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William G Flick DDS, MPHWilliam G Flick DDS, MPH
Clinical Associate ProfessorClinical Associate ProfessorUniversity of Illinois ChicagoUniversity of Illinois Chicago
Oral Maxillofacial SurgeryOral Maxillofacial Surgery
Public Health Implications Public Health Implications of theof the
Illinois Dental Anesthesia and Illinois Dental Anesthesia and Sedation Survey for 2006 Sedation Survey for 2006
Sponsored by the Illinois Dental Society of Anesthesiology, and the Sponsored by the Illinois Dental Society of Anesthesiology, and the Illinois Society of Oral Maxillofacial SurgeonsIllinois Society of Oral Maxillofacial Surgeons
Dental Anesthesia and SedationDental Anesthesia and SedationThe Lighting Rod for Public Attention !The Lighting Rod for Public Attention !
Probably the single most scrutinized area Probably the single most scrutinized area of dental practiceof dental practice
Adverse outcomes create a Adverse outcomes create a disproportionate amount of media disproportionate amount of media attentionattention
Public concern regarding the, Public concern regarding the, appropriateness, regulation and even the appropriateness, regulation and even the necessity of such services.necessity of such services.
Example of Media AttentionExample of Media Attention
The ChallengeThe Challenge
Sustain the Public’s confidence Sustain the Public’s confidence Ensure public safetyEnsure public safety Maintain availability of office based Maintain availability of office based
anesthesia and sedation servicesanesthesia and sedation services Promote the cost effectiveness of office Promote the cost effectiveness of office
based anesthesia.based anesthesia.
Multi Faceted Pro Active ResponseMulti Faceted Pro Active Response
Governmental Sector, Regulatory AgenciesGovernmental Sector, Regulatory Agencies Input From Organized DentistryInput From Organized Dentistry Research to Generate Data that Reflects Research to Generate Data that Reflects
the Scope, Utilization and Outcome the Scope, Utilization and Outcome Continual reassessment of public health Continual reassessment of public health
policy regarding services.policy regarding services.
Illinois Dental Practice ActsIllinois Dental Practice ActsRegulates Practice of Anesthesia by Regulates Practice of Anesthesia by
DentistsDentists No permit required for Anxiolysis, Nitrous No permit required for Anxiolysis, Nitrous
Oxide AnalgesiaOxide Analgesia Permit A– Conscious Sedation, includes Permit A– Conscious Sedation, includes
oral and parenteraloral and parenteral Permit B- Deep Sedation and General Permit B- Deep Sedation and General
AnesthesiaAnesthesia
Illinois Dental Anesthesia and Illinois Dental Anesthesia and Sedation Survey for 2006Sedation Survey for 2006
A follow up survey of an earlier study conducted A follow up survey of an earlier study conducted in 1996 among all dental practitioners in Illinois in 1996 among all dental practitioners in Illinois with a Type A permit for conscious sedation or with a Type A permit for conscious sedation or a Type B permit for deep sedation/general a Type B permit for deep sedation/general anesthesia.anesthesia.
The survey describes the scope and many The survey describes the scope and many aspects about the sedation and anesthesia aspects about the sedation and anesthesia services offered in dental offices in Illinois.services offered in dental offices in Illinois.
The information is useful to the profession, The information is useful to the profession, public health policy advocates and regulatory public health policy advocates and regulatory agencies.agencies.
Issues addressed in the survey :Issues addressed in the survey :
age, years in practiceage, years in practice type of practicetype of practice ACLS trainingACLS training peer review, peer review,
accreditationaccreditation staffingstaffing type of sedation type of sedation
drugs useddrugs used
intubation in officeintubation in office number of cases number of cases
treatedtreated morbidity, mortalitymorbidity, mortality use of capnographyuse of capnography AED useAED use Dantrolene in Dantrolene in
emergency kitemergency kit
Why an update of survey at this Why an update of survey at this time?time?
10 year anniversary10 year anniversary permit for oral permit for oral
sedation in Illinoissedation in Illinois Anesthesia CE for Anesthesia CE for
license renewallicense renewal New inhalation New inhalation
agents, ie. agents, ie. SevofluraneSevoflurane
Interruption of Interruption of Brevital supplyBrevital supply
Generic forms of Generic forms of Propofol and VersedPropofol and Versed
Mandatory AAOMS Mandatory AAOMS peer reviewpeer review
Dental anesthesiology Dental anesthesiology specialty specialty
Anecdotal reports of Anecdotal reports of anesthesia related anesthesia related deaths in dental officedeaths in dental office
MethodsMethods
a mail survey to all dentists in Illinois , a mail survey to all dentists in Illinois , registered with Illinois Dept. Professional registered with Illinois Dept. Professional Regulation with Anesthesia Permit (Regulation with Anesthesia Permit (n n 471)471)
25 questions, 3 page, fill in, survey25 questions, 3 page, fill in, survey second mailing after 6 weeks second mailing after 6 weeks respondents remained anonymous.respondents remained anonymous. computer data base analysiscomputer data base analysis University of Illinois Chicago, Institutional University of Illinois Chicago, Institutional
Review Board, exemption grantedReview Board, exemption granted
Initial Survey ResultsInitial Survey Results
Initial mailing, list from IDPR, N 471Initial mailing, list from IDPR, N 471 Undeliverable, returned , n 27Undeliverable, returned , n 27 Responses, n 305Responses, n 305 Response rate 2006/ 69%Response rate 2006/ 69% Response rate 1996 / 71%Response rate 1996 / 71%
Type of PermitType of Permit
19961996 14% Type A 14% Type A
Conscious SedationConscious Sedation 86% Type B General 86% Type B General
Anesthesia/ Deep Anesthesia/ Deep SedationSedation
20062006 34% Type A 34% Type A
Conscious Sedation Conscious Sedation 64 % Type B General 64 % Type B General
Anesthesia/ Deep Anesthesia/ Deep SedationSedation
Type of Anesthesia Permit
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1996 2006
Type A Conscious Sedation
Type B Deep/ General Anesesthesia
Type of PracticeType of Practice
19961996 General Dentistry General Dentistry
11%11% Oral Max Surg 84%Oral Max Surg 84% PeriodonticsPeriodontics 5% 5% PedodonticsPedodontics 0%0% Dent. Anesthesia Dent. Anesthesia
<1%<1%
20062006 General Dentistry General Dentistry
20%20% Oral Max Surg 63%Oral Max Surg 63% Periodontics 6%Periodontics 6% Pedodontics 9%Pedodontics 9% Dent. Anesthesia 1%Dent. Anesthesia 1%
Type of Dental Practice
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Gen. Dentistry Oral Max. Surgery Periodontics Pediatric Dentistry DentalAnesthesiology
1996
2006
Years In PracticeYears In Practice
N 299N 299 Mean 20.7 (16.3 in 96)Mean 20.7 (16.3 in 96) MedianMedian 22.022.0 Std. Deviation 10.5Std. Deviation 10.5 Minimum 1.0Minimum 1.0 Maximum 50.0 Maximum 50.0
Age of PractitionersAge of Practitioners
n 295n 295 Mean 49.8Mean 49.8 MedianMedian 51.051.0 Std Deviation 9.7Std Deviation 9.7 Minimum 30.Minimum 30. Maximum 78.0Maximum 78.0
Practitioners With MDPractitioners With MD
Practitioners reporting additional Practitioners reporting additional qualification of M.D. degree 2006, n 15 qualification of M.D. degree 2006, n 15 (5%)(5%)
Practitioners reporting additional Practitioners reporting additional qualification of M.D. degree 1996, n 10 qualification of M.D. degree 1996, n 10 (4%)(4%)
ACLS TrainingACLS Training 19961996 85% Initial Course85% Initial Course 48% Recertification48% Recertification
20062006 90% Initial Course90% Initial Course 80% Recertification80% Recertification
ACLS Training
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1996 2006
Initial ACLS Training
ACLS Current
Peer Review/ Office Peer Review/ Office AccreditationAccreditation
ISOMS/AAOMS office anesthesia review ISOMS/AAOMS office anesthesia review program n 159 (53%)program n 159 (53%)
JCAHO or AAAHC office facility JCAHO or AAAHC office facility accreditation n 10 (4%)accreditation n 10 (4%)
None n 129 ( 43%)None n 129 ( 43%)
Office Anesthesia Team Office Anesthesia Team ConfigurationConfiguration
Operator, one assistant Operator, one assistant 11.5% (12%,96)11.5% (12%,96)
Operator, two assistantsOperator, two assistants 66.5% (82%, 96)66.5% (82%, 96)
Operator, R.N or CRNA., assistantOperator, R.N or CRNA., assistant 13% ( 4%, 96)13% ( 4%, 96)
Operator, MD /DDS anesthesiologist, Operator, MD /DDS anesthesiologist, assistant 8.8% (2%, 96)assistant 8.8% (2%, 96)
Anesthesia Team ConfigurationAnesthesia Team Configuration
Office Anesthesia Team Configuration
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Operator with twoassistants
Operator, oneassistant
Operator, RN/CRNA, assistant
Operator, DDS/MDanesthesiologist,
assistant
1996
2006
Practitioners Indicating Utilization of CRNA, Practitioners Indicating Utilization of CRNA, MD or DDS AnesthesiologistMD or DDS Anesthesiologist
CRNA CRNA n 29 (10%) n 29 (10%) MD anesthesiologistMD anesthesiologist n 28 (9%) n 28 (9%) DDS anesthesiologistDDS anesthesiologist n 42 (15%) n 42 (15%)
Elective Intubations in OfficeElective Intubations in Office
19961996 Do not intubate Do not intubate
96%96% 2% intubate < 25%2% intubate < 25% 1% intubate >51%< 1% intubate >51%<
75%75%
20062006 Do not intubate Do not intubate
94%94% 3% intubate <25%3% intubate <25% 2% intubate 2% intubate
<25<75%<25<75% 2% intubate <75%2% intubate <75%
Intubation in OfficeIntubation in Office
Percentage of Practitioners Intubating in Office
0%
20%
40%
60%
80%
100%
120%
Do not intubate Intubate up to 25% Intubate more than25%
1996
2006
Usage of Intravenous Agents, Practitioners' Preference
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Versed
Fentan
yl
Valium
Brevit
al
Propof
ol
Ketam
ine
Demer
ol
Nubain
Pentot
hal
Talwin
2006
1996
Versed, Fentanyl, PropofolVersed, Fentanyl, PropofolPractitioners’ Preference 2006Practitioners’ Preference 2006
Practitioners’ PreferencePractitioners’ PreferenceSevofluraneSevoflurane
Usage of Inhalation Agents, Practitioners' Preference
0%
20%
40%
60%
80%
100%
120%
Nitrous Oxide Halothane Ethrane Sevoflurane Other
2006
1996
Usage of Oral Sedation, Practitioners' Drug Preference
0%
10%
20%
30%
40%
50%
60%
70%
ChloralHydrate
Versed Halcion Vistaril Valium Other
2006Agents
Reported Number of Patients Treated Reported Number of Patients Treated With I.V. Sedation/General AnesthesiaWith I.V. Sedation/General Anesthesia
For the year Jan 1, 05 thru Dec. 31, 05For the year Jan 1, 05 thru Dec. 31, 05 109,121 Total for all Dentists109,121 Total for all Dentists 100,269 ( 92%)by Oral Maxillofacial 100,269 ( 92%)by Oral Maxillofacial
SurgeonsSurgeons
Reported Number of Patients Treated with Reported Number of Patients Treated with Oral Sedation Oral Sedation
For the year Jan. 1, 2005 thru Dec. 31, For the year Jan. 1, 2005 thru Dec. 31, 20052005
By all dentists n 6,819By all dentists n 6,819 By oral maxillofacial surgeons n 2,959 By oral maxillofacial surgeons n 2,959
(43%) (43%)
Morbidity/ MortalityMorbidity/ Mortality10 year period Jan.1, 1996 thru December 10 year period Jan.1, 1996 thru December
31, 200631, 2006
Death associated with treatment n 2Death associated with treatment n 2 (Approximately one death/500,000)(Approximately one death/500,000) Patients transferred to hospital with long Patients transferred to hospital with long
term morbidityterm morbidity n 2n 2 Patient transferred to hospital with no long Patient transferred to hospital with no long
term morbidity n 30term morbidity n 30
Controversial Practice TrendsControversial Practice Trends
Capnograpy usage Capnograpy usage 9.0%9.0%
Automated Electronic Automated Electronic Defibrillator 63%Defibrillator 63%
Dantrolene stocked as Dantrolene stocked as emergency drug emergency drug 21.6%21.6%
Summary and ConclusionsSummary and ConclusionsProviders and StaffingProviders and Staffing
The proportion of non-oral surgeon dentists The proportion of non-oral surgeon dentists providing sedation services has increased.providing sedation services has increased.
Based upon number of cases, oral maxillofacial Based upon number of cases, oral maxillofacial surgeons continue to provide vast majority of surgeons continue to provide vast majority of sedation and anesthesia services in the dental sedation and anesthesia services in the dental settingsetting
Utilization of CRNAs, DDS and MD Utilization of CRNAs, DDS and MD anesthesiologists, although relatively low is anesthesiologists, although relatively low is increasing.increasing.
Summary and Conclusions Summary and Conclusions Training and AirwayTraining and Airway
90% of providers are ACLS trained90% of providers are ACLS trained 80% of providers report ACLS training is 80% of providers report ACLS training is
current (within 2 years)current (within 2 years) The number of patients intubated in the The number of patients intubated in the
dental office remains very lowdental office remains very low Use of capnography monitoring remains Use of capnography monitoring remains
lowlow
Summary and ConclusionsSummary and ConclusionsRegulation and Peer reviewRegulation and Peer review
The number of dentists providing sedation in an The number of dentists providing sedation in an office accredited by the JCAHO or AAAHC is 4%office accredited by the JCAHO or AAAHC is 4%
84 % of Oral Surgeons have participated with 84 % of Oral Surgeons have participated with the AAOMS anesthesia evaluation program.the AAOMS anesthesia evaluation program.
43% of providers do not participate in any peer 43% of providers do not participate in any peer review or accreditation programreview or accreditation program
Significant number of providers may not be Significant number of providers may not be staffing consistent with Illinois Dental Practice staffing consistent with Illinois Dental Practice Act rules and regulationsAct rules and regulations
Summary and ConclusionsSummary and ConclusionsMedicationsMedications
Versed and Fentanyl are now the favored Versed and Fentanyl are now the favored IV sedative agents.IV sedative agents.
Propofol has replaced Brevital as the Propofol has replaced Brevital as the favored short acting anesthesia inducing favored short acting anesthesia inducing agentagent
Versed is the favored oral sedative agentVersed is the favored oral sedative agent For inhalation agents, Sevoflurane is the For inhalation agents, Sevoflurane is the
favored agent.favored agent.
Summary and ConclusionsSummary and ConclusionsMorbidity and MortalityMorbidity and Mortality
Two mortalities in 10 years were reportedTwo mortalities in 10 years were reported (In excess of one million patients treated)(In excess of one million patients treated) Two long term morbidities were reportedTwo long term morbidities were reported Thirty events required transfer to ER for Thirty events required transfer to ER for
managementmanagement
Comparison of Mortality RatesComparison of Mortality Rates
Illinois Survey*Illinois Survey* 10 years, 2 deaths 10 years, 2 deaths
over one million over one million patients.patients.
1:500,0001:500,000
OMSNIC Claims*OMSNIC Claims* 1:900,0001:900,000
McCarthy*McCarthy* 1:400,000 U.S., 1:400,000 U.S.,
CaliforniaCalifornia 1:300,000 U.K. Dental 1:300,000 U.K. Dental
OfficesOffices 1:40,000 T and A’s 1:40,000 T and A’s
U.S.U.S. !:15,000 Teaching !:15,000 Teaching
Hospital U.S.Hospital U.S.
Summary of Emergency Eevents
0 1 2 3 4 5 6 7
Prolonged Recovery
Chest Pain
Arrhythmia
Airway
Aspiration
Blood Pressure
Seizures
MI
Drug Abuse
Allergic Reaction
ER and dischargedPatient developed atypical tachycardiaArrhythmia
ER discharged without complications
Unstable blood pressure, hpotensive and hypertensive.
Bood Pressure
ER, discharged without complications
48 y/o had vasovagal reaction, 15 minutes after completion of procedure
Prolonged Recovery
ER for managementSustained seizure activity, did not respond to anti-convulsives. Previous history of epilepsy and had therapeutic levels of anti-seizure meds.
Seizures
ER, monitored and discharged
Slow recovery from I.V. sedationProlonged Recovery
ER, tooth retrieved with endoscopy
Aspiration of tooth crown under sedationAspiration Object
ER , discharged without complications.
45y/o developed post op chest pain Chest Pain
ER, discharged, no cardiac dysfunction was uncovered.
Patient had multiple dental extractions under general anesthesia. Slow recovery. Pulse dropped from 80 to 12 to 7. Treated with atropine.
Prolonged Recovery
ER, hospitalized for three days, patient developed mild stroke
62y/o undisclosed labile hypertension, non-compliant with medications. Under IV sedation developed unstable hypertension
Blood Pressure
ER transfer, pacemaker inserted one month later
General anesthesia for multiple dental extractions. Patient complained of chest pain and feeling faint. EkG revealed atrial fibrillation
Arrhythmia
ER transfer. MI diagnosis, died five days later.
Patient had full mouth extractions under general anesthesia. Patient stopped breathing 50 minutes into procedure. Patient intubated
Myocardial Infarction
ER transfer, died
50 y/o suffered MI on way to post anesthesia recovery following multiple dental extractions under general anesthesia. Never regained consciousness, patient had a non-disclosed history of MI at age 48 with sever cardiac muscle damage.
Myocardial Infarction
OUTCOMESCENARIOEVENT
Emergency Event Summary
ER, antibiotics45 y/o aspiration of vomitus post opAspiration Vomitus
ER, hospital to manage airway edema
Laryngospasm, intubated in officeAirway Management
ER, monitored and discharged
Asthma during anesthesiaAirway Management
ER, monitored and discharged
Seizures under IV sedationSeizures
ER, monitored and discharged
Undisclosed cocaine us, dropped BPDrug Abuse
ER, monitored and discharged
Ventricular arrhythmiaArrhythmia
ER, monitored and discharged
Arrived and discharged with new onset atrial fibrillation
Arrhythmia
ER, diagnosed as pinched intercostal nerve
26 y/o chest pain following IV sedation Chest Pain
ER, monitored and discharged
Apnea, airway loss, unable to ventilate, intubated in office
Airway Management
ER, gauze retrieved4x4 gauze loged in airway under IV sedationAspiration Object
ER, monitored and discharged
Allergic reaction to BrevitalAllegric Reaction
ER, hospital two days40 y/o diabetic vomited under general anesthesia, aspirated.
Aspiration Vomitus
ER, thought to be related to h/o psychiatric problems
Unresponsive post-op, normal breathing, stable vital signs
Prolonged Recovery
ER, monitored and discharged
Hypeertensive episodeBlood Pressure
ER, hospital, mangement of bronchospasm
19 y/o undisclosed drug abuse, laryngospasm, intubated, excessive secretions
Airway Management
ER, monitored and discharged, non-cardiac
30 y/o post-op chest painChest Pain
ER, monitored and discharged
Delirium, hypertension post-op, no intraoperative hypertension, resolved with narcan
Prolonged Recovery
ER, monitored and discharged, non-cardiac
Post-op chest painChest Pain
ER, monitored and discharged, non-cardiac
Post-op chest painChest Pain
ER, monitored and discharged, non-cardiac
Post-op chest painChest Pain
ER, monitored and discharged
Slow recovery from versedProlonged Recovery
ER, monitored and discharged
18 y/o developed tachycardia under sedationArrhythmia
Illinois Dental Practice Act ChartIllinois Dental Practice Act Chart