Sedation by Dentist
American Dental Association
(ADA)
Sedation by Dentists
Summary
American Dental Association
Sedation Teaching Guidelines
Summary
1. "Predoctoral dental students must complete a course in Basic Life Support for the Healthcare Provider." (p.2)
2. "Level of sedation is entirely independent of the route of administration. Moderate and deep sedation or general anesthesia may be achieved via any route of administration and thus an appropriately consistent level of training must be established." (p.2)
3. "For children, the American Dental Association supports the use of 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." (p.2)
3. "...Deep sedation and/or general anesthesia are beyond the scope of predoctoral and continuing education programs".(p.2)
4. "All areas in which local anesthesia and sedation are being used must be properly equipped with suction, physiologic monitoring equipment, a positive pressure oxygen delivery system suitable for the patient being treated and emergency drugs.
Protocols for the management of emergencies
must be developed and training programs held at frequent intervals." (p.2)
5. Competent in evaluating physical status of the patient; monitoring vital functions; prevention, recognition and management of related complications; proper records with accurate chart entries recording medical history, physical examination, vital signs, drugs administered and patient response. (p.8)
6. Physiologic monitoring (p.8):
a. central nervous systemb. respiratory oxygenation and ventilationc. cardiovascular
7. ASA physical status (p.9)
8. Techniques of venipuncture (p.10)
9. "Following didactic instruction in minimal and moderate sedation, the student must receive sufficient clinical experience to demonstrate competency in those techniques in which the student is to be certified. It is understood that not all institutions may be able to provide instruction to the level of clinical competence in pharmacological sedation modalities to all students".
(p.10)
Enteral Minimal Sedation Curriculum
Summary
A minimum of 16 hours plus clinically-orientated experiences
Experience managing a compromised airway is critical.
Can be completed in predoctoral education curriculum or postdoctoral continuing education competency course.
Course director must certify the competency of participants upon satisfactory completion.
(p.14-15)
1. "Dosing for minimal sedation via the enteral route - minimal sedation may be achieved by the administration of a drug, either singly or in divided doses, by the enteral route to achieve the desired clinical effect, not to exceed the maximum recommended dose (RMD)". (p.3) [RMD is defined as FDA approved-labeling for unmonitored home usage.]
2. If more than one enteral drug is administered or dosing exceeds RMD,
then this is deeper sedation than minimal sedation. (p.3) "...The drug(s) and/or techniques used should carry a margin of safety wide enough never to render unintended loss of consciousness. Th use of the MRD to guide dosing for minimal sedation is intended to create this margin of safety." (p.3)
3. Protocol for management of emergencies in the dental office and list and discuss the emergency drugs and equipment required for management of life-threatening situations. Demonstrate the ability to manage life-threatening emergency situations, including current certification in Basic Life Support for Healthcare Providers. (p.13)
4. Prevention, recognition and management of complications and life-threatening situations. (p.14)
5. Records "medical history, physical examination, informed consent, time-oriented anesthesia record, including the names of all drugs administered including local anesthetics, doses, and monitored physiological parameters." (p.14)
Moderate Sedation Curriculum
Summary
Demonstrate technique of intravenous access, intramuscular injection and other parenteral techniques. (p.15)
Prevention, recognition and management of complications and emergencies.
Airway maintenance and support of respiratory and cardiovascular systems.
Demonstrate ability to manage emergency situations: principles of advanced cardiac life support; protocol for management of emergencies, emergency drugs and equipment. (p.16)
ASA Classification
Monitoring Equipment: vital signs, ventilation/breathing. (p.16)
Records "medical history, physical examination, informed consent, time-oriented anesthesia record, including the names of all drugs administered including local anesthetics, doses and monitored physiological parameters.: (p.16)
"A minimum of 60 hours of instruction plus administration of sedation for at least 20 individually managed patients.
"Certification of competence
in rescuing patients from a deeper level of sedation than intended including managing the airway, intravascular or intraosseous access, and reversal medications."
"Records of instruction and clinical experiences (i.e. number of patients managed)".
"The course director must certify the competency of participants upon satisfactory completion of training in each moderate sedation technique, including instruction, clinical experience, managing the airway intravascular/intraosseous access and reversal medications".
(p.17)
American Dental Association
Use of Sedation & General Anesthesia
Guidelines
"Because sedation and general anesthesia are a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to diagnose and manage the physiological consequences (rescue) for patients whose level of sedation becomes deeper than initially intended. For all levels of sedation, the qualified dentist must have the training, skills, drugs and equipment to identify and manage such an occurrence until either assistance arrives (emergency medical service) or the patient returns to the intended level of sedation without airway or cardiovascular complications." (p. 3)
Minimal Sedation
"...the drug(s) and/or techniques used should carry a margin of safety wide enough
never to render unintended loss of consciousness." (p. 2)
Current Certification in
Basic Life Support for Healthcare Providers (p.6)
Equipment to deliver oxygen under positive pressure (p.8)
"Pulse oximetry may be clinically useful and should be considered" (p.9)
Baseline vital signs including body weight, height, blood pressure, pulse rate, respiration rate unless invalidated by nature of the patient. (p.8)
"If a patient enters s deeper level of sedation than the dentist is qualified (permitted) to provide, the dentist must stop the dental procedure until the patient returns to intended level of sedation." (p.9)
Moderate Sedation
"the drugs and/or techniques should carry a margin of safety wide enough to render unintended loss of consciousness unlikely." (p. 3)
All areas in which local anesthesia and sedation are being used must be properly equipped with suction, physiologic monitoring equipment, a positive pressure oxygen delivery system suitable for the patient being treated and emergency drugs". (p.2)
Current Certification in Basic Life Support for Healthcare Providers and
Advanced Cardiac Life Support (ACLS or equivalent or dental sedation/emergency management)
current certification/recertification (p.6)
Oxygen supply and equipment necessary to deliver oxygen under positive pressure (p.10)
Baseline vital signs including body weight, height, blood pressure, pulse rate, respiration rate and blood oxygen saturation by pulse oximetery unless invalidated by nature of the patient. Evaluation of
NPO (nothing by mouth) status. (p.10)
"Equipment necessary for monitoring end-tidal carbon dioxide and auscultation of breath sounds must be immediately available." (p.10)
Monitor
end-tidal carbon dioxide
unless precluded ... (p.11)
Precordial or pretracheal stethoscope (p.11)
"Continuous EKG monitoring of patients with significant cardiovascular disease should be considered." (p.11)
"Oxygen saturation must be evaluated by
pulse oximetry
continuously." (p.11)
Time-oriented anesthetic record including names, doses and time of drug(s) administration, pulse oximetry, heart rate, respiratory rate, blood pressure and level of consciousness recorded continually (p.11)
"Equipment necessary to establish intravascular or intraosseous access should be available..." (p.11)
"At least one additional person trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist." (p.10)
"If a patient enters s deeper level of sedation than the dentist is qualified (permitted) to provide, the dentist must stop the dental procedure until the patient returns to intended level of sedation." (p.12)
Deep Sedation or General Anesthesia
Baseline vital signs including body weight, height, blood pressure, pulse rate, respiration rate and blood oxygen saturation by pulse oximetery unless invalidated by nature of the patient. Evaluation of NPO (nothing by mouth) status. (p.12)
"An
intravenous line, which is secured throughout the procedure, must be established except as provided (for Special Needs Patients)." (p. 12)
Qualified Dentist with
Advanced Cardiac Life Support (ACLS or equivalent or dental sedation/emergency management)
current certification/recertification (p.6)
A minimum of
three individual must be present
Dentist qualified to administer deep sedation or general anesthesia.
2 additional individuals with current Basic Life Support for the Healthcare Provider (BLS) Certification
(p.13)
Equipment and drugs to provide advanced airway management and
advanced cardiac life support must be immediately available. (p.13)
"Equipment necessary for monitoring
end-tidal carbon dioxide
and auscultation of breath sounds must be immediately available."
"End-tidal carbon dioxide must be continually monitored unless precluded..."
(p. 13)
Continuous
EKG
and continual blood pressure
(p.14)
"Resuscitation medications and an appropriate
defibrillator must be immediately available". (p.13)
