William Flick - I Floss Presentation.ppt

William G Flick DDS, MPHWilliam G Flick DDS, MPH

Clinical Associate ProfessorClinical Associate ProfessorUniversity of Illinois ChicagoUniversity of Illinois Chicago

Oral Maxillofacial SurgeryOral Maxillofacial Surgery

Public Health Implications Public Health Implications of theof the

Illinois Dental Anesthesia and Illinois Dental Anesthesia and Sedation Survey for 2006 Sedation Survey for 2006

Sponsored by the Illinois Dental Society of Anesthesiology, and the Sponsored by the Illinois Dental Society of Anesthesiology, and the Illinois Society of Oral Maxillofacial SurgeonsIllinois Society of Oral Maxillofacial Surgeons

Dental Anesthesia and SedationDental Anesthesia and SedationThe Lighting Rod for Public Attention !The Lighting Rod for Public Attention !

Probably the single most scrutinized area Probably the single most scrutinized area of dental practiceof dental practice

Adverse outcomes create a Adverse outcomes create a disproportionate amount of media disproportionate amount of media attentionattention

Public concern regarding the, Public concern regarding the, appropriateness, regulation and even the appropriateness, regulation and even the necessity of such services.necessity of such services.

Example of Media AttentionExample of Media Attention

The ChallengeThe Challenge

Sustain the Public’s confidence Sustain the Public’s confidence Ensure public safetyEnsure public safety Maintain availability of office based Maintain availability of office based

anesthesia and sedation servicesanesthesia and sedation services Promote the cost effectiveness of office Promote the cost effectiveness of office

based anesthesia.based anesthesia.

Multi Faceted Pro Active ResponseMulti Faceted Pro Active Response

Governmental Sector, Regulatory AgenciesGovernmental Sector, Regulatory Agencies Input From Organized DentistryInput From Organized Dentistry Research to Generate Data that Reflects Research to Generate Data that Reflects

the Scope, Utilization and Outcome the Scope, Utilization and Outcome Continual reassessment of public health Continual reassessment of public health

policy regarding services.policy regarding services.

Illinois Dental Practice ActsIllinois Dental Practice ActsRegulates Practice of Anesthesia by Regulates Practice of Anesthesia by

DentistsDentists No permit required for Anxiolysis, Nitrous No permit required for Anxiolysis, Nitrous

Oxide AnalgesiaOxide Analgesia Permit A– Conscious Sedation, includes Permit A– Conscious Sedation, includes

oral and parenteraloral and parenteral Permit B- Deep Sedation and General Permit B- Deep Sedation and General

AnesthesiaAnesthesia

Illinois Dental Anesthesia and Illinois Dental Anesthesia and Sedation Survey for 2006Sedation Survey for 2006

A follow up survey of an earlier study conducted A follow up survey of an earlier study conducted in 1996 among all dental practitioners in Illinois in 1996 among all dental practitioners in Illinois with a Type A permit for conscious sedation or with a Type A permit for conscious sedation or a Type B permit for deep sedation/general a Type B permit for deep sedation/general anesthesia.anesthesia.

The survey describes the scope and many The survey describes the scope and many aspects about the sedation and anesthesia aspects about the sedation and anesthesia services offered in dental offices in Illinois.services offered in dental offices in Illinois.

The information is useful to the profession, The information is useful to the profession, public health policy advocates and regulatory public health policy advocates and regulatory agencies.agencies.

Issues addressed in the survey :Issues addressed in the survey :

age, years in practiceage, years in practice type of practicetype of practice ACLS trainingACLS training peer review, peer review,

accreditationaccreditation staffingstaffing type of sedation type of sedation

drugs useddrugs used

intubation in officeintubation in office number of cases number of cases

treatedtreated morbidity, mortalitymorbidity, mortality use of capnographyuse of capnography AED useAED use Dantrolene in Dantrolene in

emergency kitemergency kit

Why an update of survey at this Why an update of survey at this time?time?

10 year anniversary10 year anniversary permit for oral permit for oral

sedation in Illinoissedation in Illinois Anesthesia CE for Anesthesia CE for

license renewallicense renewal New inhalation New inhalation

agents, ie. agents, ie. SevofluraneSevoflurane

Interruption of Interruption of Brevital supplyBrevital supply

Generic forms of Generic forms of Propofol and VersedPropofol and Versed

Mandatory AAOMS Mandatory AAOMS peer reviewpeer review

Dental anesthesiology Dental anesthesiology specialty specialty

Anecdotal reports of Anecdotal reports of anesthesia related anesthesia related deaths in dental officedeaths in dental office

MethodsMethods

a mail survey to all dentists in Illinois , a mail survey to all dentists in Illinois , registered with Illinois Dept. Professional registered with Illinois Dept. Professional Regulation with Anesthesia Permit (Regulation with Anesthesia Permit (n n 471)471)

25 questions, 3 page, fill in, survey25 questions, 3 page, fill in, survey second mailing after 6 weeks second mailing after 6 weeks respondents remained anonymous.respondents remained anonymous. computer data base analysiscomputer data base analysis University of Illinois Chicago, Institutional University of Illinois Chicago, Institutional

Review Board, exemption grantedReview Board, exemption granted

Initial Survey ResultsInitial Survey Results

Initial mailing, list from IDPR, N 471Initial mailing, list from IDPR, N 471 Undeliverable, returned , n 27Undeliverable, returned , n 27 Responses, n 305Responses, n 305 Response rate 2006/ 69%Response rate 2006/ 69% Response rate 1996 / 71%Response rate 1996 / 71%

Type of PermitType of Permit

19961996 14% Type A 14% Type A

Conscious SedationConscious Sedation 86% Type B General 86% Type B General

Anesthesia/ Deep Anesthesia/ Deep SedationSedation

20062006 34% Type A 34% Type A

Conscious Sedation Conscious Sedation 64 % Type B General 64 % Type B General

Anesthesia/ Deep Anesthesia/ Deep SedationSedation

Type of Anesthesia Permit

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1996 2006

Type A Conscious Sedation

Type B Deep/ General Anesesthesia

Type of PracticeType of Practice

19961996 General Dentistry General Dentistry

11%11% Oral Max Surg 84%Oral Max Surg 84% PeriodonticsPeriodontics 5% 5% PedodonticsPedodontics 0%0% Dent. Anesthesia Dent. Anesthesia

<1%<1%

20062006 General Dentistry General Dentistry

20%20% Oral Max Surg 63%Oral Max Surg 63% Periodontics 6%Periodontics 6% Pedodontics 9%Pedodontics 9% Dent. Anesthesia 1%Dent. Anesthesia 1%

Type of Dental Practice

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Gen. Dentistry Oral Max. Surgery Periodontics Pediatric Dentistry DentalAnesthesiology

1996

2006

Years In PracticeYears In Practice

N 299N 299 Mean 20.7 (16.3 in 96)Mean 20.7 (16.3 in 96) MedianMedian 22.022.0 Std. Deviation 10.5Std. Deviation 10.5 Minimum 1.0Minimum 1.0 Maximum 50.0 Maximum 50.0

Age of PractitionersAge of Practitioners

n 295n 295 Mean 49.8Mean 49.8 MedianMedian 51.051.0 Std Deviation 9.7Std Deviation 9.7 Minimum 30.Minimum 30. Maximum 78.0Maximum 78.0

Practitioners With MDPractitioners With MD

Practitioners reporting additional Practitioners reporting additional qualification of M.D. degree 2006, n 15 qualification of M.D. degree 2006, n 15 (5%)(5%)

Practitioners reporting additional Practitioners reporting additional qualification of M.D. degree 1996, n 10 qualification of M.D. degree 1996, n 10 (4%)(4%)

ACLS TrainingACLS Training 19961996 85% Initial Course85% Initial Course 48% Recertification48% Recertification

20062006 90% Initial Course90% Initial Course 80% Recertification80% Recertification

ACLS Training

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1996 2006

Initial ACLS Training

ACLS Current

Peer Review/ Office Peer Review/ Office AccreditationAccreditation

ISOMS/AAOMS office anesthesia review ISOMS/AAOMS office anesthesia review program n 159 (53%)program n 159 (53%)

JCAHO or AAAHC office facility JCAHO or AAAHC office facility accreditation n 10 (4%)accreditation n 10 (4%)

None n 129 ( 43%)None n 129 ( 43%)

Office Anesthesia Team Office Anesthesia Team ConfigurationConfiguration

Operator, one assistant Operator, one assistant 11.5% (12%,96)11.5% (12%,96)

Operator, two assistantsOperator, two assistants 66.5% (82%, 96)66.5% (82%, 96)

Operator, R.N or CRNA., assistantOperator, R.N or CRNA., assistant 13% ( 4%, 96)13% ( 4%, 96)

Operator, MD /DDS anesthesiologist, Operator, MD /DDS anesthesiologist, assistant 8.8% (2%, 96)assistant 8.8% (2%, 96)

Anesthesia Team ConfigurationAnesthesia Team Configuration

Office Anesthesia Team Configuration

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Operator with twoassistants

Operator, oneassistant

Operator, RN/CRNA, assistant

Operator, DDS/MDanesthesiologist,

assistant

1996

2006

Practitioners Indicating Utilization of CRNA, Practitioners Indicating Utilization of CRNA, MD or DDS AnesthesiologistMD or DDS Anesthesiologist

CRNA CRNA n 29 (10%) n 29 (10%) MD anesthesiologistMD anesthesiologist n 28 (9%) n 28 (9%) DDS anesthesiologistDDS anesthesiologist n 42 (15%) n 42 (15%)

Elective Intubations in OfficeElective Intubations in Office

19961996 Do not intubate Do not intubate

96%96% 2% intubate < 25%2% intubate < 25% 1% intubate >51%< 1% intubate >51%<

75%75%

20062006 Do not intubate Do not intubate

94%94% 3% intubate <25%3% intubate <25% 2% intubate 2% intubate

<25<75%<25<75% 2% intubate <75%2% intubate <75%

Intubation in OfficeIntubation in Office

Percentage of Practitioners Intubating in Office

0%

20%

40%

60%

80%

100%

120%

Do not intubate Intubate up to 25% Intubate more than25%

1996

2006

Usage of Intravenous Agents, Practitioners' Preference

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Versed

Fentan

yl

Valium

Brevit

al

Propof

ol

Ketam

ine

Demer

ol

Nubain

Pentot

hal

Talwin

2006

1996

Versed, Fentanyl, PropofolVersed, Fentanyl, PropofolPractitioners’ Preference 2006Practitioners’ Preference 2006

Practitioners’ PreferencePractitioners’ PreferenceSevofluraneSevoflurane

Usage of Inhalation Agents, Practitioners' Preference

0%

20%

40%

60%

80%

100%

120%

Nitrous Oxide Halothane Ethrane Sevoflurane Other

2006

1996

Usage of Oral Sedation, Practitioners' Drug Preference

0%

10%

20%

30%

40%

50%

60%

70%

ChloralHydrate

Versed Halcion Vistaril Valium Other

2006Agents

Reported Number of Patients Treated Reported Number of Patients Treated With I.V. Sedation/General AnesthesiaWith I.V. Sedation/General Anesthesia

For the year Jan 1, 05 thru Dec. 31, 05For the year Jan 1, 05 thru Dec. 31, 05 109,121 Total for all Dentists109,121 Total for all Dentists 100,269 ( 92%)by Oral Maxillofacial 100,269 ( 92%)by Oral Maxillofacial

SurgeonsSurgeons

Reported Number of Patients Treated with Reported Number of Patients Treated with Oral Sedation Oral Sedation

For the year Jan. 1, 2005 thru Dec. 31, For the year Jan. 1, 2005 thru Dec. 31, 20052005

By all dentists n 6,819By all dentists n 6,819 By oral maxillofacial surgeons n 2,959 By oral maxillofacial surgeons n 2,959

(43%) (43%)

Morbidity/ MortalityMorbidity/ Mortality10 year period Jan.1, 1996 thru December 10 year period Jan.1, 1996 thru December

31, 200631, 2006

Death associated with treatment n 2Death associated with treatment n 2 (Approximately one death/500,000)(Approximately one death/500,000) Patients transferred to hospital with long Patients transferred to hospital with long

term morbidityterm morbidity n 2n 2 Patient transferred to hospital with no long Patient transferred to hospital with no long

term morbidity n 30term morbidity n 30

Controversial Practice TrendsControversial Practice Trends

Capnograpy usage Capnograpy usage 9.0%9.0%

Automated Electronic Automated Electronic Defibrillator 63%Defibrillator 63%

Dantrolene stocked as Dantrolene stocked as emergency drug emergency drug 21.6%21.6%

Summary and ConclusionsSummary and ConclusionsProviders and StaffingProviders and Staffing

The proportion of non-oral surgeon dentists The proportion of non-oral surgeon dentists providing sedation services has increased.providing sedation services has increased.

Based upon number of cases, oral maxillofacial Based upon number of cases, oral maxillofacial surgeons continue to provide vast majority of surgeons continue to provide vast majority of sedation and anesthesia services in the dental sedation and anesthesia services in the dental settingsetting

Utilization of CRNAs, DDS and MD Utilization of CRNAs, DDS and MD anesthesiologists, although relatively low is anesthesiologists, although relatively low is increasing.increasing.

Summary and Conclusions Summary and Conclusions Training and AirwayTraining and Airway

90% of providers are ACLS trained90% of providers are ACLS trained 80% of providers report ACLS training is 80% of providers report ACLS training is

current (within 2 years)current (within 2 years) The number of patients intubated in the The number of patients intubated in the

dental office remains very lowdental office remains very low Use of capnography monitoring remains Use of capnography monitoring remains

lowlow

Summary and ConclusionsSummary and ConclusionsRegulation and Peer reviewRegulation and Peer review

The number of dentists providing sedation in an The number of dentists providing sedation in an office accredited by the JCAHO or AAAHC is 4%office accredited by the JCAHO or AAAHC is 4%

84 % of Oral Surgeons have participated with 84 % of Oral Surgeons have participated with the AAOMS anesthesia evaluation program.the AAOMS anesthesia evaluation program.

43% of providers do not participate in any peer 43% of providers do not participate in any peer review or accreditation programreview or accreditation program

Significant number of providers may not be Significant number of providers may not be staffing consistent with Illinois Dental Practice staffing consistent with Illinois Dental Practice Act rules and regulationsAct rules and regulations

Summary and ConclusionsSummary and ConclusionsMedicationsMedications

Versed and Fentanyl are now the favored Versed and Fentanyl are now the favored IV sedative agents.IV sedative agents.

Propofol has replaced Brevital as the Propofol has replaced Brevital as the favored short acting anesthesia inducing favored short acting anesthesia inducing agentagent

Versed is the favored oral sedative agentVersed is the favored oral sedative agent For inhalation agents, Sevoflurane is the For inhalation agents, Sevoflurane is the

favored agent.favored agent.

Summary and ConclusionsSummary and ConclusionsMorbidity and MortalityMorbidity and Mortality

Two mortalities in 10 years were reportedTwo mortalities in 10 years were reported (In excess of one million patients treated)(In excess of one million patients treated) Two long term morbidities were reportedTwo long term morbidities were reported Thirty events required transfer to ER for Thirty events required transfer to ER for

managementmanagement

Comparison of Mortality RatesComparison of Mortality Rates

Illinois Survey*Illinois Survey* 10 years, 2 deaths 10 years, 2 deaths

over one million over one million patients.patients.

1:500,0001:500,000

OMSNIC Claims*OMSNIC Claims* 1:900,0001:900,000

McCarthy*McCarthy* 1:400,000 U.S., 1:400,000 U.S.,

CaliforniaCalifornia 1:300,000 U.K. Dental 1:300,000 U.K. Dental

OfficesOffices 1:40,000 T and A’s 1:40,000 T and A’s

U.S.U.S. !:15,000 Teaching !:15,000 Teaching

Hospital U.S.Hospital U.S.

Summary of Emergency Eevents

0 1 2 3 4 5 6 7

Prolonged Recovery

Chest Pain

Arrhythmia

Airway

Aspiration

Blood Pressure

Seizures

MI

Drug Abuse

Allergic Reaction

ER and dischargedPatient developed atypical tachycardiaArrhythmia

ER discharged without complications

Unstable blood pressure, hpotensive and hypertensive.

Bood Pressure

ER, discharged without complications

48 y/o had vasovagal reaction, 15 minutes after completion of procedure

Prolonged Recovery

ER for managementSustained seizure activity, did not respond to anti-convulsives. Previous history of epilepsy and had therapeutic levels of anti-seizure meds.

Seizures

ER, monitored and discharged

Slow recovery from I.V. sedationProlonged Recovery

ER, tooth retrieved with endoscopy

Aspiration of tooth crown under sedationAspiration Object

ER , discharged without complications.

45y/o developed post op chest pain Chest Pain

ER, discharged, no cardiac dysfunction was uncovered.

Patient had multiple dental extractions under general anesthesia. Slow recovery. Pulse dropped from 80 to 12 to 7. Treated with atropine.

Prolonged Recovery

ER, hospitalized for three days, patient developed mild stroke

62y/o undisclosed labile hypertension, non-compliant with medications. Under IV sedation developed unstable hypertension

Blood Pressure

ER transfer, pacemaker inserted one month later

General anesthesia for multiple dental extractions. Patient complained of chest pain and feeling faint. EkG revealed atrial fibrillation

Arrhythmia

ER transfer. MI diagnosis, died five days later.

Patient had full mouth extractions under general anesthesia. Patient stopped breathing 50 minutes into procedure. Patient intubated

Myocardial Infarction

ER transfer, died

50 y/o suffered MI on way to post anesthesia recovery following multiple dental extractions under general anesthesia. Never regained consciousness, patient had a non-disclosed history of MI at age 48 with sever cardiac muscle damage.

Myocardial Infarction

OUTCOMESCENARIOEVENT

Emergency Event Summary

ER, antibiotics45 y/o aspiration of vomitus post opAspiration Vomitus

ER, hospital to manage airway edema

Laryngospasm, intubated in officeAirway Management


Asthma during anesthesiaAirway Management


Seizures under IV sedationSeizures


Undisclosed cocaine us, dropped BPDrug Abuse


Ventricular arrhythmiaArrhythmia


Arrived and discharged with new onset atrial fibrillation

Arrhythmia

ER, diagnosed as pinched intercostal nerve

26 y/o chest pain following IV sedation Chest Pain


Apnea, airway loss, unable to ventilate, intubated in office

Airway Management

ER, gauze retrieved4x4 gauze loged in airway under IV sedationAspiration Object


Allergic reaction to BrevitalAllegric Reaction

ER, hospital two days40 y/o diabetic vomited under general anesthesia, aspirated.

Aspiration Vomitus

ER, thought to be related to h/o psychiatric problems

Unresponsive post-op, normal breathing, stable vital signs

Prolonged Recovery


Hypeertensive episodeBlood Pressure

ER, hospital, mangement of bronchospasm

19 y/o undisclosed drug abuse, laryngospasm, intubated, excessive secretions

Airway Management

ER, monitored and discharged, non-cardiac

30 y/o post-op chest painChest Pain


Delirium, hypertension post-op, no intraoperative hypertension, resolved with narcan

Prolonged Recovery


Post-op chest painChest Pain






Slow recovery from versedProlonged Recovery


18 y/o developed tachycardia under sedationArrhythmia

Illinois Dental Practice Act ChartIllinois Dental Practice Act Chart

William Flick - I Floss Presentation.ppt

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