AMERICAN SOCIETY for the ADVANCEMENT OF ANESTHESIA and SEDATION in DENTISTRY
Parenteral Sedation Course
St. Joseph’s University Medical Center
703 Main Street, Paterson, NJ
Look to our conscious sedation training course for a comprehensive 100+ hour, hands-on IV training package based on ADA guidelines for teaching IV sedation in dentistry. Designed to provide the scientific basis for safe sedation as well as simulation and clinical training leading to basic skill acquisition, you can have peace of mind that you will feel confident in your ability to administer anesthesia safely and effectively. The optional 16-hour American Heart Association ACLS program is included at no extra charge.
Below we offer our extensive syllabus to inform our students on what they can expect to get out of our IV oral sedation dentistry courses. If you dream of having a dental parental sedation certification, we encourage you to sign up for our classes today to learn the innovative techniques and tools necessary for the job. Contact Dr. Joseph Portale at (201) 945-5777 with any questions you may have regarding our training courses and schedule.
ASAASD SEDATION PROGRAM-Goals & Objectives
In affiliation with St. Joseph’s University Medical Center
Goals of the continuing education program:
- To provide general dentists and dental specialists with a knowledge base and clinical experiences leading to competency in the provision of sedation for dental treatment;
- To maintain consistency with ADA Standards and to meet or exceed the requirements of the various States in which participants are licensed;
- To ensure that participants are trained to utilize sedation appropriately, safely and effectively for properly selected patients.
Objectives of the program:
At the conclusion of the sedation program, participants should be able to:
- discuss indications for and contraindications to the use of sedation in dentistry;
- list medical conditions that may preclude the use of sedation or require further data gathering prior to administering sedative agents;
- describe pre-sedation instructions given to patients and ensure that these are followed prior to administering sedative agents;
- discuss the physiologic parameters monitored during sedation and how each is measured and recorded;
- describe the physiologic impact of each medication used in his/her sedation practice and the potential interactions among these medications;
- identify the potential risks as well as the intended benefit of the medications used in his/her sedation practice for each patient evaluated for such procedures;
- list the appropriate dosages, maximum dosages and reversal modalities for each medication used in his/her sedation practice;
- discuss methods for obtaining intravenous access and the potential complications (local and systemic) associated with intravenous administration of sedatives;
- describe the monitoring of and level of attention paid to the recovering patient;
- articulate appropriate discharge criteria utilized in his/her sedation practice;
- develop office policy that is consistent with ADA Standards for sedation in dental practice
- ensure that emergency equipment, supplies and medications are adequate to meet or exceed the requirements for sedation dentistry as determined by the State Board of Dentistry where he/she practices;
- identify and appropriately manage urgencies and emergencies related to sedation;
- utilize ACLS level interventions when indicated in the management of medical emergencies;
- describe post-sedation instructions given to patients and reviewed with the accompanying adult at the time of discharge.
The sedation program consists of didactic presentations, lab exercises and hands-on clinical training under supervision (see two-week grid). The following are specific objectives for each segment of the course:
At the conclusion of the didactic phase of instruction, participants will be able to:
- Discuss the critical elements of the pre-anesthetic evaluation;
- Describe the process of risk stratification for dental patients requesting procedural sedation;
- Identify underlying that impact on safe administration of sedation;
- Modify planned treatment appropriately when indicated and refer those patients who will benefit from a higher level of care;
- List indications and contraindications for the use of oral triazolam and oral midazolam in dentistry;
- Conduct a focused history and physical relating to the airway and risk stratify potential sedation patients relative to airway management;
- Describe airway devices used to assist in airway maintenance, their indications and an algorithmic approach to their use.
- Articulate basic principles of risk management for dentists using sedation;
- Cite cases with adverse anesthesia- related outcomes and list the actions or failures to act that might have led to these adverse outcomes;
- Describe the stages and planes of anesthesia and their clinical significance;
- Discuss the routes used for providing sedation, their potential benefits and liabilities;
- Describe the physiologic impact of nitrous oxide alone or in combination with oral and parenteral sedation agents;
- Identify key issues for anesthesiologists conducting risk stratification for patients requiring some form of procedural sedation or general anesthesia;
- Compare and contrast pertinent anatomy in infancy, childhood and adulthood focusing on the airway.
- List the most common medical emergencies in dental practice and their management;
- List the most common sedation-related emergencies and their management;
- Discuss all basic elements of the normal EKG and identify dysrhythmias that require urgent attention;
- Recognize EKG changes that might be associated with patients receiving procedural sedation;
- Discuss oral midazolam use in children: indications, contraindications, monitoring, recovery and reversal;
- Describe the use of benzodiazepines and opioids as sedation agents, individually and in combination;
- Discuss other pharmacologic agents that may be used during procedural sedation.
- Describe the venous anatomy of the upper extremity and select an appropriate vessel for venipuncture;
- Demonstrate the correct technique for establishing IV access;
- Discuss the behavioral management of pediatric patients with selected pharmacologic agents as well as adjunctive techniques;
- Describe the use of alternate forms of sedation in adults;
- List key issues in cardiac physiology that have major potential clinical significance;
- List key issues in respiratory physiology that have major potential clinical significance;
- Discuss cardiac and respiratory monitoring during procedural sedation.
- List the validated risk factors for post-operative nausea and vomiting (PONV) and known associations;
- Develop a protocol for preemptive as well as rescue management for PONV and a plan for post-discharge N&V;
- Identify checklist elements that must be assessed prior to initiating sedation;
- Gather data, utilize the checklist and present a patient to the supervising doctor with an anesthesia plan;
- Participate in simulations designed to prepare participants for the general and emergency management of dental patients who are being treated under some form of sedation;
- List the benzodiazepines used for sedation, their five important properties and relative merits of those commonly used;
- Identify changes in a dental office that must be incorporated to properly prepare for the practice of sedation;
- Describe the role of the dental anesthesiologist and the cases that might be managed under general anesthesia;
- Review closed cases with adverse outcomes that have resulted in litigation and use these as tools to develop safe practices;
- Identify drug-food, drug-drug and drug-supplement interactions of significance to the dental sedation provider;
- List emergency drugs / devices that should be added to the basic emergency kit when a dental office is preparing to offer procedures under sedation;
- Successfully complete a final examination that reflects the content of the program.
At the conclusion of each of the following didactic presentations, participants will be able to:
Patient evaluation and anesthesia treatment planning – Richard P. Szumita, DDS
- list medical issues of concern associated with each major body system;
- describe the ASA classification system and how it is utilized;
- determine whether any given patient is a candidate for sedation in his/her practice;
- develop an appropriate anesthesia plan for any patient deemed a candidate for sedation in his/her office;
- provide alternative strategies including appropriate referral for those who are not considered candidates for sedation in his/her practice.
Introduction to Enteral Sedation – Joseph J. Portale, DMD, MAGD
- discuss indications and contraindications for the use of sedation in dental practice;
- describe the appropriate use of triazolam for sedating anxious dental patients;
- identify characteristics of patients that may lead to modifications in dosage of sedation agents in dental practice.
Introduction to Sedation –Hillel Ephros, DMD, MD
- list available routes and methods for relieving anxiety in dental patients;
- discuss the advantages and disadvantages of each of the above;
- describe the stages and planes of anesthesia;
- discuss the rationale for sedating anxious dental patients using the intravenous route;
- identify classes of drugs that may be used to provide sedation in dentistry;
- discuss “balanced anesthesia” in contrast with single drug techniques for sedation in dentistry;
Monitoring the Sedated Dental Patient* – Hillel Ephros, DMD, MD
- list all required monitoring equipment used during sedation for dental procedures;
- discuss office staffing and staff training to appropriately monitor and care for dental patients receiving sedation;
- describe the functions and limitations of each piece of monitoring equipment;
- develop a form that accurately reflects all of the monitoring done during each sedation procedure and is consistent with standards of care and regulatory requirements.
Benzodiazepines – Hillel Ephros, DMD, MD
- identify medications that belong to this class of drugs;
- list the five shared properties of the benzodiazepines;
- select and provide rationale for the selection of those benzodiazepines most suitable for use in the sedation of dental patients;
- describe potential complications associated with these agents and their management including the use of a reversal agent.
Nitrous Oxide Inhalation Sedation – Hillel Ephros, DMD, MD
- discuss the pharmacology of this agent and its impact on major organ systems;
- list the contraindications to nitrous oxide inhalation;
- utilize nitrous effectively as a single agent with oxygen or as part of a balanced anesthesia technique;
- describe the use of nitrous oxide with oxygen in the management of specific medical emergencies;
- articulate how to avoid, identify and manage stage II when using nitrous oxide for sedation in dentistry;
- incorporate into his/her standard practice appropriate precautions designed to minimize the likelihood of allegations of impropriety from patients who receive nitrous oxide;
Sedation Agent Interactions with Other Drugs, Food and Herbal Supplements
Michael Erlichman, DDS
- list critical drug-drug interactions between sedation agents and other medications that might be prescribed or administered by the dentist or by the patient’s physician;
- discuss interactions that may occur between sedation agents and other substances including commonly used herbal remedies and supplements;
- describe several mechanisms for such interactions and a system for grading interactions
- develop methods to be utilized in his/her dental practice in an effort to avoid serious interactions
Pediatric Sedation – Dr. Yasmi Crystal
Identify pediatric dental patients who may benefit from oral sedation; describe the potential risks and benefits of each agent listed;
- identify major differences between children and adults that impact on the use of sedation in dental practice;
- discuss the anatomy of the pediatric airway and contrast with the adult airway;
- discuss appropriate medications and their dosing for children who may benefit from sedation in dental practice;
- describe the limitations of sedation techniques related to the age of the patient;
Medical Emergencies in Dental Practice – Hillel Ephros, DMD, MD
- discuss the most common causes of medical emergencies in dental practice and the phases of treatment at which they are most likely to occur;
- list the medical emergencies most likely to arise in a dental practice;
- discuss the recognition and management of each emergency below:
- angina pectoris,
- myocardial infaction,
- hypoglycemic episode,
- allergic reaction;
- develop a medical emergency kit suitable for the general dental office capable of addressing these emergencies without requiring intravenous access;
- participate in the development and implementation of emergency protocols in a dental office including assignment of roles for various office staff members.
Emergencies Related to Sedation – Hillel Ephros, DMD, MD
- identify the most common causes of emergencies associated with the use of sedation in dental practice;
- discuss the recognition and management of common urgencies and emergencies related to sedation including laryngospasm, bronchospasm, respiratory depression, nausea/vomiting and aspiration;
- develop appropriate protocols and an expanded medical emergency kit suitable for an ACLS level provider trained in venous access and is administering sedation in his/her dental practice.
Dental Anesthesiology – Dr. Jonathan Mendia
- identify patients who require deeper sedation or general anesthesia
- discuss options in the management of patients with greater needs relative to anxiety and more complex treatment plans
Pharmacology of Sedation Agents –Seth Landa, MD
- list medications commonly used to produce sedation;
- provide for each listed agent a clear statement of the drug’s indications, contraindications, potential benefits and risks including common adverse effects;
- provide for each listed agent a clear statement of the drug’s utility in dentistry;
- discuss the appropriate dosage and route for each listed drug;
- describe the potential risks and benefits of a multi-drug approach to sedation.
Cardiovascular Physiology and Monitoring – Pam Upadya, MD
- discuss basic principles of cardiovascular physiology;
- describe how sedation agents may impact upon the cardiovascular system;
- list monitoring devices used to provide information about the status of the cardiovascular system during sedation;
- explain how each of the listed devices is used during sedation;
- interpret readings on cardiovascular monitoring devices used during sedation in dental practice.
Respiratory Physiology and Monitoring – Pam Upadya, MD
- discuss basic principles of respiratory physiology;
- describe how sedation agents may impact upon the respiratory system;
- list monitoring devices used to provide information about the status of the respiratory system during sedation;
- explain how each of the listed devices is used during sedation;
- interpret readings on respiratory monitoring devices used during sedation in dental practice.
Managing the Airway in Sedated Patients – Robert DeFalco, DDS
- identify airway structures found in the adult and the child;
- describe the impact of sedation agents on the airway and on respiration;
- discuss maneuvers that may be used to support the airway;
- list airway devices that may be used to access, protect and secure the airway;
- identify airway devices that will be available in his/her dental practice.
Intravenous Fluids – Richard Szumita, DDS
- discuss the rationale for the use of IV fluids for sedated patients in dental practice;
- list the different types of fluids available for IV administration;
- describe the constituents, indications, and contraindications for each fluid listed;
- demonstrate an appropriate technique for preparing and administering an IV fluid infusion;
Venipuncture (lecture) – Robert DeFalco, DDS
- discuss the anatomy of the upper extremity as well as alternate sites for IV access;
- describe an approach to selecting an appropriate venipuncture site;
- describe two commonly used devices to gain venous access for sedation in dental practice.
Risk Management for Sedation Dentistry – SJ Risk Management Department
- discuss the process of informed consent and how the use of sedation impacts on this process;
- describe changes in office policy, forms and documentation that should accompany the transition to a sedation dental practice;
- identify regulations and guidelines that govern the use of sedation*
Reversal Agents – Meredith Blitz, DDS
- discuss the appropriate indications for the use of reversal agents;
- list reversal agents that may play a role when sedation is administered in dental practice;
- describe for each agent listed, the potential risks and benefits of its use;
- describe for each agent listed, an appropriate dosing regimen and route(s) of administration.
Incorporating Sedation into Dental Practice – Dr. Joseph Portale
- identify the potential risks and benefits of incorporating sedation into his/her practice;
- describe facilities, staff, equipment, continuing education and office policy issues that require attention as part of this process.
Management of a sedation practice – Dr. J. Gaspari
- identify the special needs of a sedation practice
- discuss strategies for successful integration of sedation into a dental practice
Alternate methods and techniques – Dominic Lu, DDS
- describe alternatives to conventional drug-based techniques for sedation
- discuss the use of acupuncture and acupressure in dentistry
Avoiding disasters in sedation dentistry – Seth Landa, MD
- describe strategies for avoiding complications during sedation
- discuss the risks and potential benefits of multiple drug sedation
Non-pharmacologic behavior modification – Dr. Robert Korwin
- describe alternate means of modifying behavior
- develop a risk / benefit analysis for various behavior modification schemes
*The ASAASD sedation program has been designed to meet or exceed training requirements for sedation certification in all states represented by course participants. It is also the intent of the ASAASD to ensure that this course maintains consistency with ADA guidelines for the teaching of sedation. Each course participant is strongly advised to carefully review and abide by the regulations of the Board of Dentistry in his/her home state, to follow guidelines established by the ADA and promoted in this program and to meet or exceed standards of care established by dentists certified to provide sedation in the region in which he/she practices.
Venipuncture Lab – Faculty
- identify anatomic landmarks relevant to establishing IV access;
- successfully establish IV access on a mannequin arm;
demonstrate appropriate technique when performing venipuncture.
Advanced Cardiac Life Support (ACLS)
The ACLS program required of all participants in this course is comprehensive and meets all standards set by the American Heart Association. It is given in a way that reflects the anticipated mode of practice of course participants. The ACLS component of this program begins with self-study prior to arrival and culminates with full-time training on days 6 and 7.
While it is included in the description of the comprehensive sedation course, ACLS is sponsored by the AHA through one of that body’s accredited training sites and is a separate program that conforms to AHA guidelines and is taught by AHA certified instructors. However, it should be noted that successful completion of ACLS is a strict requirement for the sedation course.
At the conclusion of ACLS, participants will be able to:
- Demonstrate skills required to successfully complete ACLS;
- Achieve a passing grade on the test used to evaluate the didactic components of the ACLS course.
ASAASD SEDATION PROGRAM
Clinical training in the sedation course begins on the afternoon of day 4, continues on day 5 and is full-time on days 8-12. On each of these days, participants are assigned to either the operating room, the endoscopy suite or the oral and maxillofacial surgery clinic. Assignments are rotated so that every participant is exposed to each of the three training sites.
At the conclusion of the clinical component of this program, each participant will be able to:
- document direct involvement with the administration of sedation to twenty or more patients;
- discuss for each of these cases,
- the pre-sedation assessment,
- the assignment of an ASA classification,
- the anesthesia plan and its rationale,
- all monitoring used intraoperatively and during recovery,
- the IV site, type and size and fluid given,
- all medications administered and their dosages,
- complications, if any, and their management;
- demonstrate techniques for obtaining venous access and discuss the relative merits of different IV sites;
- document successful achievement of IV access in twenty or more sites;
- develop an appropriate anesthesia plan for any patient deemed a candidate for sedation in his/her dental practice;
- competently conduct patient selection and properly prepare patients for sedation;
- utilize a sedation checklist to ensure that no required element is omitted;
- identify each component of an emergency kit consistent with the practice of sedation in dentistry and discuss its use;
- discuss how he/she uses clinical parameters and monitoring equipment to evaluate the patient under sedation;
- describe titration and how it is used during sedation procedures;
- demonstrate airway maneuvers utilized in the sedated or unconscious patient;
- demonstrate the proper use of devices that support and secure the airway;
- Utilize good technique to establish and maintain IV access;
- Demonstrate competency in intraoperative airway management and patient monitoring;
- Demonstrate competency in directing emergence from anesthesia, monitoring during recovery and applying discharge criteria.
- Discuss the management of sedation-related post-discharge issues including PDNV and pain management.
ASAASD SEDATION PROGRAM
Oral and Maxillofacial Surgery Service – SJRMC, Paterson, NJ
- Patient NPO (asked 3 times) and accompanied by adult who waits here for patient
- History and Physical done/reviewed, ask again about allergies including latex and document allergy status
- Consent done with full discussion and documentation of potential risks vs. benefits
- Additional consent on sedation sheet reflects having offered patient options re: type of anesthesia, patient to read drug information sheet first!
- Room set up with suction on and all necessary instruments and supplies including mouth prop, handpiece, local, blades, suture etc.
- Anesthesia set up including tape, syringes, alcohol wipes, restraints, monitor on and correctly programmed, fluids (if indicated) etc.
- Urine HCG required of all females of childbearing age unless a signed waiver is executed
- Seat patient in pre-operative room, check H&P, vitals and any other pertinent data
- Present case and treatment plan to attending who reviews and signs off on H&P and approves of anesthetic as well as surgical plan
- Draw up medications only after all of the above is completed / verified / approved
- When surgical and anesthesia set ups are both complete, seat patient in surgical chair in a comfortable chair position, place all monitoring equipment, record initial vital signs
- Start oxygen with nitrous (FEMALE patients are not to have this done until a female staff member is physically present in the room)
- Tourniquet over sleeve rather than on skin, especially for men with arm hair, look for best vein, DO NOT make any attempts unless the vein appears adequate, using appropriate gauge angiocath
- Secure IV access properly, always use arm restraints with appropriate explanation to patient
- Conduct a time out and make sure it is included in case documentation
- The initial dose administered during a sedation case must be given with an appropriately credentialed licensed independent practitioner, start at a reasonable, conservative initial dose which can be titrated upward
- Never begin the procedure without a throat screen in place!!!
- After the procedure, the recovery period must be overseen by an ACLS certified individual
- Any drug wastage must be witnessed and signed by two individuals with licenses or permits in NJ
- The surgical and anesthesia records should be completed during the patient’s recovery after necessary entries are made in the medication log book
- The sedation form must be completed so that all requested information is provided, however, all patient identifying information MUST be redacted before any forms leave the premises
- Dismiss patient to care of accompanying adult only when discharge criteria have been met, safe discharge documented and attending has signed off
- Any anesthesia-related complication must be reported to the attending and Dr. Ephros (or Dr. Szumita) immediately and a complication form must be completed and sent to Dr. Winikoff.
The program receives no commercial support.
No member of the faculty has any known conflicts of interest.