Moderate sedation has evolved significantly in the past 15 years. Historically, dentists avoided it over concerns such as safety, but now the vast majority of those concerns no longer even apply. Dentists can now safely provide sedation in ways that never before were possible.
Modernized moderate sedation training no longer has patients teetering on unconsciousness, needing reversal agents, suffering airway loss, or other events requiring intervention. Current training leans more towards medications and techniques that obtain something more like an ideal nitrous oxide case: No loss of airway, no loss of consciousness, and patients are amnestic, responsive, and very relaxed.
The question is no longer “Should I do sedation?”, but “What kind of sedation is safest, most predictable, and allows me to provide care without increasing my stress?”
Should I Get Trained in Oral or IV Sedation?
It’s no surprise that practitioners are largely shifting towards moderate (IV) sedation training courses. Many new graduates are moderate sedation certified and many residencies have it as core curriculum. The medications are better, the techniques are better, the training is better, and the outcomes are more predictable. As dentists realize that IV sedation is not deeper sedation, but simply a method to obtain a better controlled, more predictable clinical outcome, they are widely adopting it.
Why now?
Over the past few decades, we have taken great strides to protect our ability to provide sedation services safely. Two major arms of this effort have been: (1) to more clearly define the various levels of sedation/anesthesia, and (2) to better define what kind of training and permitting is appropriate for dentists wishing to provide each kind and level of sedation. This movement is reflected in several ADA publications:
- Policy Statement: The Use of Sedation and General Anesthesia by Dentists (2007)
- Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (2007, 2012, 2016)
- Guidelines for the Use of Sedation and General Anesthesia by Dentists (2007, 2012, 2016)
- Guidelines for Teaching Pediatric Pain Control and Sedation to Dentists and Dental Students (2021)
These documents are updated periodically and they influence continuing education, residencies, dental schools, prevailing thought by dental professionals, and rules/regulations governing dental sedation practices at state, regional, and national levels.
All this means that the standard of care has shifted. For example, historically many dentists elected for “oral conscious sedation” training where they could take a weekend course with clinical videos and get a permit to administer multiple oral sedatives to any patient of any age for any dental procedure. This “conscious sedation” practice was reflected in the 2007 version of the various ADA guidelines, but it has since been entirely removed. Now such practices are considered off-limits to any dentist who has not obtained residency-based training in general anesthesia. This is just one of the many significant changes that have come into effect in recent decades.
What Does All of This Mean for You?
If guidelines like these aren’t yet reflected in state law, they will be. Think about that for a moment. Even practices which were standard in 2007 have been eliminated as of 2016. It is reasonable, therefore, that sedation dentists who trained prior to 2016 should at least consider retraining in sedation, maybe entirely from scratch.
Does this mean oral sedation dentists can no longer stack oral medication doses? No it doesn’t. It does, however present them with a dilemma: Either limit oral sedation practices to no more than one dose of one medication not exceeding the MRD for unmonitored home use, or get moderate sedation certified. Once certified in moderate sedation, a dentist can administer pills, IV medications, and nitrous oxide in combination or alone to a level of moderate sedation. So, unless one prefers to avoid sedation entirely, that is the pathway that makes the most sense.
What Are Your Choices?
Dentists will naturally self-select into one of three groups:
- Dentists who provide nitrous oxide and local anesthesia only. They would then engage a 3rd party anesthesia provider (such as a dentist anesthesiologist) for select patients.
- Dentists who obtain moderate sedation certification and provide a range of sedation services, including oral sedation and IV sedation. They, too, would engage a 3rd party anesthesia provider when needed.
- Dentists who complete residency training to provide the full range of sedation/anesthesia services.
What Does Moderate Sedation Training Look Like?
By ADA standards, moderate sedation training courses must include 60 didactic hours and 20 live patient care experiences. This training can be obtained in a number of residencies or through a number of continuing education companies. Each course tends to have a unique format requiring various time and financial commitments, some reaching upwards to $30,000. Some are taught by nurses and physicians, others by general dentists, others by dentist anesthesiologists, or a mixture of providers.
Where Should I Get Trained?
Generally, you should look for courses with faculty members who are intimately familiar with the dental setting, who come from a variety of backgrounds, and have reasonable tuition and scheduling requirements. There is a tremendous amount of information that could be taught, but finding a course that focuses on what is the most relevant information—not just regarding sedation care, but regarding sedation care in the dental setting specifically—is paramount. Keep in mind, too, that that the top results from Googling “IV sedation training” might not be the best, and that courses that focus on quality and word-of-mouth-reputation over advertising and brand recognition might be ideal.
The Future of Sedation in Dentistry is Bright!
Sedation dentistry has never been safer, more accessible, and more in demand. Choose wisely how you implement it in your practice and, above all, stay current, relevant, and safe!
About The Author
Kevin Croft DDS is a board-certified dentist anesthesiologist who holds an active license to practice in the Commonwealth of Pennsylvania and several other regions. He is a director at large for the American Society of Dentist Anesthesiologists (ASDA) and he teaches an array of continuing education courses, including a moderate sedation certification course based out of St. George, Utah. He is also Dean of the AGD/ASDA’s joint sedation education endeavor: the Institute for the Management of Pain and Anxiety. He can be reached for inquiry/comment at dr.croft.dds@gmail.com or dentinomics.com.
