Joseph A. Rodriguez, MSN, CRNA

AzAS Managing Partner, 2016-17 President, Arizona Association of Nurse Anesthetists

Joseph A Rodriguez, MSN, CRNA

This article originally appeared in INSCRIPTIONS, the official publication of the Arizona Dental Association.  

Implications for Dentists

Dental anxiety is an issue for any practicing dentist, with implications for patients and dentists alike.  Anyone familiar with the dentist office knows that dental anxiety is real, with a measurable impact on office efficiency and patient experience.  Dental anxiety has well-documented physiological and psychological effect, that can be deleterious to the lives of our patients, even in the long-term.  Literature demonstrates that the majority of dental patients prefer sedation for endodontics, periodontics, and extraction procedures, and those with anxiety even prefer sedation for simple cleanings. 

While the phenomenon of dental anxiety is present in a wide variety of populations, less frequently discussed is the emotional stress placed on dentists themselves, who over time may feel burdened by the anxiety that dental care causes patients.  I’ve spoken with many Dentists who feel limited in their options for treatment without increasing their liability, especially for those who need deeper, titrated levels of sedation and anesthesia. 

Fortunately, high-quality, safe, and affordable dental sedation is available to Arizona dentists through a number of different anesthesia providers.   

“Will the cost of IV sedation affect the profitability of my office?”

Partnering with an anesthesia group who offers you an essentially cost-neutral way to attract more patients into your office.  Offering patients flexible, affordable anesthesia care is a marketable asset.  Not only is offering IV sedation “in vogue” with trends, having sedation readily available is something that can be included in advertising materials and can be a draw even for patients who may be considering your office for non-sedation procedures and regular dental care. 

For dentists performing specialized procedures, being partnered with an anesthesia group is another factor which drives referrals into your office, as many patients prefer to have some form of sedation available (even if not utilized for the current procedure) as an option for their treatments. 

Sedation utilizes minimal resources in your office while offering an attractive treatment option for patients.  Typically, most anesthesia providers supply all of their own equipment.  The dentists I partner with typically add a small fee (ie $50) to cover staff resources and drug supplies.  Between the minimal cost and potential for increased volume, coupled with the safety and liability protection of another licensed, insured provider administering anesthesia, having a relationship with a responsive anesthesia group can drive profitability for dentist offices. 

“Partnering with an anesthesia group who offers you an essentially cost-neutral way to attract more patients into your office. Offering patients flexible, affordable anesthesia care is a marketable asset. Not only is offering IV sedation “in vogue” with trends, having sedation readily available is something that can be included in advertising materials and can be a draw even for patients who may be considering your office for non-sedation procedures and regular dental care. ”

“What is the right type of provider for my office?”

For over a century, anesthesia has been the domain of dentists, certified registered nurse anesthetists, and physicians.  Each of these professions currently provide all types of sedation in dental offices, from IV sedation to general endotracheal anesthesia.  While each has a different background, they all have similar training in anesthesia and related sciences, and all three professions have a comparably impressive level of safety.  With this overlap, it’s important to get to know an individual providers’ background.  Be sure to ascertain an individuals comfort and experience in resuscitative measures, co-morbidities, and difficult airway management.  An airway emergency is not the time to be attempting techniques that have never been used – it’s a time to use skills honed by years of practice.   The difference between an “event” in your office and a brief change in physiological status is often based on the experience of the provider in your office.    As the old saying goes, “All providers are licensed, not all providers are the same.”

“Is IV sedation and general anesthesia safe for my patients? 

Anesthesia requires constant attention for safe administration, because anesthesia is a “spectrum” that is unique for each patient.  Even using straight-forward intravenous medications such as midazolam and fentanyl, can easily put a patient into deep sedation – or even general anesthesia –  where airway reflexes are obtunded or lost.   Even with advanced monitoring and extensive education – administering anesthesia requires constant vigilance. 

With that said, anesthesia is 50 times safer than it was in the 1950s, and dentists can partner with anesthesia providers to provide sedation with a high degree of confidence in regards to safety for their patients.  Anesthesia related morbidity is far more frequent than mortality – with human error (poor teamwork, lack of communication, inexperienced providers) being the most common culprit – so it’s important to choose an anesthesia group that emphasizes teamwork, safety and communication. 

“What are the Arizona regulations regarding sedation in dental offices?”

There are 4 permits pertaining to sedation and anesthesia.  R4-11-1301 allows dentists to administer general anesthesia and deep sedation.  R4-11-1302 pertains to parenteral sedation.  R4-11-1303 pertains to oral sedation.  R4-11-1304 allows dentists to work with Certified Registered Nurse Anesthetists or Physician Anesthesiologists without having any of the other permits.  If the dentist has no permit, dentists must work with a Dentist Anesthesiologist, who themselves carry the proper permits.  Further information on these permits is available from the dental board of examiners. 

“How will sedation cases affect the ‘flow’ of my office?”

IV sedation and general anesthesia, as intimidating as they may seem, does not have to disturb the normal flow of the dental office, however some modifications must be made from non-sedation cases.  Dentists should allow additional time for pre-operative and post-operative recovery, especially in the instance of using one operatory for the surgery and recovery.  Your anesthesia provider must know the details of the procedure to efficiently and skillfully administer the anesthetic, so communication is paramount for safety.  Putting the “sedation lineup” in a room that is further away from patients coming in for routine care keeps the case out of sight for your other patients.  I also suggest asking your anesthesia provider to keep the volume of their monitors and alarms to a minimum.  Many patients report a feeling of anxiety when they hear alarms, as media portrayals of anesthesia give them the idea a sedated patient is in critical condition.  Although monitors and alarms need to be audible, especially the high (indicating oxygen saturation within normal limits) or low (oxygen saturation below acceptable levels, needing immediate intervention) tones of the pulse oximeter – none of these tones need to be so loud that they disturb the entire office. 

Summary

There are significant benefits for dentists developing a relationship with an anesthesia group.  Offering your patients IV sedation is a powerful marketing tool – and having a relationship in place means you can offer this service in an efficient way with minimal interruption to other service lines.  Sedated patients are nearly always satisfied patients who in-turn share with their family and friends what type of experience they had in your office.  Finally, a separate professional administering the anesthetic provides not only a the dentist protection from liability for anesthesia outcomes, but another team member who is focused on the safety and positive experience of your patient. 

Joseph Rodriguez is a managing partner for Arizona Anesthesia Solutions, an anesthesia group solely focused on dental and office anesthesia, and President-Elect of the Arizona Association of Nurse Anesthetists.  Find out more at AzAnesthesiaSolutions.com, or email him with questions at joseph@azanesthesiasolutions.com.