shu-Tung Fang, MD, PhD, have pioneered the advanced clinical training of general dentists in the pharmacology, physiology, psychology, and clinical techniques necessary to incorporate the complete care of medically complex patients into mainstream dentistry.
Dr. Feck is an internationally renowned clinician, author, and educator, who co-founded DOCS Education in 1999, and serves as its Dean of Faculty. Dr. Fang, who maintains an active international practice in Internal Medicine and Nephrology, is the John R. Gallagher III and Katherine A. Gallagher Endowed Chair in Clinical Excellence at Massachusetts General Hospital and Harvard Medical School.
Along with other distinguished faculty members, Drs. Feck and Fang lead the two-day Master Series: Advanced Sedation didactic and hands-on course on behalf of DOCS Education. Hundreds of general dentists, along with members of their teams, have completed advanced sedation training and in turn, have successfully and safely treated thousands of patients with serious medical and psychological problems.
Prerequisites and Careful Screening
Before taking Advanced Sedation, DOCS Education requires dentists to hold a current sedation permit (if their state requires one) and to have completed a minimum of 50 standard sedation cases.
Upon completion of the weekend course, dentists can care for most patients with congestive heart failure; pacemakers; cardiac stents; type 1 diabetes mellitus; complicated type 2 diabetes mellitus; hepatitis B and C; various bleeding disorders, and asthma, among other illnesses. (Patients, of course, must be screened and evaluated on a case-by-case basis to ensure their suitability for in-office oral sedation treatment.)
Drs. Feck and Fang have also played a leading role in training general dentists and specialists in the use of IV Sedation, which allows them to treat even more complex cases — both medical and psychological — without requiring the patients to be seen in a hospital setting.
According to Dr. Fang, these include patients with COPD; patients with automated implantable cardioverter defibrillators; and patients with Class III congestive heart failure.
To obtain an IV permit requires a much larger commitment of training time; typically, 60 hours of classroom education coupled with at least 20 live-patient experiences.
Yet the demand by general dentists to obtain their IV permits is growing, in part, so that the dentists may include even more patients among those they are qualified to treat, and in part because regulators in some states now require an IV permit even for general dentists who only use moderate enteral sedation (and in some instances, any sedative other than nitrous oxide).
(Be sure to read more on this topic on Thursday, March 22, 2018, when the Sedation Safety Week essay of the day will be “The Shaky Regulatory Landscape and What It Means for Dentists.”)
Despite all the advances, some patients are still too medically fragile to be treated in-office using oral or IV sedatives. These include patients with complicated arrhythmias, patients with advanced COPD; patients with severe congestive heart failure, and patients with hepatic decompensation, according to Dr. Fang.
Spread the Word
Because the advances in oral sedation dentistry have come gradually, and sometimes in subtle increments, it’s not surprising that many patients – and even dentists – remain unaware of the great strides that the profession has made over time in expanding the circle of adults who are now able to avail themselves of safe, in-office, oral sedation.
We’ve known for almost 20 years that healthy patients who fear the dentist have the option of being seen by a qualified sedation dentist, without fear, pain, or discomfort. Word is still spreading that many patients with chronic medical or psychological problems can also receive similar, compassionate, safe dental care.
Wednesday: We dig into the EliteDOCS archives to revisit some of the more interesting questions raised and answered over the years – on pharmacology, protocols, equipment, and drugs – and share the answers that were posted.
Plus, general dentists and their team members are invited to email us your sedation safety-related questions to be shared with EliteDOCS forum members, including the continuing dental education faculty who regularly respond to requests for advice and support.
• To register for an upcoming Master Series: Advanced Sedation course led by Drs. Feck and Fang, or to learn more, click here.
• To register to obtain your IV Sedation Certification, learn more, or join a wait list, click here.
• Incisor Profile: Sedation dentist David Kurtzman caters to special-needs patients, including those with developmental disabilities, physical handicaps, significant mental and medical problems, and severe dental phobias.
Open Forum: Answering Your Questions, and the Best of EliteDOCS Over the Decade
(EDITOR’S NOTE: The theme of this year’s 10th Annual Sedation Safety Week is “Awareness.” Many dentists remain unaware of the availability of EliteDOCS, a unique 24/7 peer-to-peer forum where there are always friendly and knowledgeable fellow dentists – and expert faculty – happy to respond to requests for advice and support.
To enjoy a free, no-obligation two-month trial membership in EliteDOCS, see the invitation at the bottom of today’s article.)
If there’s something strange, in your neighborhood (dental practice), who you gonna call? EliteDOCS!
Over the years, thousands of the nation’s most well-respected sedation dentists have shown that they ain’t afraid of the unknown. When they have a question about how to treat a patient who presents with an unusual medical or dental history, they turn to EliteDOCS for friendly, timely, and knowledgeable advice and support.
The complete EliteDOCS archives contain thousands of questions and responses divided among a dozen categories, including Pharmacology, Protocols and Case Studies, Patient Management, Regulations and Dental Board Meetings, Medical Emergencies, and even – for those times when dentists could use a good laugh after a long day – a Jokes category.
The EliteDOCS forum is restricted to members in good standing of DOCS Education, a community of professionals who are dedicated to providing the safest, state-of-the-art, dental services. (DOCS Education is the host and founding sponsor of Sedation Safety Week.) But for this year’s Sedation Safety Week, any dentist – whether a member of DOCS Education or not – can email sedation safety-related questions to be shared with EliteDOCS forum members.
To ask a sedation-related question, send your email to EliteDOCS@docsedu.com. Forum administrators and faculty will make every effort to respond in a timely fashion to your queries. Nonetheless, please allow up to 10 business days for a response.
(Note, the answers you’ll receive – like all the information contained on the EliteDOCS forum – should never be considered a proper replacement for necessary training and/or education regarding adult and pediatric oral conscious sedation. EliteDOCS is an educational and informational resource only. See the site and posts for additional disclaimers.)
What follows is a sampling of some of the posts and responses featured on EliteDOCS over the past decade, as selected by the forum’s administrators. See if you knew the answers or agree with them.
You are invited to accept a free two-month, no-obligation, full membership in DOCS Education, the respected community of professionals serving at the forefront of dentistry.
DOCS Education members enjoy exclusive year-round access to EliteDOCS, just one of the many privileges of membership.
Facing a difficult case? Not sure what the best dosing is for a patient with unusual drug allergies? Or do you have an inspirational success story to share?
Join thousands of fellow members on EliteDOCS, a secure, safe forum designed for dedicated dentists just like you.
Thursday: Even dentists who have been safely providing oral sedation to their patients for years, without incident, are at risk of losing their sedation privileges due to overzealous regulators and a small group of influential dentists who act out of self-interest, not the public interest.
Where does your state stand in the regulatory merry-go-round and what can you do to help ensure the widespread availability of safe sedation dentistry? We’ll have some answers for you tomorrow.
FOR MORE INFORMATION:
• To start your free, two-month membership in DOCS Education and gain 24/7 unrestricted access to the EliteDOCS forum, contact Lindsay Olsen, membership director, at 206-812-7712, or email her at: email@example.com.
• To learn more about the many other privileges afforded to DOCS Education members, or to become a permanent member, click here.
EliteDOCS Case Studies
Question: I have a new patient who sought out my care after her mom had a very positive experience with the sedation protocol. This patient is, however, much more complex.
She presents with a mental health history of anxiety, depression, mood dysregulation, and agoraphobia. This is a 23-year-old white female with a BMI of 23. She is 5'3" and 130lbs. She is otherwise healthy aside from her mental health issues. She has no known drug allergies. Her only other previous surgery was cholecystectomy. She is a non-smoker.
We had a very good conversation in the office as I was the first dentist in a while to not automatically dismiss her. I am concerned with the amount of regular medication she takes, and if an enteral conscious sedation protocol is even appropriate for her. Her current meds are:
• Ativan® 0.5 mg bid
• Effexor® XR 150 mg qd
• Gabapentin 300 mg bid
• Seroquel® 100 mg bedtime
• Wellbutrin® XL 300 mg qd
Although I have been providing enteral conscious sedation for a long time, this case concerns me with the multiple benzodiazepines and CNS depressants. Would it be worth a try with just nitrous oxide?
Reply: Patients on multiple CNS depressants present some of the greatest challenges to the success of oral conscious sedation. As a result of tolerance to CNS depressants, these patients hyporespond, taking longer and requiring higher doses to sedate.
Occasionally, these patients reach TOP Dose before they become comfortable, requiring another method of sedation, such as by IV.
You may choose to attempt sedation on this patient after a frank discussion regarding the possibility she may need another method of sedation. Reassure her that if she isn’t comfortable, the appointment will not proceed.
Question: I have a 25-year-old patient of record. He has no significant medical history and is on no medications. His most recent physical was within the last 12 months. He called and asked if I could prescribe him “something to relax him and take the edge off.” He lives about 30 minutes from the airport and will be driving himself. The flight takes about two hours.
My thought is that I can prescribe him Zaleplon since it is short-acting and the sedative effects should have worn off by the time he lands if he takes it about 45 minutes to an hour before his flight.
I would love this group’s feedback on what medication would accomplish his goal of “taking the edge off” and also would be out of his system quickly, with no after effects.
Reply #1: I would not do this. You have no dental reason why you are prescribing this medication. I understand wanting to help, and your familiarity with this patient, but where is the line? Protect your license and yourself by not doing anything.
Faculty Member Reply: I strongly agree. It is not within the scope of dental practice to prescribe anything for anyone who does not have a documented dental diagnosis. You would be risking your career and dental license if there would be any adverse outcome, no matter how insignificant. In short, this is illegal. Don’t do it.
Question: My patient is a 44-year-old male with a history of head trauma and a deviated septum. As a result of the head trauma, he suffers severe daily migraines and is taking the following medications:
• Gabapentin 400mg - 2/day
• Butterbur 75mg - 2/day
• Motrin - 1600 to 4800 / day as needed
\• Immitrex® injection as needed
As a result of his sinus problems, which is caused by a deviated septum, he suffers from sleep apnea and is using a CPAP machine. This patient is normal in weight with an athletic build, and his baseline vitals from the pulse oximeter are: BP 122/65, SPO2 hovering around 96%.
This patient is treatment planned for four fillings, and he has elected to pursue this treatment under conscious sedation due to fear. Gabapentin is a C interaction with diazepam and triazolam, and is already a CNS depressant.
Reply: The gabapentin will aid in the sedative effect of the benzodiazepines, but that is not your biggest concern. The sleep apnea and his preoperative O2 saturation is a significant concern.
You have stated his baseline saturation is 96%. When sedated and reclined, his oxygen saturation will drop significantly since he suffers from sleep apnea. Your goal would be to keep his sedation level very light to prevent any unsafe O2 levels. This might mean limiting him to a single dose protocol with nitrous.
Original Posting: - https://www.docseducation.com/blog/sedation-athlete-repeated-head-trauma
Question: I have a new patient, and below is my thought process. Please critique, and let me know if you would advise something different.
Please note that this patient has not been seen yet for a proper workup: I only saw the patient for a “free consultation.” As such, baseline vitals are not available.
She is a 67-year-old female of average weight who meets the “Rule of 4” with regards to medications: she is on four. She has general dental anxiety, and requires a difficult extraction of tooth #3. The appointment is expected to be two hours or less.
• Buspar (buspirone) 10mg, bid for anxiety
• Used mainly to treat GAD (Generalized Anxiety Disorder)
• Central acting
• Pharmacology is NOT related to benzodiazepines (not a GABA receptor agonist)
• Metabolized mainly by liver, slightly by kidney
• Remeron (mirtazapine) 15 mg, qd for anxiety and sleep
• Mechanism is unknown, but believed to enhance central noradrenergic and serotonergic activity
• Potent antagonist of H1 receptors, which may explain sedative effects
• Benicar 40mg, qd for hypertension
Ursodiol 500mg bid for autoimmune biliary cirrhosis of the liver (non-alcohol related)
Preliminary Protocol Evaluation:
• Night-before Diazepam: NO! SKIP!!
• Insomnia drug at bedtime (Remeron). Refer to page Vâ€“4 of DOCS NYU manual.
• Same page of manual:
• ‘If 2 CNS depressants / day, use 2.5mg diazepam’
• I still say skip the diazepam, due to insomnia drug above.
• Triazolam 0.125mg:
• 1 pill at 7am.
• Arrive at office at 8am. Assess patient. Take vitals. If needed, provide second pill. Let patient sit. Assess. If ready, administer nitrous, administer local anesthetic.
Faculty Reply: I appreciate the thought and homework that went into your inquiry. Well done! My comments:
The ‘Rule of 4’ says that if four or more medications are used to treat the same medical condition, that medical condition is more fragile (more challenging to control, and therefore more likely to become out of control when challenged – e.g. stress).
Buspar’s pharmacology is related to that of the benzodiazepines in that they are both CNS depressants. Therefore, the potential exists for both potentiating CNS depression or cross-tolerance. It’s more accurate to say, Buspar’s pharmacodynamics are not the same as those of the benzodiazepines.
Since the Remeron is being used as a sleep aid prior to sleep, I would not use diazepam the night before. Even if the patient was not taking the Remeron, I would not use diazepam the night before due to the patient’s age.
I agree with your loading dose of triazolam.
Of course you will need a comprehensive evaluation of the patient prior to final consideration of the candidate for sedation. Again, well planned!
Question: I have a 62-year-old male diabetic patient who is coming to the office for the pre-sedation workup.
He is taking the following medications
• Amlodipine benzilate 20mg /day
• Atorvastatin 10mg/day
• Bisoprolol fumarate 1.25 mg 2 tabs/day
• Omeprazole 40mg/day
• Bupropion HCL 150mg
• Metformin 500mg
• Claritin 2 / day
I intend to use incremental protocol 2, with the time of treatment being three hours. The needed treatment is four quadrants of scaling and root planing, two extractions (tooth #31 and #15) with bone graft, and a crown for #19.
Because of his schedule, he cannot arrive at 7:00 am; so he made the treatment appointment for 10:00 am.
Question #1: Can he still take diazepam the night before?
Question #2: Can he have a light breakfast at 7:00 am?
Question #3: I am planning to use 4 carpules of Lidocaine 2% with 1:100,000 epinephrine. In the extraction side, I will probably use 4 carpules of septocaine 4% locally.
Please give me your thoughts or any suggestions!
Faculty Reply: Yes, diazepam the night before is ok. He should take a light non-fatty breakfast since he is diabetic.
Sounds like you have thought through this case and planned it out well!
Original Posting: - https://www.docseducation.com/blog/unusual-scheduling-diabetic-patient
Question: I have a 41-year-old, 200-lb female patient who is being sedated by a medical anesthesiologist at my periodontist’s office. She will have all of her maxillary teeth extracted and eight implants placed
I will be there to take impressions, and she will return to my office two days later to have fixed temporary teeth screwed into the implants. I would like to be able to give her local anesthesia, but she is extremely fearful of the dentist.
I am not looking to do conscious sedation, but just want to give her something to take the edge off. I plan to give her nitrous oxide prior to the local anesthesia. Her medical history is extensive.
She has a history of asthma, sarcoidosis, high blood pressure, and psychiatric treatment. She takes Keppra, Zyprexa, Xanex XR, Zoloft, Lamictal, Vivance, and an inhaler. Her psychiatrist suggests that I use 1 mg Xanax (non XR) or 0.25mg triazolam. I wonder if these will be enough and I am interested in your thoughts
Faculty Reply: There’s no way of knowing for sure until you try. But given her level of anxiety and the tolerance that she has developed due to multiple CNS depressants, the level of anxiety control is likely to be minimal with the doses of Xanax or triazolam that you mention. Combining those with nitrous will help, but this patient is going to be a hyporesponder.
The good news is that you will not be doing an invasive procedure, although your patient will need to be numb given her recent surgical procedure. If you want to be more confident of her anxiety control, then I would perform a regular oral conscious sedation.
In addition to the multiple CNS depressants she is taking and the associated tolerance, there is the issue of her psychiatric disorder. If it is schizophrenia, I would not use oral sedatives, but rather use IV sedation titrated to the appropriate level of effectiveness.
Question: We are trying to decide what to give the patient the night before her sedation. The patient states that she cannot take Valium because it makes her sick, but she can take Ativan (lorazepam). What do you suggest the patient take the night before sedation?
Faculty Reply: If the patient truly cannot take diazepam, then I wouldn’t have her take anything the night before. Lorazepam is too efficacious, decreasing the safety margin for pre-operative sedation.
Follow-Up Question: What about having the patient take a Lorazepam one hour before her appointment?
Faculty Response: If you can do an incremental protocol, then taking a lorazepam loading dose is part of incremental protocols #3 and #4 (see your course workbook). If the patient can take triazolam, I would use a triazolam incremental protocol, which would be triazolam as the loading dose.
If you cannot do an incremental protocol, then a loading dose before the appointment on the day of the appointment is not allowed.
Original Posting: - https://www.docseducation.com/blog/sedation-patient-unable-take-valium
Question: I would like to know if I can use oral conscious sedation on a 62-year-old female patient. She is a nonsmoker. She is also pre-diabetic and not obese. She does have a slight gag reflex.
However, she has a laundry list of meds she is taking for arthritis, asthma, a heart attack in 2000, heart stint 2005, psychiatric issues, heart burn, daily pain meds (for back surgery), constipation, border-line diabetes, and acid reflux.
The long list of medication:
• Breo Ellipta®
• Fleet Enema
Do you feel like we can safely sedate this patient? I know she can come off of Nexium, and put her on Pepsid AC, but I am not sure how to address the class D reactions, with Ambien, Narco, Theophylline.
I understand that she has many medications listed but I feel like this may not be no-go, just because she is on so many medications.
Faculty Reply: This is a patient with multiple drugs for multiple medical issues. Any time you see a patient on at least four meds for a problem, it is usually an issue that is not well-controlled. An example here is four meds for, I presume, asthma.
Also, she is on multiple CNS depressant meds including sedatives, sleep aids, pain meds, muscle relaxers, anti-depressants, and the list goes on.
It is not just a list of meds that determine if we should sedate a patient or not but also their medical health and status. The majority of the meds do have a "D" interaction with our sedation meds.
I personally would not expect to have a safe and successful sedation with this patient with oral conscious sedation. If she is sedated, it would be better controlled with IV sedation. Even with IV sedation, there are still many issues to overcome.
Remember we do not have to sedate everyone who wants sedation.
Original Posting: - https://www.docseducation.com/blog/oral-sedation-not-extremely-ill-patients
The information contained in these EliteDOCS posts should never be considered a proper replacement for necessary training and/or education regarding adult and pediatric oral conscious sedation. This is an educational and informational piece only.
Regulations regarding sedation vary by state.
DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient’s use of, or failure to use, any of the information contained herein.
DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of the specific posting and include it with your question or request.
EliteDOCS posts and replies in this article are edited for clarity.
The Shaky Regulatory Landscape and What It Means for Dentists
(EDITOR’S NOTE: The theme of this year’s 10th Annual Sedation Safety Week is “Awareness.” Many dentists remain dangerously unaware of the regulatory climate that threatens their ability to serve their patients as they deem most appropriate, as well as their livelihood. Overzealous regulators in a growing number of states are moving – without scientific or clinical basis – to dramatically restrict the use of oral sedation.)
The earth is flat.
Elvis is still in the house.
And even dentists who’ve administered oral sedatives to their patients for years – safely, effectively, and without incident – must go back to the classroom and obtain an IV sedation permit to continue to treat their patients using moderate enteral sedation (and to comply with newly adopted dental guidelines and regulations.)
In the spring of 2018, it makes no difference if science, clinical experience, and common sense disagree. The push to further regulate oral sedation dentistry is in full bloom
Indeed, for all the advances that the dental profession has made in attracting and caring for fearful and anxious patients, overzealous regulators in some states – supported by a small but influential group of financially self-interested specialists – are working overtime to reverse much of the progress of the past 20 years.
Dental anxiety remains an overwhelming public health crisis, with tens of millions of Americans still too fearful of visiting a dentist to get the preventative and restorative treatment that is necessary for both their oral and overall physical health.
Those calling for still tighter regulation of sedation dentistry do so, ostensibly, to better protect the public’s safety. Their actions come in the wake of a small number of highly publicized deaths involving patients – both adults and children – who were anesthetized in their dentist’s office.
The entire point of Sedation Safety Week, now marking its tenth year, is to help prevent such sedation-related deaths and injury.
If the new regulations would actually do that, there is no doubt that every fair-minded dentist in the country would favor such regulation, and Sedation Safety Week would be the biggest champion of the new laws.
But the new regulations not only fail to increase the safety of sedation dentistry, they actually make our profession less safe because they drive both patients and dentists away from taking full advantage of proven oral sedation treatments.
Raymond A. Dionne, DDS, MS, PhD, is a noted expert on the subject of pharmacologic management of dental fear and anxiety, having previously served as Chief of the Pain and Neurosensory Mechanisms Branch and Clinical Director for the National Institute of Dental and Craniofacial Research. He is currently a research professor in the Department of Pharmacology and Toxicology in the Brody School of Medicine at East Carolina University.
Dr. Dionne says that recent stricter oral sedation guidelines adopted by the American Dental Association in October 2016, and written into law (before or after) by more than a dozen state dental boards are “illogical.”
Dr. Dionne contends that the basis for some of those individuals who are promoting additional restrictions and training requirements for dentists who offer oral sedation is “just another restraint of trade strategy.”
Whatever their motivation, and no matter how sincere or insincere the regulators are, tighter oral sedation laws are being adopted – or at least considered – by an alarming number of state dental boards.
Take a minute to study the multi-colored map of the United States at right. It was prepared by John P. Bitting, Esq., who is the full-time regulatory counsel for DOCS Education, and the nation’s foremost attorney specializing in dental sedation regulations.
Only the Blue states, for now, have stuck with the national oral sedation guidelines that have effectively and safely governed the profession since at least 2007, with some going all the way back to 2000. “These states do not appear to be actively considering fresh restrictions,” says Mr. Bitting.
The Red states have already embraced regulations and restrictions on oral sedation that go well beyond what either science or clinical experience have demonstrated are necessary to protect public safety.
The Yellow and Gray states, based on Mr. Bitting’s analysis, are either likely to embrace stricter sedation regulation, or are at least weighing the possibility.
Question: If there are dentists who fail to follow the mandated regulations to the extent that one of their patients is grievously harmed, will tightening those regulations prevent such harm?
The dental office tragedies that have occurred since the annual Sedation Safety Week first began in March 2009 did NOT arise from weak or insufficient regulations and training. They arose, as best as anyone can determine* because dentists failed to carefully follow existing safety regulations, best-practice protocols, and proper patient selection.
Moreover, millions of Americans who would otherwise avail themselves of regular dental care are being priced out of the dental care marketplace, as the new and unnecessary guidelines and regulations continue to push up the cost of oral sedation care while simultaneously reducing the pool of dentists who are licensed, trained, and permitted to provide it.
Down the road – and not very far down the road at that – public anger over these developments in dentistry threatens to engulf our profession in the same type of “us v. them” mindset that fuels the widespread protests that we’ve seen over the cost and availability of medical care.
If the dental profession itself doesn’t correct this overreach, then access to care and the price of dentistry may well – for better and worse – face the specter of federally mandated oversight and a blurring of the lines that have, to date, separated medical regulation from dental regulation.
Sedation Safety Week is the perfect time for caring, dedicated dentists to commit themselves to protecting their patients’ access to oral sedation care and to fight to prevent further unnecessary regulation of oral sedation.
(* The lack of publicly available records in most states pertaining to dental-office fatalities greatly hinders the scientific community’s ability to pinpoint exactly what caused patients to die – and hence, what might be done in the future to prevent similar deaths. One of the only published studies that does exist, Risk Factors for Dental Outpatient Sedation Procedures Derived from Deaths Reported in the Public Domain, by Dr. Raymond A. Dionne, had to rely on the compilation of news reports – not exactly ideal when it comes to accuracy or detail.)
WHAT CAN YOU DO?
- There is strength in numbers. Become a member of DOCS Education and join with thousands of other sedation dentists in opposing unnecessary national and state-wide dental guidelines and regulations.From its founding in 1999, DOCS Education members have fought to reduce unnecessary regulation and interference that only serve to raise the cost of dental care (and the profits of a small group of “elite” specialists) without benefiting patients.
Professional activism is a core component of DOCS. Be sure to read the DOCS Education Proclamation, outlining the goals and principles of the membership community at: https://www.docseducation.com/membership.
- Join your state dental board or become a member of one of its rules or anesthesia committees. Too few dentists who rely on oral sedation to care for their patients are represented on their state regulatory boards. As a result, dentists who do NOT provide oral sedation – or actively oppose it for reasons of financial self-interest – are the ones who pass the overzealous regulations.
- Recruit some of your most satisfied oral sedation patients to write or call your state dental board and express their support for reasonable, affordable oral sedation regulation. You may also encourage your patients to write your state’s governor, who typically is the individual who appoints dental regulators.
- Speak up. Literally. Accept invitations, or solicit invites, to speak about oral sedation and access to care at local civic clubs, churches, synagogues, mosques, health fairs, and any similar venue where you can spread the message. If you need help preparing your remarks, contact John P. Bitting, Esq., DOCS Education’s full-time regulatory counsel.(Members of DOCS Education are entitled to unlimited consultations with Mr. Bitting, who is available to answer all of their legal and regulatory questions. If you’re not already a DOCS Education member, until March 30th, you can get a free, two-month membership by contacting Lindsay Olsen, membership director, at 206-812-7712, or at: firstname.lastname@example.org.)
Friday: Meet our 10th Annual Safe Sedation Dentist of the Year honoree. Chosen by a jury of their peers, each year a dentist (or dentists) is selected to represent the finest example of oral health professionals who elevate our profession and its commitment to safe, effective, comfortable, sedation dentistry.
Do you know this year’s Safe Sedation Dentist? What can you take away from the success that she (or he) has had in treating fearful and anxious patients who would otherwise avoid the dentist altogether?
Find out tomorrow on the final day of 2018’s Safe Sedation Week.
Meet Our 10th Annual ‘Safe Sedation Dentist of the Year’ Honoree
(EDITOR’S NOTE: The theme of this year’s 10th Annual Sedation Safety Week is “Awareness.” Dr. Michael D. Silverman, founder and national chairman of the annual event, believes that it is incumbent upon sedation dentists to spread the message that oral sedation – when practiced in accordance with all national guidelines and state-mandated regulations – is safe, effective, and of great value to the estimated 92 million Americans who exhibit dental anxiety.
“Selected by a jury of his peers, Dr. Chiang is an exemplary model of professionalism and dedication,” Dr. Silverman says. “He does our profession honor, and we hope this recognition will encourage other dentists to emulate him and his strong commitment to patient safety.”)
Meet Dr. Peter C.J. Chiang – 2018’s Safe Sedation Dentist of the Year
When Peter C.J. Chiang, DDS, isn’t treating kids from the mostly rural, blue-collar area surrounding his Salinas, California office, you might find him powering through a team roping event at a local rodeo, where he and a partner race on horseback to rope a calf in the fastest possible time.
Though team roping and pediatric dentistry may seem worlds apart, Dr. Chiang sees a common thread. In both undertakings, he has found ways to avoid pitfalls, maximize safety, and use the best possible equipment.
His practice, Central Coast Pediatric Dental Group (CCPDG), located about an hour south of San Jose, has three locations and some 130 employees, including six pediatric dentists, six general dentists, and one dual degree MD,DDS.
“Sedation and hospital dentistry is an important part of our practice,” Dr. Chiang says. It comprises at least one-third of CCPDG’s overall business and takes more than 90% of Dr. Chiang’s time.
Dr. Chiang is originally from Seattle but went to the University of California at Los Angeles for his undergraduate studies, and completed a residency in pediatric dentistry at the UCLA Medical Center. He is now a UCLA faculty member, spending one day a month helping to train future pediatric dentists.
Dr. Chiang always wanted to live in a rural area, so when he was recruited upon graduation from dental school to go to an established Salinas practice by his business mentor, Dr. Roger Sanger, and his clinical mentor, Dr. Ray Stewart of the University of California at San Francisco, he jumped at the opportunity.
It was a good fit.
Dr. Chiang has been with CCPDG for 27 years, developing an approach that evolved into a mission statement. The vision of his practice group, Dr. Chiang explains, is to “treat all kids in our community with the same compassion and care; addressing their needs equally.” CCPDG not only sees to the dental needs of its patients but also holds year-round community events, including reading and sports contests.
An essential component of the practice is safety in pediatric sedation. The core of Dr. Chiang’s approach is to stay abreast of developments in his field and always go beyond the minimum standard of care.
“We have a strict sedation protocol that not only adheres to our academy’s safety guidelines, but we practice protocols above and beyond the minimum levels,” he says. “We require all our sedation doctors to have continuing education.” Training extends to his staff in both the front and clinical offices. The clinic holds emergency drills and protocol rehearsals on a regular basis, covering topics including PALS medications, complications of anesthesia, and rescue concepts.
“Not knowing what you don’t know is a scary thing versus knowing what you don’t know. You need to be careful with oral sedation and pediatric dentistry. Knowing the danger and the margin of safety is what is going to keep a patient safe in a sedation environment.”
CCPDG utilizes a “surgicenter,” which Dr. Chiang designed to handle the practice’s sedation dentistry patients. He describes it as a “facility within a facility.” The idea came to him when he noticed that friends of his who were ENT doctors (ear, nose & throat) were beginning to handle some procedures in the office.
As outpatient surgery centers became more common, “that idea morphed in my mind, to establish a section of the office dedicated to oral conscious sedation and in-office IV sedation. We concentrate all our resources in terms of monitors, chairs, and back-up systems so that our sedations are done with minimal disruption to the normal flow.”
Dr. Chiang has instituted other important procedures at the practice, including the use of monitoring devices.
“In our oral conscious sedation monitoring protocol, we started using capnography in 1997,” he says, “and now, 21 years later, it’s required in some offices. But I would like to think that our contribution to oral conscious sedation is having patients’ safety as our utmost goal.”
Safety and education go hand in hand in Dr. Chiang’s experience.
“Not knowing what you don’t know is a scary thing versus knowing what you don’t know. You need to be careful with oral sedation and pediatric dentistry. Knowing the danger and the margin of safety is what is going to keep a patient safe in a sedation environment,” he explains.
Like so many quality pediatric sedation dentists who are devastated when they read news reports of pediatric deaths in dental offices, Dr. Chiang knows such tragedies – though tiny in number – are preventable, and should never occur.
Kids who are seriously injured or die at the dentist’s office represent a lack of quality assurance and experience; what Dr. Chiang deems the “ultimate failure.”
‘It’s just an absolute tragedy, and my heart goes out to the families and all the people who are involved,” he says. “We are still addressing the lack of understanding, the lack of education, and the lack of attention to patient safety that resulted in these tragic cases. Education is key.”
For dentists who may be considering using sedation, particularly in places where medical services are few and far between, Dr. Chiang emphasizes preparation.
“For general dentists in underserved areas, in a rural area in which there are few backups – EMS or hospitals not readily at hand – education and never compromising patient safety is of primary importance. I think it’s important that dentists who are new to sedation pair themselves with a good mentor who is a fit, so they can have good equipment and have a safe philosophy.”
Mentors – such as Dr. Sanger and Dr. Stewart – have been instrumental to Dr. Chiang, even when it comes to recreation.
He rode horses as a child and got interested in rodeo as an adult, when he had the chance to hang out with some professional cowboys. “I started roping, and had the opportunity to team up with some of the best people in the profession. I had great mentors who steered me to good equipment, allowed me to learn quickly, and steered me away from danger. They helped me be good at what I like to do.”
Dr. Chiang excelled at rodeo from the start.
“I’ve been fortunate,” he says, “I was able to win in my division quickly.” He keeps his many awards in a separate room in the house, kitted out with special tables, a wall stand, and even a wagon wheel to hold the trophies, buckles, and the particularly prestigious saddles. His fastest roping time was an incredible 6.1 seconds at an event in Maui (under ten seconds is considered ideal in team roping), but, he still says, “My best event ever is the next one.”
Looking ahead, Dr. Chiang sees a bright future for pediatric dentistry.
“We anticipate growth. We’re still having kids, and kids aren’t very good brushers. It allows me to discuss growth and development; it allows me to see my patients grow from young kids to young adults leaving the practice, and then coming back with their own kids.”
Dr. Chiang’s successful career and life have been characterized by always doing more than the minimum, and taking every precaution to avoid unnecessary risk.
Does his work in pediatric dentistry fulfill him? “It has exceeded my expectations both financially and personally,” he says. “I have been rewarded by the profession, by my patients, and by my community in ways I never expected.”
(This article was reported and written by Nancy LeBrun, a regular contributor to Incisor, the free biweekly cutting-edge dental news and features newsletter. To subscribe to Incisor, click here.)
Safe Sedation Week Recap:
Monday: Where We’ve Come and Where We Still Must Go
A decade after the launch of Sedation Safety Week was first launched, there is still much work to be done. The theme for this year is “Awareness.” The goal is to increase public and professional understanding of the many benefits of safe, effective, oral sedation.
Tuesday: Safely Serving Greater Numbers of Sedation Patients
Advanced oral sedation dentistry has changed the dynamics of caring for medically-complex patients, allowing large numbers of those suffering from chronic medical and psychological problems to be seen and safely treated in-office by a qualified general dentist.
Wednesday: The Best of EliteDocs Over the Decade
Knotty questions about safe, sedation dentistry are no problem for the dentists and faculty who are ever-present on the unique EliteDOCS forum. Today is your opportunity to ask a question or simply review examples of those posted by other oral health professionals.
Thursday: The Shaky Regulatory Landscape
Despite a complete lack of scientific or clinical evidence, some overzealous dental regulators are pushing new rules that threaten to reverse much of the progress dentistry has made over the past 20 years in the safe, effective treatment of fearful and anxious patients.
Friday: Meet Our 10th Annual ‘Safe Sedation Dentist of the Year’ Honoree
Peter C.J. Chiang, DDS, is the 2018 Safe Sedation Dentist of the Year, honored for his career-long, pioneering commitment to making safety the “utmost goal” of his pediatric group practice, as well as his commitment to community and public service.
• Start your free, two-month membership in DOCS Education and gain 24/7 unrestricted access to the EliteDOCS forum. Contact Lindsay Olsen, membership director, at 206-812-7712, or email her at: email@example.com. Offer expires March 30, 2018.
• Learn more about the many other privileges afforded to DOCS Education members, or to become a permanent member, click here.
• To subscribe to Incisor, the free biweekly cutting-edge dental news and features newsletter – offering exclusive sedation dentistry case studies, click here. Membership is not required.