Friday, November 8, 2013

Lessons in Conscious Sedation

Under the guidance and supervision of oral surgeons at my AEGD, I am to complete the program with the requirements for obtaining a moderate conscious sedation license in dentistry. As we know, there are many patients that experience anxiety and stress when it comes to visiting the dentist, let alone having surgical procedures completed. Thus, a form of sedation can be appealing to them and extremely helpful for both the patient and dentist to feel comfortable in completing the treatment.

In my residency, we have discussed the different methods of achieving conscious sedation, such as orally and intravenously. We are completing our cases with IV access and administration of midazolam and fentanyl. IV access allows for titration of the medication, easier reversal, and a line is already started should any other medication need to be given in the event of a medical emergency. While oral administration may be easier for a nervous patient to handle, it is not as controlled.

The oral surgeons in my program have made it clear that when it comes to sedation, it’s not about how MUCH you can give, it’s about how little you can give and still get the work done comfortably. This is a very important point to understand because more meds means more likely to experience unwanted side effects, such as respiratory depression and other medical emergencies. Being selective in what patients you treat with sedation is critical to your success and comfort. We are only offering IV sedation to ASA I and II patients with Mallampati I and II, who are not obese and can withstand the treatment. This is a lesson in setting yourself up for success, not failure.

We began offering IV sedation after becoming ACLS-certified. The clinic has Criticare monitors that measure blood pressure, heart rate, heart rhythms and oxygen saturation. Our first 10 sedations are partnered, where one resident performs the sedation and the other is doing the dental procedure. After these 10, we will be required to complete at least 15 cases of sedation and treatment on our own. In the end, we have a review with our oral surgeons about the details of sedation and the management of medical emergencies. After clearing that, we have to get a final sign-off by the oral surgeon that says they recommend us for a moderate conscious sedation license.

I am curious to know how many AGD members are using sedation in their practices, and if that sedation is oral and/or IV. When I’ve browsed area websites online that state they offer sedation dentistry, they seem to just be offering it as a pill. I hope to get comfortable enough with IV sedation managing medical emergencies that I will be able to offer this to my patients in my future practice.

Katie Divine, DDS

5 comments:

Andy Alas, D.D.S. said...

Katie,
great post.

There are three very important reasons why most dentists do not offer IV sedation in their practices. Rules may be different in each state but generally:

1) Not only do you need special permits but so does your facility. It WILL be inspected before you get the permit. As such:

2) Each operatory will now resemble a surgical (hospital) room much more that a dental operatory. You are very aware of the type of equipment (crash carts, etc.) that you need to have easy access to. You'll need to build out LARGE operatories to accomodate this.

3) Your malpractice insurance premiums skyrocket.

That is why you'll find that most dentist use oral sedation.

Andy Alas, D.D.S.

Ed Paul DDS said...

I totally agree with the previous comment. I might add that IF you are able to deal with the 3 obstacles listed, you also must be able to feel 100% confident to get out of a medical emergency when (not if) it happens. In a hospital with oral surgeons around, there is a wide safety net. In your private office, you're on the high wire without any net.

Bob Oro, DMD, MAGD said...

Katie,

Agree with both above.
Had 2 year Hospital GPR and was fully trained in IV Sedation. Have never done it in private practice.
My feelings is that either you do it or you do not do it. This is very serious stuff and fun when you are doing it on a consistent basis with full commitment in training, equipment and staff.
We have an over 50 practice and we find oral lorazepam works really well.
Best of luck!
Enjoy the Journey,
Bob

Ronnie Garrett said...

Oral conscious sedation has provided access to care for hundreds of thousands of Canadians who otherwise would have been without the dental care they need. from West Airdrie Dental sedation for dentistry.

Angel Clarissa said...

Nice info keep going..The purpose of sedation is to relax you just enough to combat the fear and anxiety that holds you back, without any ill feeling or uncomfortable side effects as a result.conscious sedation in dentistry

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