Virginia Board of Dentistry,

This is intended to be a response to the currently proposed regulation requiring the use of an EKG machine when a dentist is performing oral titration.

Current ADA and state standards already ensure patient safety

The current training requirements as adopted by the ADA for dental sedation are sufficient. As you are aware the dentist and staff are required to be certified at CPR, ACLS, AED use and the proper sedation medication titration techniques. Patients are constantly monitored for heart rate, blood pressure and blood oxygen saturation. I and 4 dental associates have been practicing sedation dentistry in Midlothian Virginia for approximately 9 years and have served well over 200 patients without incident. In addition we are consistently attending continuing education courses such as: 2003 Dental Organization for Conscious Sedation, LLC (15 hours), 2006 Dental Organization for Conscious Oral Sedation, LLC (22.5 hours) and 2009 Sedation Solutions for the Challenging Patient (15 hours).  Most recently, the state imposed a permit requirement to continue performing this procedure and I and the other dentists in my practice complied with those requirement by taking another 26 hour course that included 3 live patient clinics. Existing regulations are more than adequate to ensure patient safety and the additional requirement of EKG monitoring is simply not needed for patient safety.

Increased costs would price vulnerable patients with significant dental care needs out of moderate sedation procedures

The cost of the EKG machine and the disposable items necessary for each patient will add to the cost of treatment. Many patients requiring sedation dentistry are in their current predicament because they delayed care for many years due to the already high costs. This new board requirement will actually make it more difficult for patients to afford their dental care thus contributing to the declining dental health of an already needy population. The other most common reason patients delay dental care is fear. Requiring the dentist to use this invasive monitoring device will only contribute to this already overwhelming fear, thus causing patients to further delay treatment. Requiring EKG monitoring for all titration sedation patients would unintentionally cause more patients not to receive the dental care they so desperately need.

EKG monitoring requires patients to do a certain amount of disrobing, which patients do not expect at a dental office and for which dental offices are not well equipped.

Many dental offices are set up in an open concept where there is not enough privacy for patients to comfortably have the EKG leads attached. Whereas patients are accustomed to disrobing in physician’s offices, this is certainly not the case in dental offices and will undoubtedly cause awkward situations. Many sedation patients need to get up 2 or 3 times during the 4-5 hour procedure to urinate. Un-attaching and reattaching the EKG leads is simply not practical, in addition to being costly and time consuming.

EKG was not required by the emergency regulations

I don’t believe this requirement was part of the recent emergency regulations on moderate sedation procedures.  Furthermore, while EKG is standard of care for IV sedation (whether the regulations require it or not), no state currently requires EKG for moderate oral sedation, UNLESS the state doesn't split moderate sedation by the route of administration. I.e. if an IV permit is required for any moderate sedation (e.g. Florida, Pennsylvania). In addition, ADA guidelines require it for deep/general anesthesia, but only recommend it for moderate (whether oral or IV): "Continuous ECG monitoring of patients with significant cardiovascular disease should be considered." In cases such as these I would never even consider oral conscious sedation as an option due to the extremely high risk involved.

Patient care and safety is my first priority and I would not perform any procedure for which I did not feel adequately trained and equipped or any procedure which I thought unsafe.  The practice of moderate sedation dentistry is extremely important because it allows most individuals who have been putting off dental care out of fear, to finally get proper treatment.  Certain major surgical procedures obviously require a deeper sedation and are rightly performed by oral surgeons or other medical doctors, but moderate oral sedation does not pose anywhere near the risks inherent in the sort of deep sedation required for those procedures.  It would be helpful to know on what medical basis the Board feels the need to necessitate this proposed regulation

Sincerely,

M. Scott Gore, DDS     

Jared A. Hoover, DDS

Amanda A. Hoover, DDS                              

r this text and enter your comments here. You are limited to approximately 3000 words.