In an ADA News article published February 1, 2007, Dr. Guy S. Shampaine, chairman of the Committee on Anesthesiology (Committee H) and a member of its ADA overseer, the Council on Dental Education and Licensure (CDEL), attempted to “spin” the truth about the ADA’s newly proposed anesthesia guidelines.

Dr. Shampaine and his supporters would have ADA members believe that the radical changes are really quite mild and actually would benefit those already practicing oral conscious sedation.  What a canard!

The truth is nearly 180 degrees the opposite of what Dr. Shampaine portrays.  TEAM 1500 has prepared a detailed rebuttal to the ADA News article and Dr. Shampaine’s remarks.  We encourage those interested in this subject to believe only what is written in the actual ADA’s proposals, not Dr. Shampaine’s revisionist spin.  If he and Committee H didn’t mean what they wrote, then why did they write it?

The original ADA article may be found by clicking here.  (An ADA user id and password may be required to view the story.)

[Paragraphs are in order of appearance, not in order of importance.  Some text that is not in dispute or makes redundant points has been left out.]

A.     The Council on Dental Licensure issued its call for comment on proposed changes to the ADA’s anesthesia guidelines documents last month [January 2007], and since then staff at ADA Headquarters have fielded a number of calls both supportive and critical.

The ADA would have you believe that there was a “balance” between supportive and critical calls.  Team 1500 has yet to hear from its first dentist who currently uses oral conscious sedation and supports the ADA’s proposed changes.  The only supporters calling the ADA are the small cabal of Dr. Shampaine’s pals who are the instigators of the changes in the first place.

B.      The revisions are the result of a comprehensive review of the existing anesthesia guidelines by the CDEL’s Committee on Anesthesiology, which includes a cadre of anesthesia experts from other-well respected dental and medical organizations.

The so-called “cadre of anesthesia experts” numbers exactly eight, seven of whom are not general dentists and have not received continuing education training in oral conscious sedation.

The key words of deception in this paragraph are “anesthesia experts.”  Being licensed to administer deep sedation or general sedation does not make one an expert on oral conscious sedation.  This is a case of people who never use a prescribed methodology trying to dictate what is best to the people who do use it on a daily basis.

Remember, too, that the ADA House of Delegates, less than two years ago, applauded the “remarkable record of safety” enjoyed by dentists who use anxiolytic sedative and anesthetic techniques.

C.     “When submitting comments, whether you favor the proposed changes or not, we ask that you note the specific text you are referring to,” said Dr. Shampaine.  “Some of the comments that we are seeing are generalizations about the documents which do not specifically reference language from the documents.  Some seem to be the result of a misunderstanding of the documents’ content.”

How convenient.  Dr. Shampaine wants to tell dentists who understand the full-force impact of the document – i.e. disenfranchising millions of fearful and anxious patients – to keep their thoughts to themselves.  He only wants dentists to see and comment on the ‘small picture’ on a line-by-line basis.

And there is no misunderstanding of the documents’ content.  The individual changes Dr. Shampaine supports, taken together, constitute an outright declaration of war against general dentists and their patients.  The message actually comes through loud and clear.

D.     “Unfortunately, some people have been very upset because they have been told that the proposed guidelines would prevent the administration of these services by general dentists,” he continued.  “The ADA unequivocally supports the use of oral sedation in dental practice and the introduction of each document includes language stating that the use of sedation and anesthesia by appropriately trained dentists is an integral part of dental practice.”

To Dr. Shampaine, “an appropriately trained dentist” is one who is an oral surgeon, a dental anesthesiologist or any dentist with an IV permit (as long as they only provide enteral sedation.) 

The thousands of general dentists who have completed ADA and state-compliant continuing education courses in oral conscious sedation and have used OCS safely, effectively and without incident in their practices for many years are not, in Dr. Shampaine’s view, “appropriately trained” and hence won’t be able to continue to administer OCS if they wish to comply with the newly proposed ADA guidelines.

E.     “What’s more, said Dr. Shampaine, the revisions actually allow dentists to do more than the existing guidelines.  The committee also included a ‘grandfather clause’ so that it would be clear that the ADA is not proposing new basic educational requirements for dentists who are currently appropriately and safely administering these services.

This is the first of many instances where Dr. Shampaine is telling ADA members, “believe what I’m telling you, not what we actually wrote in the proposed guidelines.”

True, Dr. Shampaine, the word “grandfather” is included the proposed guidelines, but not in the context you would have us believe.  The exact wording is:

“This should not exclude dentists who might be grandfathered by individual state dental boards prior to the adoption of this document.”

You fail to mention that dentists also “might not” be grandfathered by individual state dental boards.  You fail to explain what happens if qualified dentists aren’t grandfathered “prior to the adoption of this document.”  You fail to note that some states don’t regulate their dentists and thus can’t grandfather them into compliance.  And you don’t even begin to address the logic of why the ADA would be willing to create two classes of general dentists – ‘grandfathers’ and those who aren’t ‘grandfathers.’  Is that your way of saying to today’s dentists, “we won’t harm you, but we will harm all the dentists who come after you?”

F.     The call-for-comment period is essential to developing guideline documents that constitute the framework of the profession’s position on the appropriate training and conditions of use of outpatient sedation and general anesthesia in dentistry.

The ADA wishes to formulate “the profession’s position” on sedation in dentistry, yet it is deliberately excluding the most significant group of dentists from the process – general dentists.  Both Committee H and CDEL may purport to represent the profession, but they are almost exclusively populated with specialists, oral surgeons, academics and dental anesthesiologists who are out of touch with mainstream dentistry. 

In 2006, the Dental Organization for Conscious Sedation, the leading continuing education trainer of oral sedation dentists, offered to let ADA trustees, members of Committee H and members of CDEL attend its three-day course for free so that they could judge the training and curriculum first hand.  The matter was brought to the ADA’s Board of Trustees in February 2006.  And the ADA responded, “No.”

(The exact wording of the defeated resolution, according to ADA documents, was:

Resolved, that the ADA accept the invitation to attend an upcoming Dental Organization for Conscious Sedation “Oral Sedation Dentistry” three-day seminar and that two Board members (one oral surgeon and one general practitioner) be appointed to attend and report back to the Board, and be it further

Resolved, that the chair and one member of the Council on Dental Education and Licensure’s Committee on Anesthesiology be encourage to accept their invitation to attend the same seminar.)

How can the ADA speak for a profession when it knows not of what it speaks? 

And how intellectually honest can Dr. Shampaine and his so-called “cadre of anesthesia experts” be in judging oral conscious sedation when they wouldn’t even personally witness the training they are condemning as inadequate?

G.    “However, keep in mind this is the first step in proposing changes,” said Dr. Shampaine.  “The ADA has not adopted any changes to the anesthesia documents yet.  This is how the process works:  the committee recommends changes, the communities of interest review and comment on the changes, the comments are reviewed by the committee and CDEL to propose further refinement, if necessary, then the House of Delegates decides whether to adopt the revisions.”

That is a long-winded way of saying, “we’ll give you a fair trial, and then we’ll hang you.”

The historic record of the ADA is crystal clear.  If CDEL approves the Committee H proposals, the new guidelines will pass muster with the House of Delegates (barring some unique, unprecedented effort to thwart those actions, such as the one being organized by TEAM 1500.)

At this point in the February 1, 2007 ADA News article, Dr. Shampaine provides both the questions and answers that the ADA feels its members need to consider.  We continue our point-by-point rebuttal.

Q:  What is included in the proposed revisions to the ADA’s anesthesia documents?

Dr. Shampaine:  The existing guidelines prohibit multiple dosing of oral agents when providing enteral sedation….

TEAM 1500:  There is no such prohibition in the existing guidelines.  This is flat out inaccurate.

Dr. Shampaine:  The requirement for moderate sedation training in situations where the patient is managed exclusively by the enteral or enteral-inhalation route has been reduced from 20 to 10 patient experiences per participant, but requires that they be hands-on under specified conditions rather than observational experiences.

TEAM 1500:  The devil, as we all know, is in the details.  In this case, the ADA makes it seem as if going from 20 observational experiences to 10 live patient experiences is a reduction in effort.  It is decidedly not!

Live patients, unlike video, don’t allow for “editing” out time delays and non-pertinent aspects of the procedures.  Moreover, the ADA is asking that these live patients be seen by a teacher-to-student ratio of as little as one-to-one or one-to-three.  While 100 doctors can receive appropriate training via observational education with one faculty member, it could take between 33 and 100 faculty members to train the same 100 doctors via live-patient education.  Obviously, the costs and logistics of such training are far, far more significant than used in the current, very effective, courses on oral conscious sedation.

Both dentists and their patients will pay dearly for the additional costs created by this proposal.  Are there even enough dental educators in the entire United States to train a fraction of the dentists who would need retraining?

Q.:   Will the proposed new guidelines eliminate the use of sedation and anesthesia in general dental practice?

Dr. Shampaine:  No.  The proposed guidelines make recommendations for the safe use of sedation and anesthesia and the appropriate levels of education for dentists to safely administer these modalities.

TEAM 1500:  Yes.  The new guidelines set the bar so high for general dentists to acquire the so-called “appropriate levels” of education that the vast majority of general dentists will effectively be prevented from administering these modalities.  The rules may not specifically exclude general dentists from Dr. Shampaine’s exclusive “club” of oral surgeons, dental anesthesiologists and specialists, but there is no mistaking the intended message:  “General dentists need not apply.”

 Q.:  What do the proposed guidelines say about multiple dosing or titration of oral medications for the purposes of sedation?

Dr. Shampaine:  The existing guidelines do not support multiple dosing or titration of oral medications. 

TEAM 1500:  Nor, as noted above, do they prohibit it.  Multiple dosing and titration are key aspects of safe, effective oral conscious sedation.  OCS, stripped of the ability to administer multiple doses or titration, is not really OCS.  It’s like saying you can get a license to drive a car, but you can’t put any oil in the engine or gas in the tank.  What is the point of such a license?

Dr. Shampaine:  The proposed guidelines allow for incremental dosing up to the maximum recommended therapeutic dose of a drug approved for unmonitored home use, and for titrating doses for deeper levels of sedation by appropriately trained dentists.

TEAM 1500:  So the ADA is granting dentists permission to use medications in their offices with monitoring equipment and extensive and costly extra training that patients could administer to themselves at home, unmonitored.  How innovative!

Why require all this new training on the part of dentists when the medications are safe enough for patients to take without any supervision on their own?

Moreover, as Dr. Shampaine should well know, there is no maximum recommended therapeutic dose for Triazolam, the most commonly used sedative in oral conscious sedation.  How can the ADA require dentists not to exceed a “limit” that does not even exist?

Finally, we again hear Dr. Shampaine talking about “appropriately trained dentists.”  That is, we repeat, code for “general dentists need not apply.”

Q.:  Will I need to have an IV permit to administer minimal or moderate sedation?

Dr. Shampaine:  The concept of an “IV permit” is not in the existing guidelines.  This notion is probably the most misunderstood area of the new educational guidelines document.  The old documents were organized by route of administration rather than therapeutic endpoints and therefore permits associated with parenteral sedation were sometimes referred to as “IV permits.”  However, the proposed guidelines do call for training programs in moderate sedation to include clinical experience in establishing IV access.  This is only for the purposes of training for emergencies and is not a recommendation for establishing an IV if the patient’s sedation is managed through the enteral route.  A permit is not needed to establish IV access.

TEAM 1500:  Basically, the ADA wants dentists to train as if they’ll be IV dentists, even though they won’t be.  In a true emergency, dentists who don’t use IV regularly – and oral conscious sedation dentists don’t – won’t suddenly feel confident administering an IV reversal agent, even after completing the ADA’s onerous training regime.  Realistically, these dentists are much more adroit with a submucosal needle and are best able to reverse a patient following this familiar documented and effective pathway.

Remember, only a fraction of one percent of oral conscious sedation ever require reversal and of the very few that have, dentists have not reported any difficulties in safely reversing their patients submucosally.

Q.:  Is it true that the proposed guidelines require the dentist to remain in the room with the sedated patient until that patient meets criteria for discharge for post-sedation and anesthesia care?

Dr. Shampaine:  Yes.  The requirement has remained unchanged from the current guidelines and is the standard of care for all health care personnel who provide sedation and anesthesia.

TEAM 1500:  Wrong.  Page six, paragraph three of the existing guidelines only requires the dentist to be present “during administration” of oral conscious sedation, not the entire time prior to discharge.  The new proposals, page seven, paragraph four, require “a qualified dentist…must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for recovery.”

To top this off, Dr. Shampaine’s new guidelines require this in-operatory monitoring during minimal sedation.  That means with 5 mg of Valium® given to a patient before the appointment a dentist can't leave the patient even for a minute!

Dr. Shampaine:  Provisions in state statutes or regulations that allow appropriately trained individuals (other than dentists) currently authorized to monitor patients under sedation would continue.

TEAM 1500:  Again, Dr. Shampaine is telling us, “Listen to what I say, not what we wrote.”  The written proposals say no such thing.