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Sedation in Dentistry: Luxury? Necessity? Or Both?

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Date: 03-13-2019 07:28:11 am


"It is no longer enough that dentistry be technically competent, it must be humanely presented" —Dr. Wm. Dover, dentist, dentist/anesthesiologist

 
Modern dentistry—with its biomaterials, advanced implant techniques, cosmetic emphasis, state-of-the-art laboratory procedures, local anesthesia sophistication, and wonder drugs. Is one factor any more important than the other? Yes. But it's not in this list.

As dentists, dental hygienists, dental assistants, and office managers, we must never lose sight of the fact that we are treating real people, not actors, as TV commercials lead us believe.

Dentists often approach me at a podium, by email, or at a reception to share the following sentiments:

"I've never needed to use sedation for my patients. I'm a gentle, patient, communicative person and use tender loving care to get my patients through a tough appointment."
 

"I've only ever referred one difficult to manage child in 30 years of practice."

That's admirable. But sooner or later, if a dentist practices long enough, a patient will have an indication for referral.

Here's another example:

"I treat a lot of senior citizens in my practice who have a variety of medical issues such as heart problems, diabetes, and physical and mental challenges. They just don't need sedation."

The stress of a dental appointment and myocardial compromise don't go well together. Cardiac patients, those with high blood pressure, and of course, the apprehensive patient can all benefit from a reduced stress level.

 
The ADA has found that a significant portion of the population—around 85 million Americans—avoids dental treatment due to fear. It's ranked up there with public speaking, heights, flying, snakes, claustrophobia, and crowds. As with any therapeutic treatment modality, patient management by sedative inhalational gases or oral/IV medications such as midazolam (Versed®) could help the patient feel better about dentistry, make the appointment go by faster, or provide memory gaps in parts of the appointment that really don't need to be remembered.

Some dentists who use sedation say it may be the only way to get certain patients into the dental chair. Parents of uncooperative, caries-ridden children feel it may be the only way their child can be managed.

So, how does a practitioner deal with the major disadvantages of oral sedation, namely "guessing" at a dose because titration is impossible? And what happens if it’s the wrong guess? How do you minimize the time of onset? Doesn't waiting for it to work just exacerbate an already apprehensive patient?

MINIMIZING THE ORAL ROUTE DISADVANTAGES:

How do you choose a dose? The first appointment is a true guessing game, but the guesswork can be successfully reduced by considering a few practical and rational patient factors:
 
  1. Body weight: adult vs. child.
  2. Age.
  3. Level of apprehension.
  4. Drug experience—including prescription drugs, over-the-counter medications, drug tolerance and dependence, chronic prescribed medications, benzodiazepine history, and liver enzymatic induction.
  5. Difficulty of the dental procedure.
  6. Time required to treat the patient and appointment length.
WHAT TO USE? Prototype: Triazolam - Halcion®
 
What do I mean by "amnesia is conditional?” Isn't that why a benzodiazepine is administered? Yes, but there are two overriding events that negate amnesia:
  1. Trauma/Pain:
    Example: You’re elevating a patient’s lower third molar that is not adequately anesthetized, and you repeatedly tell the patient, “It’s just pressure,” while all the while thinking, "They won't remember it anyway.” This couldn’t be farther from the truth. It hurts!
  2. Audio Comments:
    During a procedure, you say something like, "Don't you love my new Porsche? I'm going to Hawaii for a month.” This conjures anger and resentment in the patient, and may also give way to a “have” vs. “have-not” emotion.
In other words, anything that stimulates physical pain or an emotional reaction from the patient, such as envy or anger, has the potential to be remembered. When in doubt, just don't say it!
There are many types of consents in dentistry, and sedation consent forms are one example. During a consent appointment, the first question should be, "Is English your first language?" or "Is English your preferred language of discussion?" If the patient’s answer is “no,” it will be a very short appointment. The patient must then arrange to bring an interpreter to the consultation and consent appointment. I have held consultations where I believed that because a patient was nodding "yes" at almost every point (as opposed to nodding off), it meant that they understood me. Ultimately, they had understood virtually nothing because their first language was an East Asian dialect.

The most important point after communication confidence has been established is for the patient to 100% understand:

  • Not to drive a motor vehicle, operate machinery, use sharp objects, or make any important decisions for 24 hours. A patient may go back to work but must first sign off on the above.

The most important points for the dentist to adhere to are:

  • Although the initial question and answer format can be conveyed in the printed word, consent must be discussed verbally with an adequate time allowed for questions and answers. Remember that obtaining consent is not a single event but rather a process that occurs over time. 
  • An oral sedative cannot be administered and then consent be given later because the onset of the drug’s effects will not occur for a few minutes. Why waste time? Why handle all the consents first, and then administer the tablets, pills, or capsules, and then wait even longer? Answer: Because you must.
  • Never change the treatment plan while the patient is under the influence. For example, extracting a tooth that you said you would initiate endodontic therapy on because you found a crack and realized that the tooth is obviously doomed. So, you take it out without permission, or with "permission" from the intra-operatively sedated patient, or just as bad, the spouse, which of course is not permission at all.
What are the criteria for assessing a professional fee for the reimbursement of a 25-cent tablet (or two or three)? Of course, this is not about the cost of the medication. It is very much about the education and expertise of the dentist, the time and money expended to administer the medication, the responsibility of administering and monitoring the drugs involved, pre-op and post-op, the ability to manage side effects, including a medical crisis, and the challenge of managing not only an uncooperative child but also a parent or guardian who may be equally as challenging, demanding, or skeptical. In other words, what is sedation really worth? Should it be free, because it allows the dentist to be more efficient?

What, then, is the overall value of administering sedation in a dental practice? It depends. Would the dentist even want to treat the patients it may attract? Would the dental team accept it, or be afraid of change? Would it be a practice builder? Is it worth the time, expense, and effort to implement it? Would it ultimately be a wonderful, peaceful, satisfying, and profitable way to help patients, and therefore be exciting and fulfilling for the dentist? Perhaps the best way to answer these questions is to envision the way that sedation can both relax the dentist and create a relaxed dental office environment that can be extended to your patients in a safe, comfortable setting.
Sedation is a wonderful adjunct to the practice and delivery of modern dentistry. Not only is the apprehensive patient a prime indication for consideration, but longer, more sophisticated, and intricate procedures necessitate a cooperative and relaxed patient.

Mel Hawkins, DDS, BScD AN, FADSA, DADBA
Article 12 of 13

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Think Differently

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Course Type: elearning

Target Audience: Dental Assistants, Dental Hygienist, Dentists

  

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Educational Objectives

  • Learn why airway has become the new foundation over TMJ and occlusion for every restorative patient.
  • Learn simple, predictable systems your team can implement tomorrow to diagnose.
  • Learn to see the 20% growth that’s sitting in your charts already.
  • For the driven, learn to build your reputation in your community to drive results and explosive growth.

Abstract

Maybe you’re brand new to the practice and you don’t know what to expect. Maybe you’ve been doing this for a while and you’ve seen the downward trends. Worse, maybe you’re living it. What if there were a better way? A way to increase patient satisfaction? A way to increase team commitment? And a way to grow your practice at least 20% in the process? Would you want to learn more?

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 89 of 90

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Analgesics in Dentistry

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Course Type: elearning

Target Audience: Dental Assistants, Dentists

  

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Educational Objectives

The overall goal of this course is to provide information on nonparenteral analgesics used in dentistry. After completing this article, the reader will be able to:
1. Describe opioid medications and aspects of the new ADA policy on opioids.
2. List and describe ingested nonsteroidal anti-inflammatory drugs (NSAIDs) used in dentistry for pain management.
3. Describe an inhaled NSAID that can be used for acute pain management.
4. Review findings from systematic reviews and trials comparing opioid and non-opioid analgesics.

Abstract

Historically, management of acute odontogenic pain in adolescents and adults has typically been accomplished through an approach that incorporated nonparenteral opioid and/or nonopioid analgesics. However, the availability of opioid analgesics has resulted in epidemic levels of opioid abuse and addiction. Alternative treatment strategies utilizing non-opioids are preferable for management of acute pain, where indicated, including moderate to severe pain. Non-opioids include NSAIDs, acetaminophen, and combination medications, and are more, or as, effective as opioids. This article reviews opioid medications before focusing on non-opioid analgesics, as both monotherapy and combination therapy, for the safe and effective management of acute postprocedural pain in dentistry.

COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Orapharma.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 77 of 90

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Dental Sleep Dream Team – Physician Referrals and Collaboration Crucial to Interdisciplinary Team

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Course Type: elearning

Target Audience: Dental Assistants, Dental Hygienist, Dentists

  

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Educational Objectives

  • A framework for Physician-Dentist Collaboration in Obstructive Sleep Apnea (OSA)
  • How to network with physicians and build a collaborative, inter-disciplinary treatment team
  • The referral process: integrating and collaborating primary care with oral health
  • After diagnosis: importance of communication and a sound medical billing process

Abstract

Without collaborative relationships with physicians, dentists’ efforts to provide an acceptable standard of care are compromised. For example, to fit an oral appliance without a proper medical evaluation gives patients a false sense of diagnosis, deterring them from pursuing a comprehensive exam with a licensed physician.  Partnerships between qualified dentists and physicians are not only key for optimal patient care; they also increase the breadth of a dentist’s dental sleep medicine practice. During this webinar, we will cover how dentists can bridge the treatment gap to secure more physician referrals and work as an interdisciplinary team to treat your patient’s sleep breathing disorders, like obstructive sleep apnea (OSA), with oral appliance therapy (OAT).

COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from SOMNOMED.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 69 of 90

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Dental Sleep Practice Your Dream Team

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Course Type: elearning

Target Audience: Dental Assistants, Dental Hygienist, Dentists

  

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Educational Objectives

•  How to transition a routine dental visit into sleep disordered breathing with oral appliance therapy (OAT)
•  In-practice roles and responsibilities to establish your dental “dream team” for sleep apnea treatment
•  Commitment to achieve success: what your team needs
•  Establishing a patient experience for better sleep/health the moment they interact with your practice
•  Scenarios for better case acceptance for OAT

Abstract

From the receptionist and billing coordinator to the hygienist and dental assistant, every employee should play an integral role in the screening and managing of potential patients who might not know they suffer from obstructive sleep apnea. In Dental Sleep Medicine, a team approach is vital as each team member evolves with the new roles and responsibilities to help obstructive sleep apnea (OSA) sufferers. During this webinar, we will explore staff member’s roles in to help your practice build an in-office dental sleep “dream team.”


COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from SOMNOMED.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 68 of 90

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Analgesics in Dentistry

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Date: 01-15-2018 13:25:04 pm


Historically, management of acute odontogenic pain in adolescents and adults has typically been accomplished through an approach that incorporated nonparenteral opioid and/or nonopioid analgesics. However, the availability of opioid analgesics has resulted in epidemic levels of opioid abuse and addiction. Alternative treatment strategies utilizing non-opioids are preferable for management of acute pain, where indicated, including moderate to severe pain. Non-opioids include NSAIDs, acetaminophen, and combination medications, and are more, or as, effective as opioids. This article reviews opioid medications before focusing on non-opioid analgesics, as both monotherapy and combination therapy, for the safe and effective management of acute postprocedural pain in dentistry.

Analgesics are prescribed and/or recommended to dental patients to relieve pain, which may be acute or longer-term chronic in nature. Pain experienced following oral maxillofacial surgery is acute pain, while an example of chronic pain would include patients with long-term temporomandibular joint pain associated with temporomandibular joint disease. Analgesics for postprocedural pain management are mainly used following oral maxillofacial surgery for extractions, implant placement, bone grafting, endodontic therapy, and periodontal surgery. However, they may also be recommended and prescribed preprocedurally for the management of postprocedural pain. The main focus of this article is the use of nonparenteral analgesics that are ingested orally or ministered nasally for the relief of acute dental pain in adults. Analgesic medications used in dentistry include opioid and non-opioid medications, typically given orally.

Educational Objectives
The overall goal of this course is to provide information on nonparenteral analgesics used in dentistry. After completing this article, the reader will be able to:
1. Describe opioid medications and aspects of the new ADA policy on opioids.
2. List and describe ingested nonsteroidal anti-inflammatory drugs (NSAIDs) used in dentistry for pain management.
3. Describe an inhaled NSAID that can be used for acute pain management.
4. Review findings from systematic reviews and trials comparing opioid and non-opioid analgesics.

Download course PDF or take course.
Article 6 of 13

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Identifying Sleep Apnea In Your Dental Patients

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Course Type: elearning

Target Audience: Dental Assistants, Dentists

  

Educational Objectives

After completing this webinar, participants will be able to identify:

  • The impact of sleep apnea on your patient's quality of life
  • Science of sleep and how the positioning of the jaw impacts the airway
  • Dental signs of sleep apnea and patient evaluation processes for oral appliance therapy treatment
  • Oral appliance therapy treatment (OAT) results and how to make OAT a pragmatic portion of your practice
  • Valuable resources for implementing medical billing and OAT manufacturer partnerships

Abstract

The need for dentists to take a greater role in the identification and treatment of obstructive sleep apnea (OSA) has never been higher; according to a Harvard health report approximately 25 million adults in the U.S. suffer from the condition and almost 19 million of them are undiagnosed. OSA is a condition that affects the airway and since dentists and dental hygienists see the airway of their dental patients every day, they can potentially be the first line of defense in the identification of OSA. During this webinar, we will explore screening options to identify OSA patients in your practice, oral signs and symptoms, the referral process, how oral appliances work, and device options by patient type.

COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Somnomed.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 64 of 90