I am a dentist in Virginia and am writing in regards to a proposed regulatory change by the BOD. This change suggests moving from a 2-person monitoring team to a 3-person monitoring team for the management of IV moderate conscious sedation.

For background, the American Dental Association established the National Commission on Recognition of Dental Specialties in 2017. Recently, this specialty certifying body recognized the American Society of Dentist Anesthesiologist as the 10th specialty in dentistry. A move of historic and future significance for this group of specialized practitioners.

The American Dental Association and the American Society of Dentist Anesthesiologist collaborated to develop guidelines for management of sedation in the dental office. These guidelines were significantly influenced by the medical arena via the American Society of Anesthesiologist. In those guidelines, which can be found on both the ADA and ASDA websites, it clearly states that a 2-person team is the standard of care.

Hundreds of safe IV moderate sedation procedures are performed across the Commonwealth of Virginia every day. It is a vitally important aspect to the delivery of dental care for anxious and apprehensive patients. I am a practicing general dentist that has provided IV moderate sedation for my patients that need it for almost 30 years with the help of a single well trained assistant. While I applaud the addition of certifications and continuing education in the past, the addition of a third person to monitor is unnecessary.  The record of safety speaks for itself. There is no literature to suggest that adding a person to the treatment team will result in elimination of moderate sedation issues as it is already an immensely safe procedure with greater than a 99% successful safety record.

With regards to our current environment involving Covid-19, the unnecessary addition of a third person in the operatory subjects patients and other employees to increased potential exposure.

Furthermore, the economic considerations cannot be overlooked. Dental offices run efficiently and effectively relative to the number of employees required to deliver care and manage administrative tasks. Taking an employee away from their assigned task to simply stare at a monitor is unproductive and quite frankly, unnecessary. The requirement to add an employee for this task simply increases the overhead expenses to run the office. This expense will be passed on to the patient and thus increasing the costs associated with delivery dental care. These types of decisions should have an evidence based approach to support implementation. There is no evidence to support this. Also, I am unaware of any other state in the U.S. that has this requirement.

I strongly oppose the proposed modification to make mandatory a third member of the dental team during IV moderate conscious sedation.

Erik Roper, DDS, MAGD

I disagree with the proposal to add a 3rd person to monitor during IV moderate conscious sedation. As I mentioned during the phone meeting today, this regulation has no documentation to support it and it will make it more difficult for those patients who need or want sedation to receive it. Also this regulation will cost more in overhead and the patient will incur this additional expense. 

I do work with a nurse anesthetist for many of my moderate conscious sedation cases when I deem it necessary from a medical and/or dental standpoint but do not agree with this being an across the board regulation. 

Thank you for allowing us to comment on this important proposal to how we practice dentistry.

Stephanie Voth

I am a recent graduate board eligible periodontist. I completed my dental school at Virginia Commonwealth University and my periodontal residency at University of Alabama at Birmingham. 

I recently joined a private practice in Fredericksburg, VA after a year of private practice in Burlington, VT. In Virginia, all of our sedation cases are performed with monitors which have alarm which sound if any of the patient’s vitals are not within normal limits, we can address situations such as 02 saturation and blood pressure. Additionally, the entire staff is trained in basic life support and as such, and am ACLS certified and we can manage any emergencies which arise using the proper protocol. 

A large number of IV moderate sedation procedures are performed across the Commonwealth of Virginia every day. Moderate sedation is a necessary aspect to the delivery of dental care for anxious and apprehensive patients. The record of safety speaks for itself. Moderate sedation issues are usually minimal since it is already an immensely safe procedure with greater than a 99% successful safety record.  In my professional opinion, the addition of a third person in the room only to monitor the patient is redundant. I do not perceive any added benefits to the patient safety or comfort. There is no empirical evidence that supports the addition of a third person to monitor moderate sedation cases is exponentially better or result in the elimination of any complications. These types of decisions should have an evidence-based approach to support implementation. There is no evidence to support this. Also, I am unaware of any other state in the U.S. that has this requirement. 

With regards to our current environment involving Covid-19, As medical professionals, we are working hard to make safety and comfort a top priority for our patients during these uncertain times. The extraneous addition of a third person in the operatory subjects patients and other employees to increased potential exposure.  We should be working towards safety and a decrease in exposure instead of the opposite. 

Furthermore, the economic impact the requirement would have on a dental office cannot be overlooked. Taking an employee away from their assigned task to simply stare at a monitor is neither productive or necessary. The requirement to add an employee for this unnecessary task will increases the overhead expenses of any dental practice. This expense will be passed on to the patient and as such increase the overall cost associated with dental care. Increased cost to patients could be detrimental in these uncertain times where many Virginians are struggling to stay financially afloat due to the pandemic. Oral healthcare is essential and directly linked to the overall health of an individual. We should be striving to make dental care and medical more accessible instead of less so.  My fear that if this frivolous regulation is required, price for care will increase making dental care less accessible to those who need it most. 

I very much appreciate the opportunity to share this information and my concerns.