August 10th, 2018

Dear Virginia Board of Dentistry,

In reference to a copy of a letter I drafted to clarify some misconceptions regarding the mandate of a 3rd individual being present during the performance of moderate sedation in a dental office-based setting, I was asked to re-iterate some of the points that currently exist in not only the American Society of Anesthesiologists (ASA) 2018 Moderate Procedural Sedation and Analgesia Guidelines, but also in the newly affirmed American Academy of Pediatrics/American Academy of Pediatric Dentistry (AAP/AAPD) Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016.

I’ve maintained and continue to maintain that the intent and goals of all of the authors of the ASA 2018 Guidelines, which were comprised of not only dentists, but also pediatric physician anesthesiologists, a gastroenterologist, a cardiologist, an emergency medicine physician, an interventional radiologist, and other physician anesthesiologists, were to establish the two-person model of moderate sedation provision as the de facto standard of care, regardless of the setting. 

If the sedation provider truly intends for the patient to be in moderate sedation, in which patients purposefully respond to verbal stimulation and are awake during the procedure, you, in essence, already have three individuals present to ensure a minimum level of safety in monitoring and response: 1) The treating dentist, who is providing the sedation, 2) the dental assistant, who is monitoring the patient along with the treating dentist, and 3) the patient themself who is providing verbal and purposeful response to the dentist and assistant  during the procedure to indicate safe levels of sedation. 

I would respectfully urge the Virginia Board of Dentistry to reconsider the proposed language to mandate 3 individuals needed for the safe provision of moderate sedation as unnecessarily exceeding established and researched national guidelines.  Given the greater context of patients undergoing procedural moderate sedation in different healthcare venues outside of dentistry, the proposed mandate goes well beyond the intent of guideline committees specifically tasked to examine this matter.

As others have already stated, 3 individuals are required for the delivery of deep sedation and/or general anesthesia in a dental setting.  The current ASA, ASDA, and AAP/AAPD positions on deep sedation/general anesthesia for pediatric patients in dental settings require the third individual to be a dedicated and independent anesthesia provider (DDS, MD/DO, or CRNA) not involved in the conduct of the procedure. (see: https://www.csahq.org/docs/default-source/default-document-library/asa-statement-on-sedation-anesthesia-administration-in-dental-officebased-settings-(1).pdf?sfvrsn=0 and http://www.aapd.org/media/Policies_Guidelines/BP_AnesthesiaPersonnel.pdf )

Respectfully submitted by request,

Jimmy

James Tom DDS, MS, FACD

President, American Society of Dentist Anesthesiologists

Associate Professor

Herman Ostrow School of Dentitsry

University of Southern California