February 2, 2016
by Dr. Peter Nkansah, DDS, Dip. Anaes.
We have to register for a lot of things in Canada. We’re at the point where if we are asked to register for anything else, there is a good possibility that we will object. Take the recent debates about long-gun registration and long-form censuses as examples. The need for various professions and disciplines to be regulated and for those practitioners to be registered is clear, as the public should be protected and there are too many underground dentists working and too many grey-market materials in circulation. In my neck of the woods, sedation dentistry, one particular blind spot has made itself known to me that I think is to the detriment of the profession. In only about half of our provinces and territories, dentists who practice minimal conscious sedation do not need to register with their licensing bodies. Registration for all levels and modalities of sedation is required in (from east to west) Prince Edward Island, Québec, Manitoba, Saskatchewan and Alberta.
Currently in Ontario, if you practice minimal conscious sedation with nitrous oxide, oral sedatives, or the combination, the guidelines state that you do not have to register with the Royal College of Dental Surgeons of Ontario (RCDSO). If you practice any other modality, you do. I sort of get this, but it raises two significant issues. First, no one knows how many dentists are offering sedation/anaesthesia services to their patients. Second, and more significantly, since there is an easy way to get around registration and since there is an associated cost, some dentists choose to offer “minimal” sedation and to forego registering their practices, when they know or ought to know that they should. It is possible to induce any level of anaesthesia using any technique. I have induced general anaesthesia on a patient with only nitrous oxide and oxygen. It wasn’t intentional, the dose of nitrous oxide was less than 60 percent, and everything went well, but it was general anaesthesia all the same. I confirmed this by doing several moderate-sized cavity preparations without the use of local anaesthetic. I know that I’m not the only one this has happened to, because over the years, others have told me that the same thing has happened to them. Again, fortunately in these cases, everything was fine, but unfortunately, that is not always the case. There are too many cases of patients getting hurt while under our care. That number will never be zero (because of the human factor) but there are some ways in which we can do better.
Here’s a composite scenario put together from things that I know to be happening: Let’s say that I have recently (or not-so-recently) graduated from the University of Toronto’s Faculty of Dentistry qualified to offer minimal sedation to my patients. I am practicing in Toronto, which is full of dentists. To help bring more patients to my door, I’ve decided to emphasize my conscious sedation services to my patients and to promote the service more in my marketing materials. Oral sedation is my chosen method because of the negligible start-up cost and because benzodiazepines seem to be safe and effective drugs. After reading Ontario’s Standard of Practice document for the Use of Sedation and General Anaesthesia in Dental Practice as well as the guidelines regarding drug choices and maximum doses (Dispatch, Nov/Dec 2014; Dispatch, May/June 2015), I decided that my protocol will be to use 0.5 mg of triazolam on all of my patients. Because I don’t need to register with the RCDSO, I don’t. Technically, I have done nothing wrong so far. Is this practically also true? I don’t think so. First, I have isolated myself from whatever support (oversight?) I might have been able to get from my colleagues. Second, the model is too simple to be safe. A standard dose regimen for sedation is a recipe for disaster.
I have made the argument many times over the years that sedation dentistry is very safe. Here, I have the support of both my experience and the literature. I teach courses in sedation dentistry and I practice it, so here (and maybe only here) I walk the talk. I absolutely do not want to see anybody hurt (or worse). However, mishaps become more likely with one or some combination of the following factors: regulation-fatigue; a desire to maintain or improve personal income; the desire to add a wanted and needed service to a practice; and the ease of adding this service.
I’m no fan of regulation but I’m even less of a fan of non-accountability. In my opinion, any dentist who practices sedation dentistry without officially acknowledging that they do so is flying under the radar in a bad way. Apart from the nominal cost of registration and possibly some philosophical stance, I see no downside in making it mandatory for all dentists in Canada who practice any level of sedation to have to register. The benefits would include: better data collection on the need for sedation dentistry; better access to data on the use of sedation dentistry; decreasing the likelihood of dentists pushing minimal sedation boundaries; improved reputation to the public, to our physician colleagues and to the governmental bodies; and improved safety for patients. Thanks PEI, QC, MB, SK and AB, for showing us the way. To the rest of the provinces and territories: C’mon, it’s time to move.OH
Dr. Nkansah is a Dental Anaesthetist with a private practice in Toronto. He is a member of the editorial board for Oral Health and is an Assistant Professor at the University of Toronto’s Faculty of Dentistry.