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Inside Dentistry
April 2016
Volume 12, Issue 4

Monitoring Sedated Patients

The level of sedation being used dictates the choice of and requirements for patient monitoring. Weaver notes that practitioners who work without a dedicated anesthesiologist benefit from monitoring devices that can be heard and don’t need to be watched, such as a pulse oximeter, which is required for all sedation procedures.

“Pulse oximetry assesses circulating blood, measuring the amount of oxygen in the red blood cells coursing through the fingertip. Variations in its sound—a beep with each pulse—audibly signal whether the patient is being oxygenated normally or not,” he explains.

As a dedicated anesthesiologist, Saraghi finds that multiple pieces of monitoring equipment are needed to provide a more complete picture of a patient’s status during sedation. These include an audible monitor, precordial stethoscope, which enables her to hear each breath, and a capnograph, which provides a readout of the amount of carbon dioxide that comes out during that breath.

“The pulse oximeter has a delay in reflecting a missed breath and the corresponding drop in oxygen saturation, and this delay may be as long as 1 minute. During that minute, the patient may suffer from going without oxygen,” Saraghi notes. “Meanwhile, the precordial stethoscope may be difficult to hear, especially during the use of a high-speed suction device. The capnograph provides data instantly; however, it too has limitations in that it may not detect the exhaled carbon dioxide in a mouth breather. However, when used together, these monitors complement one another.”

Moore says careful monitoring is critical, especially for those at higher risk. But monitoring standards are different between medicine and dentistry, and that’s problematic. The ADA Guidelines and the many state regulations based on them are less stringent than those for medicine, Moore says, which suggests a double standard of care that continues to dog dentistry. Capnography is one example. Although it is recommended for moderate sedation by both the Academy of Oral and Maxillofacial Surgeons (AAOMS) and the American Society of Anesthesiology (ASA), Moore says, “What I want to know is why MDs and oral surgeons think they should use capnography and dentists don’t. Is the risk different? Sedation risk has to do with drugs and patients, not what type of surgery is being done.”

Drug Safety Considerations

With patient risk uppermost in mind, Dionne believes many doctors in general are too casual about the sedation methods that depress the CNS the most. He asserts that the patient’s interests are better served by focusing not on the doctor’s qualifications and ability to resuscitate a patient, but on avoiding the need by administering safer drugs.

“There is a wide margin of safety for nitrous oxide and benzodiazepines, but as reported in a 2001 JADA article5 and elsewhere, there is a greater risk of respiratory depression when opioids, barbiturates, or general anesthetic drugs are administered to produce ‘deep sedation’ but little or no benefit is detected by patients,” Dionne says. “This translates into increased risk without anxiety reduction benefit for the patient.”

The most important determinant of safety, he says, is the drugs (and doses) given, and, secondarily, the skill of the anesthetist. “The ability to perform resuscitation should not be a major consideration—as even in a hospital setting it usually fails. Getting the drugs and doses right minimizes the need for resuscitation.”

Choosing Dental Anesthesiology

Although properly licensed oral surgeons and dentists can legally provide dentistry and anesthesia simultaneously—with the right number of people in the room and equipment—some may choose to leave this job to an expert.

There are distinct advantages to outsourcing this responsibility in the operatory. As Weaver points out, “Anesthesiologists are handling only patient monitoring and anesthesia, so they can quickly and easily identify and respond to problems, especially airway issues.”

Providers like Saraghi have specialized training that allows them to focus strictly on the anesthesia while the dentist performs the required procedure. This offers peace of mind to clinicians and patients. “Dental anesthesiology mimics the medical model,” she says. “Like a medical anesthesiologist, I completed training specifically for anesthesia. The programs, which are accredited by CODA, require the completion of 3 years of residency training and the highest requirements for experience in general anesthesia, pediatric cases, and special needs cases. It is the only dental post-graduate residency program that also mandates that residents have experience administering anesthesia in the office-based setting.”

Emergencies can be managed more easily or prevented more readily with a dental anesthesiologist. “If the patient can’t breathe well on their own or if they are only responding to painful stimulation, that means the provider who is not trained or equipped for these events has gone too far and should halt the procedure,” Saraghi says. She can comfortably handle these situations, however. “I can manage airways and medication in intubated and non-intubated patients because I am trained for it.”

Final Thoughts

It has become increasingly clear that facilitating the delivery of medically necessary oral care is an important aspect of general health care. And part of supporting the delivery of dental treatment is addressing obstacles to receiving treatment that could be moderated by the wider availability of sedation and GA.

As Berg points out, in many cases, dentists can deliver more and better treatment due to movement control/cooperation and reduced anxiety. However, Rosenberg cautions that the need must be met with highly trained providers. “The most important thing we do is to ensure the safety and well-being of our patients. Anything can happen at any level of sedation or anesthesia. Being appropriately trained, having correct monitors, and being able to diagnose and manage emergency situations are essential,” he says.

“This whole issue of the relationship between oral and systemic health makes it more important that we do things that will make it more likely that people, including those who are fearful, will come in and get treatment,” says Dionne. He believes the use of deep sedation or GA for anxiety—when a lesser level of sedation could achieve the same goal—may in fact act as a deterrent due to the limited number of providers who can offer it and the greater risk of serious morbidity or mortality. “There are appropriate uses for all levels of sedation, including general anesthesia. However, the best way to prevent disasters related to sedation is to be more judicious about the drugs and doses on the front end, not trying to train people to be better at ACLS [advanced cardiovascular life support].”

References

1. Chanpong B, Haas DA, Locker D. Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesth Prog. 2005;52(1):3-11.

2. Hicks CG, Jones JE, Saxen MA, et al. Demand in pediatric dentistry for sedation and general anesthesia by dentist anesthesiologists: a survey of directors of dentist anesthesiologist and pediatric dentistry residencies. Anesth Prog. 2012;59(1):3-11.

3. ASA Physical Status Classification System. American Society of Anesthesiologists website. www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed February 19, 2016.

4. Guidelines for the Use of Sedation and General Anesthesia by Dentists. American Dental Association website. www.ada.org/~/media/ADA/About%20the%20ADA/Files/anesthesia_use_guidelines.ashx. 2012. Accessed February 19, 2016.

5. Dionne RA, Yagiela JA, Moore PA, et al Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients. J Am Dent Assoc. 2001;132 (6):740-751.

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