For all the contentiousness that has surrounded the ADA’s move to revamp its guidelines for oral conscious sedation, there is one point on which almost everyone agrees:  Patient safety is of paramount importance.

The conflict arises over the question of who is best equipped to decide what is best for patients and whether those determinations are colored by economic self interest.

On one side, we find general dentists and others who have years of experience offering oral conscious sedation in compliance with existing ADA guidelines and state regulations.  By the thousands, these OCS dentists report that existing training and protocols have been sufficient to ensure patient safety. 

Indeed, no one has yet to accurately point to a single instance of a death or serious injury that befell an adult OCS patient who was under the care of a dentist adhering to existing guidelines.  That is a remarkable record, given that more than one million patients have benefited from OCS treatments since 2000.

In opposition to the dentists who regularly use OCS in their practices stand oral surgeons, dental anesthesiologists and other specialists who rely primarily on methods of anesthesia other than oral conscious sedation.  Their point is that however strong the track record is for OCS to date, the risks remain too high. 

Those pushing for new, stricter guidelines, such as the oral-surgeon laden ADA Committee on Anesthesiology and the ADA’s Council on Dental Education and Licensure, would like to see the training requirements for dentists offering OCS raised dramatically.  Only then, they contend, will the patient population be truly safe.

Caught in the middle of this are the patients themselves, all of whom – if surveyed – would no doubt say that they want safe dentistry. 

So pretty much, it seems, everyone advocates safety:  General dentists, non-specialists, oral surgeons, dental anesthesiologists, specialists and patients.

What then is the issue and who gets to decide?

Once safety is no longer a debatable point, what remains is mostly economic self interest.  Once again, it is not surprising to see that just about everyone agrees here too.  They want, more or less, to do what’s in their own self interest.

If the general dentists and others who offer OCS are correct, and OCS is safe under existing guidelines, then what incentive is there for them to more than triple the training they’ve already received?  Will it bring them more business?  Decidedly not!  Will it allow them to charge more to their existing patients?  Unlikely.

As one dentist wrote us just this week referring to the ADA’s new proposals, “60 hours and ten [live] patients would take me out of the office for a month.”

Not much economic sense in that.

For the oral surgeons and others who are pushing to tighten the guidelines governing OCS, the economics look better.

These folks, after all, have already invested real dollars and time in advanced dental training.  Why should general dentists and others be able to skim off their patients after only a three-day, reasonably priced course in oral conscious sedation?

By raising the requirements on those who do or would practice OCS, the oral surgeons and their supporters are really trying to bring more parity to the economic playing field.

If general dentists want to offer sedation to patients who previously required the services of a more highly educated dental specialist, then let the general dentists and non-specialists at least invest more time and money in their training, too!  It’s not about safety, it’s about fairness.

Now the scenario unfolds in a manner more to the specialists’ liking.  General dentists and non-specialists who wish to offer their patients OCS will pay an “educational tax” to do so.  Describe the “tax” as a safety precaution if you must, but recognize it for what it really is.

Those dentist who can’t afford the new tax, won’t get the benefits of providing the protocol.

Oral surgeons have already paid their taxes, why shouldn’t the rest of dentistry follow suit?

In figuring out how to bridge these conflicting interests, it is important not to confuse the issue.  It has little, if anything, to do with safety, since everyone agrees that patients must be safe.

So what is in the patients’ best interest when dentists squabble over dollars and cents and turf rights?

If the Committee on Anesthesiology proposals are approved by the full ADA, patients will pay more – and likely wait longer – to see an OCS dentist.  Those patients who don’t have the extra money or can’t wait, will either have to make do without OCS or make do without seeing a dentist altogether.

In the end, every patient who stays away from the dentist because the cost is too high, the wait is too long, or the distance to find a qualified dentist is too far, is a patient at risk.

OCS is and will be safe no matter what the ADA does and no matter which side prevails.  The true danger to patients is pricing them out of the market for dental care – which all sides should also agree, is not at all safe.

Put succinctly:  It is the lack of OCS that is the most important safety issue to consider when weighing the ADA’s proposals.

-- DEAN ROTBART