COMMENTARIES Editorials represent the opinions of the authors and not necessarily those of the American Dental Association. COMMENTARY New sedation and general anesthesia guidelines Why the changes? Editor’s note: In Dionne’s commentary (“Raise the Bar for Safe Sedation, Jason H. Goodchild, DMD; Mark ” 133 Donaldson, BSP, ACPR, PharmD, Not Barriers for Access to Care, on page ) and in this commentary, the FACHE authors discuss the latest guidelines for using and teaching sedation and general anesthesia by dentists. Although the authors of both commentaries approach the subject of sedation and general anesthesia from different points of view, their main arguments focus on the concern for patient safety. Hope- fully, providing both of these perspectives will afford JADA readers a better and more comprehensive understanding of the very serious issues involved and the challenges ahead. uring the October 2016 American Dental Association (ADA) annual meeting, the House of Delegates voted to approve D Resolution 37 and update guidelines for the teaching and use of sedation and general anesthesia by oral health care professionals 1 2 (OHCPs). , The changes to these documents primarily update educational requirements and clinical guidelines for the use of minimal and moderate sedation. First developed in 1971, this update to the ADA’s sedation and general anesthesia guidelines is the latest evolution of a document that has been revised 10 times (most recently in 2012) and further attempts to bring 3 clarity and direction for OHCPs wishing to use these modalities. WHAT ARE THE MAJOR CHANGES? Minimal sedation. For minimal sedation via the enteral route, the dosing of medication is now limited to a single dose or multiple doses in which the cumulative amount does not exceed the US Food and Drug Administration’s (FDA) maximum recommended dose (MRD) for unmonitored home use. Supplemental dosing, as described in 2012 in which the total aggregate dose must not exceed 1.5 times the MRD on the day of treatment, is now pro- hibited and replaced by statements indicating that if cumulative doses exceed the MRD, or if multiple enteral medications are used, that guidelines for moderate sedation must apply. The revisions, including the use of the MRD as a limit, are meant to “guide dosing for minimal sedation” and are 1 “intended to create [a] margin of safety.” Also, for minimal sedation, the use of nitrous oxide and oxygen analgesia, specifically permitted by the 2012 guidelines when used in combination with a single enteral drug, has changed. Although still allowed, the original language is replaced by a statement advising that nitrous oxide and oxygen analgesia when 138 JADA 148(3) http://jada.ada.org March 2017 COMMENTARIES used in combination with a sedative guidelines is to improve procedural WHAT MAKES OUR PATIENTS SO 3 agent may produce minimal, moder- safety and efficacy. These guidelines CHALLENGING? ate, deep sedation, or general are then disseminated to the state Epidemiologic data continue to anesthesia. boards and can be incorporated into demonstrate that we are an aging 21 Moderate sedation. For moder- regulations to help fulfill the population. The authors of this ate sedation, the educational re- mandate of every dental board: to same report further predict that the quirements have been revised to protect the public. Tragic outcomes United States’s 65-and-over popu- recommend a didactic course con- after dental sedation procedures lation is projected to nearly double sisting of 60 hours of instruction and continue to occur, and these out- over the next 3 decades, from 48 administration of sedation to at least comes can prompt scrutiny of million to 88 million by 2050. 20 individually managed patients guidelines and regulations, and ulti- Moreover, this older population is with no distinction made as to the mately necessitate changes and up- 5 11 retaining their dentition and route of medication administration. dates. - It is therefore essential that requiring the expertise of OHCPs In other words, in 2012 moderate documents outlining education and much later in life than has been 22 24 enteral sedation course duration was best practices stay up-to-date and experienced in the past. - Unfor- separate and different from paren- reflect not only the evolution of tunately, although people are living teral, but the 2016 revision outlines medications and monitoring, but longer, that does not necessarily training and clinical guidelines based also incorporate knowledge gained 12 18 mean that they are living healthier. on intended level of sedation, not after review of adverse events. - Early studies had estimated that 30% route of medication administration. In addition, previous guidelines of patients visiting a dental office Moderate sedation, deep do not and cannot continuously suffer from at least 1 medical condi- 25 26 sedation, and general anesthesia. In account for the 1 variable that is tion. , The Centers for Disease addition, for moderate sedation, always changing—our patients. In Control and Prevention has reported deep sedation, and general anes- the last 4 years and beyond, the that, “As of 2012, about half of all thesia, the monitoring of ventilation most important changes clinical adults—117 million people—had 1 or more chronic health conditions. And Previous guidelines do not and cannot 1 of 4 adults had 2 or more chronic ”27 continuously account for the 1 variable that is health conditions. Further complicating the medical status of always changing—our patients. patients is that polypharmacology is must now be assisted by capnog- OHCPs have faced include becoming the norm as patients get raphy and monitoring of end-tidal providing safe and effective seda- into their sixth, seventh, and eighth carbon dioxide (CO2). In the previ- tion and anesthesia services to a decades of life, requiring more ous document, end-tidal CO2 moni- population that is older, sicker, medications to treat their different 28 29 toring was only required for and taking more medications (both concurrent chronic diseases. , It is intubated patients and was only licit and illicit). Poor patient selec- therefore essential that OHCPs un- suggested for nonintubated patients. tion, even coupled with properly dertake a comprehensive review of Finally, patient evaluation for these 3 educated OHCPs, safe drugs, and every patient’s medical as well as deepest levels of sedation and anes- up-to-date monitoring equipment, pharmacologic history before any thesia should include body mass in- can still result in unintended and 5 11 procedure. dex and the consideration of patients catastrophic outcomes. - This written and verbal review with obstructive sleep apnea as part In medical practice, there is the needs to include an emphasis on of the preoperative risk assessment. common idiom of “matching the bothlicitandillicitmedicationuse Pediatric sedation. Pediatric right drug, at the right dose and as well as any complementary and sedation is now covered by the 2016 the right time, for the right patient alternative medications. Among 19 20 update detailed in the “Guidelines and the right procedure.” - The adults 65 yearsorolder,40%take5 to 9 medications regularly and 18% for Monitoring and Management ADA has historically enhanced this 30 32 on Pediatric Patients Before, During, approach by further considering the take 10 or more medications. - and After Sedation for Diagnostic right setting, the right education, and Furthermore, considering that and Therapeutic Procedures: Update even the right equipment. Regard- nearly 70%ofthesepeopledonot 4 2016.” less, with all the excellent intentions discuss their computer-aided and iterations of the guidelines for manufacturing use with their pri- WHY ARE THESE CHANGES the teaching and use of sedation and mary care providers, OHCPs should NEEDED? general anesthesia by OHCPs, pick- ask all patients about their medica- The intent of the ADA’s revised ing the right patients can still be our tion use, particularly when pre- sedation and general anesthesia Achilles’ heel. scribing medications and when JADA 148(3) http://jada.ada.org March 2017 139 COMMENTARIES 15,45-48 considering the patients’ overall end, capnography and end-tidal CO2 patients. Although the avail- 33 sedative or anesthetic plan. monitoring should add additional able research is insufficient to clearly Finally, older adults are 7 times safety for moderate sedation. delineate the appropriateness of the more likely than younger adults to MRD for minimal sedation, it should experience adverse drug events that USING THE MAXIMUM be considered suitable for 2 impor- require hospitalization, under- RECOMMENDED DOSE FOR tant reasons. First, for OHCPs with scoring the importance for all pre- MINIMAL SEDATION? the smallest amount of sedation scribers to carefully consider In most cases in which minimal or training, it creates a definitive potential drug interactions and use moderate sedation techniques are maximum dose that when patient available resources to mitigate risk used, the use of benzodiazepines as factors and potential drug inter- (for example, Lexicomp, Micro- first-line medications continues to be actions are accounted for, should 34 medex, Clinical Pharmacology). recommended given their long his- provide a reasonable safety margin. 38 39 Evaluating the medical stability tory of efficacy and safety. , From Second, because drug effect and and appropriateness for sedation a historical perspective, it is impor- psychomotor impairment do not and anesthesia services for