Shift Magazine - Fall 2017

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Critical issues when treating some of our youngest patients

Surviving a Devastatıng


Rebuilding after a natural disaster



everyone should know about


OPERATOR ANESTHESIA A need for an FDA black box warning?

• Provide safe and superior hemostasis for your patients by using HemeRx. • Prep EZCrowns with speed and efficiency using the EZPrep diamond bur system. • Attend a Sprig University workshop to help you confidently offer your patients EZCrowns.


ICEBERGS Safety in pediatric procedural sedation




BAHAMAS CRUISE November 5-9, 2018

My kind of place.









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Complacency Challenges.



Without whom this issue would not have been possible.

20 INFORMATION ESSENTIALS It’s worth reading, because you don’t know what you don't know.


Spending good times with friends at all the Sprig-attended events throughout 2017.



Hear from a colleague how Sprig [EZPEDO] has effected his practice.


Re-familiarize yourself with one of dentistry’s most commonly used drugs.

32 TAKING LIFE IN STRIDE A dental professional tells her story from the dual viewpoints of a mom and anesthesia assistant.

40 BACK TO BASICS Understanding options for in-office procedural sedation.




Shift magazine speaks with a dentist anesthesiologist about some important issues facing the profession today.



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Safety in pediatric procedural sedation.


Taking another look at anesthesia issues when treating some of our youngest patients.




A need for an FDA black box warning?


An encouraging story about rebuilding a dental practice after a devastating tornado.


ON THE COVER COVERDESIGN COVER DESIGN BY MARKBOND MARK BOND PHOTOGRAPHY BY SLAVA DANILIUK DENTISTRY BY VICTORIASULLIVAN, VICTORIA SULLIVAN, DDS This issue of Shift magazine features Alex on the cover. On page 32, his mom tells the story about how it felt to switch roles from being a dental assistant during general anesthesia cases to being a mom accompanying her own child and experiencing anesthesia from an entirely new perspective.


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Surgery Anesthesia






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SPRIG ORAL HEALTH TECHNOLOGIES FORMALLY EZPEDO www. spr i gu s a .co m / Fa l l 2 01 7





Complacency Challenges As a dentist anesthesiologist, I go to work each day asking myself sobering, nagging questions. “What if the unpredictable happens today? Will this patient be one who experiences complications?” In anesthesiology, one never knows what challenges a new day will bring. Life itself is full of risks, many of which we don’t spend much time thinking about. To help parents imagine more clearly the relative risk of their child’s anesthesia experience, I often explain it this way. Compared to other activities of daily life which may be risky or scary, the risk of undergoing anesthesia is about the same as going on a shopping trip to buy orange juice. This analogy helps parents put the risk in perspective. Yet, while we don’t anticipate anything going wrong, we must be careful to avoid adopting a complacent attitude and prepare for that unexpected complication. A personal experience last Tuesday taught me just how quickly things in life can change. It was a day like any other, and I was doing what I have done thousands of times before. As so often in life, we tend to slip into a spirit of complacency. After all, we are doing a repetitive job, and in our own mind, we do it pretty well. Only on Tuesday, I became distracted. Something caught my eye and diverted my attention for only a couple of moments. And that’s all it took for everything to change in a split second. We prepare for situations like this. We take tests to aid us in remembering those things that will help act as safeguards, preventing accidents. As dentists, we have all taken a practical exam to test our abilities in emergencies. Sometimes, though, even when we have done everything right, things still go wrong. So, on Tuesday, I never saw it coming. I didn’t even expect it. But it happened nevertheless. I didn’t have time to think; only time to react. When tragedy strikes, this is often what happens. We aren’t able to process our thoughts simultaneously as bad things are transpiring. We simply respond instinctively. And our reactions are molded by how we have “prepared” in advance. Hopefully, with time to reflect and an opportunity to look back and evaluate what happened, we can learn from our mistakes and become even more vigilant in our actions, more committed to ensuring the safety of ourselves and those around us. Fortunately for me, my incident on Tuesday was unrelated to anesthesia. I was involved in an auto accident on my way home from work, and, gratefully, everyone was ok. So, while my accident didn’t relate to a patient at work, my experience on the road did help me once again realize the danger of complacency and focus my attention on the reality of our responsibility as anesthesia providers toward our patients.

Je rey P. Fisher, DDS Editor-in-Chief


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This issue of Shift magazine focuses on the topic of pediatric procedural sedation/ anesthesia. We are pleased to feature several timely articles addressing current vitally important issues. One deals with the risks involved in adopting a singleoperator anesthesia model. Another provides guidelines for avoiding risks based on AAPD guidelines. Other articles deal with recently required FDA warning labels, the need to return to the basics of airway anatomy and sedation pharmacology, and the safety track record of nitrous oxide. My hope is that these articles will inspire all of us to commit our lives to being even more vigilant and well prepared to conscientiously treat our patients with care and avoid falling victim to a feeling of complacency.



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Shift Contributors Jessica Harrison, RDA Alex’s mom, Jessica, has been a registered dental assistant since 2002. She currently works in pedodontics for a Sacramento area dentist. Her experience has ranged from general dentistry and oral surgery to orthodontics and endodontics. She has worked with many different demographics in Northern California, and prior to that, in San Diego. She views her job as being “the buffer” between the parent/patient and the dentist.

Stephanie Reshewsky, DMD Dr. Rashewsky received her DMD from the Harvard University School of Dental Medicine. She is dual-trained in both anesthesia and pediatric dentistry, receiving her certificate in dental anesthesia from Stony Brook University Medical Center in New York and her certificate in pediatric dentistry at the Children’s Hospital of Philadelphia and the University of Pennsylvania. Dr. Rashewsky is board eligible in pediatric dentistry, a fellow of general anesthesia in the American Dental Society of Anesthesiology, and a diplomate of the American Dental Board of Anesthesia and National Dental Board of Anesthesiology.

Thomas E. Lenhart, DMD Dr. Lenhart is a board-certified dentist anesthesiologist with 20 plus years of experience providing office-based anesthesia in Northern California. After receiving his DMD degree from Boston University School of Dental Medicine, he completed his postdoctoral anesthesia residency training at Loma Linda University Medical Center and Affiliate Hospitals. Dr. Lenhart is a diplomate of the American Dental Board of Anesthesiology and lectures in the US and internationally on topics related to sedation and general anesthesia.

Rita Agarwal, MD Dr. Agarwal, clinical professor of anesthesiology at Stanford University and pediatric anesthesiologist at Lucille Packard Children's Hospital, completed her training at Baylor College of Medicine in Texas and at the University of Colorado. Dr. Agarwal is board certified in anesthesia and pediatric anesthesia by the American Board of Anesthesiology. She was pediatric anesthesia program director at the University of Colorado for 18 years prior to transitioning to Stanford. From 2015–2017, she served as chair, American Academy of Pediatrics Section on Anesthesiology and Pain Management. Her interests include pediatric acute pain management, regional anesthesia, ambulatory anesthesia, neuroanesthesia, and medical student/resident/fellow education.


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Benjamin Rosenberg, DDS

Bobby Thikkurissy, DDS, MS Dr. S. “Bobby” Thikkurissy is professor and division director at Cincinnati Children’s Hospital. He earned his DDS degree from New York University in 1998 and received a certificate in pediatric dentistry from The Ohio State University in 2003. He served as director of the pre-doctoral program in pediatric dentistry at OSU from 2006–2011 and has served as program director at Cincinnati Children’s Hospital since 2013. He has published in the areas of morbidity associated with dental disease and procedural sedation. Dr. Thikkurissy served on the ADA Council of Dental Education and Licensure from 2013–2016 and as chair of the AAPD Committee on General Anesthesia and Sedation from 2012–2016. He has presented CE courses in over 15 states as well as in China and Serbia. He is a diplomate of the American Board of Pediatric Dentistry and serves on their Qualifying Examination Committee. Dr. Thikkurissy is also a national spokesperson for the AAPD.

Dr. Rosenberg graduated from the University of Missouri Dental School in Kansas City where he also completed his internship and pediatric residency at Children’s Mercy Hospital. After being in private practice in Joplin, Missouri, since 1972, the tornado of May 2011 destroyed his dental office completely. Missing only one week of work, Dr. Rosenberg began rebuilding a new office which he moved into a year later. When not in the office, Dr. Rosenberg enjoys going to auctions and sales looking for antique toys. He and his wife Patty have four grown children.

Stephen Ganzberg, DMD, MS Dr. Ganzberg, clinical professor of anesthesiology at the UCLA School of Dentistry, is a dentist anesthesiologist with over 25 years of experience in pain management. Dr. Ganzberg graduated from MIT in 1977 and the University of Pennsylvania School of Dental Medicine in 1981. He completed his pain management training at New York University and his anesthesiology training and master’s degree at The Ohio State University. Dr. Ganzberg taught at OSU for 17 years where he directed the anesthesiology residency program in the College of Dentistry before coming to UCLA. He is currently section chair of dental anesthesiology at UCLA where he teaches pharmacology, sedation, and anesthesiology in the School of Dentistry. He also engages in private dental anesthesiology practice. Dr. Ganzberg is the editor of Anesthesia Progress and has lectured extensively on topics involving anesthesiology, sedation, and medicine.

Michael Mashni, DDS Dr. Michael Mashni received his DDS degree from Loma Linda University School of Dentistry in 1992 and continued to complete his anesthesia training there in 1994. He is a diplomate of the American Dental Board of Anesthesiology. He is a past president of the American Society of Dentist Anesthesiologists and a past board member of the American Dental Board of Anesthesiology. Dr. Mashni is a founder and current board member of the American Board of Dental Specialties. He maintains a private practice in Southern California primarily providing anesthesia services to pediatric patients.

James Tom, DDS, MS Dr. Tom is associate clinical professor at the Herman Ostrow School of Dentistry, University of Southern California, where he earned his DDS degree. He completed his anesthesia training and received an MS degree in anesthesiology from The Ohio State University. Dr. Tom currently serves as president of the American Society of Dentist Anesthesiologists and as the assistant editor of Anesthesia Progress. Dr. Tom is the appointed ADA and ASDA representative on the American Society of Anesthesiologists Task Force on Guidelines for Moderate Procedural Sedation. He also maintains a private dentist anesthesiologist practice in Los Angeles.

Charles J. Coté, MD Dr. Coté, professor of anesthesia (emeritus) at Harvard Medical School’s Division of Pediatric Anesthesia, is board certified in both pediatrics and pediatric anesthesiology. From 2005–2014, he served as director of clinical research in the Division of Pediatric Anesthesia, MassGeneral Hospital for Children. He has been the primary author of every sedation guideline published by the American Academy of Pediatrics since 1985. Dr. Coté’s textbook, A Practice of Anesthesia in Infants and Children is currently in its fifth edition. He has also authored numerous peerreviewed publications, reviews, editorials, and clinical practice guidelines. Dr. Coté has also served as a member of the FDA's Committee on Medical Devices and the ASA's Committee for Patient Safety and Risk Management. www. spspr r i gu s mm/ /Fa l l l2 77 www. i gu a .co Fa l 01 2 01


Issues in Pediatric Dentistry Previously published biannually as EZPEDO Magazine 2015—2016.





MARK BOND Cover Designer

ANN FISHER Copy Editor/Proof Reader

Senior Designer

Art Director

Senior Consulting Editor

Senior Design Consultant

Contributing authors Bobby Thikkurissy, DDS, MS / Stephanie Reshewsky, DMD / Thomas E. Lenhart, DMD / Stephen Ganzberg, DMD, MS Michael Mashni, DDS / Benjamin Rosenberg, DDS / Jessica Harrison, RDA / Rita Agarwal, MD, Charles J. Coté, MD, James Tom, DDS, MS

Contributing photographers Slava Daniliuk / Daniel Vakaruk / Timothy Shambra

Special thanks to Victoria Sullivan, DDS / Shelli Crane / Kim & Tiffany Fisher


LYUBA KOLOMITETS Finance & Accounting

TIMOTHY SHAMBRA Advertising Sales

For editorial enquiries please email: For advertising enquiries please email: Subscriptions are available online by visiting: For additional enquiries please call: 888 539 7336 / Int. (1) 916 677 1447


Shift magazine, a contemporary dental publication highlighting relevant topics of interest for busy practitioners in private practice, publishes scientific articles, case reports, and human-interest stories focusing on current issues in pediatric dentistry. Pediatric and general dentists will learn about new concepts in restorative treatments and the latest innovations in techniques and products, all available in the one magazine that helps them keep pace with rapid changes in pediatric dentistry. © Copyright 2017 Shift magazine, a subsidiary of Sprig Oral Health Technologies, Inc. All Rights Reserved.


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What are pediatric dentists saying? “HemeRx pellets make my Zirconia crown cementation so much easier. They are on my ‘top 5 list’ of products that I can’t live without!”


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Meet HealthFirst

HealthFirst helps dentists ensure their offices are ready to practice with solutions in the form of emergency preparedness, infection control, and dental waste management. Through its smart automation of your practice’s readiness needs, your emergency medical kit is kept up-to-date and you have full visibility into your preparation status at all times. 7 ESSENTIAL MEDICATIONS SMART AUTOMATION OF MEDICATION EXPIRATION MANAGEMENT ADA BUSINESS RESOURCES ENDORSED VIEW ACCOUNT AND STATUS ONLINE AT ANY TIME For more information, contact HealthFirst. 11629 49th Pl W, Mukilteo, WA 98275 (800) 331-1984,

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AAPD 2017

GOOD TIMES This year's 2017 AAPD in Washington, D.C., was amazing. We hope you enjoyed listening to all the great speakers that presented on engaging and relevant dental topics, and we thank each of you who took time to stop by our booth for a visit.


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SPECIAL MOMENTS What an absolute joy to spend quality time with familiar faces and have the opportunity to meet new friends. We can't wait to see you at our next educational event and discuss the future of pediatric dentistry.

Sprig University 2017


DOCTOR TO DOCTOR Lary W. Deeds, DMD, obtained his Doctor of Dental Medicine degree at the University of Florida. He completed a residency in pediatric dentistry while serving in the U.S. Army. After retiring from the Army, Dr. Deeds and his family have made Clarksville, Tenn. their home. He opened The Children's Dentist in April 1998. He is board certified and a diplomate of the American Academy of Pediatric Dentistry. He lectures to local civic organizations and enjoys running marathons and competing in Scrabble. To stay abreast of the latest advancements in pediatric dentistry, Dr. Deeds maintains memberships with the American Dental Association, Tennessee Dental Association, American Academy of Pediatric Dentistry, and the Southeast Pediatric Dental Association.

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myexperience. I have been using Zirconia EZCrowns for the last three years. These crowns look so beautiful and natural that I have actually had mothers cry with joy when they have seen their children's restored teeth after treatment. Dr. Je Fisher has been readily available for telephone mentoring with challenging cases. I wholeheartedly recommend Sprig’s EZCrowns; in fact, I would use no other.

Lary Deeds, DMD

271 Stonecrossing Drive, Clarksville, TN 37042 931-551-4400 |

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OXIDE From Dentist to Superhero By Stephanie Rashewsky, DMD


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An American dentist, Horace Wells, is recognized as the father of anesthesia.

It is impossible to induce general anesthesia with nitrous oxide as a sole agent.

Nitrous oxide has an excellent safety record with no evidence of mortality when used appropriately and as the sole agent in a dental office.

Nitrous was first used in dentistry in the 1840s by Horace Wells, a dentist in Hartford, Conn., when he inhaled the agent prior to the extraction of one of his own teeth.1 Today, nitrous oxide usage in pediatric dentistry is so common that it’s use is often considered a routine adjunct for behavior management. In fact, recent studies show that 97 percent of pediatric dentists use nitrous (laughing gas) in their offices.2

The minimum alveolar concentration (MAC) of nitrous oxide is 104 percent, making it impossible to induce general anesthesia with nitrous oxide as the sole agent. It is the least potent of all anesthetic gases in use today. When administering general anesthesia, nitrous oxide is commonly used in combination with other volatile agents. Be aware that patients undergoing nitrous oxide sedation in concentrations greater than 50 percent—or in combination with other sedating medications (e.g. midazolam/ Versed, meperidine/Demerol)— have an increased risk for falling into moderate or deep sedation.

The main inherent danger in nitrous oxide use is hypoxia. However, fail-safe mechanisms ensure a minimum oxygen concentration of 30 percent is delivered in the gas mixture. Other safety considerations include the following: a) preventing the interchange of connections via the pin-index safety system and diameterindex system, b) having appropriate scavenging systems to minimize room air contamination and occupational risks, and c) providing available emergency equipment— specifically a 650-liter “E” cylinder of oxygen.4

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Nitrous oxide is an ideal agent because its actions relieve anxiety and it possesses specific qualities that relieve discomfort. Plus, once patients quit breathing the gas, its e ects dissipate rapidly, making it safe to discharge your patients and send them home soon following a procedure. Nitrous oxide has a morphine-like e ect, and while it doesn’t eliminate discomfort, it mutes it, and removes the emotional component of pain, making it an excellent drug for use in children.




Diffusion hypoxia can lead to patients experiencing headaches and disorientation.

Nitrous may not be the agent of choice for everyone.

Nitrous oxide’s most common side effects are nausea and vomiting.

Nitrous oxide is 34 times more soluble than nitrogen in blood. At the end of the procedure, 100 percent oxygen should be administered for five minutes to prevent the rapid release of nitrous oxide from the bloodstream into alveoli which then dilutes the concentration of oxygen, increasing the risk of hypoxia. Acute hypoxia may result in patients experiencing headaches and disorientation. Also, remember that children desaturate more quickly than adults.3


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Nitrous oxide is a great option for most patients. However, a number of relative contraindications exist, including patients with the following conditions: chronic obstructive pulmonary disease, pneumothorax, severe asthma, upper respiratory tract infections (blocked sinuses, blocked nasal passages, colds, influenza), acute otitis media or history of middle ear surgery (tympanic membrane graft), cystic fibrosis, colostomy bags or bowel obstructions, severe mental/psychiatric conditions or drug-related dependencies, first trimester of pregnancy, history of bleomycin sulfate treatment, and deficiencies in methylenetetrahydrofolate reductase and cobalamin. When in doubt, initiate a medical consult and obtain medical clearance prior to the use of nitrous oxide.3-4

Despite nausea and vomiting being the most common side effects, these outcomes are still rather rare, occurring in only 0.5 percent of patients. No strict fasting guidelines govern the use of nitrous oxide, but it may be wise to recommend that patients eat only a light meal prior to its administration. Other recommendations to decrease the incidence of nausea and vomiting include: a) avoid lengthy administration ( > 1 hour), b) minimize wide fluctuations in nitrous oxide levels, and c) avoid nitrous concentrations above 50 percent.3

AMAZING FACTS ABOUT N20 SYNONYMS & TRADE NAMES: • Dinitrogen monoxide, Hyponitrous acid anhydride, Laughing gas

• Colorless inhalation anesthetic with a slightly sweet odor. Note: Shipped as a liquefied compressed gas. • Molecular weight: 44.0 g/mol • Boiling point: -127 degrees F • Solubility: (77 degrees F) 0.1% Vapor Pressure • Nonflammable gas, but supports combustion at elevated temperatures. • Incompatibilities & reactivities: Aluminum, boron, hydrazine, lithium, hydride, phosphine, sodium

TARGET ORGANS • Respiratory system, central nervous system, reproductive system

SYMPTOMS OF OVEREXPOSURE • Dyspnea (breathing di culty), drowsiness, headache, asphyxia, reproductive e ects, liquid frostbite

The National Institute for Occupational Safety and Health (NIOSH)


Nitrous oxide allows pediatric dentists to be superheroes!

4. Nitrous oxide consistently ranks as one of the behavior management techniques most well accepted by parents. In a 1984 survey, sedation— including nitrous oxide—was listed as eighth (out of ten) in terms of acceptability. By 1991, nitrous was rated second in terms of parental acceptance following “Tell-Show-Do” (TSD). Nitrous oxide remained second behind TSD in a separate study in 2005.6 Today, parents increasingly accept the use of the technique. However, make sure you obtain informed consent before using nitrous oxide. Also, be sure to document the following in the patient’s chart: a) an indication for use of this type of sedation, b) the nitrous oxide dosage used, c) the duration of nitrous sedation, and d) the post-treatment oxygenation procedure.

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3. 3.

2. 2.

Analgesia, anxiolysis, Analgesia, anxiolysis, Analgesia, anxiolysis, and euphoria, Oh my! and and euphoria, euphoria, Oh Oh my! my!

Titrate, titrate, titrate! Titrate, Titrate, titrate, titrate, titrate! titrate!

Nitrous oxide has multiple Nitrous oxide multiple mechanisms of action that lead Nitrous oxide has has multiple mechanisms of that to central nervous system mechanisms of action action that lead lead to central system and euphoria. todepression central nervous nervous system While depression and While the mechanism by which nitrous depression and euphoria. euphoria. While the mechanism by which nitrous oxide acts upon nervous the mechanism bythe which nitrous oxide acts the system not fully understood, oxide actsisupon upon the nervous nervous system isis not the analgesic andunderstood, anxiolytic system not fully fully understood, the analgesic and effects are thought to be similar the analgesic and anxiolytic anxiolytic effects are to be to those of opioids effects are thought thought toand be similar similar to those respectively.5 tobenzodiazepines, those of of opioids opioids and and benzodiazepines, respectively. Nitrous oxide—when used in55 benzodiazepines, respectively. Nitrous oxide—when used conjunction with communicative Nitrous oxide—when used in in conjunction with behavior guidance techniques—is conjunction with communicative communicative behavior guidance techniques—is especially effective in helping behavior guidance techniques—is especially in childreneffective learn to cope with their especially effective in helping helping children learn their fears, anxieties, and with the children learn to to cope cope withstress their fears, anxieties, and the associated with dental treatment. fears, anxieties, and the stress stress associated associated with with dental dental treatment. treatment.

Initially, 100 percent oxygen Initially, percent should100 be administered for 1–2 Initially, 100 percent oxygen oxygen should be for minutes followed by titration should be administered administered for 1–2 1–2 of minutes titration nitrousfollowed oxide inby intervals ofof 10 minutes followed by titration of nitrous oxide in intervals of percent until desired nitrous oxide inthe intervals of 10 10 percent until the sedation is achieved, with most percent until the desired desired sedation isisrequiring achieved, with patients sedation achieved,30–40 with most most patients requiring 30–40 percent nitrous oxide. patients requiring 30–40The percent nitrous The concentration of nitrous percent nitrous oxide. oxide. The oxide concentration of oxide should not routinely exceed concentration of nitrous nitrous oxide50 should not routinely exceed percent. treatment, should notDuring routinely exceed 50 50 percent. During monitoring thetreatment, status of the percent. During treatment, monitoring following the items will of help monitoring the status status of the theyou following will to selectitems the appropriate following items will help help you you to select of nitrous oxide: toconcentration select the the appropriate appropriate concentration of a) patient’s respiratory rate and concentration of nitrous nitrous oxide: oxide: a) patient’s respiratory rate patient’s response a)rhythm, patient’sb) respiratory rate and and to rhythm, b) commands, and c)response level of to rhythm, b) patient’s patient’s response to commands, and patient’s consciousness. commands, and c) c) level level of of3 patient’s patient’s consciousness. consciousness.33

1.1. Nitrous oxide is Nitrous is Nitrous oxide is nearlyoxide an ideal nearly an ideal nearly an ideal anesthetic agent. anesthetic anesthetic agent. agent.

Nitrous oxide has many Nitrous oxide many characteristics an ideal Nitrous oxide has hasof many characteristics of anesthetic agent. has a great characteristics of an anItideal ideal anesthetic agent. track record in It terms safety anesthetic agent. It has has aof a great great track safety duerecord to the in fact that of it be track record in terms terms ofcan safety due to itit can delivered in athat noninvasive due to the the fact fact that can be be delivered noninvasive manner,in itaalacks serious side delivered in noninvasive manner, lacks serious side effects,ititit’s simple to use, manner, lacks serious sideand has effects, simple and rapidit’s onset and to quick effects, it’s simple to use, use,recovery. and has has 7 77 rapid quick recovery. Foronset theseand reasons, oxide rapid onset and quicknitrous recovery. For these reasons, nitrous has many health-care For these reasons, nitrous oxide oxide has many applications including fracture has many health-care health-care applications reduction, including laceration repair, applications including fracture fracture reduction, otologic laceration procedures, labor pain reduction, laceration repair, repair, otologic labor pain relief, procedures, and of course, pediatric otologic procedures, labor pain relief, and course, dentistry relief, and of oftreatment. course, pediatric pediatric dentistry dentistry treatment. treatment.

As pediatric dentists, our role is akin to that of superheroes, and nitrous As pediatric dentists, our role that of nitrous sedation is the extraordinary power gives us anand alternative Asoxide pediatric dentists, our role isis akin akin to to thatthat of superheroes, superheroes, and nitrous to oxide sedation isis the power us other more advanced behavioral-management techniques such as to oxide sedation the extraordinary extraordinary power that that gives gives us an an alternative alternative to other more behavioral-management techniques such protective stabilization, deep sedation, and general anesthesia. other more advanced advanced behavioral-management techniques such as asSince its protective deep sedation, and Since discoverystabilization, more than 170 years ago, nitrous oxide anesthesia. has had an impeccable protective stabilization, deep sedation, and general general anesthesia. Since its its discovery more than years nitrous oxide has impeccable safety track record. With theago, Internet, every parent nowan has the potential discovery more than 170 170 years ago, nitrous oxide has had had an impeccable safety track With parent now to become an “expert.” Consequently, we receive daily about safety track record. record. With the the Internet, Internet, every every parentinquiries now has has the the potential potential to become an Consequently, receive inquiries daily concerns, including questionswe about fluoride, radiographs, tosafety become an “expert.” “expert.” Consequently, we receive inquiries daily about about safety concerns, including questions about fluoride, radiographs, sedation, and more. Fortunately, nitrous is well accepted by safety concerns, including questions aboutoxide fluoride, radiographs, sedation, more. Fortunately, nitrous oxide isis well accepted parents,and mainly due to its excellent safety record, rapid onsetby of action, sedation, and more. Fortunately, nitrous oxide well accepted by parents, mainly to safety short duration, reversibility, and titratability. parents, mainly due due to its its excellent excellent safety record, record, rapid rapid onset onset of of action, action, short short duration, duration, reversibility, reversibility, and and titratability. titratability. This colorless and virtually odorless gas—the one that allows us to This colorless gas—the one allows us provide safeand effectiveodorless analgesia and anxiolysis treating This colorless and virtually virtually odorless gas—the one that thatwhile allows us to to provide safe effective and anxiolysis while challenging children—deserves our deep appreciation. Nitrous oxide provide safe and and effective analgesia analgesia and anxiolysis while treating treating challenging children—deserves deep Nitrous allows us as pediatric dentistsour to enhance the effectiveness ofoxide our challenging children—deserves our deep appreciation. appreciation. Nitrous oxide allows us to enhance the of communication anddentists improve cooperation in anxious children. allows us as as pediatric pediatric dentists topatient enhance the effectiveness effectiveness of our our communication patient cooperation in children. How fortunateand we improve are that Horace introduced dentistry to nitrous communication and improve patientWells cooperation in anxious anxious children. How fortunate we Wells introduced to nitrous oxide’s amazing superpower qualities, allowing us todentistry fulfill our as How fortunate we are are that that Horace Horace Wells introduced dentistry torole nitrous oxide’s amazing superpower qualities, superheroes in our patients’ eyes! allowing oxide’s amazing superpower qualities, allowing us us to to fulfill fulfill our our role role as as superheroes superheroes in in our our patients’ patients’ eyes! eyes!

References References Gifford EE. Horace Wells discovers pain-free dentistry. Retrieved from: Gifford EE. horace-wells-discovers-pain-free-dentistry. Gifford EE. Horace Horace Wells Wells discovers discovers pain-free pain-free dentistry. dentistry. Retrieved Retrieved from: from: Wilson S, Gosnell ES. Survey of American Academy of Pediatric Dentistry on nitrous oxide sedation: 20 horace-wells-discovers-pain-free-dentistry. 2. horace-wells-discovers-pain-free-dentistry. Gosnell ES. Survey of yearsS, later. Pediatr 2016;38:385—392. Wilson S, Gosnell ES.Dent Survey of American American Academy Academy of of Pediatric Pediatric Dentistry Dentistry on on nitrous nitrous oxide oxide sedation: sedation: 20 20 2. 2. Wilson later. Dent American Academy of 2016;38:385—392. Pediatric Dentistry. Guideline on use of nitrous oxide for pediatric dental years later. Pediatr Pediatr Dent 2016;38:385—392. 3. years of Dentistry. patients.Academy Pediatr Dent 2016;38:211—215. American Academy of Pediatric Pediatric Dentistry. Guideline Guideline on on use use of of nitrous nitrous oxide oxide for for pediatric pediatric dental dental 3.3. American Pediatr Dent 2016;38:211—215. Clark MS, Brunick Handbook of nitrous oxide and oxygen sedation. 4th edition, Mosby, 2015. patients. Pediatr DentAB. 2016;38:211—215. 4. patients. nd edition, MS, Brunick AB. of oxide oxygen 4th Mosby, 2015. Wright Kupietzky A. Behavior management in for children. Wiley Blackwell, Clark MS,GZ, Brunick AB. Handbook Handbook of nitrous nitrous oxide and anddentistry oxygen sedation. sedation. 4th2edition, edition, Mosby, 2015. 4. 4. 5. Clark nd nd 2014. GZ, Wright GZ, Kupietzky Kupietzky A. A. Behavior Behavior management management in in dentistry dentistry for for children. children. 22 edition, edition, Wiley Wiley Blackwell, Blackwell, 5.5. Wright Levering NJ, Welie JVM. Current status of nitrous oxide as a behavioral management practice routine 2014. 6. 2014. NJ, JVM. Current of in pediatric dentistry. Dent Childstatus 2011;78:24—30. Levering NJ, Welie Welie JVM. Current status of nitrous nitrous oxide oxide as as aa behavioral behavioral management management practice practice routine routine 6. 6. Levering pediatric dentistry. Dent Child U, Robinson Allshouse A. End-expired nitrous oxide concentrations compared to inKlein pediatric dentistry.TJ, Dent Child 2011;78:24—30. 2011;78:24—30. 7. in U, TJ, Allshouse A. nitrous concentrations compared to flowmeter settings operative dental treatment in children. Pediatr Dent 2011;33:56—62. Klein U, Robinson Robinson TJ,during Allshouse A. End-expired End-expired nitrous oxide oxide concentrations compared to 7.7. Klein flowmeter flowmeter settings settings during during operative operative dental dental treatment treatment in in children. children. Pediatr Pediatr Dent Dent 2011;33:56—62. 2011;33:56—62.




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From amom, Alex’s mother’s an RDA, perspective, shares her Alex’s experience mom, an RDA, facing shares her her ownexperience son’s dental her facing work own under son’s general dentalanesthesia work from ageneral under mother’s anesthesia. perspective. By Jessica Harrison, RDA


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hen you found out your son, Alex, needed crowns, what went through your mind, knowing what you know as an RDA? JESSICA

As soon as Alex's second primary molars started to erupt, I noticed they had hypoplasia (defective enamel formation.) I watched these four teeth closely as they erupted. When Alex was almost 3 years old, and as soon as the molars had erupted fully, I knew it was time to cap those teeth with crowns. Being a mom as well as an RDA and knowing what I do about the importance of prevention, I found it hard to face the reality that my own child needed dental treatment. Yet, in Alex's case, since the hypoplasia on his teeth resulted from uncontrollable causes, there was no way for me to have prevented the condition. All I could do was to make sure his teeth would be treated correctly.

With your background assisting with general anesthesia on a monthly basis in the dental o ce, did that experience a ect your decision on how and where Alex would be treated? JESSICA I have watched children go under sedation for over 15 years. I have also seen kids in the dental office undergoing treatment and experiencing unpleasant situations which could have been avoided if their parents had chosen to request sedation. My son Alex is young, and I did not want him to be "traumatized" if the visit did not go well. I have seen that happen far too many times. Previously, my older son Jordan had a small occlusal cavity on #L. I decided to treat him in the dental office, but the visit did not go well. Let’s just say it has taken him three years to finally be at ease during his routine visit to take X-rays and do a prophy. I did not want Alex to have that kind of experience. As soon as I knew Alex would need treatment, I was 100 percent in favor of choosing sedation for him. If I was not experienced in the use of anesthesia, then I may have felt differently and not wanted my son sedated. I probably would have wanted to see how the treatment would go in the dental office without sedation. However, due to my previous experience as a RDA, I did not even consider having Alex's dental treatment attempted while he was unsedated. I wanted his future cleaning visits to continue to go well without creating any fear on his part. He is a very wiggly little boy, and I know he would have had trouble holding still for treatment. As a dental professional, I know that when kids do not hold still, the dentist has a difficult time doing the dental work and achieving 100 percent ideal results. So, I put my full trust in the sedation process with the knowledge that my son would have no idea of what happened and would continue to experience easy routine cleanings in the future.

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How did your experience with Alex in the hospital di er from your own experience being part of the anesthesia team o ering sedation in an o ce setting? Why did you choose one location over the other? JESSICA

I chose for my son to have sedation done at Kaiser Permanente Medical Center, and it went flawlessly. Seizures run in our family, and since he has experienced one seizure already, I felt safer with him being sedated in the hospital instead of receiving IV sedation in my office. I also have Kaiser Insurance, so my co-pay was not that much. My experience as a mom with Alex in the hospital was good. I knew the steps that the nurses, dentist, and anesthesiologist would take. I understood why they were checking his vitals. I knew what was going to happen once he was wheeled away from me on the gurney. Prior to this experience, when I was part of the anesthesia team, I did not empathize that much personally with the patient’s parents because I had not been through it myself. Now that I have had my own experience with my child being sedated for dental treatment, I can sympathize more fully with parents.

When you saw Alex in recovery after the procedure, how did that make you feel? What was going through your mind? JESSICA

I was happy to see Alex once he was in recovery. I had full confidence in the staff at Kaiser and prayed for no complications. I know from an assistant’s viewpoint, it is best to just let the child wake up on his own, slowly. I have seen many parents start to rock their children trying to rush them awake. My husband and I just sat there quietly with Alex, and once he started to wake up on his own, then we were right there to assure him. He woke up with no tears. The nurse gave him a popsicle, and he left happy. He even wanted to go to the park later that day.

How has your personal experience with Alex going through his anesthesia changed the way you interact with other parents whose children are preparing for sedation? JESSICA

After my positive experience with my own son’s sedation, I am even more in favor of using sedation than I was before. I would not want to put a child through the fearful experience of unsedated treatment when there is such an easier way. In my opinion, children should have as positive a dental experience as possible. Now when I talk to parents, I am able to share with them my own experience and am better informed to advise them regarding the benefits of treating children with sedation. I am a parent first and a dental professional second. Sedation/anesthesia can be scary for both patients and their parents. The media have not helped the situation. I always recommend that parents educate themselves in advance. I urge them to ask questions and not rely only on news stories, since the information they report may not always be accurate.


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Thank you to the entire Harrison family for sharing your story. Mr. and Mrs. Harrison, along with their three beautiful children, live in Folsom, California. Mr. Harrison is a police officer with the Los Rios Police Department at the Folsom Campus.


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Does this ever happen at your office?

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oung children 2–5 years of age are cognitively, emotionally and/or physically unable to consistently follow commands and instructions or to adequately control their emotions.1 The two main approaches to behavioral management in this age group are non-pharmacologic and pharmacologic. In the past, nonpharmacologic behavioral management techniques were the most frequently used as a means by which the pediatric dentist could safely and efficiently provide treatment and leave the young child with an emotionally and physically positive experience. The most common non-pharmacologic behavioral management techniques utilized are communication, humor, behavioral shaping, voice control, hypnosis, coping skills, aversive conditioning, distraction, and physical restraint.2,3 As an office-based, mobile anesthesiologist and educator for more than 20 years, I have seen a definitive shift in the

choice of behavioral-management techniques adopted by dentists when treating children in the 2–5-year age group. Over the last few decades, child behavior (which is increasingly difficult to control) along with changes in parental expectations have resulted in the restraint forms of non-pharmacologic behavioral management becoming almost obsolete. Today, pharmacologic behavioral management is the new standard/norm governing patient care in pediatric dentistry. The standard I am referring to is the use of oral conscious sedation or general anesthesia. An estimated 100,000–250,000 pediatric dental sedations are performed each year in the United States.4 This treatment norm provides comfort, pain relief, and anxiolysis. It also minimizes psychological trauma related to dental surgery. The major objectives of sedation are to alter the child’s awareness, ensure intact reflexes (including the muscles of the airway), maintain normal vital signs (heart rate, respiration rate, blood pressure, temperature), increase the patient’s pain threshold, and produce amnesia in order to allow the dentist to effectively and successfully complete treatment.

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I will highlight three topics that, if properly attended to, I believe can dramatically increase the overall safety and effectiveness of procedural sedation and/or general anesthesia associated with children in the office-based dental setting: 1) case selection tools for use in identifying patients eligible to receive sedations, 2) choosing the appropriate type of sedation, and 3) recognition and management of complications associated with sedation. CASE SELECTION TOOLS Patient selection is the most important step in minimizing the risk of sedation for children. Pediatric dentists need to use all assessment tools available to develop criteria which will allow them to choose the proper treatment location, type of sedation to be used, appropriate medications, and route of administration. The major tools available to ensure proper patient selection include: 1) a thorough review of the child’s medical history, 2) a review of systems, 3) a focused physical exam, 4) ASA risk classification, and 5) airway evaluation.

Medical History:

The purpose of a medical history is to gather as much information about your patient as possible. One complicating factor in obtaining an accurate medical history is due to the current trend of parents not being forthcoming when reporting their child’s past or present health history and related medical problems. This reluctance of parents to disclose health problems may be due to issues relating to insurance exclusions or fear of a potential increase in premiums. Because of these factors, it is important, especially when your assessment warrants it, to request a recent history and physical—along with any test or lab results— from the patient’s pediatrician.

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Review of Systems:

This next tool presents a list of questions, arranged by organ system, designed to uncover any existing dysfunction or disease. The review gives a pediatric dentist an opportunity to discover any subjective symptoms that parents either forgot to describe or considered relatively unimportant at the time they filled out the medical history form. In summary, this review serves as a tool enabling a dentist to reveal omissions, inconsistencies, or patient comorbidities not previously mentioned.

Focused Physical Exam:

This exam is used to build on the information gathered during the medical history and review of systems. The first step in a proper physical exam is to obtain the child’s base-line vital signs such as heart rate, respiratory rate, blood pressure and temperature along with the knowledge of the normal values associated with patients of that specific age. The next step is to auscultate the child’s heart and lungs with a quality stethoscope in order to rule out dysrhythmias, murmurs, congenital heart defects, stridor, croup, congestion, or decreased breath sounds. Remember, you don’t need to be a cardiologist, but you do need to know normal sounds from abnormal sounds. I recommend that you execute a search for “heart and lung sounds.” The most common reasons to cancel a child’s scheduled sedation procedure include the following: an undiagnosed heart murmur or murmur greater than a grade II/VI, an upper respiratory infection (URI), cough, cold, flu and/or fever within two weeks of the scheduled procedure. Remember to ask specific questions. This history is critical in avoiding intra-operative airway complications.

ASA Risk Classification:

This tool provides a means of assessing the child’s overall physical health or "sickness" prior to sedation. It is also a predictor of whether or not the child should be treated in an office-based setting. My personal opinion is that only ASA I & II patients should be sedated in an office-based setting.

Medical History Review of Systems Focused Physical Exam ASA Risk Classification Airway Evaluation

Airway Evaluation:

“Airway, Airway, Airway.” NEVER forget this phrase. This emphasis on maintaining an open airway takes priority over everything else we do. From my perspective, without a patent airway, the teeth do not matter. Why do I say this? Children’s anatomy and physiology inherently increases their risks during sedation. They very quickly desaturate, becoming hypoxic, cyanotic, and bradycardic, which leads to cardiopulmonary arrest. Sometimes the slightest increase in the opening of the mouth or the slightest change in head positioning can partially or completely block the child’s airway during the surgical procedure without a dentist realizing it.

oral sedation on children with a Class III or IV Mallampati classification.

Finally, I will assess the patency of the child’s nose. Is the child congested? One can only imagine how difficult it must be to move air in and out through a partially obtunded airway.

I start my airway evaluation with an overall assessment of the head. I ask myself the following questions: Is there any craniofacial dysostosis or syndromic features? Does the child have any facial asymmetries? Does the child have full range of motion of their neck? I have the child look up, down, left and right in order to evaluate full extension and flexion of the neck. What is the maximum opening of the mouth? Is there any limitation to opening or closing of the mouth? Is the child a mouth breather? Do they have rhinitis? What is the thyroid mental distance? I will then have a child open his mouth and stick out his tongue without saying “awwh” in order to assess his Mallampati classification. This evaluation is a good predictor of obstruction, apnea, and/or difficult airway. It is best to avoid

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CHOICES TO MAKE— ORAL SEDATION OR GENERAL ANESTHESIA? When making a decision regarding sedation options for a pre-cooperative young child with extensive dental decay, the pediatric dentist must most often choose between treatment under oral conscious sedation with passive restraint or general anesthesia. What are the factors to consider when making such a decision?

Choosing an Anesthetic Agent:

The common oral medications used to sedate fearful or uncooperative children have not changed much in the past 50 years. Many of these medications are antiquated with narrow margins of safety. Newer medications, like midazolam, have a shorter duration of action and a high incidence of paradoxical reactions. One of the challenges when choosing oral sedation over general anesthesia involves predictably dosing a child whose physiology is being greatly affected by “fight or flight” responses. When delivering sedatives orally, a child is often under stress which may affect the efficiency of the medication being absorbed in the stomach. Because the stomach’s emptying time is adversely affected by the stress of preop procedures, medications are often much less predictably absorbed, and their therapeutic effects are often delayed. As a result, practitioners may be tempted to administer a second dose. This may lead to an unanticipated deeper level of sedation than originally planned. Why is this the case? When the child begins to calm down under the effect of the sedation, and the “fight or flight” reflex subsides, the GI system relaxes, and both doses kick in, potentially deepening the sedation to dangerous, unintended levels. General anesthesia on the other hand, delivered via inhalation, intramuscularly, or intravenously, exhibits much more predictable absorption results, unaffected by the potential “shut down” of the GI system observed with oral sedation.

Choosing the Setting for Delivering Anesthesia:

When considering whether it is safe to administer general anesthesia in an office setting, a dentist anesthesiologist typically considers minimum physical eligibility criteria. These may require that a child be at least 18 months to 2 years of age and 10–12 kg in body weight. Manifestations of the following conditions in young patients should be seen as contraindications when considering giving them sedation in an office setting: 1) uncontrolled asthma, requiring multiple medications and the use of a rescue inhaler daily/weekly, 2) syndromes whose physical characteristics could result in a compromised airway or difficulty intubating if an emergency were to arise, 3) a prior history of openheart surgery, 4) a recent diagnosis of DM type I, as patients often manifest large swings in blood glucose levels during the first few months/years after initial diagnosis, or 5) potentially complicating airway factors such as a history of tracheo/laryngeal malacia or a lengthy stay in the NICU requiring prolonged intubation resulting in trachea atresia. When considering the safety of office-based sedation, additional questions to weigh include these: 1) Is the child currently under treatment with chemotherapy drugs? 2) Has she been diagnosed with a bleeding disorder? 3) Is there even a suspicion that he has a pseudocholinesterase deficiency? A positive response to any of these questions should cause a practitioner to think carefully when deciding on the best location for treatment. Remember, it is always wise and prudent to involve your medical colleagues when making decisions based upon your patients’ medical conditions. Often physicians will have additional information and recommendations that will assist you in arriving at a treatment decision. If a child fails to meet any of the above criteria, manifests any of the contraindicating conditions, or has any other issue that you feel could compromise the safety of treatment in an office setting, your wisest choice is to consider performing the dental procedure at a surgery center or in a hospital operating room.

Choosing the Mode of Anesthesia Delivery:

When oral conscious sedation is not an appropriate option or is ineffective, general anesthesia is the preferred choice. Induction of general anesthesia is most often accomplished using one of three methods: 1) inhalation, 2) intramuscular, or 3) intravenous. All three of these administration routes are more effective than using oral sedation because they allow medications to avoid the first-pass effect in the liver. This reality allows them to act much more predictably regardless of the patient’s level of cooperation. After induction, anesthesia maintenance is also more easily controlled because medications can be injected directly into the circulatory system. These intravenous medications can be titrated to elicit the desired effect, or, if necessary, they can be reversed. Newer medications have very rapid onset and elimination times, making them ideal for use in the outpatient dental setting.

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Challenges when choosing oral sedation over general anesthesia involve predictably dosing a child whose physiology is being greatly affected by “fight or flight” responses.

Summary Criteria for Choosing Oral Sedation or General Anesthesia in the Office Setting:


When deciding on the type of sedation to use— oral sedation or general anesthesia—I generally recommend making the decision based on the following criteria:

We all know that sedation has inherent risks due to numerous factors such as airway complications, physical status changes, drug sensitivities, tolerances, etc. Also, we recognize that the level of sedation is not a static, fixed state, but exhibits a sliding continuum depending on surgical stimulation.5 For example, oral sedation can have a wide variability of efficiency regarding onset of action and duration of action due to the route of administration and the first-pass effect through the liver. Emergencies can and do happen in the office-based setting for sedation. Being aware and prepared is vital.

When to Use Oral Sedation Mild to moderate anxiety Fearful but cooperative patient Short treatment time No history of any significant medical conditions ASA I or II stable Normal focused physical exam Mallampati score I or II

When to Use General Anesthesia Moderate to severe anxiety Fearful and combative patient Moderate to long treatment time Behaviorally or intellectually disabled ASA I or II stable Normal focused physical exam Mallampati score I–IV (No obstructive sleep apnea)

Common problems associated with sedation are respiratory and/or cardiovascular in nature. The most common problems associated with pediatric sedation are respiratory: respiratory depression due to hypoventilation or airway obstruction, laryngospasm, bronchospasm, or aspiration. Common cardiovascular problems include syncope, hypotension, hypertension, bradycardia, or tachycardia. A practitioner and his/her team is only as safe as they are prepared. Regular continuing education in medical emergency management and routine checks of all emergency equipment and medications are vital for any practice providing sedation/general anesthesia for their patients. Only through proper monitoring, situational awareness, access to emergency equipment and training, and participating in mock emergency drills will we decrease the risk of morbidity or mortality of our pediatric patients. We owe it to our patients and their families to practice each and every day with the upmost of care and safety.

Choices and Parental Informed Consent: As the controversy increases relative to the possibility of whether certain medications given to young children effect brain function and cognitive development,6 obtaining informed parental consent prior to delivering sedation or general anesthesia is imperative. Pediatric dentists must be sure to adequately inform parents of the various options available for treatment, including discussing non-pharmaceutical options as possible modalities, even when their own clinical evaluation might indicate otherwise.

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Conclusion Recently, reports have highlighted a disproportionate increase in the number of cases nationally that have resulted in the death or permanent neurologic damage of children being treated by dentists and involving oral conscious sedation, moderate to deep sedation or general anesthesia.7,8,9,10 These incidences have involved various anesthesia providers, different surgical settings, different levels of sedation, different airway approaches, and different anesthesia delivery models. So, my question is “Why?” Although I don’t have a definitive answer, this question should concern all of us involved in pediatric sedation and stimulate a renewal of our commitment to following the sedation guidelines of the AAPD and to doing everything we possibly can to ensure the safety of our pediatric patients. The dental profession faces a dilemma. We understand that early childhood caries are associated with pain, tooth loss, impaired growth, decreased weight gain, failure to thrive, and negative effects on quality of life such as problems with eating, speaking, playing, and learning. As healthcare providers, we understand that not treating or extracting carious teeth can result in serious complications, including emergency-room visits, hospitalization, and/or death. On the other hand, we also understand that sedation itself carries inherent risks. Our challenge? How can we reduce the risks associated with moderate to deep sedation and/or general anesthesia for children undergoing dental procedures? My recommendation is that we go back to the basics and re-familiarize ourselves with pediatric airway anatomy and physiology, sedation pharmacology, and the recognition and management of complications associated with sedation.

3. Law CS, Blain S. Approaching the pediatric dental patient: A review of nonpharmacologic behavior management strategies. J Calif Dent Assoc 2003;31(9):703–13. 4. Nelson TM, Xu Z. Pediatric dental sedation: challenges and opportunities. Clin Cosmet Investig Dent 2015; 7: 97–106. Published online 2015 Aug 26. doi: 10.2147/CCIDE.S64250. 5. Becker DE, Haas DA. Management of complications during moderate and deep sedation: respiratory and cardiovascular considerations. Anesth Prog 2007 Summer; 54(2): 59–69. 6. Sun L. Early childhood general anaesthesia exposure and neurocognitive development. Br J Anaesth 2010 Dec; 05(Suppl 1): i61–i68. doi: 10.1093/bja/aeq302. PMCID: PMC3000523. 7. Chmura C, Roher C, Horn M, Rojas J. “Dental anesthesia under scrutiny after child dies.” dental-anesthesia-under-scrutiny-after-childdies-381594491.html. Bay Area NBC News, June 2, 2016. 8. Recede K, McLaren G. “California girl dies during dental procedure, family says.” http:// Health, Fox News. June 16, 2017. 9. WFTV 9 ABC News. “9 Investigates teenager’s death after routine dental procedure.” http:// May 16, 2016. 10. Bradford H. “Dental sedation responsible for at least 31 child deaths over 15 years.” http:// Huffington Post, July 13, 2012.

References 1. Anthonappa RP, Ashley PF, Bonetti DL, Lombardo G, Riley P. Non-pharmacological interventions for managing dental anxiety in children (Protocol). Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No: CD012676. doi: 10.1002/14651858.CD012676. 2. Sheller B. Challenges of managing child behavior in the 21st century dental setting. Pediatr Dent 2004; 26(2): 111–13.

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My recommendation…

Re-familiarize ourselves with pediatric airway anatomy and physiology, sedation pharmacology, and the recognition and management of complications associated with sedation. Thomas E. Lenhart, DMD

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Got questions about

anesthesia? We all have questions, but sometimes it’s difficult to find reliable answers. With sedation and general anesthesia recently featured so prominently in national news, Shift magazine goes behind the scenes in an interview with a past president of the American Society of Dentist Anesthesiologists to discover answers to some important questions dealing with dental anesthesia and related issues involving patient safety in pediatric dentistry. 448 8

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• In data from from more than 3.2 million cases of anesthesia use between 2010 and 2013, the rate of complications decreased from 11.8 percent to 4.8 percent. The most common minor complication was nausea and vomiting (nearly 36 percent) and the most common major complication was medication error (nearly 12 percent). • The death rate remained at three deaths per 10,000 surgeries/ procedures involving anesthesia. • Among the other findings: complication rates were not higher among patients who had evening or holiday procedures; patients older than 50 had the highest rates of serious complications; and healthier patients having elective daytime surgery had the highest rates of minor complications. a recent update, Dr. Jeana Havidich, an * Inassociate professor of anesthesiology at

Dartmouth-Hitchcock Medical Center in New Hampshire, presented the above preliminary data at an American Society of Anesthesiologist convention in October 2014. (

Shift magazine 1. With recent nation-wide news stories reporting sedation-related tragedies in dental o ces, are the risks for in-o ce anesthesia going up? Or is it still safe? MM We are all concerned when we read reports of poor outcomes occurring in dental offices. Of course, even a single poor outcome is one too many. One problem we face, however, is that the facts are rarely available for the experts to review. Furthermore, we don’t have access to a centrally maintained database which allows us to track all outcomes. Much of what we know regarding the circumstances surrounding reported poor outcomes is based on what we hear from the media or from attorneys pleading the case for their clients. The safety of anesthesia will always be questioned after any poor outcome, and hopefully we can all take the opportunity to review how we practice and explore how we can improve the safety of the patients we treat. We must continually ask ourselves probing questions. How can we learn from these



cases to determine what went wrong? And how can we prevent the same problems from occurring again? Many factors can affect the safety of anesthesia. Safety is related to the training of the individual anesthesia provider, his/her experience (particularly with pediatric patients), and coexisting or current medical conditions such as a concurrent upper-respiratory-tract infection. Additional risk factors include such things as food in the stomach, length of the procedure, and even the common sense of the provider. If an anesthesia provider determines that a patient would be put at increased risk while undergoing anesthesia, then treatment may need to be referred to a hospital or surgery center, depending on the specific circumstances. In many cases, however, children can still be safely treated in the dental office by practitioners who are properly trained and prepared.

Shift magazine 2. What are the di erences between using a medical anesthesiologist vs. a dental anesthesiologist? Are they trained di erently?


Michael Mashni, DDS

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MM Physicians and dentists each travel a different pathway prior to their anesthesia training. Physician anesthesiologists are well trained in all aspects of anesthesia. Historically, dentists have trained side by side with physician colleagues in the same program. When this practice was no longer an option, training programs for dentists developed with rotations in the anesthesia departments of hospitals and medical centers, but also concentrating on treating patients for dental reasons, and more specifically, in the dental office setting. Prior to the accreditation of dental anesthesia training programs, the training varied by location and school. Now, however, set standards exist which all dental anesthesiology training programs must follow. Currently, the length of such training is three years. These programs maintain high minimum standards for treatment of pediatric patients and train dentists in providing outpatient anesthesia in a dental office. Both physician anesthesiologists and dentist anesthesiologists are qualified to treat patients in the office setting. We may conclude that all anesthesia providers— whether trained via a medical or dental track—must be properly qualified to work in a dental office setting that will ensure the safety of patients.

Shift magazine 3. With increasing scrutiny becoming the norm, should I as a pediatric dentist be requesting a medical clearance on all my sedation cases, or is it ok to just let the anesthesiologist do the H&P? MM That is a good question. A medical history and a focused physical evaluation (H&P) must be performed on each patient prior to administering anesthesia. One purpose of the medical history is to review the medical systems and determine if more questions need to be answered or more tests performed. Routine lab tests or chest x-rays used to be standard prior to surgery, but this practice has long been abandoned as these procedures rarely altered treatment, unless they revealed an existing contraindication. Medical clearance by itself may not be helpful and may only give a false sense of security. After reviewing a medical history and/or evaluating the patient, if you determine that a consult is necessary, then you should absolutely obtain one prior to treatment. Just as routine laboratory tests or chest x-rays are not necessary, a medical consult is not necessary for every patient. A medical consult should be directed towards addressing specific conditions and not be a general request for “clearance.” A note from a physician which only indicates “ok to treat” is worthless. A child with a failing heart may be “ok to treat” for the purpose of repairing the cardiac defect. This does not mean the patient would be ready for dental treatment in an office-based setting.

Shift magazine 4. Do any statistics demonstrate whether it is safer to have my patient intubated vs. using an open-airway technique? MM Both techniques have been used safely and successfully for

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many years. I am not aware of any studies comparing the two modes of practice. Medicine has tended to intubate patients and more recently adopted a practice of using supraglottic airways such as a laryngeal mask airway. Dentistry, on the other hand, has a strong history of utilizing an open-airway technique. The main benefit of intubation is achieving a protected airway. The downside of using an intubation technique is the potential soreness or trauma it may cause. These results, however, are infrequent, particularly when performed by skilled providers. When using an open-airway technique, the anesthesiologist must manage the airway. My observation is that patients wake up more smoothly following an open-airway procedure. My friends who choose to intubate their patients would disagree. So, the debate continues….

Shift magazine 5. What are some important factors to consider when choosing an anesthesia provider to assist my practice? MM Safety is your number one consideration; but it is also number two, three, and four! Start with the provider’s training. Make sure the anesthesiologist completed an anesthesia residency either in medicine or dentistry. Look at the amount of training and experience the provider has had with pediatric patients. Kids are not small adults and shouldn’t be treated as such. Board certification in anesthesia by the American Dental Board of Anesthesiology (dentists) or the American Board of Anesthesiology (physicians) is verification of training at the highest level. For dentists, active membership in the American Society of Dentist Anesthesiologists indicates the highest level of ongoing training in anesthesia for dentistry. Make sure the provider has experience or training in providing sedation in the dental office setting. Ask for references from other dentists or physician colleagues.

Shift magazine 6. With the rising cost of medical insurance deductibles, do you foresee more people opting to request in-o ce sedation for dental procedures in the future?

For dentists, active membership in the American Society of Dentist Anesthesiologists indicates the highest training in anesthesia for dentistry.

MM There is no question that in-office anesthesia is more cost effective than performing procedures in a surgery center or a hospital. Since I began my training in anesthesia in the early 1990’s, I have observed pressure to move anesthesia outside the hospital to ambulatory settings. However, cost savings should not be the only consideration. As discussed above, safety is our first priority, and if a patient’s needs require the use of a surgery center or hospital operating room, then finances shouldn’t dictate that treatment be performed in a dental office. This being said, anesthesia provided in ambulatory centers and even in dental offices has a long track record of safety. Advances in medicine will only improve this record. New devices such as bluetooth precordial stethoscopes, video laryngoscopes, vein finders, and supraglottic airways have been developed. These instruments have become widely available since my training and all give me tools that help me treat patients more safely in ambulatory settings. I cannot foresee a decrease in utilization of in-office anesthesia.

Shift magazine 7. If I currently use oral sedation in my o ce, are there reasons I should consider inviting an anesthesiologist to partner with me in providing in-o ce sedation? MM My opinion is that minimal sedation—more specifically, sedation administered by the oral route—is the most underutilized tool in dentistry. A divide exists between medicine and dentistry regarding providing sedation and anesthesia for potentially painful or uncomfortable procedures. I once had a chalazion (blocked duct in my eyelid) for which my ophthalmologist recommended treatment in the hospital operating room despite most ophthalmologists performing such treatment under local anesthesia in the office. I’m told this procedure involves only a simple excision, yet my medical insurance authorized the anesthesia in the hospital without question. I never had the procedure performed, but compare this simple chalazion procedure to a dental procedure requiring you to do several pulpotomies, seat a number of SSCs, and maybe even perform an extraction. Why is it that in dentistry we expect patients to just grin and bear it? Pediatric dentists or others with training in minimal

sedation, should continue providing sedation services as long as the treatment falls within the scope of both the dentist’s training and the AAP/AAPD guidelines (AAP/AAPD Guidelines for Monitoring and Management of Pediatric Patients Before, During and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016). If done within the guidelines for minimal and moderate sedation, failures can be expected. If you experience a 100 percent success rate using minimal sedation, then you are either ultra conservative and lucky with your patient selection or you are overdosing a small percentage of your patients. An anesthesiologist is available for the patients that require deeper levels of sedation.

Shift magazine 8. Where do you see in-o ce sedation moving in the future, and how can dental professionals help ensure this option will be available for future generations of pediatric dentists? MM In-office sedation is growing due to the strong safety record and the current demand. By choosing appropriate patients that can be treated in the office by minimal sedation and utilizing a qualified anesthesiologist, dentists will be providing a much-needed and safe alternative to a surgery center or hospital. As a profession, we need to continue to improve outcomes and continuously look at our processes and procedures to see how we can improve, even if we think we are doing a good job as it is now. Poor outcomes will always prompt a review and sometimes new regulations and laws. Tracking outcomes data will either establish our practices as safe or show us how to improve. Poor outcomes will always prompt a review and sometimes may result in new regulations being adopted and/or new laws being passed. This is the best defense we have against reflex moves that would place limits on anesthesia in the dental office.

additional questions about anesthesia related topics Got


Send us an email at If there is interest, we can make this forum a regular part of Shift magazine.

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Navigating Icebergs Safety in Pediatric Procedural Sedation By Sarat “Bobby� Thikkurissy, DDS, MS

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When any one asks me how I can best describe my experiences of nearly forty years at sea, I merely say uneventful. Of course, there have been winter gales and storms and fog and the like, but in all my experience, I have never been in an accident of any sort worth speaking about.... I never saw a wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in disaster of any sort. I will say that I cannot imagine any condition which could cause a ship to founder. I cannot conceive of any vital disaster happening to this vessel. Modern shipbuilding has gone beyond that. Captain E. J. Smith (HMS Titanic) www. sp ri gu s a .co m / Fa l l 2 01 7


Safety in Pediatric Procedural Sedation


rony aside, the quote on the previous page belies our inability to plan for unexpected adverse outcomes. It would seem complacency is an inevitable by-product of success, but one achieved at grave cost. Procedural sedation is a vital part of the behavior management continuum advocated and practiced by the American Academy of Pediatric Dentistry (AAPD) and its members. Every day thousands of children are sedated safely and without harm across the country. In spite of sedation’s safety track record, it is the unexpected outcome—a death, hospitalization, and the like—that drive us to analyze and reanalyze our processes in an attempt to keep our children safe. In weighing the option to use procedural sedation, we truly must strive to achieve a standard of “zero tolerance” for adverse outcomes. The AAPD is committed to making safety the key factor in determining all its recommendations regarding the therapies and care provided by its members. This commitment has been underscored when formulating its best practices, developing its continuing education courses, designing its webinars, and drafting its operating principles.

In 1818, The Lady’s Magazine published a sidebar on the foundations of basic-skills-oriented education programs emphasizing reading, writing, and arithmetic—the Three R’s. Along this same line of thinking, I’d like to put forward the “Three A’s” for basic-sedation skills: Assumptions, Assessment and Awareness. I will frame these skills within the parameters of our current AAPD guidelines.

ASSUMPTIONS 1. Assume parents will fib. I may have taken this assertion from the TV series “House,” but it’s true none-the-less. Because parental assessments are not always reliable, be sure to rely on your physician colleagues to obtain a history and physical (H&P) when scheduling procedural sedation of children. While I have participated in research demonstrating that physician H&Ps are dubious at times, the point is that someone (either the dentist or physician) is objectively assessing the child’s health.1 The AAPD guidelines do an excellent job of not only outlining basic components of assessment but also highlighting areas that impact sedation—items such as BMI/obesity, history of prematurity and associated airway illness during early


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childhood, and a review of systems. The adage “never treat a stranger” comes to mind. In summary, know your patient.

2. Assume parents will not understand. The AAPD clearly states that informed consent is the “process of providing patients/parents with relevant information regarding diagnosis and treatment needs so that an educated decision regarding treatment can be made.” Requiring informed consent compels discussion of risks, benefits, and alternatives to any therapy. A compelling reason must exist before making a decision to use pharmacologic therapy (sedation or general anesthesia). In a time when insurance companies attempt to drive clinical decision making, practitioners must be the ones who step back, examine risks to the child, and, using this assessment as their guiding “north star,”2 plan for appropriate procedural sedation to which parents give consent. Additionally, health literacy can impact a parent’s ability to understand written documents. According to the National Assessment of Adult Literacy, the understanding of 14 percent of adults (30 million people) falls below the basic level of health literacy.3 This fact underscores the importance of drafting a carefully worded, easily understood consent form and discussing it adequately with a child’s parents before administering sedation or general anesthesia.

3. Assume the family will get stuck in traffic! Flippancy aside, an issue of constant discussion and debate is whether children can be dosed with “anxiolytics” at home. The AAP/AAPD guidelines clearly state that “The administration of sedating medications at home poses an unacceptable risk.”4 Case reports indicate that children have been given medications at home which induce an unexpected depth of sedation and lead to tragic situations which result in the worst of all imaginable outcomes, a child’s death. It is worth noting that the AAPD guidelines adopt the American Academy of Pediatrics (AAP) definition5 of “pediatric,” i.e. all patients aged 18 and under. Both AAP and AAPD guidelines apply to this entire age group.

ASSESSMENT 1. Assess ventilation. Studies have demonstrated as much as a 200-second diagnostic lead time when using capnography testing to detect apnea as compared to using a pulse oximeter alone. The American Society of Anesthesiologists (ASA) and the American Society of Dentist Anesthesiologists list capnography as the standard of exhaled carbon dioxide assessment. The AAP/AAPD recommend capnography as the preferred measure of

The key preventive measure is to assess the quality of ventilation, because evidence of impaired ventilation will typically precede oxygenation problems noted on the pulse oximeter.


Titanic — 1997 film “Mr. Ismay, it was under your directive that we were traveling through an ice field at the arrogant speed of twenty-one knots! I am the master of this vessel and I have been too complacent! “ Captain E. J. Smith (HMS Titanic)

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Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures policies_guidelines/g_sedation.pdf

Policy on the Use of Deep Sedation and General Anesthesia in the Pediatric Dental Office Policies_Guidelines/P_Sedation1.pdf

Guideline on Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/ General Anesthesia to the Pediatric Dental Patient Policies_Guidelines/ G_AnesthesiaPersonnel1.pdf

Guideline on Use of Local Anesthesia for Pediatric Dental Patients Policies_Guidelines/ G_LocalAnesthesia2.pdf

ventilation, although replaceable with amplified pre-tracheal stethoscope, if appropriate, and purposeful bi-directional communication is present. The key preventive measure is to assess the quality of ventilation, because evidence of impaired ventilation will typically precede oxygenation problems noted on the pulse oximeter. In many cases, the anatomy of a young patient will lead to upper airway obstruction caused either by a forward-tilted head, or most commonly, the tongue, which exhibits a relative macroglossia in a child.

2. Assess your staff. In private offices, particularly in rural areas, 911/first-responder response times may be variable. Therefore, dentists and their staff are the key link ensuring the patient’s survival. Early identification of respiratory or cardiovascular problems and high-quality basic life support and airway management are essential in successful rescue of the patient. This is where running mock codes, or testing office preparedness is key. The importance of dental office staff in an emergency cannot be overstated, as their skills are essential to ensure successful outcomes. The AAP/AAPD guidelines have distinct sections relating to on-site preparedness and facility requirements. Visit the Society for Pediatric Anesthesia website at where you may download multi-lingual emergency checklists.4

All providers must prepare to rescue the child from one sedation level deeper than was intended.

3. Assess the child. This concept cannot be reinforced enough. On several occasions a dental team has been so focused on treatment of the tooth that they failed to realize the child had stopped breathing. The AAP/AAPD guidelines underscore that “If sedating medications are administered in conjunction with an immobilization device (i.e., protective stabilization), monitoring must be used at a level consistent with the level of sedation achieved.” This underscores a point that is fundamental in pediatric sedation—children exhibit variable responses to sedative medications. All providers must prepare to rescue the child from one sedation level deeper than was intended. There is no such thing as “only Versed.” Even when using Versed alone, a patient may require resuscitation or rescue. A basic principle taught in Basic, Advanced Cardiac, and Pediatric Advanced Life Support (BLS/ACLS/PALS) training courses is to treat the patient, not the monitor. Even if the pulse oximeter reads 100 percent, is the child cyanotic? Is she obstructing? Understand what “normal” is, and then constantly be alert for signs indicating that a deviation from normal is occurring. If a deviation does occur, be prepared to act swiftly and without hesitation.

AWARENESS 1. Be aware of potential adverse events. The American Dental Association, AAPD, ASA and a host of other organizations have affirmed the importance of


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Safety in Pediatric Procedural Sedation

simulation-based continuing education. I teach in the AAPD Sedation Simulation course, and one of the most gratifying things for me is to have someone who is initially nervous gradually realize that they have acquired the knowledge and demonstrated the ability to keep a child safe. The more simulation-based scenarios a provider encounters the more this training will reinforce the basic skills needed to rescue a patient should the need arise. PALS has changed over the years; now it is a heavy scenario-based course which reinforces the fundamental principles of rescue.


2. Be aware of how vital signs are related and interpreted. During procedural sedation, a child’s vital signs may be altered because of medication being administered. Again, if the practitioner understands normal (and in this case pre-sedation baselines) they will be prepared to act in the case of aberrations. With greater depths of sedation, the necessity of monitoring becomes increasingly important, and having a dedicated person available to monitor physiologic parameters is required. If this person is a staff member, they need to understand how a low blood pressure may be indicative of hypovolemic shock in a non-responsive patient—particularly since patients are kept without food or water prior to sedation. Case-based scenarios and continuing education courses for staff and dentists help hone the skills needed to interpret how vital signs are interconnected and how they may reflect the patient’s level of physiologic stability.


isk management is not something routinely incorporated into dental school curricula, yet it is the basis for all we do in dentistry. Caries risk assessment, periodicity of radiographs and recall appointments, and procedural sedation workups are steeped in the mindset of risk management. Our national guidelines and consensus statements give us boundaries for what should be “acceptable risk” (within the confines of standard-of-care), but each provider accepts or rejects risk when they make a treatment plan. The “Triple A’s” I’ve listed above are suggestions of how to modify our risk management decisions in approaching pediatric procedural sedation, couched within terms of the AAP/AAPD guidelines. These suggestions represent the best collection of evidence we have on how to mitigate adverse outcomes associated with sedation in children.

MINDRAY Passport 12 Monitor $4,800 (starting price)

SEDATION RESOURCE Bluetooth Stethoscope $649

HEINE Laryngoscope $732

We live our professional and personal lives avoiding risk-related icebergs. Our AAPD/AAP guidelines act as buoys to keep us in safe waters. They assist us in steering clear of uncharted dangers lurking in dark waters and enable us to keep the children we treat—our most precious cargo—safe and without harm.


LEARDAL Resuscitator $192

1. Thikkurissy S, Smiley M, Casamassimo PS. Concordance and contrast between community-based physicians' and dentist anesthesiologists' history and physicals in outpatient pediatric dental surgery. Anesth Prog 2008 Summer;55(2):35–39. 2. American Academy of Pediatric Dentistry. Guideline on Informed Consent. Council on Clinical Affairs. Reference Manual. 2015 Revision. 3. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. 1993. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey (NALS). Washington, DC: National Center for Education Statistics, U.S. Department of Education. 4. Cote CJ, Wilson S, American Academy of Pediatrics. Guideline for monitoring and management for pediatric patients before, during and after sedation for diagnostic and therapeutic procedure: update 2016. Pediatr Dent 2016;38(4):E13–E39. 5. American Academy of Pediatrics, Committee on Pediatric Workforce. Definition of a Pediatrician. April 2015.135(4).


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Contact FDA For more info 855-543-DRUG (3784) and press 4 DrugSafety/ucm532356.htm

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FDA Warning on Anesthesia Drugs By Steven Ganzberg, DMD, MS

[This article originally appeared as an editorial in Anesthesia Progress, a journal published by the American Dental Society of Anesthesiology. Because the issues it addresses need to be the concern of all dentists treating pediatric patients, we are sharing its timely discussion with Shift magazine readers.]

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This past December, the FDA required that a warning be added to labels of many anesthetic drugs (Table 1) stating, “Repeated or lengthy use of general anesthetic or sedation drugs during surgeries or procedures in children younger than 3 years of age, or in pregnant woman during the final trimester may affect development of children's brains.” The FDA's definition of “lengthy” was greater than three hours of exposure.”1 This was not a “black box” warning per se, but rather an effort by the FDA to highlight a growing concern and alert anesthesia providers that a discussion of the concern of the “potential adverse effects of anesthesia on brain development” should take place in the informed consent process. The data from animal models have convincingly found changes in brain development related to exposure to anesthetic/sedative drugs, including nitrous oxide which was not on the list. How these animal models, many of which have rodents in cages rather than human infants and toddlers that are encouraged and stimulated, to name just one difference, translate to our children is far from clear. Many recent human studies, including the General Anesthesia Compared to Spinal Anesthesia (GAS)2 and Pediatric Anesthesia Neurodevelopment Assessment (PANDA),3 provide evidence that a single general anesthetic exposure does not affect intelligence or neurocognitive development. More studies are needed regarding repeated or prolonged exposure to anesthetic agents. We are awaiting the publication of the Mayo Safety of Anesthesia in Kids (MASK) study that will hopefully shed some insight on these questions. Regardless, as doctors, our primary dictate is to Do No Harm. So, we all take this concern quite seriously. There is no question that if a child needs surgery for a serious illness or congenital disease, caregivers should not withhold anesthesia for months or years out of concern for impaired neurocognitive development, still unproven. But, the most common surgeries for children with general anesthesia include ear tube placement, tonsillectomy and dental surgery for caries. I am not an ENT surgeon, but if my child's hearing could be impaired by repeated otitis media or they had obstructive sleep apnea from enlarged tonsils, I would personally consent to anesthesia for these procedures which might take 15–45 minutes—a so-called brief anesthetic exposure. But what of general anesthesia for dental decay? Dentist anesthesiologists (DAs) are the only dental anesthesia providers who routinely anesthetize children 1–2 years old. Infants generally do not have dental decay requiring treatment, and congenital defects, such as cleft lip/palate and other craniofacial abnormalities, are usually managed by specialized hospital teams. Most dentist anesthesiologists have criteria for the selection of pediatric patients deemed safe for general anesthesia in the office setting. Children at least 18 months of age, 10 kg of body weight, and ASA I or non-cardiopulmonary ASA II are common criteria for many DAs. For the youngest in this age group, the treatment may consist of restoration of only the four maxillary incisors. As the children get older, we commonly see the four primary first molars with or without the four maxillary incisors requiring treatment. As children get closer to 3 years of age, when the second primary molars have erupted, we start approaching 12–16 primary teeth requiring treatment for aggressive caries. As dentists, DAs appreciate the importance of the teeth to overall health and psychological wellbeing of children and their parents. But, as anesthesiologists, are we always


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TABLE 1 Inhalational Anesthetics

• Isoflurane • Sevoflurane • Desflurane • Halothane

Intravenous Anesthetics

• Midazolam • Propofol • Methohexital • Lorazepam • Ketamine • Pentobarbital • Etomidate

considering the benefit-risk ratio of a functional, pain-free, aesthetic dentition vs. the potential neurocognitive effects of general anesthesia? Should we, for instance, counsel parents and their dentists to have the four maxillary incisors extracted in a procedure with mask sevoflurane anesthesia taking at most 10 minutes from induction to emergence vs. what, for some operating dentists, may be a 90-minute restorative procedure? What if we know of other dentists who could accomplish that same quality restorative procedure in 30 minutes? Many of us have seen children provided anesthesia when they were 20 months old for aggressive caries of the primary first molars and four maxillary incisors, only to be seen again one year later for treatment of the primary second molars. Do we delay general anesthesia until after 3 years of age since now multiple anesthetics before age 3 are needed? Is 3 years the magic age such that we should consider discussing with the treating dentist the possibility of delaying dental treatment four months for a 32-month-old child? What if only early caries are present? Can we then wait four months? What if the child is in pain with abscessed teeth? All of us have seen children who developed facial cellulitis from untreated caries that required incision and drainage under general anesthesia with intravenous antibiotics and a hospital stay. And then these children needed another general anesthetic to treat the remaining dentition! Do we extend this line of questioning to children who have had ear tubes or tonsillectomy and now will have “multiple” anesthetics due to a needed dental procedure? Is there a difference in our thinking if the previous anesthetic was a 15minute ear tube anesthetic vs. a longer hypospadias repair anesthetic?

As doctors, our primary dictate is to Do No Harm. So, we all take this concern quite seriously.

No one has the answers to any of these questions. Every situation is different. There are additionally too many other variables beyond the dental and anesthesia issues to also consider. For instance, social factors, such as distance that economically disadvantaged parents have to travel for dental treatment, to name just one, have to be considered. At the same time, we cannot be cavalier in our approach to this emerging concern and just throw up our hands and say all children should be treated if the operating dentist chooses to do so. I have always felt that the anesthesia provider is the ultimate last-chance patient advocate in the surgical process. As independent anesthesia providers not involved in the surgical procedure, we are the gatekeepers taking all aspects of the procedure, without regard to economic incentives, and the anesthesia into perspective. We must always do what we feel is in the best interest of the patient. As dentist anesthesiologists, we are arguably more knowledgeable about dental procedures than our physician anesthesia colleagues are regarding medical surgical interventions. We are, therefore, in an ethically more challenging position to take all these competing factors into consideration. In the meantime, the American Society of Anesthesiologists, the American Academy of Pediatrics, Society of Pediatric Anesthesia, International Anesthesia Research Society and the Society for Obstetric Anesthesia and Perinatology have issued a joint statement regarding this concern which we can use with our parents and caregivers. In part, it states: “While there is abundant animal data concerning suspected toxicities in prolonged and multiple anesthetics, the

accumulated human data suggest that one brief anesthetic is not associated with cognitive or behavioral abnormalities in children. Most but not all studies in children do however suggest an association between repeated and or prolonged exposure and subsequent difficulties with learning or behavior. It is not yet known whether the anesthetic drug or some other factor is responsible for these findings. Rigorous research to further characterize any possible associations is ongoing.”4 One or two more studies will not settle the issue of a possible relationship between anesthesia and neurocognitive development any time soon. In the meantime, perhaps the American Society of Dentist Anesthesiologists can develop their own consensus statement for dentist anesthesiologists as this matter will be with us for many years to come.

REFERENCES 1. US Food and Drug Administration. 2. Davidson AJ, Disma N, de Graff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awakeregional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016;387(10015): 239–250. 3. Sun LS, Li G, Miller TL, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016 Jun 7;315(21):2312–20. 4. ASA Response to FDA Med Watch Warning, December 16, 2016: washington-alerts/2016/12/asa-response-to-the-fda-med-watch.


anesthetic drug, chemical structure.


Reprinted from Anesthesia Progress: Summer 2017, Vol. 64, No. 2, pp. 57-58 with permission of the American Dental Society of Anesthesiology.

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Surgery Anesthesia


BOTH? Single-operator Anesthesia Model for Pediatric General Anesthesia: A NEED FOR

AN FDA BLACK BOX WARNING? By Rita Agarwal, MD, Charles J. Coté, MD, and James Tom, DDS, MS

The American Academy of Pediatrics (AAP), jointly with the American Academy of Pediatric Dentistry (AAPD), clearly state that for children who are deeply sedated, the sedation provider “must be trained in and capable of providing advanced pediatric life support and is skilled to rescue a child with apnea, laryngospasm, and/or airway obstruction. Required skills include the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, LMA), and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation.” A second individual must be a trained observer “whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration. This individual must be trained in PALS and capable of assisting with any emergency that might arise.” An individual, including dental assistants, without formal and extensive medical training does not meet the AAP/AAPD standards of being capable of assisting with a medical emergency.


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n 2015, 6-year-old Caleb Sears died in his oral surgeon’s office. He had received multiple sedating medications, including propofol, ketamine and midazolam. When Caleb either obstructed his airway or stopped breathing, the oral surgeon failed to administer reversal or resuscitative agents, failed to attempt placement of a supraglottic device, and failed to ventilate or intubate. In fact, when the EMTs arrived, Caleb was pulseless and no one was performing basic CPR. As a result of his death, Caleb’s Law ( was passed in the State of California. The law required three things in regards to deep sedation or anesthesia for children: 1. 2. 3.

A study by the Dental Board of California on current practices, incidence of adverse events and the safety of dental anesthesia. A data-collection tool to gather reliable information on dental anesthesia occurrences and adverse events. An updated informed-consent form that explains to the patient’s parents or caregivers that delivering deep sedation or general anesthesia in a dental office is different from general anesthesia practiced in a hospital or accredited surgical center.

Following completion of the study by the Dental Board of California, there has been an attempt to codify these recommendations in Caleb’s Law 2 (California Assembly Bill AB224). Unfortunately, this process has been met with considerable resistance. There should be no misunderstanding regarding the skill set which the AAP/ AAPD guidelines require the independent observer to have. This individual must also be at least PALS trained and capable of assisting with emergencies for deeply sedated children. Specifically, PALS training includes recognizing and diagnosing heart rhythms, independent administration of resuscitative drugs, and directing or performing the delivery of any other rescue interventions (defibrillation, synchronized cardioversion, intraosseous access, etc). Dental assistants or hygienists do not receive such training and therefore cannot fulfill the AAP/AAPD guideline recommendations. Yet, some in the oral surgery community feel that such a person fulfills the AAP/AAPD guideline with minimal additional training. The oral surgery “team model” utilizing dental assistants is not in any way equivalent to the American Society of Anesthesiologists’ “team model” (see anesthesia%20care%20team) for anesthesia care. Furthermore, on every box of Diprivan (propofol) Injectable Emulsion—a drug used commonly for inducing deep sedation and/or general anesthesia in office-based settings—the FDA has mandated that the following language be displayed prominently:

DIPRIVAN injection should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Notwithstanding the fact that other medications can place children into deep sedation or general anesthesia, the warning on this product certainly seems to be very prudent.


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In fact, the expectations of the vast majority of parents and caretakers are that their child’s deep sedation/general anesthesia is being administered and/or monitored by someone explicitly trained to do so while their dentist or oral surgeon performs the dental procedure. We have arrived at a critical juncture in the provision of deep sedation and general anesthesia in numerous places throughout the United States and Canada where the root-cause analysis of high-profile bad outcomes and adverse events has highlighted the suboptimal practices currently occurring in many dental and oral surgery offices. How is it still acceptable—as is often typical in oral surgery practice—that the dentist extracting the tooth or performing the oral surgery procedure is simultaneously tasked with the ultimate responsibility of both administering and monitoring general anesthesia, particularly in young children? Obviously, this practice model is profitable, since the oral surgeon is able to bill separately for the procedure and for the administration of anesthesia. An argument has been proposed stating that well-trained dental assistants are surrogates for the training and judgment of an oral surgeon who may have spent up to six months in a hospital setting learning a separate-provider model of general anesthesia under the strict tutelage of physician-led training programs. But dental assistants, no matter how well trained they may be, have not had the medical training required to assist with life-threatening emergencies and are incapable of assuming the responsibility for making important clinical—sometimes critical—decisions that rely on adequate medical experience. Dental assistants and auxiliaries cannot possibly have the extensive knowledge or thorough understanding of physiology and pharmacology that has made anesthesia/ sedation in other settings so safe. Dental assistants, unlike registered nurses, generally are not trained to start an intravenous line; nor are they allowed to independently administer drugs intravenously in most jurisdictions. In terms of scope of practice, they are therefore severely limited in their ability to assist in a true, life-threatening pediatric emergency. Another nuance we must consider is that in any pediatric medical emergency, the timeline of an unfolding crisis is accelerated. The loss of an open airway due to a laryngospasm, pharyngeal collapse or apnea, the hypotension from anaphylaxis, or the development of seizures caused by fever or local anesthetic overdose, requires a more rapid intervention than is the case when treating someone older. The need for this accelerated response when treating children is due to pediatric patients’ greater oxygen consumption and the rapidity with which they may develop severe hypoxemia. It is simply unrealistic to think that a dental provider will be able to insert an IV or administer rescue medications while simultaneously attempting to manage the airway, perform chest compressions, or handle any other evolving medical emergency alone. Surgeons with bravado may seem capable and willing, but when we recognize the hubris of this attitude and insist on the principle of “one person dedicated to one task,” better outcomes will be the result.

Societies committed to the highest standards in pediatric safety in the area of deep sedation and general anesthesia

We believe that parents—if given the option of having a separate anesthesia provider who has expertise in managing pediatric patients under general anesthesia and uses these skills regularly instead of only occasionally—would undoubtedly reject the single-provider model. Caleb’s Law in California was meant to make all dental patients and their caregivers aware of safer options.

Will we be satisfied with the

WORST-BEST OPTION, or will we recommit to providing best-practices in




The American Academy of Pediatrics, the American Academy of Pediatric Dentistry, the American Society of Anesthesiologists, and the American Society of Dentist Anesthesiologists have all made firm and unwavering commitments to promoting pediatric patient safety in the area of deep sedation and general anesthesia. The FDA has also made their commitment to this goal exceedingly clear. No matter what arguments have been or will be proposed, the standard of care endorsed by these professional societies and by the federal government clearly indicate that the practice of adopting a single-operator anesthesia model to provide general anesthesia in dentistry is the least-best option— perhaps the best-worst option—we can offer to our children in terms of safety and outcomes. It is unclear if a “black box warning” from the FDA would improve patient safety or alter current practice. However, it might be a step in the right direction by emphasizing that, as wonderful as anesthetic drugs are, they also can be a loaded gun fired by an untrained or minimally trained individual, potentially leading to subsequent tragic consequences.

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A LOOK BEHIND THE SCENE. True leaders create their own content, and that’s exactly what we do at Sprig. So remember, the beautiful pictures of smiling children in our ads are not stock photos, they’re all special because they’re all patients treated with our crowns.


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Mention “Joplin, Missouri” to almost anyone in the Midwest (or the entire US for that matter), and they almost immediately respond with a question, “Were you in the tornado?” My answer is always the same, “Yes, I was. And yes, my community suffered a horrific loss that day six and a half years ago.” One can hardly comprehend the extensive devastation and the tragedy of lives lost in such a traumatic event. But, I can tell you this—that day has inspired many changes and has resulted in a community dedicated to hope and regrowth.

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A familiar red chair lies tangled in a twisted heap of metal and concrete.


n Sunday, May 22 (the day the tornado struck in 2011), my wife, Patty, who is a nurse, received a call summoning her to the St. John's Regional Medical Center to help treat the many people who had been injured. As we left home, we had no idea of the true extent of the damage. Although my house lay in the path of the tornado, the damage it suffered was minimal. As we drove closer to the hospital, the landscape changed dramatically. No buildings, no trees; everything lay twisted and broken with roads covered in debris. Our drive took us past my office. Looking at what remained, all I could say to my wife was, “My office, it’s gone!” The office, located one block away from the area now considered “ground zero,” was just a pile of debris. On Tuesday morning, two days after the tornado, I met with my staff at the “office.” Thankfully, everyone was safe. I knew they all were wondering if this meant the end of my practice. I was 72 years old, and I confess, for a moment even I wondered, “Is this the way it will all end?” But that moment did not last long. I was not ready to retire. Dentistry is what I do; it’s what I enjoy. I also felt a responsibility to my patients and staff to keep the practice going. In our staff meeting that day, I told my team, “We need to find a place to work and begin the overwhelming task of starting over.” Three days a week, I was able to utilize the facilities at the Joplin Community Clinic. The community has operated a free dental clinic at this site where I have volunteered for over 20 years. The clinic was furnished with the majority of equipment I needed, and the governing board very graciously provided us with a place to work. In addition, I received a phone call from the Southeast Kansas Community Dental Center in Pittsburg.


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…it would have been so easy to just give up and call it a day. Fortunately, we discovered hope, a reason to persevere.


The destructive aftermath of the devastating tornado that touched down in Joplin, Missouri, May 22, 2011. OPPOSITE BOTTOM RIGHT:

The office, located one block away from the area now considered “ground zero,” was just a pile of debris.

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Kansas, located approximately 35 miles away. They offered to make available a fully equipped four-chair office, if I was interested. So, I also began practicing there two days a week. As a children’s dentist, I also needed to find a hospital where I could take my young patients for treatment under general anesthesia. St. John's Regional Medical Center (now rebuilt as Mercy Hospital), was nearly destroyed in the tornado, and the other hospital had stopped scheduling dental cases several years ago. Fortunately, Via Christi Hospital in Pittsburg, Kansas, was available. Thus, by June 7, 2011, I was able to schedule pediatric cases. My dental office was originally built in 1972, and following the tornado, nearly every item in it needed to be replaced. On the plus side, the tornado got rid of the things I hadn’t used or needed in years. Reaching out to several companies for assistance in replacing all my needed supplies and equipment seemed a little overwhelming. However, within a couple of weeks I had most everything in order.


s I recall the traumatic events of the tornado, I’d like to express my thanks to EZPEDO (now Sprig Oral Health Technologies) for reaching out to us in our time of need. I had just received a crown order from them the week prior to the tornado, and all the crowns were destroyed on that fateful day. As a result of one phone call, they replaced my entire crown order free of charge. Dr. Fisher and the EZPEDO/Sprig team went above and beyond my expectations with their genuine caring commitment to help my office get through this difficult time.

72 72

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In May 2012, we officially moved into our new office building. As I look back to the day the tornado struck, May 22, 2011—a day filled with so much sadness and devastation—it would have been so easy to just give up and call it a day. Fortunately, we discovered hope, a reason to persevere. So, to the dentists and anyone else affected by recent hurricanes Harvey and Irma (or other events of destruction), I would encourage you to look past the destruction and the overwhelming helplessness of the situation and plan for the future. What would my advice be to you? Get yourself organized. Arrange a temporary office. Call your suppliers as soon as possible. Let your patients know you are not closed. This is not the time to sit on the sofa and let your insurance pay you. If you succumb to this attitude, you will lose patients. Current patients will not wait for you to rebuild, and new patients will be looking for someone whose doors are still open. You don’t have to face the devastation alone. Don’t be afraid; take the initiative and meet with your peers and support each other. I personally appreciate the support I received from my fellow dentists, my suppliers, my staff, and my community. I am grateful for being able to continue my practice and to enjoy the fruits of my labor long after the tragic tornado touched down in my home town of Joplin, Missouri.

Helping the sun shine again.

Support two organizations helping dentists in Florida and Texas recover from Hurricanes Harvey and Irma. When disaster strikes, communities rally together to support one another on the long road to recovery. The Florida Dental Association Foundation (FDAF) and Texas Dental Association (TDA) are doing just that through relief funds they have established to help dental professionals a ected by natural disasters like Hurricanes Irma and Harvey. Interested in contributing? Visit€for FDAF donations and€for TDA donations. In Puerto Rico, the government has launched a guide on what and how to donate emergency supplies and capital to help its citizens recover. Visit for more information.


Today, Dr. Rosenberg’s office stands tall and proud. And while the memories live on in the many pictures from that fateful day, his legacy is one of courage and hope—two qualities our world desperately needs today. So, thank you Dr. Rosenberg for sharing your inspirational story with our readers.

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BAHAMAS BAHAMAS CRUISE CRUISE November November 5-9, 2018 5-9, 2018

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BAHAMAS CRUISE November 5-9, 2018

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Critical issues when treating some of our youngest patients

Surviving a Devastatıng


Rebuilding after a natural disaster



everyone should know about


OPERATOR ANESTHESIA EZPEDO IS NOW SPRIG Sprig is an oral health technology company fighting to bring the innovation today’s patients and professionals demand to pediatric dentistry. Now offering more products than ever before, Sprig is providing you with even more tools, enabling you to do your best work and achieve superior results for your patients. We do this because the next generation deserves next generation care. • Use Sprig EZCrowns to offer space-loss solutions (cuspids, first & second molars). • Save time by placing EZCrowns quicker using our fast-setting SmartMTA. P • Provide safe and superior hemostasis for your patients by using HemeRx. • Prep EZCrowns with speed and efficiency using the EZPrep diamond bur system. • Attend a Sprig University workshop to help you confidently offer your patients EZCrowns.

Learn more at or call us at (888) 539.7336 Order any of our products today and receive 10% off your order by entering the promo code SPRIG OFFER EXPIRES ON DECEMBER 1, 2017

A need for an FDA black box warning?


ICEBERGS Safety in pediatric procedural sedation