A Risk Manager’s Practical Guide to Meeting the Demand for Sedation Services

Fear and anxiety toward dentistry are common in all cultures. Such feelings usually originate in childhood, persist through life, lead to avoidance of dental therapy, and contribute to diminished dental health.¹ Indeed, psychological factors pose significant barriers to access to oral health care. Dentists are by and large aware that anesthesia and sedation services assist with the management of anxiety, fear, and phobia. Along the same lines, it is widely appreciated that patients with cognitive or emotional diversity may struggle to cooperate during a dental procedure. The same can be said of many young children. Across the population, people undergoing extensive or prolonged procedures where pain might not be adequately controlled with local anesthesia can also benefit from dental sedation.²

While this is common knowledge in the dental world, research shows patient demand for sedation during dental procedures exceeds its supply.³ One reason for this mismatch is that many dental professionals still underestimate patient need and desire for sedation. Indeed, when asked why they choose not to offer sedation, many dentists cite an incorrect perception that demand does not exist.⁴ It is as if dentists live in two different worlds where they understand the need for sedation in theory but habitually overlook it in practice. There are, of course, other reasons dentists choose not to offer sedation, some of which will be discussed below. Whatever the reason, patients often lack access to the sedation they want (and can afford). For too many patients, sedation appointments require long waits and long travel. The dental community can do better to expand patient access to more comfortable, lower stress dental experiences.

This article is written for dentists who are considering or have made the decision to satisfy patient demand by expanding their sedation service offerings.

A three-step evaluation of sedation readiness

Numerous studies demonstrate that all modalities of sedation are offered with a high degree of safety and reliability in dental offices. Moreover, when patient safety incidents do occur, they are well managed by trained and prepared dental teams.⁵ The benefits of sedation, for the right patients in the right environments, outweigh the risks. Nevertheless, concerns about complications and adverse events rank among the leading barriers for dentists who would otherwise offer sedation.

Approaching the decision to offer sedation systematically will increase the dental office teams’ confidence, improve clinical outcomes and ultimately result in higher levels of patient satisfaction. For a busy dentist, introducing sedation may seem daunting. That’s not unreasonable as much energy and time will be required. As most dentists have learned multiple times, good things are often not easy. That said, introducing sedation into your clinic can be significantly less onerous if executed strategically and according to a plan.

What follows is a three-step evaluation of the: 1) facility and dental clinic team; 2) dental and sedation clinicians; and 3) patient base, designed to reduce this process into practical, achievable steps.

1. Assessing the Dental Practice

For the sake of this exercise, “dental practice” is defined as the people comprising the dental team together with the facility itself. A dentist interested in offering sedation services to patients must assess the strengths, weaknesses, and areas of opportunity for their dental team. This naturally means assessing the environment in which they operate.

Who? – Characteristics of the Dental Team

Experience: A practitioner should begin by assessing the extent of the dental team’s experience with providing sedation. If other providers in the clinic are currently offering sedation services, the dental team will have developed habits, practices, and strong opinions. Such experience will often make it easier for a new clinician to add sedation to their practice. At the same time, teams may have developed bad habits and fallen into certain “off label” practices. Changing processes and habits can be more difficult than forming new ones.
It is imperative to avoid making assumptions when it comes to sedation services. If the new provider’s type, level, or approach to sedation services differs from the existing provider’s, the team’s experience and habits will require modification.
Furthermore, the new provider may be tempted to assume that the team has obtained all the training, skills and certifications required to provide sedation safely and legally. This would be a mistake. The training and qualifications of the team should be compared to the requirements spelled out in (the newly revised) Sedation and General Anesthesia Standard._⁶

Mindset: It is as vital to assess the mindsets and the culture of the dental team as it is their experience and skill. While experience may be measured objectively, (i.e., the team has been supporting X modality of sedation for X years), measuring attitude may feel more slippery. Such an assessment becomes more achievable once broken down into a series of questions. Here are some that will help you determine whether to add sedation to your clinic’s offerings or whether to focus on managing culture and team engagement first.

Is the team excited about offering sedation or are they fearful and nervous?
Does the team view sedation as improving the patient experience or simply as more work?
Are team members excited about developing new skills or reluctant to change?
Do people in the dental office share ideas openly or hesitate to speak up for fear of being blamed or getting others in trouble?⁷
Soft skills: A clinician must keep in mind that providing sedation to patients requires patients to consent to such treatment. With sedation (especially deeper modalities) and general anesthesia, informed consent takes on a new importance. Many providers have paid for expensive training and spent countless hours gaining the expertise needed to administer sedation only to see their schedules remain empty. Given the well documented demand for sedation services, softness in provider schedules may confuse, frustrate, and surprise. To prevent this from happening, it’s critical the team is prepared and competent to engage with patients about the benefits of sedation. It’s doubly important they’re motivated to do so. If the dental office team does not educate patients, if they lack the ability or confidence—or worse if they suggest sedation “is risky and not really necessary”—few patients will opt in. The development of sedation specific “soft” skills and the assurance of alignment are too often ignored. When patient demand is there but the chair remains empty, dentists will need to teach their team how to engage with patients. Failure to does a disservice to both patients and would-be sedation providers.
Administration: Receiving payment for sedation services is a must. Accordingly, dental teams should not overlook the importance of properly training the front office on how to bill for sedation. Whoever submits claims to third parties may not be familiar with the procedure codes for sedation. This can become more complicated if the sedation provider is someone other than a dentist, for instance a medical anesthesiologist. Failing to bill appropriately can lead to uncollected AR and a number of more severe headaches down the line. Dentists deserve to be paid; accordingly, they should invest due time on the administrative side of the office.

Where? – Attributes of the Facility:

While a dentist assesses and prepares their team for the addition of a sedation program, they should simultaneously survey the clinic. Sedating patients may require changes to the layout of a dental office. In such cases, those changes should be put into place in advance. Even if the facility’s design facilitates safe sedation of patients, the clinician will need to procure sedation monitoring equipment, information resources, sundries, and emergency drugs, among other things. Many dentists have completed their sedation certification course only to realize they will require many months to prepare the facility. This can result in the loss of momentum and confidence.

Advanced planning pays. Understandably, a busy dentist can feel overwhelmed when compiling a list of facility requirements, and this is truer when they have never done it before. Here is where a checklist comes in handy.⁸ The CDSS has included several checklists within the Sedation Standard⁹ covering the equipment and emergency drugs required, the sedation procedures to follow and what information to document in the sedation records. Reviewing the Standard will enhance both safety and confidence; it’s also worth remembering that facilities where sedation “is administered are subject to random on-site inspections and evaluation by the CDSS.”¹⁰

2. Dentist, Evaluate Thyself – Assessing the Clinician

For reasons discussed above, clinicians should not wait until they have completed sedation (continuing) education and training to begin preparing the team and facility. Assuming the dentist has completed or (better yet) is in the process of completing their sedation training and education, there are critical other matters to consider.

Does the clinician inspire confidence among the team? Dental office workers care deeply about patient safety. Before sedating patients, dental assistants, sedation assistants, registered nurses and others want to know that the dentist cares just as much about the patient’s wellbeing. Saying “patient safety is our number one priority” is good but not sufficient. Rather, dental office workers want to be shown that the provider cares. How does a dentist accomplish this? The answer lies in sharing this multi-factorial evaluation process with the team. Dentists will inspire confidence and trust when they involve their teams in the assessment processes and readiness planning. Taking this approach shows the due care and attention to detail the dental team is looking for. More importantly, such behavior demonstrates a willingness and readiness to lead.

Does the clinician inspire trust in their patients? As with their teams, dentists must practice introspection relative to their patients. Patients seek out sedation because they are anxious. Such patients crave reassurance almost by definition. A dentist who increases patients’ anxiety (by rushing or adopting a condescending tone of voice) will largely undo the benefit of the sedative drugs. Dentists must ask themselves, therefore, whether their presence reassures and comforts or whether they should focus on improving their verbal and non-verbal communication. Studies consistently demonstrate “good communication, trust and a personal relationship between the patient and the dentist promote patient satisfaction and loyalty.”¹¹ The importance of a dentist’s rapport with patients (and their guardians) increases when the patient is under the influence of mood-altering sedative drugs.

Plan for the unexpected. A dentist who aims to add sedation services must be ready to handle any difficult situations that may arise. Nothing destroys a team’s support and confidence faster than watching the dentist panic when a sedated patient shows signs of distress. There is no substitute for planning and preparation to ensure a team remains calm during, for example, the onset of a medical emergency.¹² Fortunately, a dentist who implements mandatory emergency training (with their team at the clinic) not only benefits from a more prepared team, but they also themselves grow more confident and resilient. By organizing and participating such training, the dentist displays patient-centeredness and positive leadership qualities: i.e., they win the team’s respect.

3. For whom? Assess Your Patient Base

Dentists should know who they will be providing sedation to and for what treatments long before sedating their first patient. Different kinds of patients will demand different training (and modalities). Dentists should consider whether their clinic treats many pediatric or geriatric patients. If so, single drug IV sedation may not be indicated. Has the clinic historically recorded patients’ anxiety levels on medical and dental history forms? Has the practice recorded patients’ overly sensitive gag reflexes, aichmophobia, claustrophobia, and difficulty controlling head motions? If so, that data will help define the portion of the patient base that would benefit from sedation. The dentist should survey the patient base to plan what services they will offer with sedation. If there is a high clinical need for lengthy services including implants, third molar extractions, complex endodontics, perio-surgery, etc., there will be an abundance of opportunities to integrate sedation.

By assessing patients (both individually and as a group), dentists determine how to coach their treatment coordinators and dental hygienists to discuss sedation. Patients who experience phobia, anxiety or who require extensive dental work will appreciate learning about sedation, even if they don’t accept it the first time it’s offered. Such patients will see that the team and dentist are offering the service because they really believe it’s in their best interest. Over time, the team will grow more confident, and the dentist will consistently demonstrate the benefits of sedation to their patients. These synergistic forces will drive higher and higher conversion rates. All the work will have been worth it.

2024 Sedation Standard Requirements for License Renewal

And finally, a word to the wise. Dentists in Canada should be familiar with the new Sedation and General Anesthesia Standard that have just come into effect. As part of the dental license renewal process, clinicians offering moderate or deep sedation will be asked to include specific documentation with their renewal form. Dentists planning to utilize minimal sedation will not need to submit any sedation-related documentation, but they must indicate this level of sedation on the renewal form.

Oral Health welcomes this original article.

References

Dionne RA, Yagiela JA, Cote CJ, et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. J Am Dent Assoc. 2006; 137:502-513.
Berthold, Charles, DDS, MS, Enteral Sedation: Safety, Efficacy, and Controversy, Compendium, May 2007;28(5):264-272.
Huh, Yoo K,, et al, Assessment of Patients’ Awareness and Factors Influencing Patients’ Demands for Sedation in Endodontics, Journal of Endodontics. Feb2015, Vol. 41 Issue 2, p182-189.
Patodia, Sangeeta, Ontario Dentists’ Practice of Sedation and General Anesthesia: Barriers to Access and Use, Journal of the Canadian Dental Association. 2/16/2021.
McLernon, M., Complications and outcomes associated with midazolam conscious sedation of dental patients: An evaluation of regional services, SAAD Digest. 2023, Vol. 39, p32-36.
https://saskdentists.com/wp-content/uploads/2023/10/Sedation-and-General-Anesthesia-October-2023-v2.pdf
Good communication is an essential prerequisite for the implementation of a successful sedation program. O’Daniel, Michelle and Rosenstein, Michelle, See, e.g., Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Ch. 33, Professional Communication and Team Collaboration.
For a discussion on and guide to creating checklists for dental procedures, see Dr. Trotti, Domenic, Checklists in Dentistry, Ontario Dentist. Sep2022, Vol. 99 Issue 7, p26-29.
CDSS Sedation and General Anesthesia Standard, available at: https://members.saskdentists.com/images/pdf/Professional_Resources/CDSS_Sedation_and_General_Anesthesia_Standard_October_2021_FINAL.pdf, last accessed on November 27, 2023.
Id.
Szabó, Réka Magdolna, Factors Influencing Patient Satisfaction and Loyalty as Perceived by Dentists and Their Patients, Dent J (Basel). 2023 Sep; 11(9): 203, Published online 2023 Nov 27 at: 10.3390/dj11090203.
See Dr. Feck, Anthony, Preparing for Medical Emergencies in the Dental Office, Vol. 102 Issue 12, p69-73. 7p; www.DENTALECONOMICS.com.

About the Author:

Julian Perez is Chief Legal Officer at dentalcorp, where he oversees legal, regulatory compliance, corporate governance and enterprise risk functions to support practices in the delivery of optimal patient care. He earned his bachelor’s degree from Yale University and a JD from Columbia University’s School of Law.