This will be very simple.  I have a letter from Dr. James Toms, DDS, MS, FACD.  Dr. Toms serves as both the American Dental Association (ADA) and American Society of Dentists Anesthesiologists (ASDA) representative to the Amerian Society of Anesthesiologists (ASA) Task Force on the 2018 PRACTICE GUIDELINES FOR MODERATE PROCEDURAL SEDATION AND ANALGESIA.  The letter clearly states that the current two-person delivery of IV Moderate Conscious Sedation is NOT, I REPEAT, NOT being changed in the ADA nor ASA guidelines.  This letter is of public record and I have copied it here. PLEASE READ and appreciate the contents:               

April 25, 2018

As both the American Dental Association (ADA) and American Society of Dentists Anesthesiologists (ASDA) representative to the American Society of Anesthesiologists (ASA) Task Force on the 2018 Practice Guidelines for Moderate Procedural Sedation and Analgesia, I want to make exceedingly clear the intent and recommendations on specific language in a section of the Guidelines that is entitled “Availability of an Individual Responsible for Patient Monitoring” (pg. 443, second column).

In regards to the first bullet-point stipulated in the recommendation, where in the Guidelines it states,

• The individual responsible for monitoring the patient should be trained in the recognition of apnea and airway obstruction and be authorized to seek additional help.

We agree that this responsibility is fulfilled by any dental assistant with basic life support (BLS) training. Recognition of unconsciousness, apnea, airway obstruction, cardiac arrest, and the summoning of emergency medical services has been a long held competency in all current BLS certificate courses. A dental assistant, whether a registered dental assistant or otherwise, by virtue of BLS training and certification, can adequately perform these tasks.

Secondly, in regards to the subsequent bullet-point in the Guidelines which state,

• The designated individual should not be a member of the procedural team but may assist with minor, interruptible tasks once the patient’s level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patient’s level of sedation is maintained.

The intent of this statement is to assure that at least one individual can assist the operating dentist in monitoring the moderately sedated patient AND concurrently be involved in minor, interruptible tasks such as suctioning, light-curing, tissue or tongue retraction, etc. Note carefully that this statement contains a “should” statement that is emphasizing that this individual should not be involved with the conduct of the procedure or surgery, but instead  act in a supplemental role that assists in patient monitoring and minor surgical/procedural tasks. Akin to Commission on Dental Accreditation (CODA) standards, a “should” statement is NOT a requirement, but rather presents an intent statement that implies “highly desirable, but not mandatory” as per CODA definition of terms.

We discussed this issue at great length at the ASA Task Force meetings to ensure that not only the dental profession can continue to practice to current ADA Moderate Sedation Guidelines which only require the presence of one other individual beside the operating dentist to assist in monitoring, but also that various other physician disciplines may operate in settings where the physician providing the moderate sedation can rely on the assistance of only one nurse, respiratory therapist, physician’s assistant, etc.

When I presented the draft document to the ADA for scrutiny, it was carefully examined for this exact issue and found to be congruent with existing 2017 ADA Guidelines, which explicitly state:

• At least one additional person trained in Basic Life Support for Healthcare Providers must be present in addition to the dentist.

With this understanding, the ADA gave expressed sponsorship and published endorsement of the 2018 ASA Guidelines as reinforcing and supporting past and present dental moderate sedation guidelines. The 2018 ASA Guidelines also concur with the 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 wherein the authors (one of which is also an author of the ASA Guidelines) state the following:

• Support personnel. The use of moderate sedation shall include
the provision of a person, in addition to the practitioner, whose
responsibility is to monitor appropriate physiologic parameters
and to assist in any supportive or resuscitation measures, if
required. This individual may also be responsible for assisting
with interruptible patient-related tasks of short duration, such
as holding an instrument or troubleshooting equipment. (AAP/AAPD p. 223)

To clarify even more and remove all ambiguity, the ASA Guideline document includes a “Summary of Recommendations” found in Appendix 1 (pg. 450, column two). Within the section found on page 450 and continuing on to page 451, within the subheading of “Availability of an Individual Responsible for Patient Monitoring,” language is clear in requiring only “a designated individual other than the practitioner performing the procedure is present to monitor the patient throughout the procedure.” Further, this individual is only responsible for monitoring the patient for signs of apnea and airway obstruction AND “may assist with minor, interruptible tasks.” The summary removes the “should” statement and for brevity and clarity, and stipulates only one additional person other than the practitioner needs to be present to assist in monitoring.

I wanted to assure you and others that the traditional dental model of only requiring one dental assistant while the operating dentist performs the procedure and administers moderate sedation is strongly supported by these ASA Guidelines. As a dental educator that provides a long-standing parenteral moderate sedation certification course for general practitioners and dental specialists from all over the nation, I made great efforts to promote the safety and continued use of this practice model to the ASA Task Force.

There is no effort underway or planned to require a third individual to be a sole monitor in moderate sedation practice in dentistry or medicine.

Please feel free to contact me at any time regarding this issue or any other issues involving patient safety, sedation, or anesthesia in general dental or specialty dental practice.

Respectfully,

Jimmy

James Tom DDS, MS, FACD
Dentist Anesthesiologist
Diplomate, American Dental Board of Anesthesiology
Diplomate, National Dental Board of Anesthesiology
President, American Society of Dentist Anesthesiologists
Associate Clinical Professor
Herman Ostrow School of Dentistry
University of Southern California
Division of Endodontics, General Practice Residency, and Orthodontics 925 W. 34th Street RM 4302
Los Angeles CA 90089
(213) 740-1081 jtom@usc.edu

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