“Gotta hit the club/Like you hit them hit them hit them angles” – Nice For What (clean version), Drake
On November 15, 2018, the Royal College of Dental Surgeons of Ontario accepted a new revision of the Standard of Practice for the “Use of Sedation and General Anesthesia in Dental Practice”. This made Ontario the most recent province to update their rules around sedation dentistry. It won’t be the last one, as I understand that Saskatchewan, Quebec, and some of the Maritime provinces are revising their rules too. The use of sedation and anaesthesia for dentistry has been under intense scrutiny for the past few years from a variety of angles for a variety of reasons: patients want the service and want more access to it; medical anaesthesiologists are generally in support of it, but have some specific objections to certain modalities; regulators are trying to make sure that the service is delivered safely while at the same time trying not to be sued into bankruptcy by aggrieved patients or practitioners; general dentists are looking at whether the service is worthwhile for them to offer; paediatric dentists, oral and maxillofacial surgeons, and dentist-anaesthesiologists are wondering why changes are being imposed on them given that their safety records are excellent. How can a working group tasked with making the revisions hit all “them angles”? Answer: It can’t (completely). There is the notion that fairest solutions to challenges leave all interested parties a little dissatisfied. That’s sound right to me but in situations like this we also need to consider the fallout (from non-compliance) with the mandated changes.
One of the trends in the new sets of rules is to mandate the reporting of adverse incidents to those bodies charged with patient safety (e.g. the Manitoba Dental Association’s Registrar, the College of Dental Surgeons of British Columbia’s Registrar). Ostensibly, this measure allows for the collection of hard data regarding the safety of sedation/anaesthesia in dentistry, which is nowhere near as robust as it should be in North America. In theory, submitting such reports should be done without fear of any sort of reprisal (e.g. investigation by the province’s College or Association). That is, the data should advance our knowledge, period. More data to examine would seem to be a good thing but as Clare Boothe Luce said, “No good deed goes unpunished”. Let’s hit the angle of the dentist who is suspicious of their College or Association. Two not-so-good possibilities emerge. The first is that dentists will not report incidents and take their chances that the incident in question will not trigger a patient complaint that in turn would lead to discovery of the event and serious regulatory consequences. The second, more serious, option is that the dentist may choose to not use a drug or corrective technique on “the list” so that truthfully no report will have to be submitted. For example, a patient who becomes oversedated on a modest dose of triazolam and has an unanticipated difficult airway might benefit from a dose of flumazenil. In provinces like Manitoba and now Ontario, the dentist would be obligated to report this use of flumazenil. The suspicious dentist might forego using the flumazenil, which “benefits” the dentist from a paperwork-and-potential-repercussion angle but exposes the patient to unnecessary risk.
Recently, I’ve had several conversations about the regulation (or over-regulation) of dentistry. From infection control to recordkeeping, the rules of the game are consistently evolving. The discipline of sedation/anaesthesia for dentistry occupies a special place because of the potential for harm. As I see it, dentists should fall into one of two camps regarding the rules surrounding their practices: those that know and accept these conditions, and those that don’t and choose not to offer sedation services. I realize that this simple approach will not accurately reflect reality. So, I will acknowledge the existence of a third camp, dentists that like offering sedation services but don’t like all the conditions (kind of like the level of religious observance of many people). This third group practices in a self-initiated hybrid style, and this is usually where dangers lie. Non-compliance is nearly universal because perfect compliance is nearly impossible. To deal with the separation between “should” and “is” in my practice, I use a Probability of Victory in a Dispute (a.k.a. The Sniff Test) formula to help me in decision-making. The current version of this home-made, introspective, oft-revised formula states that the probability of victory in a dispute is proportional to the facts of the situation x the degree of compliance x the rationale(s) for my actions. Expressed more mathematically it reads: PVD α (F)(DC)(RA). Not being a mathematician, I don’t know how to check my formula, but in my model 1 is a perfect PVD score with the variables having values between 0 and 1. Mistakes or non-compliance have a significant (i.e. multiplied) negative effect; I like that feature. The practical test of the formula lies in the observation that high scores consistently satisfy me, my patients, my regulator and in the grand scheme of things, the public. In Sniff Test terms: if it smells good, I’ll take the next step. So far, the formula has served me well.
Whether your province calls their rules “Standards” or “Bylaws” or “Guidelines” you probably ought to comply to the best of your abilities. Assuming the new document isn’t a political exercise (and it sometimes is), the intent of working groups is to standardize and improve the practice of dentistry. It’s a right-on goal and a heck of a task, and usually it’s done quite well. As such we should try to honor the work of these groups and comply without angles, even if we don’t agree with every part of it. As a closing example, I now stock insulin in my malignant hyperthermia rescue kit; I don’t like it but I like what it does for my PVD score. OH
About the Editor
Dr. Peter Nkansah is a Dentist Anaesthesiologist with a private practice in Toronto. He is a member of the editorial boad for Oral Health, an Assistant Professor at the University of Toronto’s Faculty of Dentistry and President of the Canadian Academy of Dental Anaesthesia.