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Policy for Selecting Anesthesia Providers for the Delivery of Office-Based Deep Sedation/General Anesthesia

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that it is the exclusive responsibility of the operating dentist when employing currently-licensed anesthesia providers (CLA) to safely administer deep sedation/general anesthesia (DS/GA) in the dental office to carefully verify and review the credentials (e.g., education, licensure, certifications) and experience of those providers.1 An understanding of the educational and training requirements of the various types of anesthesia professionals and candid discussions with potential anesthesia providers can assist in the vetting and selection of highly skilled CLA to help minimize risk to patients.

Methods

This policy was developed by the Council on Clinical Affairs and adopted in 20182 . This revision is based on a review of current dental and medical literature pertaining to the education and training accreditation requirements of anesthesia providers. 

Background

Historically, care necessitating DS/GA was provided in a surgical center or hospital-based setting utilizing an anesthesiologist selected and vetted by the facility or institution. The dental surgeon had little, if any, choice as to who would provide anesthesia services. Current trends find an increasing number of dental providers electing to complete such care in the confines of their dental office using the services of a CLA.3 Over the last decade, DS/GA in the dental office has proven to be a safe and effective advanced behavior guidance option when delivered by a highly competent and attentive individual.4 Further, in-office DS/GA reduces the substantial societal costs associated with the delivery of dental care in a surgical center or hospital setting.5

With the use of office-based DS/GA, the primary dental provider takes on the significant responsibility of creating a team of highly-qualified professionals to deliver care in an optimal and safe fashion. DS/GA techniques in the dental office require at least three individuals:

  • independently practicing CLA;
  • operating dentist; and
  • support personnel.1,6

Policy statement

No other responsibility is more crucial than identifying a highly-skilled CLA. Significant pediatric training, including anesthesia care of the very young, and experience in a dental setting are key considerations, especially when caring for pediatric patients and patients with special health care needs (SHCN). If the CLA will be treating patients younger than three years of age, it has been recommended that they have focused expertise in pediatric airway management and vascular access.7 Advanced training in recognizing and managing pediatric emergencies is critical in providing safe sedation and anesthetic care.1,6 Close collaboration between the dentist and the anesthesia provider can provide access to care, establish an enhanced level of patient cooperation, improve surgical quality, and offer an elevated level of patient safety during the delivery of dental care.

Federal, state, and local credentialing and licensure laws, regulations, and codes dictate who can legally provide officebased anesthesia services. Familiarity and compliance with the regulatory and professional requirements needed to provide office-based DS/GA are obligations of both the operating dentist and the CLA.1 When utilizing anesthesia providers to administer DS/GA, the operating dentist is responsible for carefully verifying and reviewing the CLA’s credentials, certifications, and licensure.1 Additional considerations in anesthesia provider selection may include verification of professional liability insurance and recommendations from professional colleagues. Utilization of a CLA to deliver DS/GA services within a dental setting may have implications for the dentist’s professional liability coverage; consultation with the practitioner’s own insurance provider is warranted.

Acknowledging that not all CLA have equivalent training and experience in delivering care during procedures performed within and around the oral cavity, especially for pediatric patients, for patients with SHCN, or on a mobile basis, is paramount. The table above summarizes the educational requirements of various anesthesia provider professions.

Sample questions to ask a potential office-based anesthesia provider*

  1. What is your experience with pediatric patient populations? ...and patients with SHCN?
  2. What is your background/experience in providing office-based DS/GA care? ...and specifically for pediatric dental patients?
  3. How do you evaluate a dental facility and staff prior to initiating anesthesia services? What expectations and requirements do you have for the dentist, auxilliary staff, and facility?
  4. What equipment do you use to administer and monitor DS/GA in the office, and what is your maintenance protocol for this equipment?
  5. What equipment and/or medications should be maintained by the dental facility?
  6. What are potential emergencies associated with the delivery of DS/GA in the pediatric dental office, noting any that may be unique to these clinical circumstances?
  7. What is your training/experience in recognition and management of pediatric anesthetic emergencies?
  8. In the event of a medical emergency, what is your plan of action? What are the roles of the dentist and auxiliary staff during a medical emergency?
  9. Do you have an affiliation with any area hospitals in case a patient requires transfer?
  10. What patient selection criteria (e.g., age, weight, comorbidities) do you use to identify potential candidates for office-based DS/GA? What patient criteria disqualify them?
  11. When a decision has been made that a patient is a candidate for office-based sedation/general anesthesia, what is the office’s role in preparing a patient for office-based DS/GA? How and when do you prepare the patient for the procedure?
  12. What is your protocol for monitoring a patient postoperatively?
  13. What are your discharge criteria and your follow-up protocols for patients who receive office-based DS/GA? Should a concern arise after a patient is discharged, how can someone reach you?
  14. Would you describe a typical general anesthesia case from start to finish?
  15. What is your protocol for ordering, storing, and recording controlled substances for DS/GA cases? 
  16. What are the patient fees associated with office-based DS/GA services?
  17. How and where are patient records related to the office-based administration of and recovery from DS/GA stored?