Sedation Dentistry: An Application of Medical Histories and Observation Records to Create A Protocol Aimed at Identifying High-Risk Patients

Ma#hewS.Bright1,JamesCur6s,D.M.D.2,Mar6nDurkin,M.D.,M.P.H.3,DavidHicklin,D.M.D.2,CynthiaNichols,D.M.D.,M.S.2

References: 1. Dionne RA. Raise the bar for safe sedation, not barriers for access to care. JADA. 2017;148(3):133-137. 2. “Guidelines for the Use of Sedation and General Anesthesia by Dentists” American Dental Association. 2007. 3. Goodchild JH, Donaldson M. New sedation and general anesthesia guidelines. JADA. 2017;148(3):138-141. 4. Malamed, SF. (2010) Sedation: a guide to patient management. St. Louis, Missouri: Mosby Elsevier.

• Thisstudyaimedtoassesspatientoutcomeswhentreatedwiththesedativemedications,midazolam,fentanyl,diazepam,andmeperidine,inthehopeofidentifyinghigh-riskmarkersthatwillguidepatientselectionforin-of<icesedationprocedures

Objective

• Aseriesoflogisticalregressionmodelspresentingoddsratiosbasedonadichotomizedvariablefor

lengthofrecovery<20min.or>20min.resultedintheselectedmodelthatincludedBMI,Co-

morbidities(>1),Age,andMorphineEquivalentschosenbytheAkaikeInformationCriterion

• Aseriesoflinearregressionmodelsbasedonacontinuousvariableforlengthofrecovery(minutes)

resultedintheselectedmodelthatincludedGender(Male),Co-morbidities(>1),Age,Drug

Combination(Versed),DrugCombination(Other),andMorphineEquivalentsperKilogramchosen

byanadjustedR2valueof(0.1018)

Analysis

• Prospectivestudiesrelatedtotheadministration,effectiveness,andsafetyofparenteraladministeredsedationhave

beencalledforasearlyas1986bytheNationalInstituteofHealthConsensusConferenceonAnesthesiaand

Sedation1

• Since2007,theAmericanDentalAssociationrequiresthefollowingfromdentistspracticingmoderatesedation:2

• Atleast60hoursofdidacticinstructioncoupledwiththesupervisedmanagementof20sedation

patientsviatheintravenousrouteduringthecourse

• BasicLifeSupportTrainingforHealthcareProfessionalsCerti<icationobtainedbythedentist,their

assistants,andanyauxiliarystaff

• AdvancedCardiacLifeSupportCerti<icationobtainedbythedentist

• InOctober2016,Resolution37oftheAmericanDentalAssociationwasapprovedbytheHouseofDelegatesin

whichmorestringentrequirementsweresuggestedforalltypesofsedationprovidedinadentalsettingincluding

CO2endtidalmonitoring3

• ThismonitoringtoolwasalreadyutilizedatthePalmettoHealthUSCDepartmentofDentistry

• Thereisstillaneedforevidencesupportedguidelinesthataccountforvariationsinindividualpatientsaswellas

identi<iedvariablesthatimpactsedationoutcomesthemost

Introduction

• Allprocedureswere:• PerformedatPalmettoHealthUSCMedicalGroup,DepartmentofDentistry• Betweenthedatesof:07/01/2013-06/30/2016• Age≥15yearsattimeofprocedure

• 298procedureswereincludedinthisstudy• Linearregressionmodelsandlogisticalregressionmodelswithoddsratioswerecreatedtoinvestigatetherelationship

betweensedativedrugsanddemographicfactorsonapatient’slengthofrecoveryfollowingmoderatesedation

Materials and Methods

1TheUniversityofSouthCarolina,SouthCarolinaHonorsCollege,Columbia,SC,USA2Palme#oHealthUSCMedicalGroup,DepartmentofDen6stry,Columbia,SC,USA

3PrismaHealthResearchCompliance,Columbia,SC,USA

Table 1

Summary of Linear Regression Analysis for Variables Predicting Length of Recovery (Continuous Variable, Minutes)

Coefficients Estimate Std. Error T-Value Pr(>|T|)

Gender (Male) 1.69478 1.02872 1.647 0.1008

Co-morbidities (>1) 3.97855 0.99248 4.009 <.0001*

Age 0.06519 0.03351 1.945 0.0529!

Drug Combination Fentanyl - Versed -1.70116 1.65944 -1.025 0.3063

Drug Combination Other -4.25424 2.34289 -1.816 0.0707!

Morphine Milligram Equivalents per

Kilogram14.87925 7.95897 1.869 0.0628!

* if p < 0.05● if p < 0.1

Residual Standard Error = 7.021

Degrees of Freedom = 236 Adjusted R2 = 0.1018 P-Value = 2.015e-05

• Moderatesedationfordentalpracticeisasafeandeffectivemodalityforprovidingdental

treatmentinaregulatedandcontrolledenvironment• Quantitativedataanalysiscanguidetheimplementationofpracticeprotocolforpatientselectionandmanagementofmoderatesedationprocedures

Conclusion

Table 2

Summary of Logistical Regression Model for Variables Predicting Length of Recovery (Dichotomized Variable, <20 and >20 Minutes)

Variables Odds Ratio -95% CI +95% CI P Value

BMI 1.033 0.991 1.076 0.127

Co-morbidities (>1) 1.890 1.011 3.533 0.046*

Age 1.023 0.999 1.047 0.057!

MorphineEquivalents

* if p < 0.05● if p < 0.1

1.052 0.984 1.124 0.141

• Althoughneithermodelaloneisofsuf<icientqualitytoexplainthecorrelationbetweenthechosenvariablesandthepatient’slengthofrecovery,whencompared,speci<icvariablesareofsigni<icant

interestandwarrantfurtherstudy• Variablesthataresigni<icantinbothmodelsincludethepatient’sageandnumberofco-morbidites

associatedwiththeiroverallhealth• Themorphineequivalents(associatedwithBMI)apatientreceiveswasfoundtobeanindicatorofextendedlengthsofrecovery

• Thespeci<icdrugcombination,(associatedwithmorphineequivalentsperkilogram),wasalsofoundtobeanindicatorofextendedlengthsofrecoveryinthelinearregressionmodel

Discussion

n=

Figure 1. Scatter plots relating variables of Length of Procedure (min) and Length of Recovery (min). Each data point represents one sedation.

• Fentanyl,althoughmorepotentthanothersedativedrugs,allowsforshorterdurationsandincreasedclinicalcontrol,resultinginamorepredictable,shorterrecoverytime4

• DiazepamandMeperidinerepresentsedativedrugswithlongerdurationsandthereforedecreasedclinicalcontrol,yetarestillviableoptionsformoderatesedation

Drug Combinations