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Dr. Ronald Davies is a USC dentist who is medically trained in Anesthesiology and double Board Certified in his field. He has an unsurpassed 30 year safety record limiting his practice to anesthesia for dentistry.
- General Anesthesia Evaluator for the Dental Board
- Past Associate Professor in Anesthesia at LLU, UCLA and USC
- Past President: American Society of Dentist Anesthesiologists, California Society of Dentist Anesthesiologists
- Member: ADA, CDA, OCDS, OCDA, ASDA, ADSA, CSDA
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Still Confusion With Oral Sedation?
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My last newsletter covered who needs an Oral Sedation (25 hours) permit, how to get one and commonly use medications. I have outlined permit requirements on my website. It is important to stress that oral conscious sedation is defined by the California Business and Professions Code: 1647.18.(c) "Oral conscious sedation" means a minimally depressed level of
consciousness produced by oral medication that retains the patient's
ability to maintain independently and continuously an airway, and
respond appropriately to physical stimulation or verbal command.
If given in dosages beyond that you need a Conscious Sedation Permit (60 hours of training) defined as 1647.1. (a) "conscious sedation" means a minimally depressed level of consciousness produced by a pharmacologic or nonpharmacologic method, or a combination thereof, that retains the patient's ability to maintain independently and continuously an airway, and respond appropriately... (b) The drugs and techniques used in conscious sedation shall have a margin of safety wide enough to render unintended loss of consciousness unlikely. Further, patients whose only response is reflex withdrawal from painful stimuli shall not be considered to be in a state of conscious sedation. This is often called an I.V. Sedation Permit.
Past that point you need a General Anesthesia Permit which requires at least a year of training (or its "equivalent" ie Oral Surgeons). Don't risk your license.
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"The Fallacy of a Lifesaving Sublingual Injection of Flumazenil"
| From Anesthesia Progress 58:1-2 2011
There also seems to be a misunderstanding circulating which could be fatal. That is whether or not an overdose of benzodiazepams can be rapidly and safely reversed in an emergency without an IV line by injecting flumazenil sublingually. It is important to remember that like Narcan reversal of narcotics, flumazenil will wear off long before the triazolam and in my opinion its use per se constitutes the admission that an emergency is underway so call 911.
Consider this email from Dr. Joel Weaver: "Many poor unsuspecting dentists are being taught that 0.2 mg sublingual flumazenil will save a patient's life if they are overdosed, such as in my example of the dentist who gave 4.5 mg triazolam and in the St Louis case where it was given after 2 mg triazolam.
For anyone to believe that a puny dose of 0.2 mg flumazenil given by any route, including IV, would save a life in a true overdose for a patent who cannot be ventilated is very sad. Competitive antagonists need a higher dose to treat a bigger overdose. There is no one dose that fits all overdoses."
Joel M. Weaver DDS, PhD
Dentist Anesthesiologist
Emeritus Professor
College of Dentistry
The Ohio State University
Anyone using oral sedation with a benzodiazepine (BZD) such as Valium or triazolam who naively thinks they can reverse an overdose using a sublingual injection of Flumazenil should read this excellent editorial in the latest Anesthesia Progess. Reprinted with permission, Joel M Weaver (2011) "The Fallacy of a Lifesaving Sublingual Injection of Flumazenil". Anesthesia Progress: Spring 2011, Vol. 58, No. 1, pp. 1-2.
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| Another Misconception? | Oral Sedation is NOT Completely Safe
I have read in some dental websites that no one has ever died from oral sedation. That is a blatant falsehood. The very reason we have oral sedation permits in California is because patients have died in the dental office from oral sedation. A simple Google search turns up many including this March news report in Missouri . While deaths are rare, proper pre-operative medical evaluations, monitoring and staying withing the law will minimize the risk greatly. A good primer on oral sedation can be read here. I am not "knocking" oral sedation. It is a wonderful way to treat mildly apprehensive patients. But it is a mistake to think that it works on highly apprehensive patients or that it is without risk. Dirty Harry said it best: "A man's got to know his limitations". |
Why Skin Prep Matters
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For those that do IV sedation or General Anesthesia themselves I highly recommend reading "Why Skin Prep Matters: According to the Centers for Disease Control and Prevention (CDC), 1.7 million people per year acquire an Healthcare Associated Infections (HAI), which results in 99,000 deaths - the equivalent of 271 people each day.1 HAIs cause more deaths annually than AIDS, breast cancer, and auto accident deaths combined.2"
A product called ChloraPrep claims to dramatically reduce HAI during catheter placement.
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| The Use of Propofol by Operator-Anesthetists |  FDA Ruling 2010
The FDA has recently denied a petition by certain surgeons to remove the Warning Label from Diprivan (propofol) which says: "For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure." The American Society of Anesthesiologists has comments here. Many are concerned that not only do some dentists while functioning as operator-anesthetists continue to administer propofol outside the manufacturer's warning (supported by the FDA) but they may allow Dental Sedation Assistants to draw up and inject this drug. The FDA considers the minimal training of someone not involved in the surgery to administer this drug under supervision is an RN with training in general anesthesia. The new California DSA (high school grad) with 110 hours of training obviously does not meet that requirement. This just in...Beyond all rationale, the Dental Board has decided to allow the employers of DSAs to be their teachers and certifiers. The CDA and Board think that 110 hours of training to inject drugs and monitor a patient's vital signs is adequate with training 'in-house" by providers whose own CODA says that they merely need to have a "Familiarity" of outpatient anesthesia. Want to bet YOUR patient's life on it? |
Previous Newsletters
Click Here to access previous newsletters
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| Assistants to Administer Local? | As predicted, Pandora's box has been opened. It has been reported that the DBC will consider allowing dental assistants to administer local anesthesia. The DBC had a Dental Assisting Forum meeting 1-21 and Agenda Item #5 delt with the possibility of RDAEF administering local anesthesia. They are taking the matter up again 4-8.
See Agenda for the April 8, 2011 meeting. Five hours seems reasonable when 110 hours is all that is needed for general anesthesia. Preps, implants and extractions are next if dentists don't get involved. |
Getting Better Anesthesia
| Buffering Local Anesthesia
ADSA Pulse Vol 44 Issue 1, 2011, S. Malamed
1. Greater patient comfort during injection
2. More rapid onset of anesthesia
3. Decreased post injection tissue injury
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Safe Anesthesia is No Accident
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Ronald O. Davies, DDS
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The information contained herein is provided for informational purposes only and does not constitute dental or medical advice. Dr. Davies shall not be responsible for any claims, damages, demands or liabilities of any kind arising from or related to the use of this information.
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