explorer Keystone Winter 2022-23 The Official Publication of the Pennsylvania Academy of General Dentistry Inside... Nitrous Oxide/Oxygen Systems: Importance of Service and Inspection Preparing for a Medical Emergency Involving Anesthesia The New Moderate Sedation Review of Concept: Anesthesia as a Spectrum Criteria for Selecting an Anesthesia Provider for the Office Based Setting 4 6 12 9 14
ii www.pagd.org President (2023) Katherine Dangler, DDS, MAGD Altoona, PA dentistaltoona@gmail.com President-Elect (2023) Carl Jenkins, DDS, MAGD Watsontown, PA drjenkins@windstream.net Vice President (2023) Amanda Sonntag, DMD, FAGD (2023) Wyomissing, PA sonntag.amanda@gmail.com Immediate Past President (2022) Raymond Johnson, DMD, MAGD Warren, PA rayjj13@gmail.com Secretary (2023) Ann Miller, DDS, MAGD Chambersburg, PA ann@millerfamilydentistry.net Treasurer (2025) Eric Shelly, DMD, MAGD West Chester, PA ericshelly@verizon.net Region 3 Regional Director (2025) Raymond Johnson, DMD, MAGD Warren, PA rayjj13@gmail.com Region 3 Trustee (2025) Michael Kaner, DMD, MAGD, JD Feasterville-Trevose, PA trevosedental@aol.com Editor (2024) Alex Frisbie, DMD Mechanicsburg, PA alexfrisbie3@gmail.com BOARD OF DIRECTORS Joseph Chipriano, DMD, MAGD (2024) Pottsville, PA joechipriano@comcast.net Kyle Dumpert, DMD, MAGD (2023) Bedford, PA radiantdentalofbedford@gmail.com Dejan Golalic, DMD, MAGD (2025) Carlisle, PA dgolalic@yahoo.com Melissa DellaCroce Grosh, DDS, FAGD (2025) Lilitz, PA mdellacrocegrosh@gmail.com Kerry Johnson, DDS, FAGD (2023) Lancaster, PA kerryjohnsondds@verizon.net David Killian, DMD, MAGD (2025) Carlisle, PA davidkillian3737@gmail.com PEAK Track I Chair Brad Strober, DMD, MAGD Edison, NJ bstrober9@aol.com PEAK Track II Chairs John Gustafson, DMD, MAGD Hershey, PA joey625@comcast.net Eric Shelly, DMD, MAGD West Chester, PA ericshelly@verizon.net Editor Alex Frisbie, DMD Graphic Designer Hiakato Draconas Contributors John Brewer, EMT-P Taylor Chock-Wong, DDS Matthew Cooke, DDS, MD, MPH Kevin Croft, DDS Katherine Dangler, DMD, MAGD Alexander DeBernardo, DMD Amit Khetan DMD, RN Amy Maya, DDS Steve Neidlinger, CAE Michael Typinski Keystone Explorer is owned and published quarterly by the Pennsylvania Academy of General Dentistry. The purpose of the journal is to print timely and appropriate material to stimulate, educate, inform, and recognize the general dentists of Pennsylvania in their pursuit of professional excellence. Views expressed in this publication are those of the authors and do not necessarily reflect the opinion of the Academy. Deadlines for material to be printed are: March, June, September, and November. Keystone Explorer reserves the right to edit or reject any article submitted for publication. Subscription is included in the annual dues of PAGD members. Domestic subscriptions are available to non-members at $26 per year. Subscription queries go to the Executive Director, Steve Neidlinger, 4076Market St, Ste 209, Camp Hill, PA 17011. www.pagd.org © 2023 PAGD. All rights reserved. Pennsylvania Academy of General Dentistry Board of Directors Keystone explorer The Official Publication of the Pennsylvania Academy of General Dentistry
KeystoneExplorer | Winter 2022-23 1 from the editor’s desk | Pain is a powerful motivator. Considering that one of the most common chief complaints from patients is “I’m in pain,” preventing and alleviating discomfort is perhaps the fundamental service dentists provide as a profession. We’re typically an empathetic group; we ourselves feel stress when a child is crying from fear or when we miss a block. Frankly, if we aren’t managing a patient’s anxiety and physical pain to the best of our ability, we are coming up short. In school, an anesthesia resident I shadowed said the most powerful drug he used was “vocal anesthesia.” What I dismissed as a joke back then I have found to be true over and over again. I have gained the trust of many patients who were previously referred for sedation by simply being calm, listening, and talking them confidently through an appointment. The concept that the subjective experience of pain entails more than just nociception and includes anxiety, sights, sounds, and physiologic stress should be ever-present in our minds. The experience of pain is highly individualized. Forming a meaningful relationship with each patient is the best way to determine what he or she needs to be comfortable. Knowing the limitations of your training, licensure, and preparedness is a responsibility all of us have when offering services to our patients. From local anesthesia to moderate sedation, we need to balance anxiolysis and pain relief with safety. Every medical emergency arising from improper administration of anesthesia is a blight on our profession. Having a clear goal for anesthesia and working towards that goal within the parameters of our ability is what has made dentists stand out as leaders in pain management from the days of Horace Wells. Let us all make safe patient comfort our specialty. More than Numb: Pain and Anxiety Control in Dentistry Alex Frisbie, DMD “The experience of pain his highly individualized. Forming a meaningful relationship with each patient is the best way to determine what he or she needs to be comfortable.”
2 www.pagd.org References 1 T. Flanagan, M. Wahl, M. J. Schmitt, J. Wahl. 2007. Size doesn’t matter: needle gauge and injection pain. Gen Dent. 55(3):216-7. 2 J. H. Goodchild and M. Donaldson. 2016. Comparing the pH Change of Local Anesthetic Solutions Using Two Chairside Buffering Techniques. Compendium. 37(5): e6-e12. It’s Not the Needle; It’s the Anesthetic Kit Dangler, DDS, MAGD Your peers may describe you as the best general dentist in the area. However, if your patients receive painful anesthesia injections, they are not likely to think you are a good dentist. Many dentists believe that using a larger diameter needle, say a 25 gauge, will result in a more painful injection. Flanagan and others (2007) are among those who say this is just not true. It is the acidity of the anesthetic that patients feel during the injection. For this reason, I was happy to be introduced to Citanest at a PEAK meeting. I now use Citanest daily. Plain Citanest 4% has a pH of 6.0–7.0. You remember that water is neutral with a pH of 7.0. The neutral Citanest anesthetic does not burn when being injected. You can produce comfortable soft tissue anesthesia. Of course, the first part of a comfortable injection is thoroughly drying the tissue with gauze before applying the topical. After the topical application, I deposit 1/4 carpule of Citanest plain 4%. I follow this injection with either lidocaine with epinephrine for a block or septocaine with epinephrine for an infiltration. With the extra preparation of the Citanest, the patient cannot feel either the needle penetration or the deposition of the acidic solution. Table 1 shows the differences between the pH values of different anesthetics (Goodchild and Donaldson 2016). As you know, the lower the pH, the stronger the acid. No discussion of comfortable anesthesia is complete without mentioning “The Wand.” The Wand, a computer controlled dental anesthetic delivery system, is my rescue tool. Occasionally, we all have a tooth that is not completely numb. Then, I will use The Wand on the PDL setting. I usually place the needle in the PDL at the buccal line angles of the tooth. A couple drops of the additional anesthetic from The Wand produces profound anesthesia. “However, if your patients receive painful anesthesia injections, they are not likely to think you are a good dentist.” LOCAL ANESTHETIC SOLUTION* DRUG LOT NUMBER pH LEVELS FROM THE MANUFACTURER† 2% Xylocaine 1:100,000 epinephrine Lidocaine D01001A 3.3 to 5.5 2% Xylocaine 1:50,000 epinephrine Lidocaine D00937D 3.3 to 5.5 4% Articadent 1:100,000 epinephrine Articaine D01020B 2.7 to 5.2 4% Articadent 1:200,000 epinephrine Articaine D01035B 2.7 to 5.2 4% Citanest 1:200,000 epinephrine Prilocaine D01042A 3.3 to 5.5 4% Citanest Prilocaine D00945A 6.0 to 7.0 3% Polocaine Mepivacaine D01034A 4.5 to 6.8 Local Anesthetic Solutions Tested *Local anesthetic solutions supplied by DENTSPLY Pharmaceutical. †Information provided by DENTSPLY Pharmaceutical; pH levels from the manufacturer indicate a range of pH values that outgoing preparations must fall within to be acceptable for sale. TABLE � | president’s message
KeystoneExplorer | Winter 2022-23 3 executive director’s message | Exciting Times at PAGD Steve Neidlinger, CAE Too many association executives dread the strategic planning session. Most association staff just want to know what buttons to press and be provided the time necessary to whittle down their inbox. But there is value to a good strategic plan. It allows me to focus my time on priority projects to fulfill PAGD’s strategic goals, and to adapt to the evolving needs of PAGD members. This summer, the PAGD board developed a three-year strategic plan and finalized its measurable action steps in late 2022. The last strategic plan was derailed largely by pandemic, but I feel this new plan concentrates our time and resources under a new and encompassing mission. Here are some of what we will undertake in 2023. • New mission: Assuming it is approved by the membership at large at the PAGD Annual Meeting in April, PAGD’s new mission will be to promote excellence and growth in dentistry through education and professional relationships. This is our north star. The strategic goals below are in pursuit of that. The pursuit of any other goals will be secondary. • Engage first-year members: Most associations identify engaging young members among its greatest challenges. But we need to know what new graduates identify as their greatest challenges before adapting PAGD programming to address them. Younger docs, you will likely hear from PAGD soon to convene focus groups in early 2023. We’re great listeners, and we want to hear what you have to say. • Provide mentorship opportunities: The experience of GPs who have worked in associateships, plunged into practice acquisition, or expanded their hand skills through education can help to guide a new graduate who is looking to do some of the same. And while social media can serve as a sounding board, the crowd on the other end of the line may not have the same priorities or sound advice that an experienced colleague might. A planning group of PAGD leaders, both young and…not-as-young…has already convened to come up with a framework for what we trust will forge a new PAGD mentorship network. • Social media content plan: You may have noticed that PAGD has already done a website overhaul to make both the user and the administrator experience easier and more esthetically pleasing. The development of a PAGD social media content strategy is also crucial. The strength of PAGD’s membership lies in its ability to learn and perform beautiful dentistry, and the thousands of followers in our social media reach need to know what opportunities participating in PAGD can afford you. A goal without a plan is a wish, and an association without a strategic plan is adrift in the ocean. This strategic plan sets a destination for PAGD. I look forward to working with PAGD leadership in building the roads to get to where we need to be by the time of its completion. “Most association staff just want to know what buttons to press and be provided the time necessary to whittle down their inbox. But there is value to a good strategic plan.”
4 www.pagd.org Q dentistry issues Nitrous Oxide/Oxygen Systems Importance of Service and Inspection By Michael Typinski (Systems Specialties, Inc.) I once went to inspect an oral surgeon’s office that was remodeled a few years prior. The office had a new nitrous oxide/oxygen manifold with an alarm and several new nitrous oxide units. Everything looked good and passed every test with no issues, but something just didn’t look right with the nitrous oxide/ oxygen manifold. I couldn’t put my finger on it at first, but then I noticed it. The nitrous oxide and oxygen lines from the manifold had been reversed. When I showed the doctor, he went pale because he understood immediately that for the past three years, he was delivering nitrous oxide to his patients in place of oxygen and delivering oxygen in place of nitrous oxide.
KeystoneExplorer | Winter 2022-23 5 dentistry issues Q Although rare, this was not an isolated incident. In the past twenty years, I have seen about five or six similar situations that could have resulted in serious injury or death. In most of these cases, the danger was not only to the patient but often to the staff as well. Even if your equipment is in good overall condition, usually there are small issues that require attention before they turn in to serious issues. Over the years I’ve noticed that a lot of people treat their nitrous oxide equipment as if it were another piece of office furniture. However, it’s important to realize that the nitrous oxide units in your office are considered medical equipment and as such are covered under federal, and in the case of Pennsylvania, state laws. The state of Pennsylvania, for example, requires that your analgesia units be inspected every two years. Generally speaking, once every two years is a good idea if your equipment is used infrequently, but in my experience, having your nitrous units serviced annually will prevent any small issues from turning into expensive large issues. Over time, your nitrous oxide equipment can fall out of calibration, develop leaks, or simply need minor parts to be replaced. These and other issues are best performed by someone who is qualified and trained to do so. There are certain things you can do yourself to prevent problems from occurring in the first place. • First, if you own a portable nitrous oxide unit that uses small nitrous oxide and oxygen tanks (E-Cylinders), then it’s important to replace the yoke washer that sits between the tank and yoke in order to keep any gases from leaking. • Second, do a visual inspection to make sure that all the rubber goods are not cracked, broken, or dry rotted. • Third, it’s important to make sure that everything is connected properly. Very often staff will remove the rubber goods from the unit to clean them, but later not reattach them back properly. • Finally, just be gentle and treat the nitrous oxide equipment with kid gloves. Certain manufacturers make their nitrous oxide equipment to be more durable than others so it’s to your benefit to use a light touch when using the flow control valves when adjusting flows. Of course, all of this is well and good, but I still haven’t mentioned the biggest issue that I see every day: Scavenging. Far too many dental offices either do not make any effort to scavenge their waste gases, or simply don’t have sufficient vacuum to scavenge their waste gases. Although this makes little to no difference to the patient, it can be a very unhealthy situation for the office staff. Each nitrous oxide unit in your office should have a scavenging flow control valve that indicates exactly how much of the waste gases are being evacuated. Simply having a dedicated line to remove the waste gases is not enough. Just like driving a car, you need to know how fast you are going. Scavenge too little and the staff is breathing in whatever your patient exhales. Scavenge too much and you may be pulling the nitrous oxide away from your patient. Most offices will have only one dedicated vacuum pump for all your needs. Frequently, I see situations where the vacuum pump isn’t powerful enough to handle the multiple tasks that it needs to perform. The bottom line is that you can never have too much vacuum in your office. Lastly, all waste gases should be removed from the building. Scavenging the waste gases out of the building may seem like common sense, but you would be surprised at how many offices scavenge their waste gases into the attic, basement, or storage closet. A lot of the problems I see every day are a result of regular wear and tear on the equipment due to normal use. However, as in the oral surgeon’s office, some problems are due to mistakes at the time of installation. Which brings me to my final point: if building a new practice or remodeling an existing one, make sure that the contractors, plumbers, electricians, etc. are qualified and licensed to work with medical gases. The last thing you want is to harm someone, yourself included. Michael Typinski is the primary operator at Systems Specialties, Inc. System Specialties is an independent dealer for Nitrous Oxide & Oxygen Analgesia equipment, calibration, testing, repairs, and sales. To contact Michael directly, call (215) 443-9293.
6 www.pagd.org Q dentistry issues Medical emergencies in the dental office related to anesthesia are something that all dentists need to be ready to manage. This article is intended to help you prevent these situations or be better prepared when they occur. There are various levels of anesthesia that need to be reviewed to help understand the various medical emergencies that can arise: PREPARING FOR A MEDICAL EMERGENCY INVOLVING ANESTHESIA By R. John Brewer, EMT-P 1. TOPICAL/LOCAL ANESTHESIA 2. ANXIOLYSIS/MINIMAL SEDATION: Defined as minimally depressed level of consciousness. Patients are able to maintain an airway and respond appropriately to verbal command physical stimulation. Pennsylvania law defines this as one drug at the manufacturer’s recommended dose (MRD) or nitrous oxide administration, for which Restricted II Anesthesia Permit is required. 3. MODERATE SEDATION: A drug induced depression of consciousness during which patients respond purposefully to verbal or light tactile stimulation. No interventions are required to maintain a patent airway, spontaneous ventilations are adequate, and cardiovascular function is maintained. If a provider administers oral sedatives above the MRD or combines with nitrous oxide, this meets the criteria of moderate sedation, for which a Restricted I Anesthesia Permit is required. 4. DEEP SEDATION/GENERAL ANESTHESIA: A drug-induced depressed level of consciousness during which patients may or may not be aroused to painful stimuli. The ability to maintain ventilatory function may be impaired. In Pennsylvania, this can only be provided by an oral surgeon or Dental Anesthesiologist who maintains an unrestricted anesthesia permit.
KeystoneExplorer | Winter 2022-23 7 dentistry issues Q I. RESPIRATORY A. FOREIGN BODY AIRWAY OBSTRUCTION B. EMESIS/ASPIRATION C. LARYNGOSPASM (MODERATE- DEEP-GENERAL ANESTHESIA) D. BRONCHOSPASM (I.E. ASTHMA) E. HYPERVENTILATION II. CARDIAC A. CHEST PAIN B. HYPERTENSION C. HYPOTENSION D. SYNCOPE E. CARDIAC ARREST III. ALLERGIC REACTIONS A. MILD B. MODERATE C. SEVERE IV. OTHER A. SEIZURES B. STROKE C. DIABETIC EMERGENCIES D. OVERDOSE While reviewing forms and taking vital signs, a cardiac, respiratory, and neurological exam needs to be completed. Simply asking, “Over the past several days have you experienced any dizziness, blurred vision, headaches, chest pain, shortness of breath?”covers the three main systems that would be a concern to the dentist. Good communication with the patient’s physicians is important to make sure the patient can tolerate the proposed treatment. The dentist should request the patients most recent history and physical, including medications, allergies, recent lab work, EKGs, and hospital admissions. Unfortunately, not all emergencies are going to be prevented. There are situations beyond the doctor’s control: Call it bad luck or Murphy’s Law, but emergencies will occur. The goal is to then recognize and treat before it becomes life-threatening. PREVENTION 1 This article is intended for the general practitioner who at times provide minimal sedation. The three key components in managing medical emergencies are: RECOGNITION 2 TREATMENT 3 Preventing medical emergencies in the office should be everyone’s goal. Dentists need to be aware of how at risk your patients are to medical emergencies. Every patient should have height, weight, and ASA status documented. Medical history forms need to be completed, reviewed, and updated with the patient at every visit. Vital signs need to be taken and recorded on every patient. This includes blood pressure, pulse oximetry, and pulse rate. The most common medical emergencies that the dental team needs to recognize and be prepared to manage can be broken down into four categories:
8 www.pagd.org Q dentistry issues The following drugs are what is recommended for the “basic drug kit”: ☑ ONE BOTTLE OF 81 CHEWABLE ASPIRIN ☑ ONE BOTTLE OF NITROGLYCERINE TABLETS ☑ ONE ORAL OR LIQUID DIPHENHYDRAMINE ☑ ONE INJECTABLE DIPHENHYDRAMINE ☑ APPLE JUICE BOXES ☑ ORAL GLUCOSE ☑ PROVENTIL INHALER ☑ 2.5MG ALBUTEROL/3CC SALINE ☑ EPI PEN ADULT ☑ EPI PEN JUNIOR ☑ NALOXONE ☑ FLUMAZENIL ☑ 3CC SYRINGES ☑ 1CC SYRINGES ☑ MUCOSAL ATOMIZATION DEVICES A large storage or tackle box is recommended to keep everything in one central location, along with the oxygen tank and AED. It is imperative that someone is responsible for checking the equipment and drugs in the office regularly. The AED should be looked at daily and the drugs checked monthly. One way to be prepared for these emergencies is to continually educate the entire staff on medical emergencies. Ideally, this training can be held in your office with both lecture and hands-on simulated training. KEYS TO GOOD EMERGENCY MANAGEMENT INCLUDE: • REMAIN CALM • CALL 911 EARLY • REMEMBER CIRCULATION AIRWAY BREATHING (CAB) • KEEP TRACK OF TIME • BE MANAGING THE PATIENT WHEN EMS WALKS IN • GOOD DOCUMENTATION • PRE-PLAN: THE DENTIST AND TEAM SHOULD KNOW THEIR RESPONSIBILITIES • MAINTAIN THE PROPER DRUGS AND EQUIPMENT • LOOK FOR DANGER IN EVERY PATIENT • PREPARE FOR EMERGENCIES, THEY ARE GOING TO HAPPEN • DO THE RIGHT THINGS AND DO THE THINGS RIGHT • TIME OF EMERGENCY • TIME 911 CONTACTED • TIME EMS ARRIVED • TIME EMS DEPARTED Once the emergency is recognized, the dental team must then begin the treatment phase. The dentist must be prepared to manage these emergencies for at least 20 minutes until EMS arrival. The dental team does not need to diagnose, but should be able to manage patient symptoms. Treatment does not always mean giving a drug or calling 911. However, there should never be a delay in calling 911 or administering a drug if it is indicated. Documentation during these emergencies is essential. The following times need to be documented so that after the emergency has subsided, you can go back and list the treatment completed. The following equipment is necessary to manage a medical emergency in the office: ☑ AED ☑ “E” CYLINDER OXYGEN TANK W/ADJUSTABLE REGULATOR, 0–15 LITERS ☑ ADULT AND PEDIATRIC BAG VALVE MASK ☑ NASAL CANNULAS ☑ BASIC/REBREATHER OXYGEN MASKS ☑ NEBULIZER MASKS ☑ VARIOUS SIZE BLOOD PRESSURE CUFFS (MANUAL) ☑ STETHOSCOPE ☑ AUTOMATED BLOOD PRESSURE CUFF ☑ GLUCOMETER
KeystoneExplorer | Winter 2022-23 9 dentistry issues Q By Kevin Croft, DDS The New Moderate Sedation Moderate sedation has evolved significantly in the past 15 years. Historically, dentists avoided it over concerns such as safety, but now the vast majority of those concerns no longer even apply. Dentists can now safely provide sedation in ways that never before were possible. Modernized moderate sedation training no longer has patients teetering on unconsciousness, needing reversal agents, suffering airway loss, or other events requiring intervention. Current training leans more towards medications and techniques that obtain something more like an ideal nitrous oxide case: No loss of airway, no loss of consciousness, and patients are amnestic, responsive, and very relaxed. The question is no longer “Should I do sedation?”, but “What kind of sedation is safest, most predictable, and allows me to provide care without increasing my stress?” Should I Get Trained in Oral or IV Sedation? It’s no surprise that practitioners are largely shifting towards moderate (IV) sedation training courses. Many new graduates are moderate sedation certified and many residencies have it as core curriculum. The medications are better, the techniques are better, the training is better, and the outcomes are more predictable. As dentists realize that IV sedation is not deeper sedation, but simply a method to obtain a better controlled, more predictable clinical outcome, they are widely adopting it. Why now? Over the past few decades, we have taken great strides to protect our ability to provide sedation services safely. Two major arms of this effort have been: (1) to more clearly define the various levels of sedation/anesthesia, and (2) to better define what kind of training and permitting is appropriate for dentists wishing to provide each kind and level of sedation. This movement is reflected in several ADA publications: • Policy Statement: The Use of Sedation and General Anesthesia by Dentists (2007) • Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (2007, 2012, 2016) • Guidelines for the Use of Sedation and General Anesthesia by Dentists (2007, 2012, 2016) • Guidelines for Teaching Pediatric Pain Control and Sedation to Dentists and Dental Students (2021) These documents are updated periodically and they influence continuing education, residencies, dental schools, prevailing thought by dental professionals, and rules/ regulations governing dental sedation practices at state, regional, and national levels. All this means that the standard of care has shifted. For example, historically many dentists elected for “oral conscious sedation” training where they could take a weekend course with clinical videos and get a permit to administer multiple oral sedatives to any patient of any age for any dental procedure. This “conscious sedation” practice was reflected in the 2007 version of the various
10 www.pagd.org Q dentistry issues ADA guidelines, but it has since been entirely removed. Now such practices are considered off-limits to any dentist who has not obtained residency-based training in general anesthesia. This is just one of the many significant changes that have come into effect in recent decades. What Does All of This Mean for You? If guidelines like these aren’t yet reflected in state law, they will be. Think about that for a moment. Even practices which were standard in 2007 have been eliminated as of 2016. It is reasonable, therefore, that sedation dentists who trained prior to 2016 should at least consider retraining in sedation, maybe entirely from scratch. Does this mean oral sedation dentists can no longer stack oral medication doses? No it doesn’t. It does, however present them with a dilemma: Either limit oral sedation practices to no more than one dose of one medication not exceeding the MRD for unmonitored home use, or get moderate sedation certified. Once certified in moderate sedation, a dentist can administer pills, IV medications, and nitrous oxide in combination or alone to a level of moderate sedation. So, unless one prefers to avoid sedation entirely, that is the pathway that makes the most sense. What Are Your Choices? Dentists will naturally self-select into one of three groups: 1. Dentists who provide nitrous oxide and local anesthesia only. They would then engage a 3rd party anesthesia provider (such as a dentist anesthesiologist) for select patients. 2. Dentists who obtain moderate sedation certification and provide a range of sedation services, including oral sedation and IV sedation. They, too, would engage a 3rd party anesthesia provider when needed. 3. Dentists who complete residency training to provide the full range of sedation/anesthesia services.
KeystoneExplorer | Winter 2022-23 11 dentistry issues Q What Does Moderate Sedation Training Look Like? By ADA standards, moderate sedation training courses must include 60 didactic hours and 20 live patient care experiences. This training can be obtained in a number of residencies or through a number of continuing education companies. Each course tends to have a unique format requiring various time and financial commitments, some reaching upwards to $30,000. Some are taught by nurses and physicians, others by general dentists, others by dentist anesthesiologists, or a mixture of providers. Where Should I Get Trained? Generally, you should look for courses with faculty members who are intimately familiar with the dental setting, who come from a variety of backgrounds, and have reasonable tuition and scheduling requirements. There is a tremendous amount of information that could be taught, but finding a course that focuses on what is the most relevant information—not just regarding sedation care, but regarding sedation care in the dental setting specifically—is paramount. Keep in mind, too, that that the top results from Googling “IV sedation training” might not be the best, and that courses that focus on quality and word-of-mouth-reputation over advertising and brand recognition might be ideal. The Future of Sedation in Dentistry is Bright! Sedation dentistry has never been safer, more accessible, and more in demand. Choose wisely how you implement it in your practice and, above all, stay current, relevant, and safe! About The Author Kevin Croft DDS is a board-certified dentist anesthesiologist who holds an active license to practice in the Commonwealth of Pennsylvania and several other regions. He is a director at large for the American Society of Dentist Anesthesiologists (ASDA) and he teaches an array of continuing education courses, including a moderate sedation certification course based out of St. George, Utah. He is also Dean of the AGD/ASDA’s joint sedation education endeavor: the Institute for the Management of Pain and Anxiety. He can be reached for inquiry/comment at dr.croft.dds@gmail.com or dentinomics.com.
12 www.pagd.org Q dentistry issues There are various methods to managing patients and optimizing dental treatment for pediatric patients and/ or patients with anxiety. When behavioral management techniques do not achieve a satisfactory result, advanced techniques can be utilized. Sedation and anesthesia support safe and compassionate care.1 Dentists who provide sedation or anesthesia to dental patients are urged to be current in their knowledge of pharmacology. They must recognize indications and contraindications to the delivery of sedation and anesthesia medications including epinephrine-containing local anesthetics. All decisions should be made based on risk and benefit. The provider must meet the national and state specific guidelines.1 Sedation and anesthesia occur along a spectrum.2 Figure 1 shows the spectrum of “pain and anxiety control.” At the left there is no sedation or anesthesia. Moving right, there are levels of conscious sedation up to the vertical bar. The bar represents loss of consciousness. To the right of the bar is deep sedation/general anesthesia. Although an experienced provider may not need a graphic representation to help determine level of sedation or anesthesia, a classification system is necessary. The dentist must understand where they are on the spectrum and its relationship to where they want to be.2 The goal should be to use the lowest level possible to achieve the desired outcome. Complications increase as you move to deeper levels and additional training by the provider is required.2 “Rescue” is an essential concept for safe sedation. Because sedation and anesthesia are a continuum, a provider must be able to recover a patient from unintended entry to a more profound level of CNS depression. To reduce morbidity and mortality, the ASA guidelines include and stress the concept of rescue during the administration of sedation by “non-anesthesiologists.”2,3,4,5,6,7 Review of Concept: Anesthesia as a Spectrum By Alexander DeBernardo, DMD; Amy Maya, DDS; Matthew Cooke, DDS, MD, MPH Department of Dental Anesthesiology, University of Pittsburgh, School of Dental Medicine Alexander DeBernardo DMD Amy Maya DDS Figure 1.
KeystoneExplorer | Winter 2022-23 13 dentistry issues Q The stages of sedation do not reflect a definitive on/off switch, but instead reflect a continuum along which the state of consciousness is gradually depressed. Minimal sedation with solely nitrous oxide or oral anxiolytics, such as Triazolam, achieves a relaxed state during which the patient is awake, able to respond to commands, and still converse with the provider. The airway, respiratory drive, and cardiovascular function is unaffected at this stage. Moderate sedation is an attenuation of consciousness in which the patient is able to purposefully respond to commands. The patient may become amnestic during moderate sedation depending on the drugs administered, and the airway, respiratory drive and cardiovascular function are minimally affected. The medications utilized in moderate sedation are typically opioids such as Fentanyl, benzodiazepines such as Midazolam, and alpha-2 agonists such as Dexmedetomidine. Deep sedation achieves loss of consciousness during which the patient is only arousable following repeated painful stimulation. While cardiovascular function is usually maintained in deep sedation, respiratory drive may be inadequate, and airway patency may require intervention. The deepest state is general anesthesia which is beyond the scope of this discussion.3,6 Patient selection and sedation modality is paramount in achieving the desired goal. A proper and thorough review of your patient’s health history via a medical consultation and/or preoperative phone call can provide valuable information to provide safer and more predictable anesthetic results. Given the patient’s medical history, ASA status, and anesthetic requirements, a balanced anesthesia technique should be utilized to achieve anxiolysis, amnesia, and analgesia by pairing decreased dosages of concurrent medications. These medications are outlined below:2 References 1 Malamed, SF (2017) Sedation: A Guide to Patient Management. 6th edition Mosby Elsevier, St. Louis Missouri. 2 Cooke MR, Tanbonliong TS. “Sedation and Anesthesia for the Adolescent Dental Patient.” 2021 Dental Clinics of North America Volume 65(4) P 753-773. 3 Excerpted from Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia, 2014, of the American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane Schaumburg, IL 60173-4973 or online at www.asahq.org. 4 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists: Practice guidelines for sedation and analgesia by non-anesthesiologists (2002), Anesthesiology 96:1004-1017. 5 American Academy of Pediatric Dentistry “Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.” (2019) Reference Manual: Volume 41 (4): E26-E52. 6 American Dental Association, Council on Dental Education and Licensure: Guidelines for teaching pediatric pain control and sedation to dentists and dental students. As adopted by the January 2021 ADA House of Delegates, Chicago, 2021 The Association. 7 American Dental Association, Council on Dental Education: Guidelines for the use of sedation and general anesthesia by dentists. As adopted by the Oct. 2016 ADA House of Delegates, Chicago, 2016 The Association. Dexmedetomidine HCl, Fentanyl Citrate, and Midazolam HCl
14 www.pagd.org Q dentistry issues Criteria for Selecting an Anesthesia Provider for the Office Based Setting By Taylor Chock-Wong, DDS; Amit Khetan, DMD, RN; Matthew Cooke, DDS, MD, MPH Department of Dental Anesthesiology, University of Pittsburgh, School of Dental Medicine Dental providers have several options available to help manage anxious patients. The least invasive route is providing traditional behavior guidance and a comfortable office environment. For patients who elect pharmacological intervention to relieve anxiety, an oral premedication can be prescribed. This may include the use of benzodiazepines or sedatives. If the dentist has obtained a moderate sedation permit, they are able to provide moderate sedation for their patients. However, if these alternatives do not provide adequate sedation for the patient, the option of general anesthesia in an office based setting may be indicated. Practitioners must always evaluate risk associated with office based deep sedation or general anesthesia. This level of pharmacologic behavioral modification should only be used when the risk of orofacial disease outweighs the benefits of other modalities. The use of deep sedation/general anesthesia may facilitate the provision of oral health care. So, you have decided you want to utilize the services of an anesthesiologist in your practice. How do you get started? First and foremost, you need to find a licensed anesthesia provider, such as a dental and/or medical provider with valid credentialing. Qualified medical personnel, including dentist anesthesiologists, physician anesthesiologists, oral and maxillofacial surgeons, certified registered nurse anesthetists (CRNA), and/or certified anesthesiologist assistants (CAA), may be considered as appropriate anesthesia providers within an office based setting. Prior to employing these personnel, state guidelines should be reviewed and considered. Depending on the state, CRNAs or CAAs may require direct supervision of an individual trained and licensed to provide deep sedation/general anesthesia. Things to look for in a provider include current licensure and general anesthesia permits in the specific state of practice. Anesthesia providers are also required to obtain valid certifications in BLS, ACLS, and PALS, as well as sufficient training and experience in managing any medical emergencies that may arise. Another thing to consider is the provider’s experience with specific patient demographics being treated, whether that be with pediatrics, individuals with intellectual disabilities, or highly anxious patients. For high-risk patient groups, it may be necessary to utilize a licensed anesthesia provider, who is independent from the individual performing or assisting with the dental/surgical procedure. Refer to Table 1 for specific education and training requirements for each anesthesia provider.2,4 Taylor Chock-Wong DDS Amit Khetan DMD, RN
KeystoneExplorer | Winter 2022-23 15 dentistry issues Q Dental anesthesia is a specialty recognized by the American Dental Association. Dentist anesthesiologists are licensed anesthesia providers who undergo 36 months of training via a Commission on Dental Accreditation (CODA) approved residency program. There are currently eight CODA accredited programs within the United States and one in Canada. General dentists and dental specialists alike utilize the services of dentist anesthesiologists. The benefits of utilizing anesthesia providers in your office include improved access to care, decreased administrative procedures, and facility fees compared to a hospital, and use of traditional dental delivery systems with access to a full complement of dental equipment, instruments, and auxiliary personnel. The use of in-office anesthesia providers offers safe, quality care for dental patients when access to traditional surgical facilities may be limited. Providers who utilize office-based anesthesia must take all necessary measures to ensure patient safety. They should vet their provider thoroughly and foster a good working relationship. Both providers should be familiar with the ASA physical status classification of the patient and risks. It is important to clarify the expectations and responsibilities to ensure the adequate care and safety of the patient. References 1 American Academy of Pediatric Dentistry. Use of anesthesia providers in the administration of office-based deep sedation/ general anesthesia to the Pediatric Dental Patient. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:372-6. 2 American Academy of Pediatric Dentistry. Policy for selecting anesthesia providers for the delivery of office-based deep sedation/general anesthesia. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:169-71. 3 Giovannitti, J.A., Jr., Montandon, R.J. and Herlich, A. (2016), The Development of Dental Anesthesiology As a Discipline and Its Role As a Model of Interdisciplinary Collaboration. Journal of Dental Education, 80: 938-947. 4 Weaver, J.M. Accreditation of Dentist Anesthesiologist Residencies is Approved by CODA. Anesth Prog 1 June 2007; 54 (2): 43–44. 5 Commission on Dental Accreditation. Accreditation Standards For Advanced Dental Education Programs in Dental Anesthesiology. Chicago, Ill.: Commission on Dental Accreditation. 31 January 2020. www.ada.org/coda. Table 1. Anesthesia Education and Training Comparison ANESTHESIA PROVIDER PERMITTED TO FUNCTION INDEPENDENTLY OF SUPERVISION BY ANESTHESIOLOGIST MINIMUM DURATION OF PROGRAM REQUIRED FOR CERTIFICATION MINIMUM # OF DS/ GA CASES MINIMUM # OF PEDIATRIC CASES DEFINITION OF PEDIATRIC PATIENT MINIMUM # OF DS/ GA CASES INVOLVING PATIENTS WITH SHCN NATIONAL EXAMINATION/ CERTIFICATION ORGANIZATION Certified registered nurse anesthetist In some states 24 months 24/400 < 2 yrs: 10 2-12 yrs: 30 ≤ 12 yrs N/A National Board of Certification and Recertification for Nurse Anesthetists Physician anesthesiologist N/A 48 months N/A 100 ≤ 12 yrs N/A American Board of Anesthesiology Oral and maxillofacial surgeon N/A Five months of anesthesia service supplemented by OMFS service* 48 months 300 50 ≤ 18 yrs N/A National Dental Board of Anesthesiology for anesthesia certification American Board of Oral and Maxillofacial Surgery for surgery certification Dentist anesthesiologist5 N/A 36 months 800 125 ≤ 7 yrs 75 American Dental Board of Anesthesiology DS/GA = DEEP SEDATION/GENERAL ANESTHESIA. OMFS = ORAL AND MAXILLOFACIAL SURGERY. SHCN = SPECIAL HEALTH CARE NEEDS. N/A = NOT APPLICABLE.
KeystoneExplorer | Winter 2022-23 17 advocacy\ Dr. Unis Sullivan called the meeting to order. The minutes were reviewed with minor typographical amendments and approved unanimously. Prosecutorial Report • Case #1: Case was presented at the June meeting but rejected as too lenient. It involved an Avesis inspection that uncovered no sterilization documentation and failing radiological equipment that was not properly registered. The Bureau of Enforcement and Investigation could not inspect as the office was closed by the time of inspection. The civil penalty was increased from $4,500 to $7,500, and the licensee received 18 months of probation. • Case #2 and #3: Case involved a hygienist who was practicing for 28 months on a lapsed license, and the dentist who employed the unlicensed hygienist. The prosecutor noted that the failure to renew the hygienist’s license was an oversight due to the pandemic and resulting shutdown. The hygienist received a $1,400 penalty and public reprimand, and the dentist received a $3,000 penalty and public reprimand. • Case #4: Case was presented in the September meeting and rejected as too lenient. It involved a practitioner who misplaced posts in an endodontic procedure, resulting in perforations. The licensee was also using Sargenti Paste, which can cause nerve damage. Additional CE in endodontics, restorative, record keeping, and ethics were added, as well as a $2,000 civil penalty. • Case #5: Case was presented in the September meeting and rejected as too lenient. It involved a licensee that had a pornographic image visible to a minor patient on an office computer, and the resulting inspection found no evidence of spore testing. Additional CE was ordered for HIPAA, infection control, and ethics, as well as a 30-day suspension followed by a probation period, as well as $3,000 in civil penalty. • Case #6: Case involved a practitioner who entered the voluntary rehabilitation program for substance use disorder. The practitioner is not licensed and must progress in the VRP before applying for relicensure. Report of Board Counsel Regulations on anesthesia, Botox, mobile vans, EFDA examination, and general revisions will be visited in the upcoming Regulatory Committee meeting. A revision of civil penalties was released to stakeholders and received no substantiative comments. Penalties are increased and delineate when formal action is taken for practicing on a lapsed license. The board approved a motion to proceed with formal drafting of the civil penalty regulations. The regulations increasing licensure fees was approved and published as final. Act 159 of 2022 was presented for the board’s information and will officially take effect in January of 2023. It will reduce the number of required CE hours for relicensure by three for no-cost volunteerism. The volunteerism must be in the field of dentistry, administration of a no-cost volunteer program would not qualify. Required regulatory revisions will be included in the general revisions. Committee Reports The Regulatory Committee met in September. Questions regarding the regulation of mobile vans was researched and presented by Dr. Mountain. Regulations involving nitrous and Botox will receive similar research. Revisions in EFDA examination, including a clinical examination, will receive priority. Review of Applications York Technical Institute has applied for approval of their EFDA program. Lisa Brown from YTI indicated that they had productive discussions with the EFDA committee. The board indicated that they would discuss the matter in executive session and will consider for a vote in a later meeting. Election of Officers Dr. Shawn Casey was elected as Board chair. Dr. Jennifer Unis Sullivan was elected as Vice Chair, and Theresa Groody was elected as Board Secretary. State Board of Dentistry Report Meeting Summary | November 18, 2022
4076 Market Street, Suite 209 Camp Hill, PA 17011 pagd.org Cecilia Bermudez Philadelphia PA Osman Cruz, DDS Harrisburg PA Andres Davila Philadelphia PA Nicholas DiRienzo Hockessin DE Harry Gohn, DMD Horsham PA Joshua Groves, DDS Mars PA Welcome New Members! Yao Lin Lancaster PA Samy Malek, DMD Glen Mills PA Kush Mangal, DMD Bensalem PA Noor Rehman, DMD Vestal NY Regina Vayner, DMD Jenkintown PA Katelyn Wray, DDS Cleona PA
pagd.orgRkJQdWJsaXNoZXIy MTY1NDIzOQ==