By John Bitting, Esq.
DOCS Education Regulatory Counsel
As regulatory counsel for DOCS Education for the past decade, I've concentrated on understanding dental regulations on a state-by-state level, and examining the guidelines proposed and approved by the American Dental Association.
My mission is twofold:
1. To advocate—first and foremost—patient safety
2. To support sensible sedation regulations and guidelines
Enteral sedation, also referred to as oral sedation, has been a godsend for tens of millions of Americans—especially for those who are fearful and anxious about seeing their dentists. In fact, no other advancement in the past 15 years has done more to bring patients back to dentist offices to restore their oral health.
Since 2007, more than 20,000 general dentists have treated their patients using oral sedation—safely, effectively and without incident—using the existing ADA guidelines.
The Biggest Mistake the ADA has Ever Made
But all of that is about to change if a small group of influential ADA members have their way to change the existing ADA guidelines that govern enteral sedation. Their recommended revisions, known as Resolution 77, have all the makings of being one of the most monumental mistakes that the ADA will have made ever in its 157-year history.
Under the ruse of public safety—and make no mistake about it, Resolution 77 is strictly an ego and power play couched as concern for patients—the proposed guidelines are designed to rollback the progress that enteral sedation has brought to the dental profession.
If approved, Resolution 77 will not only hurt all current and future general dentists who rely on enteral sedation in their practices, it will do great harm to dental patients.
How Resolution 77 ever got this far is beyond me—it's headed for an ADA House of Delegates vote on November 10. It appears that the board members at the ADA believe that the proposed changes will be good for dentists and the public at large. They are seriously mistaken.
Although each state regulates dentistry independently and has the discretion to modify or ignore the ADA's recommended guidelines, in truth, if Resolution 77 is approved by the ADA House of Delegates, most state dental boards will rubber stamp it into law—bad law.
What is Resolution 77?
Resolution 77 is a long and complicated revision. It's not surprising that members of the ADA board and committees may not fully understand the proposal. Nor is it surprising that most practicing dentists have never heard of Resolution 77, much less what it means for them and their patients.
I encourage you to carefully read Resolution 77 (click here to read it) at your own pace between now and the House of Delegates vote. Here are the CliffsNotes:
- Resolution 77 proposes to obliterate the entire 24-hour training requirement for enteral moderate sedation—which has been a benchmark of safety for the last eight years—without any justification.
- Resolution 77 would increase the required training hours for enteral moderate sedation by 150 percent. Essentially, it will require general dentists who wish to provide oral moderate sedation to spend $35,000 to $50,000 to take a 60-hour IV sedation course and obtain other certifications, equipment upgrades and an IV permit—to provide oral sedation.
- Those dentists who only wish to provide their patients with minimal sedation (which requires 16 hours of training per the current ADA guidelines) will discover that Resolution 77 also dramatically restricts their mode of treatment.
The current ADA Guidelines allow up to one-and-a-half times the manufacturer's maximum recommended dose (1.5x the MRD) for at-home, unmonitored use.
However, Resolution 77 reduces the maximum allowable dose from 1.5x the MRD to the MRD itself. If dentists want to exceed the MRD—or if they combine ANY amount of sedative with any other oral drug—they must take a 60-hour moderate sedation course and upgrade to an IV sedation permit—once again, for oral sedation.
Think about it, what the ADA is now proposing is to require dentists to take 16 hours of courses in order to administer a pill that the patient could take at home without any monitoring whatsoever.
Resolution 77 is the Real Public Safety Risk
The ADA is proposing Resolution 77 without giving serious consideration to the impact that the new guidelines will have on the cost of providing or receiving oral sedation.
That is the real big public safety risk: These new guidelines (if approved and adopted by state regulators) will price out of the dental market altogether many fearful and anxious patients. At a time when dentists are seeking means to attract more patients to their practices, Resolution 77 will drive away patients by the tens or even hundreds of thousands.
The scientific evidence is absolutely clear about the impact of neglected oral health: Patients who avoid the dentist are at far greater risk of developing serious lifelong oral health problems and even life-threatening ailments.
If you have any doubt about just how repugnant Resolution 77 really is, you need look no further than the proposal itself.
Knowing that members who regularly administer enteral moderate sedation to their patients would NEVER vote for Resolution 77, those pushing the revised guidelines designed their proposal to grandfather in all dentists who already utilize oral sedation in their practices.
Current sedation dentists will receive a “Get Out of Jail Free” card allowing them to skirt Resolution 77. The only dentists who will have to adhere to the much more restrictive, expensive training requirements will be new dentists and future dental school graduates.
If public safety was the real inspiration for Resolution 77, why would the ADA exempt current dentists from adhering to the new guidelines?
Consider this analogy: If the brakes on a make and model of car are recalled as a potential safety hazard, regulators don't exempt existing vehicles from the recall—and only require fixes to new cars. All cars with those brakes are recalled.
As I noted at the beginning, Resolution 77 is not about public safety. The existing ADA guidelines are more than sufficient to guard public safety.
In the very few, highly publicized tragic cases involving oral sedation in recent years, the dentists in question did not follow either the existing ADA guidelines or their state regulations. The guidelines were not lacking; those dentists were negligent.
The notion that the dentists currently offering enteral moderate sedation won't be impacted by Resolution 77 is both cynical and misleading.
All dentists will feel the impact of Resolution 77 both now and when they one day wish to pass on their sedation dentistry practice. They will discover that there are no longer enough sedation dentists to purchase their practices.
Moreover, there is no guarantee that state dental boards—alert to the absurdity of recalling some “faulty brakes” and not all of them—won't do away with the ADA's grandfather clause and require all dentists to conform to the new educational guidelines.
The Future is Not Bright with Resolution 77
In conclusion, let me offer you a few snapshots of what the dental profession is likely to look like if Resolution 77 is adopted.
1. There will be two classes of dentists hence forth: "First Class" dentists, who can ignore the superfluous educational requirements contained in Resolution 77; and "Second Class" dentists, who will have to spend up to $50,000 extra to provide the exact same care to their patients that First Class dentists already offer.
2. The cost of standard dental care to fearful and anxious patients will rise dramatically to offset the price of the new, excessive educational requirements required by Resolution 77. Many thousands—likely hundreds of thousands—of patients will stop seeing a dentist because they won't be able to afford it. The greatest impact will be on poor and minority communities.
Sadly, some people will even die needlessly, because they avoided the dentist altogether.
3. In time, the number of ADA qualified sedation dentists will diminish. The shortage will mean patients will have to wait longer and pay even more to see their dentists. In addition, the value of existing dental practices will fall significantly, because there simply won't be enough sedation dentists to acquire them.
Resolution 77 Helps No One
The bottom line is that Resolution 77 helps no one—not dentists and not patients. It only boosts the egos of the small, self-interested, politically motivated group of ADA members who hope to push Resolution 77 through while members of the House of Delegates and other ADA leaders have their attention on other issues.
If there are genuine ways to make oral sedation even safer, DOCS Education and I—along with thousands of our members—will be the first to propose or endorse changes to the ADA guidelines.
But Resolution 77 is not the path to safer sedation dentistry. It is the expressway to a badly divided dental profession whose real victims are your patients.
Each one of us has a professional and moral responsibility to oppose Resolution 77 and to encourage all of our ADA colleagues to do likewise.
Call your ADA delegate now to urge them to vote no on Resolution 77. Find your ADA delegate here.
The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.