VOLUME 30, ISSUE 2

Pain relief services in the dental office are not a new development. Pain relief for a dental procedure is as expected as the free toothbrush at the end of a cleaning. Throughout the years, state legislators and dental boards have addressed within their laws and rules educational/training/office requirements for dentists to administer sedation/anesthesia. The TSA has been asked to weigh in when the Texas State Board of Dental Examiners (TSBDE) considered amending their regulations on the subject. At present, TSBDE requires a permit for Nitrous Oxide/Oxygen Inhalation sedation, minimal sedation, moderate enteral sedation, moderate parenteral sedation, and deep sedation or general anesthesia.

While detailing requirements in law for anesthesia/sedation administration is not new, what has been new is the increase in media attention on the number of patient complications in these settings. From Alaska and Hawaii to Florida, hardly a state has not witnessed a media report highlighting a serious patient complication in a dental chair. Unfortunately, our pediatric patients seem to be some of the most vulnerable.

• American Dental AssociationThe American Dental Association (ADA) has offered guidelines to dentists concerning the administration and teaching of anesthesia/sedation since the early 1970’s. In the most recent update of those guidelines (2016), the language addressed, among other things, end-tidal CO2 monitoring; the independence of depth of sedation and route of sedation; body mass index (BMI) as part of a pre-procedural workup; and the removal of pediatric patients from the guidelines.
• The minimal sedation language no longer allows supplemental dosing. The previous language provided in part “during minimal sedation, supplemental dosing is a single additional dose of the initial dose of the initial drug that may be necessary for prolonged procedures. The supplemental dose should not exceed one-half of the initial dose and should not be administered until the dentist has determined the clinical half-life of the initial dosing has passed. The total aggregate dose must not exceed 1.5x the maximum recommended dose (MRD) on the day of treatment.”¹ Under the updated language, moderate sedation guidelines would apply were a patient administered enteral drugs that exceeded the MRD during a single appointment.
• An important update from previous versions includes that the moderate sedation language no longer differentiates between moderate enteral and moderate parenteral sedation. The fact that the language recognized depth of sedation is independent of the route of administration was well received. Additionally, the equipment requirements were improved to provide “The equipment necessary for monitoring end-tidal CO2 and auscultation of breath sounds must be immediately available.”² Patient history and evaluation requirements were updated to include language providing that ASA III/IV patients must consult with a primary care physician or consulting medical specialist. Finally, the guidelines language for moderate sedation included language providing that part of the pre-procedural workup should include assessment of Body Mass Index (BMI).
• The guidelines also updated the language concerning pediatric patients. The recommendations no longer define a child as one 12 years of age and under. Instead, the updated language does not offer an age limitation. As with the previous language the updated language defers to the American Academy of Pediatrics/American Academy of Pediatric Dentistry Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.
• American Academy of Pediatric Dentistry and American Academy of Pediatrics
• In June 2016, the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) released their Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016.³
• Similar to the ADA guidelines, the AAP/AAPD guidelines do not distinguish between level of sedation and route of administration, they recommend a consultation with physician anesthesiologists or appropriate subspecialists for ASA III and IV patients, and recommend capnography for moderate sedation and require capnography for deep sedation. The AAP/AAPD guidelines clearly warn “Children younger than 6 years (particularly those younger than 6 months) may be at greatest risk of an adverse event.”⁴
• American Society of Anesthesiologists
• In October 2017, the American Society of Anesthesiologists House of Delegates approved the ASA Statement on Sedation & Anesthesia Administration in Dental Office-Based Settings.⁵ The document addresses training & education, monitoring & equipment, patient selection & case selection, resuscitative measures & protocols, and data reporting & transparency. Importantly, within the patient selection and case selection section, the ASA document addresses patients age six (6) and under. Specifically, the document encourages that because such patients are at enhanced risk of respiratory and related complications, the same standard of care and monitoring for moderate sedation should be applied as for deep sedation and general anesthesia, i.e. a distinct and separate qualified anesthesia provider not otherwise involved in the procedure.
• The ASA language further advises that because ASA Physical Status III and above patients are at higher risk of adverse events, they should be evaluated by a physician anesthesiologist or primary care physician before the procedure. The ASA language also warns “Prolonged and extensive procedures with longer periods of sedation and anesthesia care are of concern in the office-based setting and qualified anesthesia providers, in consultation with such patients, should consider more suitable facilities for the procedure.”⁶

There were several other commonalities between the ASA, AAP, AAPD, and ADA documents. Readers are encouraged to review these recommendations.

In Texas, of note for the membership of this organization and under the context of this increased awareness, there have been two recent activities. In 2017, as part of the mandated Texas Legislative Sunset Review Process the Texas State Board of Dental Examiners (and the Dental Practice Act) was up for scheduled review and renewal and a strong voice for patient safety and public health emerged within the body charged with this activity. Dr. Charles Schwertner, an orthopedic surgeon as well as a Texas Senator on the Commission quickly became the advocate for reform at the TSBDE especially with regards to office-based anesthesia for dental procedures (regardless of provider).

The leadership of the TSA (and others) mobilized early in the legislative session to work with Dr. Schwertner and his staff to add language in the legislation regarding more office inspections (as with other based office based surgery), increased education and training, better reporting and more public transparency. The information in written and oral testimony was largely obtained from our own guidelines, statements, and standards developed at the ASA level. Not totally unexpected, all of our recommendations did not make it into the final rewrite and to insure better patient care still need to be addressed.

But the important formation of an Anesthesia Advisory Committee to the TSBDE was finalized in the bill and, just as importantly, a physician anesthesiologist was included by statute in this entity. Certainly, complications with surgery and anesthesia can and do occur but the public expects consistent high standards of patient safety regardless of the setting. These standards should not be tempered to save money nor should corners be cut to augment profits.

The other activity that occurred during this same time period related to this problem involved TSA members at the ASA national level. Somewhat as a result of the public awareness and outcry, ASA leadership determined that a public statement with endorsement by the members was necessary. Members of the Committee on Quality Management and Departmental Administration were assigned to an ad hoc task force to produce for Board and House approval an official statement for dissemination via the webpage.

Three TSA/ASA members and three California ASA members as well as the current ASA Liaison to the American Dental Association worked for several months to produce the now accepted Statement on Sedation and Anesthesia in Dental Office-based Settings. For the first time, our members and others have a resource that clearly states our values regarding the safe practice of anesthesia outside the hospital in dental offices regardless of the provider of the sedation/anesthesia.