Hot Issue # 2:
The American Dental Association’s (ADA) Proposed Sedation Guidelines

Background

In 2005, per the request of the ADA’s House of Delegates (HOD), the ADA’s Council on Dental Education and Licensure (CDEL), through its Subcommittee on Anesthesiology, solicited input from experts in anesthesia through an invitational anesthesia conference and reviewed the ADA’s existing sedation guidelines and policies. Based upon this solicitation and review, in November 2006, the CDEL, through its Subcommittee, proposed revisions to the sedation guidelines. The proposed revisions responded to trends in anesthesia protocols by realigning the guidelines to gradation by levels of sedation rather than routes of administration. The proposed guidelines were entitled ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (Proposed) and ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (Proposed). In December, 2006, the CDEL distributed its proposed guidelines to dentists and interested organizations, including the Academy of General Dentistry (AGD), and requested feedback by Feb. 23, 2007.

The AGD Input

In response to solicitation by the ADA, the AGD implemented an electronic questionnaire and survey to gather feedback from its members on the proposed guidelines. The AGD asked that its members voice both their concerns and their positive remarks about the guidelines. On Feb. 10, 2007, the AGD’s Dental Care Council held a conference with AGD leaders who have significant expertise in the practice of sedation, to review the proposed guidelines, supplemental documentation from the ADA and other organizations, and the comments of AGD members.

Among the Council’s concerns were the discrepancies between the language of the guidelines and the stated intent of the ADA; the lack of necessity of proposed monitoring requirements; the potential for negative impact on access to oral health care; and the lack of availability of education to comply with the proposed guidelines.

Particularly, the Council opposed the guidelines as proposed because their language appeared to indicate, for example, that general dentists currently practicing safe sedation techniques would not be grandfathered into continued practice by existing state dental boards, and that the dentist and not a BLS trained auxiliary had to monitor the patient during provision of minimal sedation treatment, such as the provision 5 mg of valium.

Additionally, by reorienting the guidelines upon levels of sedation, the proposed guidelines appeared to require training of the dentist at each level of sedation for the next higher level of sedation. That is, the proposed guidelines appeared to require dentists practicing minimal sedation to be trained for moderate sedation, and dentists practicing moderate sedation to be trained for deep sedation. While the Council appreciated and shared the ADA’s desire to safeguard patients should they descend into unintended levels of sedation, the Council was concerned that such training could be excessive and unnecessary, and that application of the proposed training for unintended levels of sedation would not be practical as a safeguard.

Further, the Council was concerned that the limited availability of training to meet the educational needs proposed by the guidelines may cause an impediment to patients’ access to care.

The Dental Care Council worked with AGD leaders to craft a response to the ADA. The AGD’s response embodied the spirit of collaboration and diligence in addressing sections of concern by specific citation to the proposed guidelines and recommending specific revisions.  Bruce DeGinder, DDS, MAGD, then president of the AGD, mailed the Council’s response to the chairperson of the ADA’s CDEL and the chairperson of the Subcommittee on Anesthesiology, on Feb. 20, 2007.

The ADA Response

The AGD’s comments were among approximately 1,500 comments that the ADA received.  However, the ADA specifically thanked the AGD for its letter for its well-researched, specific, and thorough approach to critiquing the proposed guidelines.  At its April 26-27 meeting, the ADA’s CDEL voted to amend the proposed guidelines in response to the comments.  Most of the AGD’s concerns were considered and implemented in the amended proposed guidelines.

Particularly, the amendments included a reduction to the moderate enteral sedation training hours from 60 hours down to 24 hours; a reduction of the number of live patients required for training in moderate enteral sedation from 10 patients to three patients; allowance for minimal sedation monitoring by a trained auxiliary rather than the dentist; revisions to the definitions of minimal and moderate sedation; and clarification to the grandfathering clause that dentists currently practicing in compliance with state regulations may continue to do so.

The AGD Sedation Town Hall Meeting

The AGD held a town hall meeting specifically about the ADA sedation guidelines on Sat., June 30, at the 2007 AGD Annual Meeting & Exhibits in San Diego. The AGD shared with its attendees the ADA CDEL’s newly released amendments to the proposed guidelines.

Attendees heard both an AGD representative and an ADA representative from the CDEL Subcommittee on Anesthesiology provide their respective positions on the guidelines as newly amended. Following a ten-minute presentation from each of the aforementioned speakers, attendees were able to ask questions of both representatives and provide further input about the guidelines or its revision process.  The town hall meeting, in conjunction with the newly amended guidelines, helped to clarify the document and alleviate most concerns of the AGD and its members.

Success at the ADA House of Delegates!

In October, 2007, the ADA House of Delegates (House) not only passed the majority of AGD’s recommendations as contained in the version of the guidelines revised and submitted by the CDEL, but also incorporated additional amendments to these guidelines submitted by Dr. Linda J. Edgar, Secretary, AGD, to the benefit of the AGD, its membership, and their patients.  Specifically, the ADA House implemented two additional revisions.  The first revision clarified that a medication given the night before the treatment would not necessarily be included in the 1.5 x MRD allowed under minimal sedation.  The second revision clarified that, under moderate sedation, once the procedure has been completed and the patient has reached a level of recovery equivalent to that of minimal sedation, the monitoring requirements for minimal sedation would apply, that is, the dentist could leave the operatory as long as a qualified auxiliary remained with the patient.

What Now?

The plight of general dentistry to increase access to care for fearful patients through safe sedation practice is not over yet!  State regulations take precedence over practice guidelines and, therefore, states are not required to implement the ADA’s guidelines. State dental boards may choose to provide regulations that offer a more lenient alternative to the ADA guidelines or impose burdens in excess of the ADA guidelines. 

As the voice of general dentistry, the AGD feels strongly that it should be at the table supporting the ADA guidelines before dental boards.  The AGD inspires action at the constituent level through blast e-mails, Capwiz action alerts, talking points, and other methods.  However, at the end of the day, it is each AGD grassroots member who truly makes the difference!   

AGD members should look forward to further communications on this and other matters of importance to the practice of dentistry in AGD’s newsmagazine, AGD Impact, and the AGD in Action e-newsletter. Please contact the AGD advocacy team at advocacy@agd.org if you have any questions or comments, or would like to offer your support! 

Contact Us

For more information, or if you have any questions or comments, please contact Srini Varadarajan, Esq., Director, Dental Care Advocacy, at 888.243.3368, ext. 4973, or via e-mail at srini.varadarajan@agd.org.