Question for practicing periodontists

[Sublimazing]

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It seems as though he took his website down. But this is what it said before, maybe I am misinterupting this:

"Dr. John D. Stover is one of the few triple board certified physicians in the entire state of Hawaii and is one of the state’s top-performing cosmetic surgeons. He is certified by the American Board of Cosmetic Surgery, the American Association of Oral and Maxillofacial Surgeons, and the National Dental Board of Anesthesiology. Dr. Stover is a member of the American Medical Association, the Hawaii State Medical Society, and the Hawaii County Medical Society, and he is a fellow of both the American Academy of Cosmetic Surgery and the American Association of Oral and Maxillofacial Surgeons… Dr. Angelo Cuzalina, an internationally recognized breast surgery expert, performs all cosmetic breast surgery in our Waimea surgical suite under general anesthesia and on an outpatient basis."

And lets not have everyone point fingers at anyone or even accuse the operator-anesthetist model. It was only a couple years ago we had the case in Maryland with an OMFS taking out thirds on a HEALTHY ASA I teenage girl that died under the care of a separate MD Anesthesiologist. And of course everyone instantly placed blame on the OMFS.

http://www.baltimoresun.com/news/ma...o-olenick-settlement-20130403,0,3496441.story

The NDBA is run by ADSA, it does not require a dental anesthesiology residency to be a member...ASDA (subtle difference) is the Dental Anesthesiology professional group that requires a dental anesthesiology residency, so he was not a residency trained dental anesthesiologist....as far as a I know, the DAs have a spotless record (anyone that knows otherwise I would be very interested to hear about it).

And I don't think anyone pointed the finger at the operator/anesthetist model, I mentioned that it does cause premiums to increase for malpractice in some states/plans. Both OMFS and DAs support the operator anesthetist model as a whole myself included. And OF COURSE physicians, DAs, OMFS, and the spectrum of anesthesia providers are all capable of negligence or misfortune.

I'm PRO-OMFS anesthesia, I'm PRO-DA anesthesia, I'm PRO-MD anesthesia.

 

[osteotomy01]

@Sublimazing thanks for the clarification and I agree too 🙂

 

[sed8nyank4u]

@Sublimazing what changes do you think need to be made with sedation education (CE)? Actually, now that you mention it, I can think of at least one standardization and one addition to training. What DA program are you in? Will you solely practice anesthesia when you are done?

For the other posters who seem to be so anti-anyone-but-OS taking out teeth and doing sedation, perhaps you can enlighten me. I don't believe periodontists take out many impacted thirds (or teeth for that matter). They certainly would never be on my referral list for extraction. If a tooth needs to come out it is my responsibility or I will use a oral maxillofacial surgeon. But, I find it amusing that there is a sentiment that: "the periodontists are going to ruin [ability to provide anesthesia] for the rest of us" following it up with poking fun at the probably more accurate description of "1.5 hours and 27 stitches later" regarding their extraction skills and suturing technique.
So, are they too reckless to do moderate sedation? But yet they are too anal with their sutures and surgical technique? Can you really have it both ways? I would like to think ya'll are just poking fun or stroking each other's egos. But as it is, it reeks of arrogance and rings hollow of logic.
Now, don't get me wrong it is so cool you can admit someone to the hospital and round with the docs there. I am sure your patients appreciate it. And we have oral surgeons to thank for keeping anesthesia in dentistry and giving strong evidence for the operator/anesthetist models safety.
There is a lot of pressure from medicine and the ASA to regulate delivery of anesthesia in outpatient dental procedures (mandatory EtCO2 monitoring for example- although for deep sedation I can see how it may be more beneficial). Dentistry must stand strongly together to protect our right to safely provide sedation and anesthesia as we have done for years. Otherwise we will be proverbially "giving antibiotic premedication for life after total joint replacement prior to prophylactic dental cleaning whether or not there is any evidence of bacteremia and subsequent failure of said joint." The last thing we want is dentistry becoming more like medicine.

 

[Sublimazing]

@Sublimazing what changes do you think need to be made with sedation education (CE)? Actually, now that you mention it, I can think of at least one standardization and one addition to training. What DA program are you in? Will you solely practice anesthesia when you are done?

Everyone who does sedation should be able to intubate if need be, diagnose and handle basic airway problems (obstruction, laryngospasm, foreign body, aspiration), stabilize/treat the spectrum of type 1 hypersensitivity, standardized monitoring including pulse oximetry and precordial steth +/- etco2 (with the ability to interpret these measurements)...basically everything that is accomplished in the first month of any anesthesia program.

I'm at Loma Linda. And I'll be doing an operator/anesthetist model.

 

[Silent Cool]

Everyone who does sedation should be able to intubate if need be, diagnose and handle basic airway problems (obstruction, laryngospasm, foreign body, aspiration), stabilize/treat the spectrum of type 1 hypersensitivity, standardized monitoring including pulse oximetry and precordial steth +/- etco2 (with the ability to interpret these measurements)...basically everything that is accomplished in the first month of any anesthesia program.

I'm at Loma Linda. And I'll be doing an operator/anesthetist model.

Sub,
Do you mean that you will be practicing gen'l dentistry as well as anesthesia?

thanx

 

[Sublimazing]

Sub,
Do you mean that you will be practicing gen'l dentistry as well as anesthesia?

thanx

No...specialized dentistry.

But for any further inquiries into my training, life, hobbies please PM me...no one on this forum wants to hear my life story.

 

[DaleDoback]

Everyone who does sedation should be able to intubate if need be, diagnose and handle basic airway problems (obstruction, laryngospasm, foreign body, aspiration), stabilize/treat the spectrum of type 1 hypersensitivity, standardized monitoring including pulse oximetry and precordial steth +/- etco2 (with the ability to interpret these measurements)...basically everything that is accomplished in the first month of any anesthesia program.

I'm at Loma Linda. And I'll be doing an operator/anesthetist model.

Agree with above. Everyone should be able to monitor the sedation, no matter the depth, appropriately and accurately.

Sub:
I'll be the first to admit that I have been actively against DA's in my state (even expressing my opinions on this board at some point). Good for you doing the operator/anesthetist model. In my state, the DA's (less than 6) only do the sedations and are actively against the operator/anesthetist model. They spend most of their time fighting OMS at the state dental board level. This has apparently skewed my views towards DA as a whole. I just wanted to say that because I was also actively against DA as a specialty. Reading some of your comments have absolutely made me question my stand on the situation.

Let's be realistic, you guys are absolutely specialists in our field and get great training. I'm actually glad I'm not in a 6-year program because I loved anesthesia so much that I could have possibly seen myself bailing on OMS completely. All the best.

 

[sed8nyank4u]

No...specialized dentistry.

But for any further inquiries into my training, life, hobbies please PM me...no one on this forum wants to hear my life story.

@Sublimazing can you define "specialized dentistry"?

How quickly can somebody lose their skill of intubation? How often should one be incubating to be good and proficient at it?

How can someone be limited [to a level of sedation that should never require intubation] and be proficient and capable of intubating? Do you all believe that moderate sedation is so hard to achieve and maintain? Maybe I am overestimating the difficulty of intubation. I have done it before and it wasn't as easy as I anticipated. I believe OMS also rarely-never do it after residency and they are routinely doing deep sedation and GA. Must be like riding a bike?

Anyways, requiring intubation skill set for moderate sedation would be absurd, no offense.

 

[Sublimazing]

@Sublimazing can you define "specialized dentistry"?

How quickly can somebody lose their skill of intubation? How often should one be incubating to be good and proficient at it?

How can someone be limited [to a level of sedation that should never require intubation] and be proficient and capable of intubating? Do you all believe that moderate sedation is so hard to achieve and maintain? Maybe I am overestimating the difficulty of intubation. I have done it before and it wasn't as easy as I anticipated. I believe OMS also rarely-never do it after residency and they are routinely doing deep sedation and GA. Must be like riding a bike?

Anyways, requiring intubation skill set for moderate sedation would be absurd, no offense.

Yes, any OMFS could intubate any patient they deep sedate in their office...and if things hit the fan they're ready to do a surgical airway.

Your response that you shouldn't have to know how to intubate because it's "too hard" makes me scared for your patients. And when you do your informed consents I think you should bring up the fact that you cannot intubate as a risk so that your patients know.

Every single dentist who has had a death in their office because the kid slipped into a deeper level of sedation had no intention of taking them that deep, but it happened.

Not having adequate training because it's too hard is just the worst excuse ever.

You just shouldn't be doing sedation if you aren't trained in the fundamentals of anesthesia, and you'll never convince me otherwise. And when I become a consultant on these cases later in my career, I will bring the swift hammer of justice down upon those who were under trained for the procedure.

 

[sed8nyank4u]

Yes, any OMFS could intubate any patient they deep sedate But how often are they doping that? That is the point. If it is so rarely needed with OMS doing deep!sedation what makes you think it will be needed for moderate sedation? in their office...and if things hit the fan they're ready to do a surgical airway.

Your response that you shouldn't have to know how to intubate because it's "too hard" (not too hard. My concern is that it wouldbe too dangerous. Do you really want someone trying to ornate you who rarely does it?) makes me scared for your patients. And when you do your informed consents I think you should bring up the fact that you cannot intubate as a risk so that your patients know.
Thanks for your opinion but that is not the standard of care. Btw have you ever tried to intubate a conscious patient?

Every single dentist who has had a death in their office because the kid (Kids are a different beast entirely. I can see the day where only a DA or other anesthesia provider can do the sedation/anesthesia for children but to be fair I am unfamiliar with the training and safety record of pediatric dentists.

slipped into a deeper level of sedation had no intention of taking them that deep, but it happened.

Not having adequate training because it's too hard is just the worst excuse ever.
Again, no excuses here. For moderate sedation, I just don't see the need. I believe my safety record speaks for itself. Also the fact that it is not incorporated in any training program but rather taught that you have gone way too far if a patient needs intubation.
You just shouldn't be doing sedation if you aren't trained in the fundamentals of anesthesia, and you'll never convince me otherwise. And when I become a consultant on these cases later in my career, I will bring the swift hammer of justice down upon those who were under trained for the procedure.

Edit: see response above in quote as well.
It is impossible for you to remove moderate sedation permits from those already doing it. So, if you figure out the logistics of an advanced airway course, let me know. I will take it. I hope you are not taking any of this personal. I believe it is clear we are both firmly on different sides of an issue and are passionately and firmly entrenched in our stances.

So you previously said providing Moderate sedation should be available to all dentists. (Maybe I misunderstood?) There is no "intubation training" so how can a perio or endo or GP become qualified to do moderate sedation in your book?
By the way ACLS used to include placement of advanced airways but they started refusing dentists from doing that portion of the class. It is currently not the standard of care for moderate sedation providers.
My questions above are sincere so any input is greatly appreciated.

 

[Sublimazing]

Edit: see response above in quote as well.
It is impossible for you to remove moderate sedation permits from those already doing it. So, if you figure out the logistics of an advanced airway course, let me know. I will take it. I hope you are not taking any of this personal. I believe it is clear we are both firmly on different sides of an issue and are passionately and firmly entrenched in our stances.

So you previously said providing Moderate sedation should be available to all dentists. (Maybe I misunderstood?) There is no "intubation training" so how can a perio or endo or GP become qualified to do moderate sedation in your book?
By the way ACLS used to include placement of advanced airways but they started refusing dentists from doing that portion of the class. It is currently not the standard of care for moderate sedation providers.
My questions above are sincere so any input is greatly appreciated.

If your asking me what my proposed logistics are for a huge national reform...grandfather in those who have been doing sedation 5 or more years to continue their current practices.

Everyone else must go through a 1 month course. In one month you could do 75+ intubations and learn everything i detailed.

No program like this exists...but as it stands dentists are under trained for the sedation theyre providing.

I support sedation amongst dentist without a doubt, dentists invented general anesthesia. But I think it needs reform.

 

[DaleDoback]

@Sublimazing can you define "specialized dentistry"?

How quickly can somebody lose their skill of intubation? How often should one be incubating to be good and proficient at it?

How can someone be limited [to a level of sedation that should never require intubation] and be proficient and capable of intubating? Do you all believe that moderate sedation is so hard to achieve and maintain? Maybe I am overestimating the difficulty of intubation. I have done it before and it wasn't as easy as I anticipated. I believe OMS also rarely-never do it after residency and they are routinely doing deep sedation and GA. Must be like riding a bike?

Anyways, requiring intubation skill set for moderate sedation would be absurd, no offense.

Your "no fear" approach is concerning to everyone with advanced airway training. You can't define moderate sedation. PO midazolam alone send the wrong patient into deep sedation/GA. It isn't defined by the drugs or the route taken.

I personally have concern for you. I really think you have no fear and think intubation skill is unnecessary because you are educated so poorly on the topic.

 

[AU07DMD]

@Sublimazing

Anyways, requiring intubation skill set for moderate sedation would be absurd, no offense.

You're kidding, right? What are you going to do when the patient stops breathing and jaw thrust and bagging them doesn't work? Call 911 and let them wheel your patient off in a body bag 20 minutes later when they get there?

 

[DaleDoback]

You're kidding, right? What are you going to do when the patient stops breathing and jaw thrust and bagging them doesn't work? Call 911 and let them wheel your patient off in a body bag 20 minutes later when they get there?

I got $100 saying he doesn't know how to bag or even worse, doesn't even have one in office.

 

[sed8nyank4u]

If your asking me what my proposed logistics are for a huge national reform...grandfather in those who have been doing sedation 5 or more years to continue their current practices.

Everyone else must go through a 1 month course. In one month you could do 75+ intubations and learn everything i detailed.

No program like this exists...but as it stands dentists are under trained for the sedation theyre providing.

I support sedation amongst dentist without a doubt, dentists invented general anesthesia. But I think it needs reform.

@Sublimazing interesting. I think it is impossible. It is more likely to jam through some crazy regulations like MO did recently. Interesting that you pulled a similar/ essentially the same number for time (4 weeks to their 1 month) of "advanced airway training."

But can you imagine: "ok anesthesia residents of Loma Linda, step aside we are have the GP or perio intern here to do his intubation requirement for training. No we don't want them to intubate once they get out, in fact they never should. And yes, of course you all are going to be the experts and specialists, but we need to get them trained for their 'should never happen' events." I would be pissed if I was you! I just can't see it happening. Maybe your best bet is to do like MO and tie a permit into a residency. (Again, I believe what they, MO, have done is overkill and hurts the profession.)

If moderate sedation providers are so under-trained, why are we not seeing losses and damages? Why are premiums not higher? I can understand why you feel that way but I just don't see any logic or data to support the stance. I understand your rationale.
Cheers,

 

[Sublimazing]

@Sublimazing interesting. I think it is impossible. It is more likely to jam through some crazy regulations like MO did recently. Interesting that you pulled a similar/ essentially the same number for time (4 weeks to their 1 month) of "advanced airway training."

But can you imagine: "ok anesthesia residents of Loma Linda, step aside we are have the GP or perio intern here to do his intubation requirement for training. No we don't want them to intubate once they get out, in fact they never should. And yes, of course you all are going to be the experts and specialists, but we need to get them trained for their 'should never happen' events." I would be pissed if I was you! I just can't see it happening. Maybe your best bet is to do like MO and tie a permit into a residency. (Again, I believe what they, MO, have done is overkill and hurts the profession.)

If moderate sedation providers are so under-trained, why are we not seeing losses and damages? Why are premiums not higher? I can understand why you feel that way but I just don't see any logic or data to support the stance. I understand your rationale.
Cheers,

We have other trainees step in all the time...while at the hospital we'll always have at least one med student under our tutelage...or an emt, or a respiratory therapist...or whatever other vagrant they let in. Once you become confident, you don't need to do it everyday...I can't even remember the last time I missed an intubation, and that's par for the course amongst anesthetists. The pediatric dental residents an dental students come to our dental surgery center and we teach them how to start iv's and tube. There's more than enough to go around.

And my point is that if they got proficient with intubation and my fundamental skills I would be okay with them doing moderate sedation.

Anesthesia is ALL about preventing adverse outcomes, but being able to deal with them in the event they occur. So yes, the point is to train them and HOPE they never have to do it...but push comes to shove they can drop in a tube like a hotdog down a hallway.

And according to the people on our private message boards premiums are going up thanks to non-DA sedation...it was just brought up by persons in multiple states one week ago...

 

[sed8nyank4u]

Your "no fear" approach is concerning to everyone with advanced airway training. You can't define moderate sedation. PO midazolam alone send the wrong patient into deep sedation/GA. It isn't defined by the drugs or the route taken.

I personally have concern for you. I really think you have no fear and think intubation skill is unnecessary because you are educated so poorly on the topic.

@DaleDoback I have plenty of fear and profound respect for anesthesia. Fear keeps me out of trouble and far away from ever needing to intubate due to iatrogenic issues. I am not sure where you are getting this. By the way, Have you ever given PO Midazolam? If so, I would love to hear about it. Have you ever intended to take a patient to moderate level of sedation and maintained them there? Are you not almost always doing deep sedation/GA? From your perspective I can see why you say the things you do.
I appreciate your concerns but they are apples to oranges.
Consider: risk of laryngospasm in Deep/GA (probable, certainly possible, be ready at all times, high caution/protection of the airway)
Risk of laryngospasm in Moderate sedation: essentially zero. Closely monitor pt throughout procedure, watch for early signs of patient slipping into deeper level of sedation.
This is just one example. But also consider, and I have no idea where you are in training or work but I imagine you have done at least one sedation. Please if you don't mind consider sharing on the forum meds given including dose and timing and include the procedure. My only intent is to show another example of the stark contrast between moderate sedation and deep/GA that many seem to not quite grasp.
Btw, where are you practicing/studying?

Cheers,

 

[sed8nyank4u]

You're kidding, right? What are you going to do when the patient stops breathing and jaw thrust and bagging them doesn't work? Call 911 and let them wheel your patient off in a body bag 20 minutes later when they get there?

@AU07DMD after how many cases would you expect to have the need to bag someone or intubate? 1/100? 200? 400? 1,000? How often?

 

[252NCDDS]

Hey Sublimazing, I sent you a conversation and am wondering your opinion. I dont know if this is how I PM you, as I am new to the forms. Your response is appreciated. Thanks

 

[AU07DMD]

@DaleDoback I have plenty of fear and profound respect for anesthesia. Fear keeps me out of trouble and far away from ever needing to intubate due to iatrogenic issues. I am not sure where you are getting this. By the way, Have you ever given PO Midazolam? If so, I would love to hear about it. Have you ever intended to take a patient to moderate level of sedation and maintained them there? Are you not almost always doing deep sedation/GA? From your perspective I can see why you say the things you do.
I appreciate your concerns but they are apples to oranges.
Consider: risk of laryngospasm in Deep/GA (probable, certainly possible, be ready at all times, high caution/protection of the airway)
Risk of laryngospasm in Moderate sedation: essentially zero. Closely monitor pt throughout procedure, watch for early signs of patient slipping into deeper level of sedation.
This is just one example. But also consider, and I have no idea where you are in training or work but I imagine you have done at least one sedation. Please if you don't mind consider sharing on the forum meds given including dose and timing and include the procedure. My only intent is to show another example of the stark contrast between moderate sedation and deep/GA that many seem to not quite grasp.
Btw, where are you practicing/studying?

Cheers,

From this statement it appears you are missing the boat that anesthesia is a continuum, there aren't black and white dosages that will always keep you in one level of sedation. Why is this? The patient - hypersensitivity, hyposensitivity, impaired metabolism, allergies, drug/drug interaction, etc. A 2 mg dose of versed for one patient may induce an entirely different effect than in another.

@AU07DMD after how many cases would you expect to have the need to bag someone or intubate? 1/100? 200? 400? 1,000? How often?

It isn't about the number of cases you have done or will do. It is about individual patients and for whatever reason their susceptibility to have an adverse outcome to your standard protocol. This could happen on your 1,000th case, your 100th, or even your first. Most importantly, if you do enough sedations it will happen and like the others on this board I agree that you should be equipped to handle the event (the bagging at the very least).

 

[osteotomy01]

@DaleDobackConsider: risk of laryngospasm in Deep/GA (probable, certainly possible, be ready at all times, high caution/protection of the airway)
Risk of laryngospasm in Moderate sedation: essentially zero.

I disagree with this

 

[Gentledental1]

@DaleDoback
Consider: risk of laryngospasm in Deep/GA (probable, certainly possible, be ready at all times, high caution/protection of the airway)
Risk of laryngospasm in Moderate sedation: essentially zero.

I, along with the rest of us that provide anesthesia also disagree with this statement.

 

[sed8nyank4u]

I understand that you all disagree. Again, how many times have you attempted to moderately sedate someone?


I understand your concern about anesthesia being a continuum and patients entering a deeper level than intended. The hope intent of this discussion is to realize that moderate sedation is not a unicorn. It is achievable and safe.

Ya'll may have been a bit too quick to disagree with my statement, because it is actually true. A moderately sedated patient will never have a laryngospasm. Period. Now, is it possible for a moderate sedation provider to inadvertently take a patient to deep sedation. Yes. And now the patient is at much higher risk for laryngospasm, apnea, and other complications (such as aspiration). So, the real concern should be: " Are moderate sedation providers able to quickly recognize a patient who has gone past moderate sedation?" (Do we have any data to indicate moderate IV sedation providers are having bad outcomes? I haven't seen anything and certainly from my experience I find the entire push to be out of special interest, self-interest, and driven by profit. But I am ignorant to stats other than my own and about 100 other moderate IV providers. And it has been a huge windfall for my patients. It has removed significant barriers to care. I believe every dental student should receive much better and longer training regarding management of the fearful patient, physical eval, and management of medical emergencies. And schools should include sedation in their pre doc training.)

From all of the concern it seems as though:
1. Most anesthesia-providers-in-training on these boards:
A. Do not trust that moderate sedation is achievable by dentists and specialists trained through continuing education as currently offered. (Although, I wonder their true understanding of the training courses)
B. Do not feel that moderate sedation providers, after they have been trained and certified in their state, are able to recognize or treat complications that may arise from sedation.
C. Only those trained in the full scope (up to GA) of anesthesia should be providing sedation.

I understand these emotions and believe to understand why you feel this way. You all kind of dodged my questions so I haven't quite made my point yet but you are learning all about driving the Ferrari and Porsche with a real touchy gas pedal while the moderate providers are cruising in Ford Fusion, 4cylinders BABY! Yeah!

 

[osteotomy01]

I'll add my $0.02

I understand that you all disagree. Again, how many times have you attempted to moderately sedate someone?

Anesthesia is a continuum as it has been said so many times. ALL of us who may aim for a deep sedation/GA will at one point or another be at a "moderate" level of sedation. If you want to go with your analogy, no ones reaches the highway speed limit (GA) without having first traveled 30mph (moderate). It's constantly fluctuating as medications are being titrated and varying levels of stimulus are being encountered.

Ya'll may have been a bit too quick to disagree with my statement, because it is actually true. A moderately sedated patient will never have a laryngospasm. Period.

The reason we are ALL disagreeing with you on this is because you're wrong. Please look up the planes of anesthesia and when laryngospasm occurs, you'll then find that you have it backwards. You're only digging yourself deeper.

Don't get my wrong, I am not saying dentistry shouldn't have a role in anesthesia (Ether dome anyone?), I'm saying regulations on how/who is providing it needs to be changed. This has nothing to do with money and everything to do with patient safety. We don't want the recklessness of a couple bad apples to ruin anesthesia for all of dentistry.

 

[Sublimazing]

I understand that you all disagree. Again, how many times have you attempted to moderately sedate someone?


I understand your concern about anesthesia being a continuum and patients entering a deeper level than intended. The hope intent of this discussion is to realize that moderate sedation is not a unicorn. It is achievable and safe.

Ya'll may have been a bit too quick to disagree with my statement, because it is actually true. A moderately sedated patient will never have a laryngospasm. Period. Now, is it possible for a moderate sedation provider to inadvertently take a patient to deep sedation. Yes. And now the patient is at much higher risk for laryngospasm, apnea, and other complications (such as aspiration). So, the real concern should be: " Are moderate sedation providers able to quickly recognize a patient who has gone past moderate sedation?" (Do we have any data to indicate moderate IV sedation providers are having bad outcomes? I haven't seen anything and certainly from my experience I find the entire push to be out of special interest, self-interest, and driven by profit. But I am ignorant to stats other than my own and about 100 other moderate IV providers. And it has been a huge windfall for my patients. It has removed significant barriers to care. I believe every dental student should receive much better and longer training regarding management of the fearful patient, physical eval, and management of medical emergencies. And schools should include sedation in their pre doc training.)

From all of the concern it seems as though:
1. Most anesthesia-providers-in-training on these boards:
A. Do not trust that moderate sedation is achievable by dentists and specialists trained through continuing education as currently offered. (Although, I wonder their true understanding of the training courses)
B. Do not feel that moderate sedation providers, after they have been trained and certified in their state, are able to recognize or treat complications that may arise from sedation.
C. Only those trained in the full scope (up to GA) of anesthesia should be providing sedation.

I understand these emotions and believe to understand why you feel this way. You all kind of dodged my questions so I haven't quite made my point yet but you are learning all about driving the Ferrari and Porsche with a real touchy gas pedal while the moderate providers are cruising in Ford Fusion, 4cylinders BABY! Yeah!

I do moderate sedations on a regular basis. TODAY i had a patient who took 2mg of versed and was out cold for the duration of his procedure (treatment of a prolapsed rectum...not exactly pleasant) and slept for 2 hours in pacu.

Turns out he's an amphetamine addict...he denied it to my face, but a uds later that day confirmed it...that easily could have happened in a dental office...and if any opioid was added that guy would have been apneic.

It was unexpected for me, nothing I couldn't handle. There's no reason this dude couldn't have showed up in a dental office for exts and gone to deep sedation

There's no data out there about anything when it comes to office based sedation...doesn't mean people aren't going to the hospital or having close calls.

Because you have such limited training you simply don't know what you don't know. Anyone who trains in anesthesia has a great respect for it because so many things can go wrong...you haven't trained in anesthesia, so you're callous...you, like a sith, speak in absolutes. It's obvious we aren't going to convince you otherwise...but from the way you present yourself you sound like a ticking timebomb.

 

[DaleDoback]

@DaleDoback I have plenty of fear and profound respect for anesthesia. Fear keeps me out of trouble and far away from ever needing to intubate due to iatrogenic issues. I am not sure where you are getting this. By the way, Have you ever given PO Midazolam? If so, I would love to hear about it. Have you ever intended to take a patient to moderate level of sedation and maintained them there? Are you not almost always doing deep sedation/GA? From your perspective I can see why you say the things you do.
I appreciate your concerns but they are apples to oranges.
Consider: risk of laryngospasm in Deep/GA (probable, certainly possible, be ready at all times, high caution/protection of the airway)
Risk of laryngospasm in Moderate sedation: essentially zero. Closely monitor pt throughout procedure, watch for early signs of patient slipping into deeper level of sedation.
This is just one example. But also consider, and I have no idea where you are in training or work but I imagine you have done at least one sedation. Please if you don't mind consider sharing on the forum meds given including dose and timing and include the procedure. My only intent is to show another example of the stark contrast between moderate sedation and deep/GA that many seem to not quite grasp.
Btw, where are you practicing/studying?

Cheers,

Don't let your heart worry. I have given PO Midazolam plenty for "moderate sedation" purposes in preparation for GA and not. Some of us that have real training (beyond a weekend course) treat patients in the hospital during residency programs. I have given PO midazolam in holding in the pediatric population, as well as in our residency clinic. I have also had to intubate a patient in the hospital who had "just a little PO Versed". Don't question my understanding of anesthesia. If Sub wanted to argue anesthesia, it would be a welcomed discussion among an educated colleague. You don't even deserve an opinion in the matter.

As an OMS, we take patients to "moderate sedation" all the time. There are many indications for not taking a patient too deep or in full GA in an OMS setting, including obesity, medical conditions, poor mallampati (Google that, I know you don't know what it is), etc. To answer your question, I am in a well-respected, busy residency program in the south. For one of my older "GA's" today, I gave 1 of Versed and 50 of Fentanyl. In a 20 year old male, that's like a cigarette. In my 76 year old female today, it was more than enough. That is the point you don't understand. Anesthesia is dependent on too many things to say, "Moderate sedation will never have problems".

Now you have to answer a question, how do you monitor your "moderate sedation" and what does your emergency cart consist of? If your emergency cart is a post-it that says, "Call 911", please don't even respond.

I understand that you all disagree. Again, how many times have you attempted to moderately sedate someone?


I understand your concern about anesthesia being a continuum and patients entering a deeper level than intended. The hope intent of this discussion is to realize that moderate sedation is not a unicorn. It is achievable and safe.

Ya'll may have been a bit too quick to disagree with my statement, because it is actually true. A moderately sedated patient will never have a laryngospasm. Period. FALSE. Next dumb statement please. Now, is it possible for a moderate sedation provider to inadvertently take a patient to deep sedation. Yes. And now the patient is at much higher risk for laryngospasm, apnea, and other complications (such as aspiration). So, the real concern should be: " Are moderate sedation providers able to quickly recognize a patient who has gone past moderate sedation?" I don't care if you can recognize it. A dental student can recognize that a patient isn't responding. My concern is what the hell are you going to do about it!!!! How are you, in your dental shop, going to treat the patient who is responding poorly to "completely safe moderate sedation". (Do we have any data to indicate moderate IV sedation providers are having bad outcomes? I haven't seen anything and certainly from my experience I find the entire push to be out of special interest, self-interest, and driven by profit. But I am ignorant to stats other than my own and about 100 other moderate IV providers. And it has been a huge windfall for my patients. It has removed significant barriers to care. I believe every dental student should receive much better and longer training regarding management of the fearful patient, physical eval, and management of medical emergencies. And schools should include sedation in their pre doc training.) This is the scariest thing I have ever read on this board....ever.

From all of the concern it seems as though:
1. Most anesthesia-providers-in-training on these boards:
A. Do not trust that moderate sedation is achievable by dentists and specialists trained through continuing education as currently offered. (Although, I wonder their true understanding of the training courses) Wrong. Moderate sedation is achievable, just not 100% safe like you claim.
B. Do not feel that moderate sedation providers, after they have been trained and certified in their state, are able to recognize or treat complications that may arise from sedation. 100% truth. I don't think you or any other weekend course warrior can treat complications adequately. I think you and your buddies are going to ruin anesthesia for dentistry, including OMS.
C. Only those trained in the full scope (up to GA) of anesthesia should be providing sedation. I think you should be able to go down the difficult airway algorithm (again, Google me) and be able to keep a patient alive.

I understand these emotions and believe to understand why you feel this way. You all kind of dodged my questions so I haven't quite made my point yet but you are learning all about driving the Ferrari and Porsche with a real touchy gas pedal while the moderate providers are cruising in Ford Fusion, 4cylinders BABY! Yeah!Questions haven't been dodged. You are just so uneducated on the topic that you don't know how to ask the appropriate ones

Please see my response in blue above. I'm not trying to be a "dental God" either, just making sure you know that I aggressively and violently hate your opinion.

 

[Silent Cool]

Why don't we get back to the topic at hand--questions for periodontists!
How about this one: Is USC's Periodontic program worth it? Gadzook! Look at that tuition!

http://dentistry.usc.edu/programs/certificate/periodontics/

 

[sed8nyank4u]

@Sublimazing did you give the 2mg of Midazolam? How? And over what time period? Any other pre-op meds given?



@osteotomy01 As a general rule if you are driving a Ferrari or Porsche and your ultimate destination is"Deep Sedation/GA town (from my limited experience with Ferraris) you go fast and hard. Driving down the freeway and noticing the sign for "Moderate Sedation Town" is not nearly the same as planning a trip to "Moderate Sedation Town" and touring the all the sites, etc.

@DaleDoback

Certainly, most of the descriptions you guys have given do not jive with any of the standard protocols taught or employed by IV Moderate sedation providers. For example:
1. PO Midazolam (almost any PO med for that matter except with peds but that us a whole other ball of wax) is never given when the desired end-point is moderate sedation. Why? Because you have to guess the dose. This is not titratable and hence less predictable. The only time we give PO meds is for very anxious patients following a stress-reduction protocol written about by Dental Anesthesiologists. This is actually quite often for me but it ends up being an anxiolytic dose of triazolam.

@DaleDoback how long did it take you to give 1mg of Midazolam? Why did you give the fentanyl? Why 50 micrograms? How long did it take you to give the narcotic?
We use all of the same monitors and have all of the same rescue equipment as you. Although most states do not require intubation armamentarium for moderate sedation providers.


All, please consider this statement by Joel Weaver:
"We must realize that no additional amount of required hours of training or continuing education or stricter dental board rules will totally eliminate human errors or their dire consequences. Poor outcomes do not necessarily mean that the guidelines and rules are faulty or that they must be immediately changed."

Also consider that deaths in the dental office do not go unreported in he media. And if it is not a child, it is someone from an oral surgeons office. If you think that deep sedation/GA with an unsecured airway is somehow safer than moderate sedation, regardless of your training, you are fooling yourself. It is the deep level of sedation and GA that put your ability to provide anesthesia at risk because "a conscious patient never dies." Topic for another day: why are healthy patients dying from dental appointments secondary to GA complications when they can be treated under local anesthesia, LA and minimal sedation, or LA and Moderate sedation? Obviously everyone take a much more cautious low and slow approach to geriatric patients but why so much GA for dental procedures where profound local anesthetic is easily achievable?

I still cannot understand how you can claim that a patient with moderate sedation can get a laryngospasm or ever need to be intubated. We are all using the same definition right?

"moderate sedation — a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained."3

"Note: In accord with this particular definition, the drugs and/or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Repeated dosing of an agent before the effects of previous dosing can be fully appreciated may result in a greater alteration of the state of consciousness than is the intent of the dentist. Further, a patient whose only response is reflex withdrawal from a painful stimulus is not considered to be in a state of moderate sedation."

You ever try to tube someone like that? Again, why would you ever need to tube someone in moderate sedation? Only if the provider has gone waaaaaay beyond their scope and the patient is deep, deep, deep.

At our speeds with the Fusion we are always going low and slow. You may slam 3 mg Midazolam in 5 seconds followed by some GA meds. For me that same dose of Versed takes 3 minutes. You may immediately reach for a narcotic. I only reach for a narcotic if versed Valium combos haven't quite got me there. Yes. 1mg/minute Versed up to 5 mg, the 5mg/minute Valium up to 10 mg. that is 7 minutes and no local yet. You may have 1 and 32 out by then. But if my patient isn't moderately sedated yet, I am going back to versed 1mg/min up to 5 more and if still not there I am back to Valium same rate stopping at affect or at 10 mg more. If just about there (hopefully because this is approaching failure of moderate sedation) I can titrate up to 100 mics fentanyl at a rate of 20mics/minute. Yes 5 minutes to give 100 Fentanyl. If still not sedated that is a failure and we can talk the patient through treatment or set it up for GA. Keep in mind that is 19+ minutes of titration time in a failed case. Most of my cases are titrated in 5-10 mins.

Now don't get scared by the max doses because those are rare but much more common than a patient going too deep. I have done well over 500 cases. I have given reversal agents twice. I have had to pinch a few traps, do some head tilt-chin lifts, or jab the needle lingual to 8 and 9 a few times to those that over responded a bit but BIG scares, not really. I have never had to bag anyone. Throwing an airway in is only at review courses because I prevent that. Look how slow we dose. It is so safe. BZD's also carry the wide safety margin. Yes, I have had patients who only had 1mg Versed and they were snoring so I sure as he'll didn't add in a narcotic to further suppress their breathing. An ounce of prevention is a pound of cure.

I think we have beaten this horse to death. We will never be the anesthesia experts you all are. But we value anesthesia and our right to provide the small portions that are light and moderate sedation. And we are just as concerned about patient safety as you.

Holy crap that is a novel!

I appreciate response to my questions but I have no more cards to lay on this table. So, I look forward to your answers.

 

[DaleDoback]

No, we don't all use the same monitoring equipment. Please educate me on your monitors and crash cart. It's obvious you don't feel the need for a tube so you are already below standard of care.

And deaths in the dental office don't always get reported in the media. And to say if it's not a child, it's in an OMS office is not based on any facts. You don't know what you don't know.

 

[Sublimazing]

http://www.wfsb.com/story/25524255/dentist-sees-license-suspended-after-several-patient-problems

Deaths from 2013 in CT...not sure if they were reported or not, but seems like the details are just coming to light at a national level

 

[southomfs]

@sed8nyank4u I can't wait until you kill someone with your moderate sedation technique. I'll be the first to line up for free to discuss my experience, my specialization, and why you're absolutely out of control and off the reservation regarding your comments.

Can you define moderate IV sedation?

 

[sed8nyank4u]

Crazy news out of CT. Crazy. Just crazy. Of course this guy says it is all B.S. but we'll have to see. The allegations are very disturbing. Interesting to note he received his IV training and certification in a GPR residency.
@southomfs of course I can. I do it every day. I did three cases before noon this am. Four implants, a crown, an apico retro fill bone graft and membrane. Produced about 11k. Patients were grateful and none of them would have done it without being sedated.
The definition is posted above for your reference. I am surprised if you read any of my posts, comprehended them, and still are concerned. Moderate sedation is safe, achievable, quite predictable and can be safely learned as current guidelines recommend.
By the way, just learned of another dentist getting their permit this month with no increase in their malpractice insurance. I think he said CNA.

 

[Sublimazing]

Crazy news out of CT. Crazy. Just crazy. Of course this guy says it is all B.S. but we'll have to see. The allegations are very disturbing. Interesting to note he received his IV training and certification in a GPR residency.
@southomfs of course I can. I do it every day. I did three cases before noon this am. Four implants, a crown, an apico retro fill bone graft and membrane. Produced about 11k. Patients were grateful and none of them would have done it without being sedated.
The definition is posted above for your reference. I am surprised if you read any of my posts, comprehended them, and still are concerned. Moderate sedation is safe, achievable, quite predictable and can be safely learned as current guidelines recommend.
By the way, just learned of another dentist getting their permit this month with no increase in their malpractice insurance. I think he said CNA.

He WROTE that he received it from a GPR...though St. Barnabas doesn't do IV sedation for their GPR residents that I've ever heard of...He also has listed that he took the DOCS class.

 

[DaleDoback]

Sed8,

It was just a moderate sedation. Those never go wrong.

Also, looks like every non-child death doesn't involve an OMS like you stated earlier.

And please let me know your monitoring and crash cart information.

 

[sed8nyank4u]

For every smart argument, there’s a round of attacks. The debate isn’t joined. It’s cheapened, it’s debased
- Tim Grieve

 

[sed8nyank4u]

PHOENIX — "Intravenous lines were placed correctly during the execution of an Arizona inmate whose death with lethal drugs took more than 90 minutes, a medical examiner said Monday.
Incorrect placement of lines can inject drugs into soft tissue instead of the blood stream, but the drugs used to kill Joseph Woods went into the veins of his arms, said Gregory Hess of the Pima County Medical Examiner's Office.
Hess also told The Associated Press that he found no unexplained injuries or anything else out of the ordinary when he examined the body of Woods, who gasped and snorted Wednesday more than 600 times before he was pronounced dead.
An Ohio inmate gasped in similar fashion for nearly 30 minutes in January. An Oklahoma inmate died of a heart attack in April, minutes after prison officials halted his execution because the drugs weren't being administered properly.
Hess said he will certify the outcome of Woods' execution as death by intoxication from the two execution drugs — the sedative midazolam and the painkiller hydromorphone — if there is nothing unusual about whatever drugs are detected in Wood's system.
Hess' preliminary findings were reported previously by the Arizona Capitol Times (http://bit.ly/1thLaFe ). Toxicology results are expected in 4 to 6 weeks from an outside lab.
Hess is chief deputy medical examiner for Pima County, which conducts autopsies for Pinal County, where the prison is located.
Wood was sentenced to death for the 1989 killings of his estranged girlfriend, Debbie Dietz, and her father, Gene Dietz.
Wood was the first Arizona prisoner to be killed with the drug combination. Anesthesiology experts have said they weren't surprised the drugs took so long to kill him.
Arizona and other death-penalty states have scrambled in recent years to find alternatives to drugs used previously for executions but are now in short supply due to opposition to capital punishment."

Emphasis added.
Safety margin of these two drugs reinforced for anyone? With intent to kill, with the drugs most commonly taught to IV Moderate sedation providers, look how long and difficult it was. Granted, nobody sedates or goes down the same way.

On a lighter note, I hope that those opposed to the death penalty are happy that the more effective drugs for that purpose are so hard to find.

 

[flurocore]

I'm a general dentist and do surgical third molar extractions. Why not? I have the training. It isn't brain surgery.

 

[CMistry]

I'm a general dentist and do surgical third molar extractions. Why not? I have the training. It isn't brain surgery.

Do you have the training to handle its complications as well? I'm sure you can handle endo, prosth, or perio complications because extraction is always in your consent. But have you drained a submandibular or parapharyngeal abscess? And don't tell me "those never happen" because we get them from general dentists pretty often. Of course I don't fault them, since most of us like to push our comfort limits. But when the **** hits the fan with a third molar it's often a little more serious.

 

[DaleDoback]

PHOENIX — "Intravenous lines were placed correctly during the execution of an Arizona inmate whose death with lethal drugs took more than 90 minutes, a medical examiner said Monday.
Incorrect placement of lines can inject drugs into soft tissue instead of the blood stream, but the drugs used to kill Joseph Woods went into the veins of his arms, said Gregory Hess of the Pima County Medical Examiner's Office.
Hess also told The Associated Press that he found no unexplained injuries or anything else out of the ordinary when he examined the body of Woods, who gasped and snorted Wednesday more than 600 times before he was pronounced dead.
An Ohio inmate gasped in similar fashion for nearly 30 minutes in January. An Oklahoma inmate died of a heart attack in April, minutes after prison officials halted his execution because the drugs weren't being administered properly.
Hess said he will certify the outcome of Woods' execution as death by intoxication from the two execution drugs — the sedative midazolam and the painkiller hydromorphone — if there is nothing unusual about whatever drugs are detected in Wood's system.
Hess' preliminary findings were reported previously by the Arizona Capitol Times (http://bit.ly/1thLaFe ). Toxicology results are expected in 4 to 6 weeks from an outside lab.
Hess is chief deputy medical examiner for Pima County, which conducts autopsies for Pinal County, where the prison is located.
Wood was sentenced to death for the 1989 killings of his estranged girlfriend, Debbie Dietz, and her father, Gene Dietz.
Wood was the first Arizona prisoner to be killed with the drug combination. Anesthesiology experts have said they weren't surprised the drugs took so long to kill him.
Arizona and other death-penalty states have scrambled in recent years to find alternatives to drugs used previously for executions but are now in short supply due to opposition to capital punishment."

Emphasis added.
Safety margin of these two drugs reinforced for anyone? With intent to kill, with the drugs most commonly taught to IV Moderate sedation providers, look how long and difficult it was. Granted, nobody sedates or goes down the same way.

On a lighter note, I hope that those opposed to the death penalty are happy that the more effective drugs for that purpose are so hard to find.

What? I fail to see any point in this post.

I'm a general dentist and do surgical third molar extractions. Why not? I have the training. It isn't brain surgery.

I am completely fine with you doing third molar extractions. There is a big difference between third molars (fully erupted) and THIRD F'N MOLARS (nasty ones). You should be able to handle complications related to whichever one you choose to extract.

And just for the record, if you did formal OMS training, you would likely do brain surgery at some point like you reference in your post. But I'm sure your surgical training is just as good as mine.

 

[tooth knockn]

What? I fail to see any point in this post.



And just for the record, if you did formal OMS training, you would likely do brain surgery at some point like you reference in your post. ""But I'm sure your surgical training is just as good as mine.""

Sounds like you guys have super powers....

Take it easy guys...

What?

Are you in eachothers way or something?

 

[flurocore]

Do you have the training to handle its complications as well? I'm sure you can handle endo, prosth, or perio complications because extraction is always in your consent. But have you drained a submandibular or parapharyngeal abscess? And don't tell me "those never happen" because we get them from general dentists pretty often. Of course I don't fault them, since most of us like to push our comfort limits. But when the **** hits the fan with a third molar it's often a little more serious.

I can handle minor complications. Anything crazy or not worth my time I'll send to an oral surgeon who can better manage the patient and save me time. I know my limitations.

 

[DaleDoback]

Sounds like you guys have super powers....

Take it easy guys...

What?

Are you in eachothers way or something?

Listen kid, get into dental school first, then you can consider to jump into big boy conversations about OMS.

 

[tooth knockn]

Listen kid, get into dental school first, then you can consider to jump into big boy conversations about OMS.

Relax. Go pick on someone your own size.

 

[osteotomy01]

http://www.wfsb.com/story/25524255/dentist-sees-license-suspended-after-several-patient-problems

Deaths from 2013 in CT...not sure if they were reported or not, but seems like the details are just coming to light at a national level

Look who just popped up on the internet:

http://www.people.com/article/connecticut-dentist-charged-negligent-homicide

Food for thought to all the GPs / Perio looking to do IV sedation

 

[Screwtape]

Look who just popped up on the internet:

http://www.people.com/article/connecticut-dentist-charged-negligent-homicide

Food for thought to all the GPs / Perio looking to do IV sedation

I agree that many dentists are rather cavalier about providing IV sedation after attending a "weekend CE", but if they are trained appropriately i do think moderate IV sedation could be in the tool bag of dentists and specialists alike. Thoughts?

 

[krissung]

I agree that many dentists are rather cavalier about providing IV sedation after attending a "weekend CE", but if they are trained appropriately i do think moderate IV sedation could be in the tool bag of dentists and specialists alike. Thoughts?

Your right. You do not need to be "God's gift to earth" to do IV sedation. Now, there are plenty GP and SPECIALIST alike that are pigs and get greedy, decide to bite more than they can chew just for money, the recent guy on the news is one of them, but if you do a quick google search there are plenty of specialist that were in the same scenario. I will add, it is best to stay within the moderate/conscious sedation realm if you are a general dentist, not because you are "just" a dentist, but because in a court hearing no one will care if you put in 1000 hrs of hands on training, they will ask you "why didn't you refer to a specialist?" and from then on the layer's task will be to discredit you. Lastly, it is safer to do IV sedation than oral sedation; you know the specific dosage (given you know your drugs), you already have a line in case of an emergency. In all, there are well trained dentists and specialist just like there are idiot dentists and specialists alike.

 

[Screwtape]

Your right. You do not need to be "God's gift to earth" to do IV sedation. Now, there are plenty GP and SPECIALIST alike that are pigs and get greedy, decide to bite more than they can chew just for money, the recent guy on the news is one of them, but if you do a quick google search there are plenty of specialist that were in the same scenario. I will add, it is best to stay within the moderate/conscious sedation realm if you are a general dentist, not because you are "just" a dentist, but because in a court hearing no one will care if you put in 1000 hrs of hands on training, they will ask you "why didn't you refer to a specialist?" and from then on the layer's task will be to discredit you. Lastly, it is safer to do IV sedation than oral sedation; you know the specific dosage (given you know your drugs), you already have a line in case of an emergency. In all, there are well trained dentists and specialist just like there are idiot dentists and specialists alike.

Yeah I definitely agree with staying away from deep sedation. Our oral surgery faculty always pushes the fact that you should be trained in one level beyond what you will practice clinically. So if you are offering deep sedation you should know how to perform general anesthesia, which is out of the realm for most (all?) general dentists.