The question of anesthesia always comes up when discussing the removal of wisdom teeth. Mine were extracted with the use of local anesthesia and nitrous oxide. Many patients select intravenous sedation or general anesthesia, despite the increased cost and risk. The power to remove pain is one of the greatest tools and practice builders offered to oral professionals. There are a lot of dentist that offer sedation for treatments – Main Street Dental in Gresham does sleep dentistry for example for patients who struggle with anxiety brought on by trips to the dentist. Altering consciousness has been an effective way to reduce patient discomfort since the 19th century. William Morton, an American dentist, used diethyl ether to successfully perform an extraction without pain. Advances in sedation and anesthesia have led to a standardized protocol for painless surgery. However, sedation utilized without proper medical history review and training can lead to tragic consequences. In October 2016, at the American Dental Association (ADA) annual meeting, Resolution 37 was passed. The resolution called for revisions to the safety regulations for providing anesthesia and sedation. The full resolution can be found in Appendix 1 of the Report of Reference Committee C: Dental Education, Science, and Related Matters.
The ADA defines both sedation and general anesthesia as alterations of consciousness. General anesthesia involves the loss of consciousness, whereas sedation only provides a depression in consciousness. Sedation levels range from anxiety relief to general anesthesia requiring respiratory assistance. General anesthesia poses the greatest risk due to the alterations in breathing and heart rate.
Resolution 37 implemented changes to the way sedation can be provided to patients. The changes were recently outlined in the March 2017 edition of the Journal of the American Dental Association (JADA). The maximum dose of minimum sedation has been lowered to the maximum recommended dose (MRD) the FDA sets for at-home use without any supervision. A newly issued warning stated nitrous oxide used with minimal sedation could result in moderate or deep sedation. Certification requiring a 60-hour course and at least 20 patients has been recommended. Previously, only a 24-hour, 10 patient course was required. Additionally, dentists already practicing sedation dentistry before the guidelines were exempt from the training requirements. More patient information is now required for sedation. The required information includes body mass index (BMI), indications of obstructive sleep apnea (OSA) and end-tidal carbon dioxide monitoring.
Resolution 37 has been met with controversy that we may not be able to appreciate as dental students. Support for the resolution is rooted in patient safety. A more meticulous approach to sedation and anesthesia leads to less complications during surgery. Increased training requirements and a thorough review of the patient’s medical history are addressed by the resolution. Critics of the resolution cite the financial impact of the new regulation. Increased training and oversight will drive costs up. Consequently, cost may prevent dentists from pursuing sedation training. If fewer dental professionals are adequately trained, patients may struggle to obtain treatment.
Whether you choose to pursue sedation training or not, its regulation has an impact on the profession of dentistry. Sedation and anesthesia vastly expand the scope of practice and are necessary to treat many patients, but its use must not be taken lightly. Guidelines to protect patients are paramount in preventing complications. As health care professionals, we must adhere to primum non nocere: first, do no harm.
~Renz Antonio, Pacific ’19, Chapter President