Sedation Dentistry Office Equipment:
What is the current standard of care?
In answer to the frequently asked question “what equipment is required to use sedation dentistry?,” the answer will always be, “Your state dental board’s regulatory requirement and the standard of care.”
While the required equipment under a particular state dental board’s regulation can be ascertained, meeting your state’s dental board regulatory requirement is not enough. In the unlikely event that you have an allegedly imperfect outcome, you will need to show that you have met the “standard of care.”
So, what is the “standard of care” for dental sedation office equipment and who decides the standard? The “standard of care” – what a reasonable court will deem to be the required safety practice in the community of sedation dentists - is indeed a moving target, but in the world of sedation dentistry, the standard in large part derives from two organizational guideline sets:
- the American Dental Association 2016 Guidelines for the Use of Sedation and Anesthesia by Dentists (ADA 2016 Guidelines), and
- the American Society of Anesthesiologists Statement on Sedation & Anesthesia Administration in Dental Office-Based Settings* along with its Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 (ASA Guidelines).
While few state dental boards regulations were compliant with these two organizations’ guidelines when first published in 2016, increasingly state dental boards are adopting some or all the guidelines’ recommendations. Equally important, the standard of care in sedation dentistry is derived by court and experts from these critical advisory organizations.
ADA Guidelines for necessary equipment in a dental office in which minimal sedation is employed can be summed up as follows:
- "A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available."
- "Documentation of compliance with manufacturers’ recommended maintenance of monitors, anesthesia delivery systems, and other anesthesia-related equipment should be maintained. A pre-procedural check of equipment for each administration of sedation must be performed."
- "When inhalation equipment is used, it must have a fail-safe system that is appropriately checked and calibrated. The equipment must also have either (1) a functioning device that prohibits the delivery of less than 30% oxygen or (2) an appropriately calibrated and functioning in-line oxygen analyzer with audible alarm."
- "An appropriate scavenging system must be available if gases other than oxygen or air are used."
Here there are no surprises – minimal equipment required to delivery the sedation to the patient, retrieve the patient from the sedated state, rescue the patient from a more advanced state of sedation, and protect the workplace safety of workers in the operatory.
However, in offices employing moderate (as defined by the ADA) sedation, the required equipment is more extensive:
- “The equipment necessary for monitoring end-tidal CO2 and auscultation of breath sounds must be immediately available.”
- “The equipment necessary to establish intravascular or intraosseous access should be available until the patient meets discharge criteria."
The ASA Moderate Sedation Guidelines have both overlap with the ADA and more specificity as it is couched in terms of monitoring requirements:
- “Monitoring Patient Ventilation and Oxygenation"
- "Continually monitor ventilatory function by observation of qualitative clinical signs"
- "Continually monitor ventilatory function with capnography unless precluded or invalidated by the nature of the patient, procedure, or equipment"
- "For uncooperative patients, institute capnography after moderate sedation has been achieved"
- "Continuously monitor all patients by pulse oximetry with appropriate alarms"
- "Monitoring Hemodynamics"
- "Determine blood pressure before sedation/analgesia is initiated unless precluded by lack of patient cooperation"
- "Once moderate sedation/analgesia is established, continually monitor blood pressure (e.g., at 5-min intervals) and heart rate during the procedure unless such monitoring interferes with the procedure (e.g., magnetic resonance imaging where stimulation from the blood pressure cuff could arouse an appropriately sedated patient)"
- "Use electrocardiographic monitoring during moderate sedation in patients with clinically significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated"
- "Contemporaneous Recording of Monitored Parameters"
- "Record patients’ level of consciousness, ventilatory and oxygenation status, and hemodynamic variables at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient"
- "At a minimum, this should occur: (1) before the administration of sedative/analgesic agents,** (2) after administration of sedative/analgesic agents, (3) at regular intervals during the procedure, (4) during initial recovery, and (5) just before discharge"
Set device alarms to alert the care team to critical changes in patient status
Under both schemes, under many and soon most state dental board regulations, and under the standard of care, all dental offices using “moderate” sedation should have equipment measuring blood pressure, pulse oximetry, EKG, and capnography.
You may wonder: Are all four necessary to meet the “standard of care?” Sedation dentists must remember these four different readings document offer different information relevant to the condition of the sedated patient.
Under the current sedation dentistry standard of care, all four pieces of information need to be monitored in the sedated patient: two different measures of hemodynamics and two different measures of respiration.
Evidence of monitoring all four is not established merely by the presence of measurement equipment. The equipment must be:
- Maintained in accordance with the manufacturer’s direction;
- working properly; and
- used continuously while the patient is sedated.
Is writing the reading in the patient file at three or four critical times during the procedure sufficient to document the monitoring has been continuous? Maybe. Some states, along with the ASA Guidelines, require that the monitors record continuous monitoring. Rather than fill patient files with rolls of recording strips, sedation dentists should be thinking now about equipment units that record results electronically.
Anticipating future board regulation and the evolution of the standard of care, note that the ADA Guidelines (though currently a minority of dental boards) suggest sedation dental offices, “[h]ave the equipment necessary to establish intravascular or intraosseous access available until the patient meets discharge criteria.” This emergency equipment is likely to be considered the standard of care soon.
Dental Practices and Covid: How Have They Fared?
Although the United States has passed the unthinkable milestone of 500,000 deaths contributed to Covid-19, there are glimmers of hope on 2021’s horizon: two FDA-approved vaccines have already been administered to millions; financial experts are predicting a steady economic recovery by end of year; and thanks to the success of immediate and stringent protocols in the dental profession, Covid transmission has been contained at less than 1% of positive cases among dentists.
However, there are miles to go before the pandemic is really in our rearview and dentists around the world have had varying experiences, taken extra precautions, and made tough decisions in the past 12 months with just that goal in mind.
The ADA Checks In
In the early months of the pandemic, many offices shuttered temporarily to better keep their patients and staff safe while helping to flatten the curve. In order to monitor the ongoing impact of the crisis on dental practices, the American Dental Association’s (ADA) Health Policy Institute (HPI) established a biweekly interactive survey in March of last year. Thousands of dentists across the U.S. continue to participate, responding to questions covering patient volume, staffing status, personal protective equipment (PPE) availability, as well as measures taken to maintain financial sustainability.
According to the HPI survey respondents, mid-April 2020 saw almost 80% of offices closed except for emergency patients. Flash forward to February 15, 2021 and 98% of practices are open, with 42.6% reporting to business as usual, and 55.5% open, but with lower than typical patient volume.
The comprehensive survey further breaks down all the responses by practice type, size, geography, and more.
Very early in the pandemic, dentists understood the need for basic safety measures and guidelines that were needed to safely triage and treat patients, including masks, pre-visit questions and temperature checks, as well as postponement of non-emergency treatments. A scientific article on the virus and these guidelines was fully endorsed by the Center for Disease Control (CDC) and the ADA, and followed by practitioners everywhere.
In addition to the safety measures, some dentists and hygienists cut back on certain tools that can produce more droplets and aerosols that could potentially spread the virus. While a survey of hygienists last summer showed a worrying shortage of PPE protocols, as of this February, a majority of HPI respondents say they now have more than 14 days-worth of PPE on hand, including N95 masks, face shields, disinfecting supplies and gloves.
We Have the Technology
The HPI explored the expanded use of telecommunications, telehealth or virtual tech being used in dental practices. Approximately 63% of those who employ technology reported using it for triaging emergencies, consults, and post-ops or follow up care. Additional research by DentaQuest Partnership for Oral Health Advancement found that 23% of dentists are now using telehealth tools, or plan to in the near future. The group was comprised of 42% employing audio-visual tech and 60% using phone only for engaging with their patients.
The ADA is currently urging the Federal Communications Commission (FCC) to include the dental industry in the Covid telehealth program which would be included in relief funding.
Keeping the Doors Open
As with many businesses around the world, the pandemic hit dental practices hard, especially considering the necessary proximity to the source of transmission. Government assistance in the form of stimulus payments and small business loans were utilized, as well as a variety of creative steps taken to not only survive but thrive.
While 45% of dental practices weren’t able to pay any staff in April of last year, 93.9% are once again paying fully according to the February 2021 poll. In addition, those dentists surveyed recently on financial measures to sustain their business reported:
• 38.4% used or applied for government grants or loans.
• 27.3% raised fees.
• 23.3% borrowed from a bank.
• 16.5% reduced team hours.
• A small percentage downsized teams, reduced wages or personal salary, and took other steps.
While the survey doesn’t reflect the entire industry, there are already some casualties with a minor percentage selling, retiring, or considering these options sooner than planned.
Some dental professionals have used the state mandated closures to think outside of the box and capitalize on the down time. Launching membership plans to keep patients invested in their oral health and plan for future appointments has been a popular option for closing the financial gap. Dentists and hygienists alike have used the time to garner valuable continuing education credits as well.
As many dentists have seen, Covid-19 has spawned a whole new crop of patients with dental issues. Thanks to relaxed tooth and gum care habits, as well as the increased stress resulting in bruxism and cracking, some dentists are increasing staff and hours to make more mouth guards and treat more patients.
The dentists in the HPI survey concur, noting a 71% jump in bruxism visits, and a 63% increase in cracked and chipped teeth, as well as more temporomandibular joint (TMD) symptoms.
The Outlook for 2021
Economic experts report similar challenges to the dental industry after the 2008-2009 recession, but this current health crisis is expected to change dentistry in even more significant and permanent ways. The loss of health and lives has forced dental professionals to rethink their treatment systems as well as their business model.
However, many dentists hope that multiple vaccinations will bolster their practice as well as patient confidence. According to the ADA, 88% of consumers reported they have been back to see their dentist or are ready to go. And with the advancing opportunities for dentists to be the ones providing the vaccine, patients may even be able to get their teeth cleaned and a life-saving shot in the arm all in one visit!
Can Dental Sedation Reduce Stress on the Heart?
Sedation has many benefits and practical uses in the dental operatory, the most significant being reducing anxiety and fear for patients. Dental anxiety (DA) is considered to be a universal phenomenon and can be seen in patients of varying demographics. DA is closely related to the fight-or-flight reaction, a classic stress response where activation of the sympathetic nervous system leads to a catecholamine release, increasing the heart rate and thereby enhancing cardiac output.
It’s estimated that 10 to 30 percent of people have anxiety and fear regarding dental procedures. However conscious sedation has been shown to alleviate stress associated with dental care through a use of combined drugs aimed at depressing the central nervous system (CNS).
It then leaves the question:
What Effect Does Sedation Have on Alleviating Cardiovascular Stress?
In examining this question further, let’s first explore the impact the “fight or flight” response has on the heart, and the drugs used in dental sedation to combat this fear response.
There are countless studies on the negative impact stress has on the human body, and in particular on the heart. Persistent epinephrine surges created during the stress response lead to damaged blood vessels and arteries, dangerously elevated blood pressure, and increased risk for heart attacks and strokes. Elevated cortisol levels create physiological changes in the body that contribute to a buildup of fat and weight gain. Over time, uncontrolled stress and repeated exposure to the cycle of “fight or flight” can have lasting negative consequences on a diseased and healthy heart.
According to an article written by Cardiologist, Saima Husain, MD, based on both experimental and clinical evidence, stress affects the cardiovascular system by:
- Increased sympathetic nervous system activity via the “fight or flight” response, leading to elevated blood pressure and pulse rates.
- Reduced insulin sensitivity or intolerance to glucose and diabetes.
- Increased blood clotting and blood vessel dysfunction.
- Reduced blood flow to the heart.
- Individuals with high blood pressure are more likely to experience panic attacks than the general population.
Dr. Husain goes on to state that stress raises blood pressure, “both immediately and chronically.” In immediate stress, that which would be seen in dental anxiety or acute stress, elevated tension experienced by patients can cause a rapid and significant increase in blood pressure and heart rate. While this response can be relatively short-lived, patients with pre-existing high blood pressure, can experience symptoms such as dizziness, palpitations, and headache when suffering from dental anxiety.
In an effort to combat the negative impact of DA and acute stress experienced by patients, conscious sedation can be extremely useful when administered correctly in a clinical dental setting.
While each drug has its advantages and disadvantages, there isn’t a single drug that works for every patient. Only experienced and appropriately trained dentists should administer a combination of sedation drugs specific to each patient and their specific needs. Common drugs used for conscious sedation in dentistry include the following:
Triazolam belongs to a class of medications called benzodiazepines. These drugs act to calm the brain and central nervous system. It’s believed to work by increasing the effect of a natural chemical (GABA) in the brain. Benzodiazepines have been shown to lower cardiac output, arterial blood pressure, oxygen consumption, and mixed venous oxygen. Most importantly, benzodiazepines are considered the safest of all oral sedatives. Another benefit to this class of drug is that it causes amnesia during the dental appointment that allows a fearful patient to totally relax with little to no memory of the dentistry.
Another drug in the benzodiazepine family, commonly called Valium®, is used to treat anxiety disorders, alcohol withdrawal symptoms, seizures, or muscle spasms and stiffness. It has approval from the FDA for use in the very young. Due to its long-acting effects, diazepam is usually prescribed as a nighttime dose, before a dental appointment.
Classified as a benzodiazepine, lorazepam falls halfway between triazolam and diazepam when it comes to duration of action. Lorazepam is often used for longer dental appointments. Due to it unusual path of metabolism, lorazepam is often the choice for older patients who are taking other medication.
Hydroxyzine is an antihistamine that causes slight sedation, but possesses other characteristics that make it an ideal partner with benzodiazepines. Often times, sedation dentists will pair this particularly safe antihistamine with a benzodiazepine drug to create a smooth, comfortable appointment. Another benefit of this medication is its antinausea effect.
Commonly called “laughing gas”, nitrous oxide sedation may be used by itself to relieve anxiety and as an analgesic or in combination with oral sedatives. Most sedation dentists use nitrous oxide at the beginning of an appointment to relieve the worry and discomfort of dental injections to get the mouth numb. Nitrous oxide is considered the safest sedative there is.
A brand new drug in the benzodiazepine family that is indicated for the induction and maintenance of procedural sedation, Remimazolam received the green light by the FDA in July of 2020 for medical use in the United States. This new medication is in the process of being vetted for procedural dentistry and more information on its use will be coming soon.
Dental Sedation has many implications for use including the reduction of physical and mental stress experienced by patients who suffer from dental anxiety (DA). The reduction of this widely experienced phenomena can greatly improve the patient experience, encourage routine dental care, and perhaps, inadvertently decrease acute stress placed on the heart.
Free Dentistry Clinic in Lexington, KY, Delivers Hope and Health
When Covid-19 hit the United States last year, most dental offices were ordered to close temporarily to any services except for emergencies. More than half of Americans surveyed by the American Association of Endodontists said they put off routine dental care because of the crisis.
However, with or without a pandemic, there is a significant population that misses out on necessary dental care due to fear, anxiety, or financial struggles. The Happy Smiles Dentistry charitable program in Lexington, KY has spent the last three years bringing painless, stress-free, no-cost dental services to that very community.
A Learning Opportunity for Dentists
The Happy Smiles Dentistry Clinic is the charitable arm of an IV Sedation training program for general dentists. Because IV sedation allows dentists to accomplish more in a single session than traditional dentistry, it is considered a great choice for patients with extensive treatment plans or severe dental anxiety.
Dentists in the program complete a rigorous curriculum designed to give them the advanced knowledge and confidence to treat patients using IV sedation. In addition to 60 hours of didactic training, most of which is completed online and via live office hours, the participating dentists must also treat at least 20 patients in order to apply for their permit. In total, they complete 90 hours of training.
The Struggle to Find Patients
The free dentistry clinic is run by Dr. Anthony Feck, the Dean of Faculty at DOCS Education, and Dr. Carol Wilson at the state-of-the-art offices of Dental Wellness of Lexington.
At first, Drs. Feck and Wilson had difficulty finding patients in need who could benefit from the IV sedation services they could provide. They tried passing out flyers for free dentistry at local shopping areas, but most people declined.
Undaunted, Dr. Wilson asked to hang the flyers in break rooms, gave them directly to store employees, and even resorted to guerilla marketing tactics. She also approached local churches who had waiting lists for free dental care to offer their services. The program has since expanded to radio to reach more potential patients.
Gradually, the program gained enough patients to run their first clinic in May of 2018 and went on to hold two more that year. The clinics have increased in frequency and they are now operating monthly with an average of 76 patients treated each three-day session.
Connecting Patients with Dentists
Due to the complexity of IV sedation, there is a comprehensive screening process for any participating patient. They must have had physical checkups within the previous two years, have healthy organs, not suffer from severe respiratory disease, and not have conflicts with certain medications. Having a chaperone for post-sedation is also a necessity.
Patients who qualify receive a free examination and x-rays and are given a treatment plan. Successful candidates who are interested in proceeding can then return for specified treatment under IV sedation – also free of charge. The most common procedures are extractions, fillings, and deep cleanings. Some of the patients choose to come back for regular treatment to maintain their oral health. Overall, they experience a high level of dental care in a comfortable setting.
The clinic helps those who do not have dental insurance or cannot afford to meet their insurance deductible. And because the clinic is privately run, it does not experience the same challenges as some state-funded programs who are restricted by the reimbursement process.
“Happy Smiles is a great opportunity for us to share our time and resources with the community and beyond Lexington,” said Dr. Wilson. “And to let them know they are worth it; they deserve good dental care, and we can provide it in a comfortable environment.”
Since its launch, the Happy Smiles Dentistry program has served more than 1,000 patients and donated over 4,000 procedures that are valued in excess of $3 million dollars.
The core philosophy of the program is not everyone can afford to have dentistry done, but everyone deserves a happy smile.
2021 Safe Sedation Dentists of the Year
While many couples found themselves working together for the first time during Covid-19 quarantines, it was business as usual for Dr. Arthur Kwan, DMD and his wife, Dr. Sally Hsu, DDS. The successful synchronicity and innovative patient care of Nu Smile Dental in Roseville, CA made these partners a natural choice as Dentists of the Year for the 13th Annual Safe Sedation Week.
Dynamic Duo Combines Expertise, Comfort, and Technology
Dr. Kwan, a graduate of Boston University School of Dental Medicine, and Dr. Hsu from the University of Southern California have added postgraduate training from the Las Vegas Institute for advanced Cosmetic Dentistry to establish a comprehensive practice and partnership of 20+ years. In addition to cosmetic and restorative services, they provide orthodontics and aligners, as well as sedation dentistry.
The couple agrees that their common dedication to their patients, but differing and unique skillsets, can only benefit their practice. Dr. Kwan enjoys challenging neuromuscular cases and Dr. Hsu likes working with young patients to set a foundation for good dental health.
“We complement each other very much and provide an all-around, full experience for our clients,” says Dr. Kwan.
“I can give him all the problem patients,” adds Dr. Hsu, laughing.
The Advantages of Sedation Dentistry
The practice added sedation dentistry to its offerings more than 15 years ago, allowing them to provide an extra level of comfort to those with severe anxieties or dental trauma history. Surprisingly, Dr. Hsu counts herself among the fearful.
“Being a dental phobic myself because of a bad dental experience when I was a teenager, I appreciate what oral conscious sedation can provide to many people that also share my phobia,” she explains.
“I feel really fortunate that sedation dentistry provides that one ingredient for patients to get the treatment they need,” adds Dr. Kwan. “By taking the fear out of the equation it allows the quality of care they deserve.”
In addition to mild and moderate oral sedation, Nu Smile provides many other comforting options to ensure a positive experience. These include:
• Warm blankets
• State-of-the-art personal video headsets
• Stereo headphones with music of your choice
• Soothing herbal eye masks
• Calming herbal teas and more
“We get a fair amount of scaredy-cats and we welcome them,” says Dr. Kwan. In addition to the sedation protocols, these extras help bring cortisol levels down and calm the central nervous system. “On full cases, we provide booties so they can take their shoes off and fully relax.”
Although sedation patients make up approximately 20% of their practice, the couple is encouraged by the percentage of those who graduate from sedation. They estimate approximately a third of their clients who specifically seek out sedation at the beginning eventually feel safe in the chair and can get treatment without any form of additional sedation.
“Many of our patients are now able to have checkups and cleaning done without being sedated, whereas previous to their sedation appointments they would never think about getting even a cleaning done without being sedated,” says Dr. Hsu.
Complementing the sedation and slippers, Nu Smile also provides in-house, state-of-the-art technology that adds an extra layer of ease as well as delivering beautiful results.
By implementing computer-aided design and computer-aided machining (CAD/CAM) since 2007, Dr. Kwan is able to design and build crowns and veneers in their own lab during the appointment.
“It works well with sedation patients and before they ‘wake up’ they have their new smiles,” he says. And because many anxious patients have an overactive gag reflex causing difficulty with impressions, the staff is able to use digital scanning to create virtual impressions for mouthguards while they wait.
A Formidable Team
The Nu Smile duo are valued members of their community as well as to their patients. Dr. Kwan appears regularly on the local news affiliates to discuss the latest CAD/CAM technology for dentistry. He also evaluates products for numerous dental companies and is a local mentor and instructor to other dentists in the region.
Dr. Hsu has received recognition from fellow healthcare professionals from across the country and is part of the National Registry for Executive and Professional Women in Healthcare. The National Consumer’s Research Council has touted Nu Smile as one of America’s Top Dentists since 2005.
As members of DOCS Education since 2008, the doctors regularly maintain their California Certifications for oral conscious sedation and are looking into adding IV sedation to their practice’s repertoire. Dr. Kwan feels sedation dentistry is under-represented in the wider community and hopes to see more dental professionals embracing the knowledge.
Like most practices, Nu Smile closed their office last March to anything but emergency treatment. Although the couple works together, their busy schedules meant they could go all day without seeing one another, but thoroughly enjoyed the time at home with their two children. Since reopening in June, Dr. Kwan is enthusiastic about the opportunity that downtime provided.
“We’ve grown by coming back with a razor-sharp focus on life and family, and it’s shown in our practice,” he says. They are currently booked out until May and he shares similar stories from other health practitioners. With the end of the pandemic hopefully in sight, people can take care of the things that matter.
“We’re very grateful,” Dr. Kwan adds, simply.