2014 Agenda

Pediatric Sedation Standard of Care

John P. Bitting, Esq. Regulatory Counsel

By 2020, children under the age of 18 will make up 25% of the American population. What's more, the CDC states that caries are "the most common chronic disease of children aged 6 to 11 years and adolescents aged 12 to 19 years."

Most dentists don't like to think in terms of inevitabilities. It makes perfect sense: your career is built upon the ability to control and prevent problems - whether as simple as filling a small cavity or learning a new skill set to address the influx of a new demographic.

Pediatric sedation dentistry has risen to the surface as one of, if not the single most practical, safe and effective skill sets with which to address the increase of both the 0-18 population and the proportional increase of caries.

Why? Because it directly tackles some of the largest hurdles the caries crisis and rising demographics both pose. The level of efficiency pediatric sedation provides helps damper both the caries crisis while providing efficient care and reduced anxiety for the rising number of children in this country.

Accordingly, DOCS Education has chosen to devote this year's Sedation Safety Week exclusively to pediatric sedation dentistry. It is vital that pediatric sedation dentists be thoroughly and properly trained, and therefore, DOCS Education also offers Pediatric Sedation Dentistry (PSD) and Pediatric Advanced Life Support (PALS) courses to provide general and pediatric dentists alike with a firm pediatric sedation knowledge base.

PSD is a 3-day course that provides a comprehensive foundation of the drug and nitrous protocols to provide safe, effective sedation dentistry. PALS is a 3-day course that provides dentists with the knowledge to recognize and respond to pediatric emergencies inside and outside the dental office.

In conjunction with this year's Sedation Safety Week, five $1,000 educational scholarships will be awarded to dentists who work in the non-profit sector to facilitate their ability to receive advanced training in pediatric safety. Have someone deserving in mind? Submit nominations to Nominations@SedationSafetyWeek.com

So why, you may be wondering, is this training so vital?

Picture this:

Let's say you're a GP who has decided to provide access to care to pediatric dental population. Let's say for the sake of argument they are between the ages of 5 and 12 years old. You remember learning something in dental school—from professors who haven't touched a patient in 30 years—about chloral hydrate being the sedative of choice for pediatric "patient management." You read something on, let's call it, Dentistville, about combining one or two other drugs with your sedative of choice in order to manage those very young or more difficult children.

You read. You heard. You read. You heard.

You receive postcards in the mail. You see magazine ads. You stroll past the AGD or ADA annual meeting booth of a sedation training provider. You ignore all of these.

Then, perhaps in response to your ad or website, a three year old boy and his father present to your office for a crown. You recommend sedation for this procedure. You speak confidently about what you've read and heard, but never learned nor practiced, about pediatric sedation.

In the middle of the procedure, the vital signs monitor indicates a steep decrease of the child's oxygen saturation, he loses consciousness, stops breathing, and turns blue. Do you know what to do? You know CPR, right? So does every dentist in America.

The key to pediatric sedation—or sedation for any age—is knowing who to sedate and not to sedate. This takes special training. Once you learn who is okay to sedate, then you need to learn the science, procedure, and protocols behind safe but effective sedation. This takes special training. Caring for pediatric patients means responding appropriately to the needs of the parents. This takes special training.

There is a caries crisis in the United States, amongst other childhood oral issues. But we don't have enough pediatric dentists to serve the vastly growing and underserved pediatric dental population. General dentists must step up. But they must NOT step up blindly.

Learn.

Learn to assess. Learn to select. Learn to manage. Learn the procedure. Learn the protocols. Learn to monitor. Learn the equipment. Learn the drugs. Learn the follow-up. Learn to care. They'll keep coming back.

It's a shame that only seven states require pediatric-specific training before a dentist—any dentist—can give a kid a little sedative to calm his or her nerves before sticking a needle in that kid's mouth.

On the other side of the regulatory spectrum, six states require that dentist to have an intravenous sedation permit before providing even a miniscule amount of oral sedative to pediatric patients. FYI, most if not all of the IV sedation training programs cover adults only, not kids. This is what I refer to as "regulatory overkill."

DOCS Education's pediatric faculty recommend the following:

1. Patients age 5 to 12 years.
2. ASA I only. Otherwise, refer them to a specialist or, if you have hospital privileges, provide their dentistry there while an anesthesiologist provides the sedation.
3. DOCS's pediatric faculty teach a comprehensive 25-hour Pediatric Sedation Dentistry ("PSD") course that also has a two-way, live-feed live patient experience. It's really quite state-of-the-art.

Do you know what to do in an emergency?

1. The PSD course covers airway management and emergencies, but the faculty are all PALS-certified and strongly recommend that dentists providing pediatric sedation get PALS-certified as well
2. Have the appropriate monitoring equipment and emergency drugs. The following list is from California, one of those seven states that requires pediatric-specific training for pediatric sedation:
3. Operatory large enough for patient and a team of three (3) to move around;
4. Table or dental chair firm enough for CPR;
5. Adequate lighting including backup;
6. Suction including backup;
7. Portable positive pressure 02 delivery system
8. Inhalation sedation equipment, if used in conjunction with oral sedation;

Emergency equipment:

1. Oral airways (age-appropriate sizes)
2. Sphygmomanometer;
3. Precordial or pretracheal stethoscope;
4. Vital signs monitor with pulse oximetry

Emergency drugs:

1. Epinephrine
2. Bronchodilator (e.g. albuterol inhaler)
3. Appropriate drug antagonists (e.g. flumazenil)
4. Antihistamine (e.g. benadryl or hydroxyzine)
5. Anticholinergic
6. Anticonvulsant (e.g. Valium®)
7. Oxygen
8. Dextrose or other antihypoglycemic (e.g. Glucogel)

Ancillary items, not required in rules, but DOCS and others consider standard of care:

1. Recordkeeping: health history form, consent forms, companion instructions, anesthesia chart, written emergency protocols appropriate for BLS or PALS
2. Capnography
3. AED

This is a small price to pay for doing things the right way.

Two Role Models Honored with DOCS Education's 2014 Sedation Dentist of the Year Award

A general dentist who treats children at a nonprofit center that serves immigrants and a pediatric dental specialist who works with the handicapped have been named co-recipients of the 2014 DOCS Education Sedation Dentist of the Year Award.

The annual honor recognizes dentists who exhibit outstanding commitment to safety and excellence. In conjunction with the 6th Annual Sedation Safety Week, March 17 to March 21, this year's award places a special emphasis on dentists who care for children and adolescents.

This year's co-winners are Dr. Richard Gesker, Chief Dental Officer of Dental Services at Mary's Center in Washington, D.C., and Dr. Linda Blann, of Progressive Dental Care Center in Hannover, PA.

The Sedation Dentist of the Year awards and Sedation Safety Week are organized by DOCS Education, a continuing education and membership organization. DOCS Education is a pioneer and globally recognized leader in the training of oral health professionals in the effective application of sedation dentistry techniques and protocols.

Dr. Richard Gesker, a general dentist, was chosen due to his extensive, exceptional contributions to pediatric dentistry. These include his current job as the Chief Dental Officer and Director of Operations at the nonprofit Mary's Center for Maternal & Child Care, Inc. Mary's Center provides primary care and enabling services to underserved immigrants from Latin America, the Caribbean, Africa, the Middle East, and Asia.

Dr. Gesker also is a member of the adjunct faculty of Temple University, Kornberg School of Dentistry in Philadelphia, PA.

His past accomplishments include serving as the director of Simply Beautiful Smiles of Doylestown, where he implemented a practice management and care delivery model designed to optimize oral health, customer service and the efficient use of overhead into each of the company's newly-acquired dental practices.

From 2003-2006, Dr. Gesker served as Lieutenant for the US Navy Dental Corps, during which he held a multitude of responsibilities, including work in Oral Diagnosis, Digital Radiography, Rotary Endodontics, Soft Tissue and Partial Bony Impactions, Fixed and Removable Prosthodontics, Posterior Composites, Cosmetics and Minor Orthodontics and sedative care.

Today, Dr. Gesker maintains the care delivery and management model for all administrative and clinical staff at Mary's Center. He enjoys coordinating care between general dentists, but especially likes to provide same day, immediate care. His unusually comprehensive educational background includes attending both Temple University's School of Dentistry and School of Business where he received both a DMD and an MBA, respectively.

Dr. Roger Sanger, a member of the DOCS Education faculty and lead instructor for Pediatric Sedation Dentistry, said of Dr. Gesker: "I commend Dr. Gesker for his commitment not only to children but to treating those children with the most modern pharmacotherapeutics available."

Above all, Dr. Gesker routinely delivers high-quality dental care. His unwavering and longstanding commitment to excellence in pediatric dentistry made him a clear choice for the 2014 Sedation Dentist of the Year award.

For the first time since 2009, when DOCS Education began honoring a Sedation Dentist of the Year, the judging panel felt the contributions of two outstanding role models merited simultaneous recognition.

This year's co-recipient, Dr. Linda Blann has provided patient care for children, adolescents and the handicapped in the greater York and Adams County (Pennsylvania) region since 1992, and has been a pediatric specialist since 1996. She currently works at Progressive Dental Care Center in Hanover, PA—the practice she founded with her husband, Dr. Terry Gordon.

Dr. Blann is especially interested in providing pediatric specialty care for very young or very anxious children and special needs children requiring general anesthesia or sedation.

Certified in CPR, PALS (Pediatric Advanced Life Support) and ACLS (Advanced Cardiac Life Support), Dr. Blann also holds a Pennsylvania Restricted I Sedation license to provide nitrous oxide as well as oral or IV sedation.

Dr. Blann's background with children is not only extensive but comprehensive: prior to beginning her dental career Dr. Blann spent more than a decade as a teacher of elementary and learning disabled students.

In 1992, Dr. Blann received her Doctor of Dental Surgery from the University of Maryland at Baltimore. She then completed her pediatric specialty training at the University of Maryland School of Dentistry and received her Certificate in Pediatric Dentistry in 1996.

Keeping with her longstanding commitment to aid children, Dr. Blann traveled to the remote mountain villages of the Dominican Republic to care for both children and adults who rarely receive dental care.

Dr. Blann continues to improve her skills by taking more than 50 hours of continuing education per year. Her affiliations with professional organizations include the American Academy of Pediatric Dentistry, the American Dental Association, the Pennsylvania Dental Association, the Pennsylvania Academy of Pediatric Dentistry and DOCS Education, in addition to others.

Founded in 1999, DOCS Education has consistently ranked patient safety and comfort as its top educational priorities. For the past six years, Sedation Safety Week (SSW) has provided dentists with tools, materials and encouragement to review their process of patient selection, patient monitoring, staff training, staff drills, and emergency preparedness. SSW activities are always free and open to all oral health professions.

7-Step Sedation Dentistry Safety Checklist: A Review of Protocols, Equipment and Supplies

Ensuring your patients have a safe, comfortable and effective dental appointment is vital. This 7-Step Sedation Dentistry Safety Checklist reviews key steps you can take to achieve just that.

What's more, this checklist is designed specifically for dentists and oral health professionals like yourself who have received specialized training in sedation safety.

7-Step Safety Checklist:

1. Check all of your monitoring and emergency equipment this week to ensure it is up to code and in working order. This should include your pulse oximeter, blood pressure monitor, automated external defibrillator and supplemental oxygen delivery system.
2. Make note of the expiration dates of all your oral sedation medications, emergency drug kit medications, AED pads and AED battery. Continue your weekly checks and documentation of the oxygen levels in your emergency tanks. Place orders this week for any items within 90 days of expiration and restore emergency oxygen tanks to full pressure.
3. Make certain your office is equipped with an intraosseous infusion system to help you run an IV line in an emergency. This is especially important if you do not have IV certification or are required to have equipment. This equipment provides immediate vascular access for delivering emergency life-savings drugs. Review procedures for using the system.
4. Run an emergency drill this week and schedule routine practice drills for the months ahead. This is a team-wide effort and everyone should participate. Review the locations of all emergency drugs and equipment and make sure they are easily accessible.
5. Review your patient intake procedures with all team members specifically for all scheduled sedation dentistry patients. Always cross-reference your patient's medications, supplements, vitamins and herbs with the sedative and anesthetic medications you plan to administer. Use a comprehensive program, such as Lexi-Comp® drug software. If there are any doubts, confer with a patient's physician ahead of any treatment and document the conversation.
6. Be certain that everyone on your team has current CPR and/or ACLS (Advanced Cardiac Life Support) training. Sign up for a refresher course if necessary or if you feel it would be beneficial. Also, make sure everyone in the office knows how to operate a pulse oximeter and AED.
7. Register yourself and your team members for refresher courses or advanced training from a trusted and reliable educator, such as DOCS Education. Even those who regularly treat patients with sedation dentistry will benefit from reviewing the very latest safety protocols as well as previous course materials.

This checklist was created by DOCS Education, a leading sedation continuing education organization and the host of Sedation Safety Week (SSW). "Managing pain and anxiety are among dentistry's oldest challenges. Providing dental care with excellence and compassion is the mission of DOCS Education and the reason we take time annually to observe Sedation Safety Week," says DOCS Education's co-founder and SSW chairman, Dr. Michael Silverman. "It's a reminder that keeping emergency preparedness and safety skills current is critical to our patients and practices."

Tooth Faire: An Open House for Children and their Parents

Sedation Safety Week's grand finale takes place today! All across the nation, practices will be participating in our first annual Tooth Faire. This vibrant, family-friendly and educational event will include information for parents about what pediatric sedation entails, parent FAQs, handouts and of course—The Tooth Fairy will be present! What's more, attending children will be given the opportunity to fill out an application for their very own spot on the Tooth Fairy's "jr. dental assistant" team.

We encourage all participating practices to use today's event as a jumping-off point for continual communication about safety and good oral health! There is nothing more important than well-being—and opportunities like the Tooth Faire are vital for helping children develop positive, life-long perceptions of the dentist.

To all practices across the nation: thank you for participating in Sedation Safety Week and helping make this five-day learning experience our most vibrant and thorough yet.

Outstanding Dentists Selected for $1,000 Pediatric Sedation Dentistry Scholarships

In conjunction with the Sixth Annual Sedation Safety Week (SSW), four $1,000 educational scholarships were awarded to dentists who work in the non-profit sector. We are pleased to announce our scholarship winners have been selected. These outstanding dentists have all displayed an exceptional commitment to safety and excellence in pediatric dentistry:

• Dr. Arnold Cullum of Denver, CO
  
• Dr. Rabeh Ebeed of Derry, NH
  
• Dr. Brad W. Hester of Bend, OR
  

These $1,000 scholarships will help facilitate their ability to receive advanced training in pediatric safety by attending DOCS Education's Pediatric Sedation Dentistry course. This three-day, comprehensive course provides clinicians with the foundational skills to begin implementing pediatric sedation into their practices and will help these dentists continue on their journey of providing children around the nation with the dental treatment they need and deserve.