Department of Pediatric Dentistry, University of Alabama, Birmingham, and Case Western Reserve University, Cleveland, USAUnited States
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Amongst the challenges faced by advanced training programs in pediatric dentistry is adequate preparation of its students or residents to make use of the most effective and safe sedative agents and combinations for managing the diverse range of non coping behaviors of pre-cooperative and non-cooperative pediatric patients. The dilemma is complicated by a number of factors. Foremost is a constricted interval of time in which to acquire sufficient exposure and expertise in both didactic and clinical applications.
Open Journal PUBLISHERS Editorial Challenges Ahead for Advanced Training Programs in Pediatric Dentistry in the Area of Sedation for Pediatric Dentists and the Commission on Dental Accreditation * John E. Nathan, DDS, MDS* Department of Pediatric Dentistry, University of Alabama, Birmingham, and Case Western Reserve University, Cleveland, USA * *Corresponding author John E. Nathan, DDS, MDS Adjunct Professor, Department of Pediatric Dentistry, University of Alabama, Birmingham, and Case Western Reserve University, Cleveland, USA; E-mail: jnathandds@gmail.com Article information rd th th Received: November 3 , 2019; Accepted: November 8 , 2019; Published: November 15 , 2019 Cite this article Nathan JE. Challenges ahead for advanced training programs in pediatric dentistry in the area of sedation for pediatric dentists and the commission on dental accreditation. Pediatr Neonatal Nurs Open J. 2019; 6(1): e8-e9. doi: 10.17140/PNNOJ-6-e010 mongst the challenges faced by advanced training programs priate for the specific needs of a given patient.
in pediatric dentistry is adequate preparation of its students A or residents to make use of the most effective and safe sedative Considerable energies have been expended by the Com- agents and combinations for managing the diverse range of non- mission on Dental Accreditation (CODA) to determine what con- coping behaviors of pre-cooperative and non-cooperative pediat- stitutes minimally acceptable (not necessarily optimal) experiences ric patients. The dilemma is complicated by a number of factors. in the area of pediatric sedation training. Factors which influence Foremost is a constricted interval of time in which to acquire suf- the commission’s recommendations and required expectations for ficient exposure and expertise in both didactic and clinical appli- faculty competence are in some respects limited, but nevertheless cations. Having sufficient patient populations reflecting various carry foremost the responsibility to protect the public. A critical levels of patient apprehension, resistance, and dental pathology and comprehensive review of the existing pediatric sedation litera- has potential to limit student and resident experience is another ture from the perspective of pediatricians, anesthesiologists, oral complication. Faculty variability with respect to expertise, comfort and maxillofacial surgeons and pediatric dental specialists reveals a level, and firsthand experience making use of a less than diverse paucity of controlled investigations to clarify let alone shed consid- arsenal of agents no doubt has potential impact on resident ex- erable light on what agents have proven track records of efficacy perience. This is particularly disconcerting where programs have and safety. Despite the existence and perpetual revision of existing elected to reduce their armamentariums to the extent that experi- national safety guidelines for the use of pediatric sedation, mis- ence is gained exclusively with use of a single medication. haps involving morbidity and catastrophic outcome continue to be appear. Nevertheless, while it is the global intent of regulatory Fulfillment of accreditation standards in this area is rec- agencies to protect children, parents and dentists from such occur- ognizably a challenge for some if not many programs. Didactic rences, resources and manpower are not readily in place to guaran- training must include sufficient exposure and knowledge of both tee provider compliance on either a state to state or national level. classical and contemporary literature that provides clinical opin- Compliance and safety concerns however within training programs ion, substantive retrospective and prospective evidence-based sup- falls under the auspices of the program director and faculty in at- port of the efficacy, safety and recovery parameters for numerous tendance. Within private practice, providers and their staffs must agents for successful management of patient anxiety and resistive satisfy state regulations and guidelines for safety. behaviors. To ensure safety across all levels of sedation, students must be able to demonstrate competence in airway management For discussion purposes, the CODA has outlined specific and recognition of developing adverse physiologic responses. minimum experiences that must take place within a twenty-four- Knowledge and proficiency in physical diagnosis and pharmacol- month training program. Beyond the use of nitrous oxide alone, ogy of sedative and analgesic medication are prerequisite skills to students/residents must experience a minimum of 50 sedation ex- demonstrate competency. Lastly, clinical exposure must be as di- periences, half of which must occur as primary operator. No de- verse as possible using a broad range of agents and dosing appro- termination or mention to date exists to identify what agents must cc Copyright 2019 by Nathan JE. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which Pediatr Neonatal Nurs Open J. 2019; 6(1): e8-e9. doi: 10.17140/PNNOJ-6-e010 be used within these experiences. All decisions as to what agents what constitute viable agents. In an otherwise ideal world, clarifica- are employed are made by the respective program directors and tion of a range of agents for which students and residents should their institutional formulary service. In some states, specific agents receive instruction and experience would be helpful to mitigate are excluded due to an occurrence of adverse reactions, miss-use this deficiency. Without substantive data, however, to demonstrate or abuse, based on litigation outcomes and not necessarily science. evidence-based support for efficacy and safety, it is not surprising Under these circumstances, decisions on what to include or ex- that these agencies to date refrain from their inclusion. Without clude fall outside the realm of program directors. This likely con- consistent levels of comfort of program directors using a broad tributes to a reticence for CODA to identify what agents must be regimen of agents, student exposure/preparation can be expected taught in training programs. This particular judgment, however, is to be insufficient.
subject to significant concern. Surveys both recent and of old have identified use of a wide range of agents at but a few institutions; One conceptual platform remains. Complete reliance on others make use only of agents which possess reversal capabili- agents such as midazolam, with or without nitrous oxide, remains ties. If optimal agents were readily known and this was a perfect an unfortunate state of affairs for our management arsenals for world, these types of limitations might be considered reasonable. children and advanced training programs. Extensive study of mid- From the perspective of this author, the latter approach represents azolam has been performed. Distinct limitations with respect to ef- a major deficiency in preparing residents for the needs of chal- ficacy and duration of action render it of limited value for anything lenging children. For some institutions, for all intent and purposes, but short and ultra-short duration visits. Where anxiety levels and large numbers of patients who could conceivably be treated safely resistance are severe, virtually all studies report the need for per- with conscious sedation are being channeled to general anesthesia sistent adjunctive physical restraint to complete treatment. Perhaps to transfer all risk to anesthesiologists. Whether or not this falls future reports will enable better judgments associated with proper within the best interests of these children depends on the judg- dosing limits for various agents and situations.
ment of the parent and provider. Nevertheless, the CODA has systematically outlined criteria in conjunction with and consistent DISCLAIMER with the American Academy of Pediatric Dentistry (AAPD) for which sedative management of challenging behaviors maintaining This editorial reflects the opinion of the author and in no way consciousness is considered appropriate. It is noteworthy that se- should be construed to represent the views of the American Acad- dation continuing education courses offered by the AAPD while emy of Pediatric Dentistry (AAPD) or Commission on Dental Ac- alluding to the use of some regimens, avoid recommendations of creditation (CODA).