2022 Agenda

It's a TEAM Responsibility When Monitoring Sedation Patients

Dental team members who monitor sedation patients should routinely evaluate and refresh their care practices and processes to ensure the highest level of patient safety standards are in practice.

By Dr. Carol Wilson

Dental sedation services rely on the attention and training of each member of the office team. By working together, team members can jointly ensure the safety of patients, particularly registered dental hygienists and assistants. From time to time (and as required by state dental regulation), experienced sedation dentistry team members need to refresh their knowledge of monitoring responsibilities and patient safety to reduce the likelihood of mistakes.

Perhaps most important, don't sedate any patient without high quality monitoring equipment, such as the Edan X10 hospital-grade monitor. It's imperative for team members to know how to use this equipment and how to set all the alarms. Cardiac and pulmonary functions must be monitored and recorded every five minutes, or more often depending on state dental regulations. These functions include: blood pressure, pulse rate, heart rhythm, pulse oximetry (SpO2), and now end-tidal CO2 (capnography). In this article, we'll review this and other important factors to remember when monitoring sedation patients.

Establish Healthy Pre-Sedation Baselines

Before every sedation procedure, there should be a “sedation workup” appointment in which an extensive list of information is acquired.

The purpose of the pre-sedation workup appointment is to verbally ask patients about their health history, medication history, and social habits to uncover “Red Flag” conditions before they become a problem during sedation. How many times have you seen a patient check a medical condition such as high blood pressure, but list no medications to help control it? Conversely, how many times have you seen a patient deny any medical conditions, but list at least four medications that control medical conditions? In the first scenario, the patient does not receive regular medical care and is more than likely, non-compliant with regular physician visits. In the second scenario, the patient believes he/she no longer has the condition because medicines control the condition. Both are worth further discussions with the patient.

Red flags are warning signs that will alert you to conditions that may be potential management issues during sedation. Team members are crucial in helping to identify potential issues before they occur. Sedation paperwork is normally completed by clinical team members (assistants or hygienists), though the dentist is responsible for its accuracy. Front office team members assist in sending medical consultation or clearance letters to the physicians and to monitor for their return before scheduling patients for their appointments. Upon transfer to each department, the expectations the patient must meet to have a safe sedation appointment are reiterated in front of the patient and, at times, the caregiver as well.

Red Flag Conditions

Sleep Apnea/BMI: Patients with OSA, larger neck circumferences, BMI over 30, and Mallampati scores of III to IV require special consideration.

Hypertension: Increased blood pressure affects every one in three adults in the United States.

Date of Last Medical Exam: There are guidelines based on age and health of the patient as to when the patient should have seen a physician for medical evaluation.

HIV/Hepatitis: Although patients are not required to inform you if they are HIV positive, a list of their medications could clue you into some type of hepatic infection. Drugs that treat HIV often end in -ease.

Angina: When the heart muscle demands more oxygen than can be supplied to it, chest pain occurs. Angina is reversible ischemia. These patients are at higher risk for myocardial infarction (irreversible ischemia). It can be argued that sedation for these patients with stable angina is safer than treatment without sedation as sedation helps lower blood pressure, increases vasodilation, and therefore reduces cardiac workload.

Diabetes: It is estimated that one in 12 Americans is diabetic. Type 1 diabetics are insulin deficient and require insulin injections. Type 2 diabetics have tissues that are insulin resistant. A baseline blood glucose reading should be obtained for diabetics at the sedation workup visit. The patient should be asked about their most recent hemoglobin A1C value. Hemoglobin A1C is an average blood sugar level over a 90-day (three-month) period.

Respiratory Diseases: Asthma and COPD (chronic bronchitis and emphysema) are the most common respiratory conditions. Well-controlled asthmatics can be sedated, in fact, nitrous oxide could help prevent bronchospasm. Patients with COPD cannot.

Myocardial Infarction/Coronary Stents: After having a heart attack, a stent placed or undergoing other cardiac surgery, a patient should not have dental work for 6 months following the event. Emergency dental treatment should be referred to a specialist, usually an oral surgeon.

Pregnancy: Any woman in childbearing years should be asked if she is pregnant, trying to get pregnant, or could be pregnant at every appointment in the sedation process. The only time a sedative is indicated in pregnancy for dental treatment is if the emergency is life-threatening, such as an infection that is closing off the airway. However, that would not be treated in a general dentist’s office.

Advanced Age: Patients over 65 require special attention. Americans are living longer and therefore are more prone to hypertension (due to a loss of elasticity of the heart muscle and blood vessels), high cholesterol, diabetes, and heart disease. Elderly patients have decreased plasma proteins to bind to medications, so sedation drugs should be given at half the normal dose.

Cirrhosis: Cirrhosis is a hardening of the liver due to the formation of scar tissue replacing normally functioning liver tissue. The importance to sedation dentists is that a patient with cirrhosis will have decreased ability to biotransform or break down sedation drugs in the liver.

Polypharmacy: Not only are patients living longer, but they’re also taking more prescription medications. The increased number of medications a patient takes increases the possibility of drug-drug interactions. Be sure to check drug interactions with an online resource such as Lexicomp prior to sedating a patient.

Monitoring Systems

The office should invest in a high-quality monitoring device when practicing sedation. A device that can record vital signs every five minutes is paramount in providing safe sedations and may be required by your dental regulation. One such device is the Edan X. It is a hospital-grade monitor with the ability to physically print and digitally record heart rate, three lead heart rhythm, end-tidal CO2 and pulse oximetry.

Monitoring Heart Rate Throughout

It’s common for patients nervous about dental care (often a large portion of sedation patients) to experience elevated pulse rates at their appointment. As simple as it sounds, monitoring a patient’s heart rate is elemental in administering and monitoring sedative drugs.

Blood Pressure Changes During Sedation

Patients complaining of feeling dizzy, lightheaded, or blacking out may be suffering from low blood pressure. This can result in low blood flow to bodily organs and is common when a person is anxious or gets up out of the chair too quickly. Having a baseline blood pressure will aid in knowing if the patient’s blood pressure is normal for them.

Blood Oxygenation Levels

Blood oxygenation levels are the most important part of patient safety regarding the risk for negative patient impact during conscious sedation. Rarely is there a cardiac event in sedation. Most emergencies begin because the patient is not breathing. The loss of oxygen creates a cardiac emergency. Although most pulse oximeters typically have built-in alarms to alert teams to abnormally low blood oxygen levels, precautions must be taken to limit poor oxygenation to begin with, such as conducting a thorough physical exam to make sure the patient has cardiovascular levels within normal limits. Lower than normal oxygenation often indicates respiratory diseases or habits like smoking. Since conscious sedation patients are not intubated, this aspect is crucial in every procedure.

Monitoring End-Tidal CO2

End-tidal CO2 monitoring (ET CO2) is the ability to measure a patient’s exhaled carbon dioxide, which reflects the metabolic process of ventilation. Whereas oxygenation reflects the relative amount of oxygen that the blood is carrying, ventilation measures the result of oxygenation of tissues (cellular metabolism), which produces carbon dioxide as a byproduct. The waveform that is produced on the monitor is called capnography.

Another advantage of measuring ET CO2 versus SpO2, is that ET CO2 is a more real-time measurement.

Heart Rhythms

It takes cardiologists years to learn all the heart rhythms. You should know what a normal heart rhythm looks like so you can better recognize what doesn’t.

A Note About Blood Glucose Levels

Patients with a medical history of hypoglycemia or diabetes require an extra level of attention during all dental procedures, regardless of whether sedation is used or not. Be sure to watch the individual for signs of low blood sugar, such as sweating, heart palpitations, shakiness, headache, or feeling nauseous. Since any of these symptoms can also result from anxiety, be sure to conduct a thorough health history.

Annual Review for the Sedation Dentistry Team

From pre-treatment screening to in-chair monitoring and patient dismissal, team training and confidence in managing sedation cases is crucial to the success of patient care practices. All teams who work with sedation patients, particularly those who do so less frequently or haven’t had a refresher in best practices in over a year or more, must have a comprehensive review of their responsibilities and protocols to ensure industry safety standards, as well as dental regulations, are met. Likewise, frequent refreshers boost the confidence of the team and reassure practice management and doctors that patients are looked after properly.

The most efficient dental sedation teams are those who've trained every person in the office. Monitoring sedation patients is a team effort. Understanding that the most important steps in keeping patients safe are: maintaining consciousness and appropriate response to verbal commands throughout the appointment; detecting “red flags” before they become problematic; and using high-quality monitoring machines is vital to maintaining a safe and well-trained sedation team.

Author: Dr. Carol Wilson is a 2006 University of Kentucky College of Dentistry graduate with distinction. She is a DOCS faculty member and clinical instructor for the DOCS IV sedation program.

Fake News and the Dangers of Misinformation in Oral Healthcare

Americans – including your sedation dental patients – spend an average of two and a half hours a day on social media. However, the daily average for total time spent on cellphones is much higher, at five and a half hours.

The COVID-19 pandemic elevated everyone’s digital devotions, due in part to a constant cycle of breaking news, as well as the convenience of communication during lockdowns. Unfortunately, we’ve seen that anyone can post anything on social media, leaving us with an echo chamber and an infodemic. The repercussions are not only felt in politics, science, and public health initiatives but in oral healthcare as well.

"But I Googled it."

A 2018 study in Health Policy and Technology found that 40% of the most frequently shared health-related news on social media contains misinformation. And this inaccurate, misleading content was much more likely to be shared by users with "limited medical knowledge." Much of it consisted of unfounded and unreliable claims, plus anecdotal stories and fake reports meant to shock the reader, rather than providing them with facts.

“Health misinformation is a serious threat to public health. … Limiting the spread of health misinformation is a moral and civic imperative that will require a whole-of-society effort.” (“Confronting Health Misinformation”) — US Surgeon General Vivek Murthy

It's important to realize why false claims spread so quickly, and with such ease. Perhaps it's just human nature, but sensationalized and shocking stories attract our attention.

USA Today recently published a story about fact-checking a viral Facebook post that claimed "One root canal tooth can shut down 63% of your immune system.” It turns out this misinformation originated from a 2019 debunked theory documentary pulled from Netflix.

One can only imagine the alarm a story like that would evoke in an already fearful patient.

Social media can also be rife with harmful trends that are misinterpreted as legitimate dental care, such as brushing with activated charcoal and do-it-yourself dentures. It’s often difficult to differentiate facts from feelings when social media algorithms mix fake news content in with personal updates and internet bots proliferate platforms.

Sedation Misinformation

Common myths about sedation dentistry can be further blown out of proportion when a nervous patient goes to the internet for dental advice. Some false narratives about sedation include the belief that they’ll be put into an unconscious state and lose all control. Others fear that nitrous oxide will make them giddy and impel them to say or do inappropriate things while under sedation.

Another misconception is that sleep dentistry is just for patients with severe anxiety, when sedation dentists understand what a time- and money-saver different methods of sedation can be.

With so many Americans getting their news and yes, healthcare advice from social media, it's crucial for dentists to fully understand the dangers of health misinformation online.

What You Can Do

The good (not fake) news is, that dentists and hygienists are in a strong position to counter the infodemic in several ways:

Engage with patients. Take time at each visit to listen to their concerns and understand what motivates their oral health decisions.

Maintain a social media strategy. Dentists can use their digital presence to create a professional space where patients can find truthful information to counter dangerous trends and misinformation. Invest in reputation management if necessary to deal with false negative reviews.

Connect patients with SedationCare.com. The FAQ page will provide answers and bust myths for those interested in doing their own research.

It’s become far too easy for patients to find misinformation regarding their oral health. Sedation dentists can make it easier for them to find the truth and get the care they need.

The DEA and the Sedation Dentist: Proper Disposal of Controlled Substances

Addressing issues and common questions around proper disposal of controlled substances for dental practices by DOCS’ Legal Counsel, Kate Marcus.

By J. Kathleen Marcus, Esq.

On any given day, a sedation dentist may be faced with one or all of the following scenarios:

• A check of inventory uncovers that there are pills that are now past their expiration date.
• During a procedure, a sedative pill accidentally falls on the floor.
• A patient responds adequately to half of a sedative pill, leaving an unused half pill.

I will quickly respond to the first thought­–NO; none of these pills can be used on future patients. The dentist is however left with controlled substances he or she cannot use on future patients. What now, and why can’t the sedation dentist destroy the unusable pills in the office? Because federal law has limited permissible destruction of controlled substances to a requirement beyond the abilities of the average dentist office. Under the DEA Final Rule for the Disposal of Controlled Substances (2014), which implements the Secure and Responsible Drug Disposal Act of 2010, to destroy a controlled substance it must be made “non-retrievable.”

“Non-retrievable means, for the purpose of destruction, the condition or state to which a controlled substance shall be rendered following a process that permanently alters that controlled substance's physical or chemical condition or state through irreversible means and thereby renders the controlled substance unavailable and unusable for all practical purposes. The process to achieve a non-retrievable condition or state may be unique to a substance's chemical or physical properties. A controlled substance is considered "non-retrievable" when it cannot be transformed to a physical or chemical condition or state as a controlled substance or controlled substance analogue. The purpose of destruction is to render the controlled substance(s) to a non-retrievable state and thus prevent diversion of any such substance to illicit purposes.”

Title 21 Code of Federal Regulations, §1300.05.

While acceptable destruction until 2010 included crushing the pills and mixing the powder with kitty litter, this result is no longer considered “non-retrievable.” Flushing controlled substances (and other pharmaceuticals) down the toilet has been outlawed by environmental protection legislation. When asked for more guidance about what “non-retrievable” meant, the DEA released the following clarification:

“To comply with the DEA regulations when disposing of a controlled substance, registrants must use a method which renders the substance "non-retrievable" (21 CFR 1317.90(a)) and otherwise complies with relevant law and regulations. The term "non-retrievable" is defined in a results oriented manner as DEA requires the substance to be permanently rendered to an unusable state. 21 CFR 1300.05. The performance standard is that the method irreversibly renders the substance such that it cannot be transformed to a physical or chemical condition or state as a controlled substance or controlled substance analogue. Thus, regardless of whether the product claims to render controlled substances non-retrievable, to comply with the DEA regulations, a registrant that disposes of a controlled substance must use a product or method that actually does render the controlled substance non-retrievable within the meaning of the DEA regulations. Much like DEA does not evaluate, review, or approve the specific processes or methods utilized to produce, synthesize or propagate a controlled substance, DEA will not evaluate, review, or approve the processes or methods utilized to render a controlled substance "non-retrievable," as long as the desired result is achieved. EO-DEA178, October 5, 2020”

As helpful as United State Supreme Court Justice Potter Stewart’s famous definition of pornography (“I know it when I see it”[i]), the only method of destruction to which the DEA has given an approving nod is incineration. A dentist may incinerate controlled substances on premises but must maintain record of precisely what was incinerated with Form 41. When, where, why, by whom, and it’s strongly recommended this is done in front of at least two witnesses with the full knowledge of the local DEA office.

While companies advertise liquids into which pills might be dropped and rendered compliantly destroyed, no product has ever been approved by the DEA as capable of rendering controlled substances “non-retrievable.”

Ultimately for most DEA registrant dentists, there are two methods to legally disposing of expired or otherwise unusable inventory.

REVERSE DISTRIBUTOR: a company authorized by the DEA to collect and destroy medication which for any reason you cannot use it. There are many reasons why some of your drug inventory must be destroyed: a recall by the manufacturer, the drug expires, the drug is damaged (dropped on the floor, for example). Reverse distributors handle all the paperwork, collection, storage, return, or destruction of the drug, depending on what is legally required.

FORM 41: You can use Form 41 if you want to ask for the help of the local DEA field office each time you have drugs in your inventory that, for whatever reason, cannot be used. The direction you get from your field office varies depending upon the field office and the reason the drug cannot be used (expired, recalled, damaged). This process is much more time consuming than using a reverse distributor.

A reverse distributor is a company with which you contract for the destruction of controlled substances that are expired or otherwise unusable. A contract with a reverse distributor eliminates the need to file a Form 41 or to deal directly with the DEA each time you wish to dispose of inventory.

While the DEA does not recommend a particular reverse distributor, it does issue a list of approved reverse distributors.

However, reverse distributors charge for their services, and for dentists who have a “small” quantity of drugs to dispose, a DEA Form 41 may be the most cost-effective route. First, inform your regional DEA Field Division that you are in possession of expired Schedule IV Controlled Substances that you wish to dispose. Upon review of your completed form by your local field office, the DEA will send you instructions on how to destroy the controlled substances. The instruction may be to surrender the drugs to your local police department, to a particular drug take-back program, or to surrender them to the DEA Officer in Charge. Once the controlled substance has been destroyed, the remainder of Form 41 needs to be completed and returned to your local DEA Field Division.

Keep in mind that in some states, dentists are required to use reverse distributors either because state law requires it[ii] or because the local DEA office does not have the capacity to assist individual practitioners with drug destruction.

The choice of whether to use a reverse distributor or Form 41 to dispose of controlled substances is (mostly) yours.

Regardless of how you dispose of controlled substances, recordkeeping for sedation dentists is easier and more streamlined by using DOCS DEA Drug Log Book (free to DOCS members).

[i] Jacobellis v. State of Ohio, 378 U.S. 184 (Potter, J. concurring) (1964). https://www.law.cornell.edu/supremecourt/text/378/184

[ii] In Iowa, the regulations of the Iowa Board of Pharmacy requires that: “Any person or business registered to handle controlled substances in Iowa shall dispose of such drugs as follows:

The responsible person shall contact and utilize the services of a DEA-registered and Iowa-licensed disposal firm (reverse distributor) OR

The responsible person may contact the assigned compliance officer for their county for assistance or direction regarding the disposal of the drugs.” https://pharmacy.iowa.gov/controlled-substance-disposal-0

Author: J. Kathleen Marcus, Esq., is Strategic Dentistry’s General Counsel and DOCS Education's Regulatory Counsel. Uniquely qualified to advise and advocate for sedation dentistry, she draws on a healthcare law background that started over three decades ago. A 1988 graduate of Temple University School of Law, she was Research Editor of the Temple Law Review; she previously attended Bennington College and has a B.A. in Philosophy. Pennsylvania licensed, Kate spends her free time practicing sustainability in her suburban Philadelphia garden and on her land in the Guatemalan highlands around Lake Atitlan.

2022 Safe Sedation Dentist of the Year: Nilo Hernandez, DDS

Many of the dentists considered for the 14th Annual Safe Sedation Week Dentist of the Year have long and full careers in the industry, but it’s unlikely that any of them started in elementary school, as 2022 honoree Nilo Hernandez, DDS did.

When the Miami, FL native was a child, he spent many after-school hours at his uncle’s dental office. To keep the 8-year-old busy, his uncle would give him some wax and a Bunsen burner with instructions to make something – and not burn the building down. Young Nilo was soon receiving compensation for his impressions and denture repair work.

“I was the richest kid on the block,” laughs Dr. Hernandez, recalling how much candy $20 could buy back then.

Realizing he liked working with tools, Dr. Hernandez went to dental school after a brief stint as an auto mechanic. He received dual degrees, one foreign and the second at Creighton University in Nebraska in 1991, where he planned to settle down before his father convinced him to return to Florida.

Smilecreator of Naples is Dr. Hernandez’s current practice where he offers a large array of holistic dental services, including implants, root canals, oral surgery, periodontal therapy, and biological technology. The clearest common denominator of his many treatment options is easily sedation.

Sedation Advocate

Dr. Hernandez was one of the first students to join DOCS Education in 2001, an organization dedicated to sedation safety, and he can’t endorse the practice of sedation dentistry enough.

“Somebody has got to be sedated – either them or me,” he jokes before adding simply, “It helps me do better dentistry.” From reducing salivary flow to eliminating time-expending conversation, he finds everything good about sedation, especially with holistic patients who tend to be more “involved.”

In 2018 Dr. Hernandez added IV sedation to his arsenal and is unequivocal in his stance on the service.

“I tell every single person (dentist) the single most relevant thing they can do in their practice – short of opening the doors and having electricity for the lights – is to become certified in IV sedation.” He adds that, “The money is secondary, but handle the fear and they’ll get more patients.”

Dr. Hernandez is not only passionate about his patients but helping other dentists as well. In addition to heading five or more practices over the years, he has also been active in teaching, lecturing, and publishing articles. Being bilingual in English and Spanish has allowed him to speak at seminars around the world on topics such as prosthetic rehabilitation. His tenures as Chairman of Dade County Dental Research Clinic and Co-Director of the Robert Morgan Dental Implant Institute have expanded implant dentistry in his own practice and countless others.

A Natural Progression

Dr. Hernandez’s interest in holistic dentistry, and the belief that the whole body is connected, has resulted in a natural progression to other businesses in the dental industry. These ventures include biologics research and implants, as well as a new office in Alabama where he’ll be taking over research and documentation on techniques and systems he developed. Although he’s had a home in Alabama for a few years, he’ll soon be relocating there full-time.

“I’m supposed to be retiring, but that’s kind of a misnomer,” says Dr. Hernandez, explaining that he has sold the Naples practice and will be stepping away in July.

The office will remain open with a new dentist in place, and he is hopeful that they will bring the same enthusiasm for and experience with sedation dentistry that he has. Both of Dr. Hernandez’s long-time assistants have taken the required training to be IV-certified as well.

Despite the ongoing pandemic, the last two years have been the practice’s busiest yet, and he estimates they performed over 2,000 implants in that period. Dr. Hernandez contends that dentists took mitigation steps other professions didn’t, and this contributed to their success and safety.

Do Good

Although recent health issues have contributed to Dr. Hernandez taking a step back – from scuba diving, that is – he is looking forward to spending more time lakeside in Alabama with his wife and two grown children and enjoying his photography hobby.

When asked about the rewarding aspects of his work, it’s not surprising that the dentist who first claimed he got his degree from eBay, says, “We have a lot of fun.”

He adds, earnestly, “I love taking care of patients the right way and them having a spectacular experience, then thanking me. Do good and it just comes back to you.”

Great advice, Dr. Hernandez.