The Iowa Board of Dental Examiners has adopted some stringent regulations on the use of medications for sedation dentistry in Iowa. The regulations divide dental office pain control into four categories:
- Nitrous oxide inhalation analgesia. If a dentist wishes to use nitrous oxide in his or her practice, the dentist must maintain current certification in CPR and document biennial maintenance of his nitrous oxide equipment.
- Anti-anxiety pre-medication. This level of care is also considered a greater risk and in order to administer this, a dentist must maintain current certification in CPR.
- Conscious sedation, which is defined as any level of pharmacologic premedication that produces an altered level of consciousness. In order to administer this in a dental office, the dentist must maintain current certification in advanced cardiac life support, and must maintain a crash cart, defibrillator, and expensive monitoring equipment. His or her facilities are subject to routine inspection to see that they meet safety standards.
- Deep sedation/general anesthesia. To administer this in a dental office requires an even higher level of training and emergency response capability.
The Iowa Board of Dental Examiners is charged with insuring the quality and safety of dental care in Iowa. We are sympathetic with the difficulties of creating uniform regulations that give dentists the freedom to treat patients as they see fit while restraining unethical and possibly dangerous practices. We respect their role and their authority. Meanwhile, I am of the opinion that the rules need some additional work of clarification and refining. On behalf of our patients, we have the following concerns about the regulations as they currently stand:
- Their seems to be a general assumption that any sedative medication, including very light anti-anxiety pre-medication, increases the risk of the dental procedure. While it’s true that deep sedation and general anesthesia in a dental office setting have a degree of risk to them, we are unable to find any evidence that sedation with oral Valium, for example, has any degree of health risk whatsoever*. In fact, most dental office emergencies are caused by stress, which obviously increases in the presence of dental fear, and there are safe sedative medications that can reduce the stress, thus reducing the risk of heart attack, stroke, or seizure while getting dental care. A large study of oral surgery practices in Massachusetts confirmed that patients with mild sedation had a greater safety record than patients treated with only local anesthetic.
- The difference between “anti-anxiety premedication” and “conscious sedation” is not clearly defined. If a patient is given a 50 mg. dose of over-the-counter anti-histamine and falls asleep, is that an “altered level of consciousness”? Could a dentist conceivably be required to meet stringent and expensive training and emergency standards to have that patient in his office, even though such medications can be obtained easily by any patient over-the-counter? The effect of this vagueness, when combined with the fear of possible licensure sanctions and the reputation for harshness that has been earned by the Iowa dental board, causes dentists to “play it safe” by under-medicating rather than using his or her judgment as far as what is the best care to meet the needs of the patient.
- The regulations, while they don’t technically outlaw oral sedation, do so in effect, and they do it in this manner: In order to administer sedation, the dentist needs to be approved by an anesthesia committee. If this anesthesia committee finds out that the dentist advocates administering oral sedation, the dentists who have been appointed to that committee are of the professional opinion that this manner of administration should not be performed, and will not grant him or her the permit. However, to patients, the use of oral premedication is the most comfortable and anxiety-free. The administration of intravenous drugs is, in itself, a source of anxiety and something patients will avoid.
- Those who drew up the regulations said, during their deliberations, that they gave no consideration whatsoever to the economic impact of the regulations. We feel that this thinking should be revisited, because it is the very economics of the regulations that has levied an extreme hardship on Iowa patients. The effect is this: Because of the costs of the equipment and the training required, it is generally not feasible for general dentists to gain the permits required to administer conscious sedation. Therefore, in most communities in Iowa, the only place dental patients can get this treatment is in an oral surgeon’s office.For patients who need conscious sedation, they can go to an oral surgeon and have their teeth extracted, or they can travel to one of the states bordering Iowa where the regulations are more reasonable. This, indeed, is very unfortunate.
- There are a large number of patients who are unable to get numb with local anesthetic alone. A study published in the Journal of the American Dental Association in 1985 documented this phenomenon. Dentistry has a responsibility to provide affordable, reasonable dental care to these people, which responsibility we seem to be largely ignoring.
- We are concerned about the thought process behind the regulations. The regulations seem to have an underlying implication that treating patients “cold turkey” is the best and most appropriate way for all dental offices. What is it that implies that? It is this: Only if you offer no sedation of any sort will you not come under the scrutiny of the regulations. Therefore, if you do nothing to treat dental anxiety you are a “good” dental office, one that the Board doesn’t need to worry about. To be more specific, we don’t feel that dentists who give only anti-anxiety premedication need to have any additional regulations over those who use only local anesthetic. To go further, we would say that dentists who use only local anesthetic should be more prepared for possible in-office emergencies.
- Dentistry in Iowa has created such a climate around this procedure that even those few general dentists with permits to administer intravenous conscious sedation do not publicize the fact, making it of little use to patients since they can’t find these practitioners.
Recommendations – The American Dental Association has developed a policy statement on the use of conscious sedation, deep sedation and general anesthesia in dentistry, the education required to use these treatments, and suggestions for state boards of dentistry. We at Mapletree Dental Care are unsure why Iowa needs standards that are so much more restrictive than those. We feel that adopting the American Dental Association standards in Iowa would be helpful in improving patient access to needed sedation. Patient access is a key issue identified by the American Dental Association policy statement on sedation.
Neighboring states have no problem with oral sedation. Currently, in Wisconsin and Missouri, there is no permit required for administering oral sedatives, and there seems to be no safety issue in those states. Illinois has some regulations, but they permit the use of oral sedatives. Many dentists make it known that they provide sleep dentistry for patients. The Dubuque Telegraph Herald has recently run an article pointing out this unusual situation: In Wisconsin, on the east bank of the Mississippi, dentists can safely administer oral sedatives, and its use is popular in Platteville. But, when they cross over the river to Dubuque, oral sedation becomes dangerous.
*For clarification on the safety record of Valium (diazepam), the following statement from a representative of the manufacturer of Valium may be helpful:
“No human lethal dose of diazepam has been established; survival has been reported following a 2,000 mg. dose of diazepam (see enclosed copy of article by Greenblatt, et al.)
“Regarding morbidity or mortality following oral diazepam, these events have been associated with overdose settings, usually involving other drugs or chemical abuse.
“With regard to use in a dental setting, there are no in-house reports of these events associated with oral diazepam used as routine premedication. A literature search failed to reveal any such cases.”
James M. LaBraico, M.D.
Department of Drug Safety
(personal communication with Dr. Hall)
By Dr. David Hall