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Second Opinion: Progress is Inevitable, Even if Occasionally Delayed By Michael D. Silverman, DMD, president of DOCS

Progress is Inevitable,
Even if Occasionally Delayed



 
Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dentists to share their opinions on various topics, providing you with a “Second Opinion.” Perhaps some of these dentists’ observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.

–– Thomas Giacobbi, DDS, FAGD,
Dentaltown Editorial Director

Medical innovation is resilient.

Efforts to repress new treatment protocols, new technologies and new pharmaceuticals often delay the implementation of innovations – but rarely stifle them altogether.

It is a lesson worth remembering in considering the current debate over the fate of oral conscious sedation (OCS) in dentistry.

New guidelines proposed by the American Dental Association (ADA) would require considerably more continuing education before general dentists and other non-specialists would be permitted to provide, or continue to provide this increasingly popular treatment to their patients.

OCS, or “sedation dentistry,” relieves the fear and anxiety of individuals who have long avoided dental visits due to their phobias. The use of mild oral sedatives to calm patient jitters has been a safe and effective tool of wise dentists for decades.

It was not until 2000, when the Dental Organization for Conscious Sedation (DOCS) was formed, that OCS really began to gain mainstream traction.

The founders of DOCS honed the various protocols for sedation dentistry into a sleek, well-researched method that can be taught effectively to dentists and their staffs during a comprehensive three-day course. Since DOCS opened shop, almost 8,000 dentists have obtained training through its courses.

DOCS and other educators were quick to recognize the huge potential of sedation dentistry to win back the tens-of-millions of Americans who avoid regular oral health visits. Indeed, in May 2000, U.S. Surgeon General David Satcher, M.D., Ph.D., challenged the health care community to develop innovative methods to serve the large population of Americans who lack adequate dental care.

“Ignoring oral health problems can lead to needless pain and suffering, complications that can devastate well-being, and financial and social costs that significantly diminish quality of life and burden American society,” noted then Secretary of Health and Human Services Donna E. Shalala in a news release dated May 25, 2000.

As the Surgeon General noted, oral health is not just about teeth, gums and jaws. “Recent research findings have pointed to possible associations between chronic oral infections and diabetes, heart and lung disease, stroke and low-birth-weight premature births,” Dr. Satcher noted in the May 25 statement.

In keeping with Dr. Satcher’s vision, DOCS and others found a means to win back dental-phobic patients in large numbers – saving not only their smiles, but in all likelihood, many of their lives.

Since 2000, more than 1,000,000 previously hesitant patients have returned to the fold and now thousands of dentists and tens-of-thousands of new patients are singing the praises of oral conscious sedation each year. One might think that would be great news for the power elite of dentistry. Not so.

In October 2005, the ADA’s own house of delegates affirmed the safety and efficiency of OCS and other forms of anesthesia and lauded their “remarkable record of safety.” Now in 2007 the ADA is singing a different tune.



Now the ADA, following the advice of its Committee on Anesthesiology and Council on Dental Education and Licensure, is calling for an overhaul of the very guidelines that the full house of delegates lauded less than two years ago.

Why?

It is not because there have been widespread reports of death or injury due to OCS. In fact, there have been no reports whatsoever of death or injury due to OCS in adult patients who have been treated in accordance with existing ADA guidelines and state regulations.

So why is the ADA attempting to rewrite the guidelines for OCS, much to the consternation of more than 1,000 sedation dentists and patients who’ve been vocal critics of the proposals?

I will let you draw your own conclusions.

But I thought it might be helpful to paint a clear picture of what the dental landscape is to be expected to look like if the ADA succeeds in dramatically increasing the training requirements for existing and future sedation dentists.

The ADA sets the standard for professional dental care in this country. While by itself the ADA doesn’t have regulatory authority, dental boards in 18 states either automatically adopt the ADA’s guidelines as their own regulations or are heavily influenced by the ADA’s guidelines, according to an analysis made by John P. Bitting, regulatory counsel for DOCS. Many other states and even federal health officials often take their lead from the ADA’s declarations.

Should the ADA and its committees prevail, the new, stricter guidelines for OCS will be adopted in much of the country. Ironically, rather than making the world a safer place for dental patients, these guidelines could drive several thousands of patients right back out of the dental health care system.

Keep in mind, on one side of the equation we have more than 1,000,000 adult patients who have been treated safely and effectively with sedation dentistry without incident. On the other side of the equation are a small – truly small – group of dentists, none of whom practice oral sedation dentistry, who suddenly feel the existing guidelines are not safe enough and want to make them much more rigid.
Timeline of When the ADA Will Meet and Decide on This Issue

November 17, 2006: the Committee on Anesthesia (“Committee H”) released proposed guidelines

February 23, 2007: Public Comment due on proposed guidelines. DOCS submitted 50-page response including redline changes to proposed guidelines. Other communities of interest also submitted suggestions (AGD)

March 10, 2007: Committee H discussed Public Comments privately in closed session. Results kept secret.

[The proposals now go back to Committee H for cosmetic changes and then to the ADA board, which will meet in the summer. The ADA will likely publish the final proposals within two weeks.]

September 27-30, 2007: ADA annual convention in San Francisco.

September 30 or October 1: ADA reference committee hearing open to all ADA members for comments. The reference committee is charged with recommending to the House of Delegates to accept or reject any resolution.

October 1-2, 2007: ADA House of Delegates to vote on proposed guidelines. 		The real threat to public health, in this instance, appears to be from overregulation of sedation dentistry.

To understand this more clearly, it is necessary to see that the cost to dentists of acquiring oral sedation permits will rise sharply – both in terms of tuition fees and time spent out of the office – should the ADA proposals be approved this September by its house of delegates.

Many existing sedation dentists simply won’t be able to afford the higher costs and will instead opt to drop OCS as a treatment protocol. Their sedation patients will have to look elsewhere or do without.

As the supply of sedation dentists shrinks, fearful and anxious dental patients will discover that the cost of sedation dentistry rises, as do the travel distances and wait times to see a sedation dentist.

Many patients will “drop out” once again, avoiding dental care altogether.

Those most impacted will be patients who are already on the fringes of the dental system: the poor, the elderly, the disabled and the uneducated. These at-risk populations have the least resources to seek out and pay for alternative sedation dental care.

So who wins? Only those relatively few entrenched dentists who are most interested in preserving the status quo a little bit longer. That’s because sedation dentistry continues to draw patients away from oral surgeons, dental anesthesiologists and others who previously had the oral anesthesia market all to themselves.

Although the ADA and others continue to profess that their chief concern is public safety, the debate over sedation dentistry does not seem to me to be at all about what is in the public’s interest, rather it centers on real and perceived turf wars.

In the near term, I can’t handicap which side in the oral sedation dentistry debate will prevail. On the one hand we find the entrenched power structure of the ADA and the dental specialists who dominate its core councils and committees. On the other hand, there is a grassroots movement among the much larger (but less well-entrenched) body of general dentists and non-specialists who want to broaden the availability of sedation dentistry.

What I do know with certainty is that medical progress and innovation may be delayed, but ultimately they will not be denied.

Many powerful institutions and established authorities have endeavored to hold back the tide of progress in many professions because it was inconvenient or expensive to their individual interests. But innovation is irrepressible and sedation dentistry, ultimately, will emerge to safely and effectively serve millions of patients who stand to benefit.
   Author’s Bio

Michael D. Silverman, DMD, is the president and co-founder of the Dental Organization for Conscious Sedation (DOCS). He continues to impact dentistry as a champion of safe and effective use of oral sedation dentistry. A graduate of the University of Pennsylvania School of Dental Medicine in 1985, Dr. Silverman founded DOCS in 2000 to educate dentists, their teams, and the public on the crucial role anxiolysis and conscious sedation plays in quality general practices. Please visit www.docseducation.com. Dr. Silverman can be reached via e-mail: drsilverman@docseducation.com, or by phone 877-325-3627.
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