Shift magazine - Fall 2017

Anesthesia
Q&ASHIFT MAGAZINE GOES
ONE-ON-ONE WITH A PAST
PRESIDENT OF THE ASDA
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I S S U E S I N
P E D I A T R I C
D E N T I S T R Y
F A L L 2 0 1 7
10FACTSeveryone should know about
NITROUS
OXIDE
OPERATOR
ANESTHESIA
A need for an FDA
black box warning?
NAVIGATING
ICEBERGS
Safety in pediatric
procedural sedation
Surviving a
Devastatıng
TORNADORebuilding after a natural disaster
THE FDA
WARNINGON ANESTHESIA DRUGS
Critical issues when treating
some of our youngest patients
SPECIAL
SedatıonISSUEFOCUS ON PEDIATRIC
ANESTHESIA• Provide safe and superior hemostasis for your patients by using HemeRx.
• Prep EZCrowns with speed and efficiency using the EZPrep diamond bur system.
• Attend a Sprig University workshop to help you confidently offer your patients EZCrowns.

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November 5-9, 2018
SPRIG UNIVERSITY DESTINATIONS FOR 2018
NEW ORLEANS 2/16 DOMINICAN REPUBLIC 3/30 VANCOUVER 4/28

www.sprigusa.com / Fall 2017 3
PHILADELPHIA 8/24 LAS VEGAS 9/21 KEY BISCAYNE 12/7SAN DIEGO 7/20 PHILADELPHIA 8/24 LAS VEGAS 9/21 KEY BISCAYNE 12/7SAN DIEGO 7/20

32 TAKING LIFE IN STRIDE
A dental professional tells her story from the dual
viewpoints of a mom and anesthesia assistant.
40 BACK TO BASICS
Understanding options for in-office
procedural sedation.
CONTENTS Fa 2017
26 TEN FACTS PEOPLE SHOULD
KNOW ABOUT NITROUS OXIDE
Re-familiarize yourself with one of dentistry’s
most commonly used drugs.
22 ON THE SCENE
Spending good times with friends at all the
Sprig-attended events throughout 2017.
20 INFORMATION ESSENTIALS
It’s worth reading, because you don’t know
what you don't know.
26
48GOT QUESTIONS ABOUT
ANESTHESIA?
Shift magazine speaks with a dentist
anesthesiologist about some important
issues facing the profession today.
40
12 LETTER FROM THE EDITOR
Complacency Challenges.
24 DOCTOR TO DOCTOR
Hear from a colleague how Sprig [EZPEDO]
has effected his practice.
32
14 CONTRIBUTORS
Without whom this issue would
not have been possible.
48
4 Shift magazine / Fall 2017

62 SINGLE-OPERATOR
ANESTHESIA MODEL FOR PEDIATRIC
GENERAL ANESTHESIA:
A need for an FDA black box warning?
58
68 DEADLY WINDS
An encouraging story about rebuilding a dental
practice after a devastating tornado.
68
ONTHECOVER
COVERDESIGNBYMARKBOND
PHOTOGRAPHYBYSLAVADANILIUK
DENTISTRYBYVICTORIASULLIVAN,DDS
This issue of Shift magazine features Alex on the
cover. On page 32, his mom tells the story about how
it felt to switch roles from being a dental assistant
during general anesthesia cases to being a mom
accompanying her own child and experiencing
anesthesia from an entirely new perspective.
52 NAVIGATING ICEBERGS
Safety in pediatric procedural sedation.
58 THE FDA WARNING ON
ANESTHESIA DRUGS
Taking another look at anesthesia
issues when treating some of our
youngest patients.
CONTENTS
Fa 2017
&
SHOULD ONE
PROVIDER DO
BOTH?
Surgery
Anesthesia
62 SINGLE-OPERATOR
ANESTHESIA MODEL FOR PEDIATRIC
GENERAL ANESTHESIA:
A need for an FDA black box warning?
58
68 DEADLY WINDS
An encouraging story about rebuilding a dental
practice after a devastating tornado.
68
ONTHECOVER
COVERDESIGNBYMARKBOND
PHOTOGRAPHYBYSLAVADANILIUK
DENTISTRYBYVICTORIASULLIVAN,DDS
This issue of Shift magazine features Alex on the
cover. On page 32, his mom tells the story about how
it felt to switch roles from being a dental assistant
during general anesthesia cases to being a mom
accompanying her own child and experiencing
anesthesia from an entirely new perspective.
52 NAVIGATING ICEBERGS
Safety in pediatric procedural sedation.
58 THE FDA WARNING ON
ANESTHESIA DRUGS
Taking another look at anesthesia
issues when treating some of our
youngest patients.
CONTENTS
Fa 2017
&
SHOULD ONE
PROVIDER DO
BOTH?
Surgery
Anesthesia

52
62
52
62

SPRIG ORAL HEALTH TECHNOLOGIES
FORMALLY EZPEDO
FORMALLY EZPEDO

FORMALLY EZPEDO

As a dentist anesthesiologist, I go to work each day asking myself sobering, nagging
questions. “What if the unpredictable happens today? Will this patient be one who
experiences complications?” In anesthesiology, one never knows what challenges a
new day will bring. Life itself is full of risks, many of which we don’t spend much
time thinking about. To help parents imagine more clearly the relative risk of their
child’s anesthesia experience, I often explain it this way. Compared to other
activities of daily life which may be risky or scary, the risk of undergoing anesthesia
is about the same as going on a shopping trip to buy orange juice. This analogy
helps parents put the risk in perspective. Yet, while we don’t anticipate anything
going wrong, we must be careful to avoid adopting a complacent attitude and
prepare for that unexpected complication.
A personal experience last Tuesday taught me just how quickly things in life can
change. It was a day like any other, and I was doing what I have done thousands of
times before. As so often in life, we tend to slip into a spirit of complacency. After
all, we are doing a repetitive job, and in our own mind, we do it pretty well. Only on
Tuesday, I became distracted. Something caught my eye and diverted my attention
for only a couple of moments. And that’s all it took for everything to change in a
split second. We prepare for situations like this. We take tests to aid us in
remembering those things that will help act as safeguards, preventing accidents. As
dentists, we have all taken a practical exam to test our abilities in emergencies.
Sometimes, though, even when we have done everything right, things still go
wrong. So, on Tuesday, I never saw it coming. I didn’t even expect it. But it
happened nevertheless.
I didn’t have time to think; only time to react. When tragedy strikes, this is often
what happens. We aren’t able to process our thoughts simultaneously as bad things
are transpiring. We simply respond instinctively. And our reactions are molded by
how we have “prepared” in advance. Hopefully, with time to reflect and an
opportunity to look back and evaluate what happened, we can learn from our
mistakes and become even more vigilant in our actions, more committed to
ensuring the safety of ourselves and those around us.
Fortunately for me, my incident on Tuesday was unrelated to anesthesia. I was
involved in an auto accident on my way home from work, and, gratefully, everyone
was ok. So, while my accident didn’t relate to a patient at work, my experience on
the road did help me once again realize the danger of complacency and focus my
attention on the reality of our responsibility as anesthesia providers toward our
patients.
This issue of Shift magazine focuses on the topic of pediatric procedural sedation/
anesthesia. We are pleased to feature several timely articles addressing current
vitally important issues. One deals with the risks involved in adopting a single-
operator anesthesia model. Another provides guidelines for avoiding risks based on
AAPD guidelines. Other articles deal with recently required FDA warning labels, the
need to return to the basics of airway anatomy and sedation pharmacology, and the
safety track record of nitrous oxide. My hope is that these articles will inspire all of
us to commit our lives to being even more vigilant and well prepared to
conscientiously treat our patients with care and avoid falling victim to a feeling of
complacency.
LETTER THE EDITORfrom
Complacency
Challenges
PHOTOBYTIFFANYFISHER
Je rey P. Fisher, DDS
Editor-in-Chief
editor@sprigusa.com

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What are pediatric dentists saying?
LARY DEEDS, DMD
CLARKSVILLE, TENNESSEE
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Dr. Lenhart is a board-certified dentist
anesthesiologist with 20 plus years of
experience providing office-based
anesthesia in Northern California. After
receiving his DMD degree from Boston
University School of Dental Medicine, he
completed his postdoctoral anesthesia
residency training at Loma Linda
University Medical Center and Affiliate
Hospitals.Dr. Lenhart is a diplomate of
the American Dental Board of
Anesthesiology andlectures in the US
and internationally on topics related
to sedation and general anesthesia.
Contributors
Shift
Thomas E. Lenhart, DMD
Dr. Rashewsky received her DMD
from the Harvard University School of
Dental Medicine. She is dual-trained
in both anesthesia and pediatric
dentistry, receiving her certificate in
dental anesthesia from Stony Brook
University Medical Center in New York
and her certificate in pediatric
dentistry at the Children’s Hospital of
Philadelphia and the University of
Pennsylvania. Dr. Rashewsky is board
eligible in pediatric dentistry, a fellow
of general anesthesia in the American
Dental Society of Anesthesiology, and a
diplomate of the American Dental
Board of Anesthesia and National
Dental Board of Anesthesiology.
Jessica Harrison, RDA
Rita Agarwal, MD
Dr. Agarwal, clinical professor of anesthesiology at Stanford
University and pediatric anesthesiologist at Lucille Packard
Children's Hospital, completed her training at Baylor College of
Medicine in Texas and at the University of Colorado. Dr. Agarwal is
board certified in anesthesia and pediatric anesthesia by the
American Board of Anesthesiology. She was pediatric anesthesia
program director at the University of Colorado for 18 years prior to
transitioning to Stanford. From 2015–2017, she served as chair,
American Academy of Pediatrics Section on Anesthesiology and Pain
Management. Her interests include pediatric acute pain
management, regional anesthesia, ambulatory anesthesia, neuro-
anesthesia, and medical student/resident/fellow education.
Alex’s mom, Jessica, has been a
registered dental assistant since
2002. She currently works in
pedodontics for a Sacramento area
dentist. Her experience has ranged
from general dentistry and oral
surgery to orthodontics and
endodontics. She has worked with
many different demographics in
Northern California, and prior to
that, in San Diego. She views her job
as being “the buffer” between the
parent/patient and the dentist.
Stephanie Reshewsky, DMD
Dr. Lenhart is a board-certified dentist
anesthesiologist with 20 plus years of
experience providing office-based
anesthesia in Northern California. After
receiving his DMD degree from Boston
University School of Dental Medicine, he
completed his postdoctoral anesthesia
residency training at Loma Linda
University Medical Center and Affiliate
Hospitals.Dr. Lenhart is a diplomate of
the American Dental Board of
Anesthesiology andlectures in the US
and internationally on topics related
to sedation and general anesthesia.
Contributors
Shift
Thomas E. Lenhart, DMD
Dr. Rashewsky received her DMD
from the Harvard University School of
Dental Medicine. She is dual-trained
in both anesthesia and pediatric
dentistry, receiving her certificate in
dental anesthesia from Stony Brook
University Medical Center in New York
and her certificate in pediatric
dentistry at the Children’s Hospital of
Philadelphia and the University of
Pennsylvania. Dr. Rashewsky is board
eligible in pediatric dentistry, a fellow
of general anesthesia in the American
Dental Society of Anesthesiology, and a
diplomate of the American Dental
Board of Anesthesia and National
Dental Board of Anesthesiology.
Jessica Harrison, RDA
Rita Agarwal, MD
Dr. Agarwal, clinical professor of anesthesiology at Stanford
University and pediatric anesthesiologist at Lucille Packard
Children's Hospital, completed her training at Baylor College of
Medicine in Texas and at the University of Colorado. Dr. Agarwal is
board certified in anesthesia and pediatric anesthesia by the
American Board of Anesthesiology. She was pediatric anesthesia
program director at the University of Colorado for 18 years prior to
transitioning to Stanford. From 2015–2017, she served as chair,
American Academy of Pediatrics Section on Anesthesiology and Pain
Management. Her interests include pediatric acute pain
management, regional anesthesia, ambulatory anesthesia, neuro-
anesthesia, and medical student/resident/fellow education.
Alex’s mom, Jessica, has been a
registered dental assistant since
2002. She currently works in
pedodontics for a Sacramento area
dentist. Her experience has ranged
from general dentistry and oral
surgery to orthodontics and
endodontics. She has worked with
many different demographics in
Northern California, and prior to
that, in San Diego. She views her job
as being “the buffer” between the
parent/patient and the dentist.
Stephanie Reshewsky, DMD

Dr. Coté, professor of anesthesia (emeritus) at Harvard Medical School’s
Division of Pediatric Anesthesia, is board certified in both pediatrics and pediatric
anesthesiology. From 2005–2014, he served as director of clinical research in the
Division of Pediatric Anesthesia, MassGeneral Hospital for Children. He has been
the primary author of every sedation guideline published by the American Academy
of Pediatrics since 1985. Dr. Coté’s textbook, A Practice of Anesthesia in Infants
and Children is currently in its fifth edition. He has also authored numerous peer-
reviewed publications, reviews, editorials, and clinical practice guidelines. Dr. Coté
has also served as a member of the FDA's Committee on Medical Devices and the
ASA's Committee for Patient Safety and Risk Management.
Bobby Thikkurissy, DDS, MS
Dr. S. “Bobby” Thikkurissy is professor and division
director at Cincinnati Children’s Hospital. He earned
his DDS degree from New York University in 1998
and received a certificate in pediatric dentistry from
The Ohio State University in 2003. He served as
director of the pre-doctoral program in pediatric
dentistry at OSU from 2006–2011 and has served as
program director at Cincinnati Children’s Hospital
since 2013. He has published in the areas of
morbidity associated with dental disease and
procedural sedation. Dr. Thikkurissy served on the
ADA Council of Dental Education and Licensure
from 2013–2016 and as chair of the AAPD
Committee on General Anesthesia and Sedation
from 2012–2016. He has presented CE courses in
over 15 states as well as in China and Serbia. He is a
diplomate of the American Board of Pediatric
Dentistry and serves on their Qualifying
Examination Committee. Dr. Thikkurissy is also a
national spokesperson for the AAPD. Dr. Ganzberg, clinical professor of anesthesiology at the UCLA School of Dentistry,
is a dentist anesthesiologist with over 25 years of experience in pain management.
Dr. Ganzberg graduated from MIT in 1977 and the University of Pennsylvania
School of Dental Medicine in 1981. He completed his pain management training at
New York University and his anesthesiology training and master’s degree at The
Ohio State University. Dr. Ganzberg taught at OSU for 17 years where he directed
the anesthesiology residency program in the College of Dentistry before coming
to UCLA. He is currently section chair of dental anesthesiology at UCLA where he
teaches pharmacology, sedation, and anesthesiology in the School of Dentistry. He
also engages in private dental anesthesiology practice. Dr. Ganzberg is the editor
of Anesthesia Progress and has lectured extensively on topics involving
anesthesiology,sedation, and medicine.
Stephen Ganzberg, DMD, MS
Michael Mashni, DDS
Dr. Michael Mashni received his DDS degree
from Loma Linda University School of
Dentistry in 1992 and continued to complete
his anesthesia training there in 1994. He is a
diplomate of the American Dental Board of
Anesthesiology. He is a past president of the
American Society of Dentist Anesthesiologists
and a past board member of the American
Dental Board of Anesthesiology. Dr. Mashni is
a founder and current board member of the
American Board of Dental Specialties. He
maintains a private practice in Southern
Californiaprimarilyproviding anesthesia
services to pediatric patients.
Benjamin
Rosenberg, DDS
Dr. Rosenberg graduated from the
University of Missouri Dental School in
Kansas City where he also completed his
internship and pediatric residency at
Children’s Mercy Hospital. After being in
private practice in Joplin, Missouri, since
1972, the tornado of May 2011 destroyed
his dental office completely. Missing only
one week of work, Dr. Rosenberg began
rebuilding a new office which he moved
into a year later. When not in the office,
Dr. Rosenberg enjoys going to auctions
and sales looking for antique toys. He and
his wife Patty have four grown children.
Charles J. Coté, MD
James Tom, DDS, MS
Dr. Tom is associate clinical professor at
the Herman Ostrow School of Dentistry,
University of Southern California, where
he earned his DDS degree. He completed
his anesthesia training and received an
MS degree in anesthesiology from The
Ohio State University. Dr. Tom currently
serves as president of the American
Society of Dentist Anesthesiologists and
as the assistant editor of Anesthesia
Progress. Dr. Tom is the appointed ADA
and ASDA representative on the
American Society of Anesthesiologists
Task Force on Guidelines for Moderate
Procedural Sedation. He also maintains a
private dentist anesthesiologist practice
in Los Angeles.
Dr. Coté, professor of anesthesia (emeritus) at Harvard Medical School’s
Division of Pediatric Anesthesia, is board certified in both pediatrics and pediatric
anesthesiology. From 2005–2014, he served as director of clinical research in the
Division of Pediatric Anesthesia, MassGeneral Hospital for Children. He has been
the primary author of every sedation guideline published by the American Academy
of Pediatrics since 1985. Dr. Coté’s textbook, A Practice of Anesthesia in Infants
and Children is currently in its fifth edition. He has also authored numerous peer-
reviewed publications, reviews, editorials, and clinical practice guidelines. Dr. Coté
has also served as a member of the FDA's Committee on Medical Devices and the
ASA's Committee for Patient Safety and Risk Management.
Bobby Thikkurissy, DDS, MS
Dr. S. “Bobby” Thikkurissy is professor and division
director at Cincinnati Children’s Hospital. He earned
his DDS degree from New York University in 1998
and received a certificate in pediatric dentistry from
The Ohio State University in 2003. He served as
director of the pre-doctoral program in pediatric
dentistry at OSU from 2006–2011 and has served as
program director at Cincinnati Children’s Hospital
since 2013. He has published in the areas of
morbidity associated with dental disease and
procedural sedation. Dr. Thikkurissy served on the
ADA Council of Dental Education and Licensure
from 2013–2016 and as chair of the AAPD
Committee on General Anesthesia and Sedation
from 2012–2016. He has presented CE courses in
over 15 states as well as in China and Serbia. He is a
diplomate of the American Board of Pediatric
Dentistry and serves on their Qualifying
Examination Committee. Dr. Thikkurissy is also a
national spokesperson for the AAPD. Dr. Ganzberg, clinical professor of anesthesiology at the UCLA School of Dentistry,
is a dentist anesthesiologist with over 25 years of experience in pain management.
Dr. Ganzberg graduated from MIT in 1977 and the University of Pennsylvania
School of Dental Medicine in 1981. He completed his pain management training at
New York University and his anesthesiology training and master’s degree at The
Ohio State University. Dr. Ganzberg taught at OSU for 17 years where he directed
the anesthesiology residency program in the College of Dentistry before coming
to UCLA. He is currently section chair of dental anesthesiology at UCLA where he
teaches pharmacology, sedation, and anesthesiology in the School of Dentistry. He
also engages in private dental anesthesiology practice. Dr. Ganzberg is the editor
of Anesthesia Progress and has lectured extensively on topics involving
anesthesiology,sedation, and medicine.
Stephen Ganzberg, DMD, MS
Michael Mashni, DDS
Dr. Michael Mashni received his DDS degree
from Loma Linda University School of
Dentistry in 1992 and continued to complete
his anesthesia training there in 1994. He is a
diplomate of the American Dental Board of
Anesthesiology. He is a past president of the
American Society of Dentist Anesthesiologists
and a past board member of the American
Dental Board of Anesthesiology. Dr. Mashni is
a founder and current board member of the
American Board of Dental Specialties. He
maintains a private practice in Southern
Californiaprimarilyproviding anesthesia
services to pediatric patients.
Benjamin
Rosenberg, DDS
Dr. Rosenberg graduated from the
University of Missouri Dental School in
Kansas City where he also completed his
internship and pediatric residency at
Children’s Mercy Hospital. After being in
private practice in Joplin, Missouri, since
1972, the tornado of May 2011 destroyed
his dental office completely. Missing only
one week of work, Dr. Rosenberg began
rebuilding a new office which he moved
into a year later. When not in the office,
Dr. Rosenberg enjoys going to auctions
and sales looking for antique toys. He and
his wife Patty have four grown children.
Charles J. Coté, MD
James Tom, DDS, MS
Dr. Tom is associate clinical professor at
the Herman Ostrow School of Dentistry,
University of Southern California, where
he earned his DDS degree. He completed
his anesthesia training and received an
MS degree in anesthesiology from The
Ohio State University. Dr. Tom currently
serves as president of the American
Society of Dentist Anesthesiologists and
as the assistant editor of Anesthesia
Progress. Dr. Tom is the appointed ADA
and ASDA representative on the
American Society of Anesthesiologists
Task Force on Guidelines for Moderate
Procedural Sedation. He also maintains a
private dentist anesthesiologist practice
in Los Angeles.

Issues in Pediatric Dentistry
JEFFREY P. FISHER, DDS
Editor-in-Chief
JAMES R.FISHER, MSPH, PhD
Senior Consulting Editor
ANN FISHER
Copy Editor/Proof Reader
TIMOTHY SHAMBRA
Senior Designer
DANIEL VAKARYUK
Art Director
MARK BOND
Cover Designer
VLADIMIR SHCHERBAK
Senior Design Consultant
Contributing authors
Bobby Thikkurissy, DDS, MS / Stephanie Reshewsky, DMD / Thomas E. Lenhart, DMD / Stephen Ganzberg, DMD, MS
Michael Mashni, DDS / Benjamin Rosenberg, DDS / Jessica Harrison, RDA / Rita Agarwal, MD, Charles J. Coté, MD, James Tom, DDS, MS
Contributing photographers
Slava Daniliuk / Daniel Vakaruk / Timothy Shambra
Special thanks to
Victoria Sullivan, DDS / Shelli Crane / Kim & Tiffany Fisher
SPRIG ORAL HEALTH TECHNOLOGIES, INC.
Publisher
STEPHEN SMITH
Advertising Contracts
TIMOTHY SHAMBRA
Advertising Sales
LYUBA KOLOMITETS
Finance & Accounting
For editorial enquiries please email: editor@sprigusa.com
For advertising enquiries please email: timothy@sprigusa.com
Subscriptions are available online by visiting: www.sprigusa.com/magazine
For additional enquiries please call: 888 539 7336 / Int. (1) 916 677 1447
Shift magazine, a contemporary dental publication highlighting relevant topics of interest for busy practitioners in private practice, publishes scientific articles, case
reports, and human-interest stories focusing on current issues in pediatric dentistry. Pediatric and general dentists will learn about new concepts in restorative treatments
and the latest innovations in techniques and products, all available in the one magazine that helps them keep pace with rapid changes in pediatric dentistry.
© Copyright 2017 Shift magazine, a subsidiary of Sprig Oral Health Technologies, Inc. All Rights Reserved.
SPRIG ORAL HEALTH TECHNOLOGIES, INC.
6140 HORSESHOE BAR ROAD, SUITE L
LOOMIS, CALIFORINA 95650
Previously published biannually as EZPEDO Magazine 2015—2016.

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GOOD
TIMES
S O C I A LNETWORK
P E O P L E , P L A C E S , A N D PA R T I E S
AAPD 2017
This year's 2017 AAPD in Washington,
D.C., was amazing. We hope you
enjoyed listening to all the great speak-
ers that presented on engaging and
relevant dental topics, and we thank
each of you who took time to stop by
our booth for a visit.

SPECIAL
MOMENTS
E V E N T S
Sprig University 2017
What an absolute joy to spend quality time with
familiar faces and have the opportunity to meet
new friends. We can't wait to see you at our
next educational event and discuss the future of
pediatric dentistry.

Lary W. Deeds, DMD, obtained his Doctor
of Dental Medicine degree at the University
of Florida. He completed a residency in
pediatric dentistry while serving in the U.S.
Army. After retiring from the Army, Dr.
Deeds and his family have made Clarksville,
Tenn. their home. He opened The Children's
Dentist in April 1998. He is board certified
and a diplomate of the American Academy of
Pediatric Dentistry. He lectures to local civic
organizations and enjoys running marathons
and competing in Scrabble. To stay abreast of
the latest advancements in pediatric
dentistry, Dr. Deeds maintains memberships
with the American Dental Association,
Tennessee Dental Association, American
Academy of Pediatric Dentistry, and the
Southeast Pediatric Dental Association.
DOCTOR TO DOCTOR

I have been using Zirconia
EZCrowns for the last three years.
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TESTIMONIAL

KNOW
TEN FACTS
PEOPLE
{ }SHOULD
ABOUT
NITROUS
OXIDEBy Stephanie Rashewsky, DMD
From Dentist to Superhero

9.
It is impossible
to induce general
anesthesia with
nitrous oxide as
a sole agent.
The minimum alveolar
concentration (MAC) of nitrous
oxide is 104 percent, making it
impossible to induce general
anesthesia with nitrous oxide as
the sole agent. It is the least
potent of all anesthetic gases in
use today. When administering
general anesthesia, nitrous
oxide is commonly used in
combination with other volatile
agents. Be aware that patients
undergoing nitrous oxide
sedation in concentrations
greater than 50 percent—or in
combination with other sedating
medications (e.g. midazolam/
Versed, meperidine/Demerol)—
have an increased risk for falling
into moderate or deep sedation.
10. 8.
Nitrous oxide has an
excellent safety record
with no evidence of
mortality when used
appropriately and as
the sole agent in a
dental office.
The main inherent danger in
nitrous oxide use is hypoxia.
However, fail-safe mechanisms
ensure a minimum oxygen
concentration of 30 percent is
delivered in the gas mixture.
Other safety considerations
include the following:
a) preventing the interchange
of connections via the pin-index
safety system and diameter-
index system, b) having
appropriate scavenging systems
to minimize room air
contamination and occupational
risks, and c) providing available
emergency equipment—
specifically a 650-liter “E”
cylinder of oxygen.4
An American dentist,
Horace Wells, is
recognized as the
father of anesthesia.
Nitrous was first used in
dentistry in the 1840s by Horace
Wells, a dentist in Hartford,
Conn., when he inhaled the
agent prior to the extraction of
one of his own teeth.1 Today,
nitrous oxide usage in pediatric
dentistry is so common that it’s
use is often considered a routine
adjunct for behavior
management. In fact, recent
studies show that 97 percent of
pediatric dentists use nitrous
(laughing gas) in their offices.2

7.
Diffusion hypoxia
can lead to patients
experiencing headaches
and disorientation.
Nitrous oxide is 34 times more
soluble than nitrogen in blood.
At the end of the procedure, 100
percent oxygen should be
administered for five minutes to
prevent the rapid release of
nitrous oxide from the
bloodstream into alveoli which
then dilutes the concentration of
oxygen, increasing the risk of
hypoxia. Acute hypoxia may
result in patients experiencing
headaches and disorientation.
Also, remember that children
desaturate more quickly
than adults.3
6.
Nitrous may not be
the agent of choice
for everyone.
Nitrous oxide is a great option
for most patients. However, a
number of relative
contraindications exist,
including patients with the
following conditions: chronic
obstructive pulmonary disease,
pneumothorax, severe asthma,
upper respiratory tract
infections (blocked sinuses,
blocked nasal passages, colds,
influenza), acute otitis media or
history of middle ear surgery
(tympanic membrane graft),
cystic fibrosis, colostomy bags or
bowel obstructions, severe
mental/psychiatric conditions or
drug-related dependencies, first
trimester of pregnancy, history
of bleomycin sulfate treatment,
and deficiencies in
methylenetetrahydrofolate
reductase and cobalamin. When
in doubt, initiate a medical
consult and obtain medical
clearance prior to the use of
nitrous oxide.3-4
5.
Nitrous oxide’s most
common side effects
are nausea and
vomiting.
Despite nausea and vomiting
being the most common side
effects, these outcomes are still
rather rare, occurring in only 0.5
percent of patients. No strict
fasting guidelines govern the use
of nitrous oxide, but it may be
wise to recommend that patients
eat only a light meal prior to its
administration. Other
recommendations to decrease
the incidence of nausea and
vomiting include: a) avoid
lengthy administration
( > 1 hour), b) minimize wide
fluctuations in nitrous oxide
levels, and c) avoid nitrous
concentrations above
50 percent.3
Nitrous oxide is an ideal agent because its
actions relieve anxiety and it possesses
speciﬁc qualities that relieve discomfort. Plus,
once patients quit breathing the gas, its
e ects dissipate rapidly, making it safe to
discharge your patients and send them home
soon following a procedure. Nitrous oxide has
a morphine-like e ect, and while it doesn’t
eliminate discomfort, it mutes it, and removes
the emotional component of pain, making it
an excellent drug for use in children.
28 Shift Magazine / Fall 2017

4.
Nitrous oxide
consistently ranks as one
of the behavior
management techniques
most well accepted by
parents.
In a 1984 survey, sedation—
including nitrous oxide—was
listed as eighth (out of ten) in
terms of acceptability. By 1991,
nitrous was rated second in terms
of parental acceptance following
“Tell-Show-Do” (TSD). Nitrous
oxide remained second behind
TSD in a separate study in 2005.6
Today, parents increasingly accept
the use of the technique.
However, make sure you obtain
informed consent before using
nitrous oxide. Also, be sure to
document the following in the
patient’s chart: a) an indication for
use of this type of sedation, b) the
nitrous oxide dosage used, c) the
duration of nitrous sedation,
and d) the post-treatment
oxygenation procedure.
AMAZING FACTS
ABOUT N20
SYNONYMS & TRADE NAMES:
• Dinitrogen monoxide, Hyponitrous
acid anhydride, Laughing gas
PHYSICAL DESCRIPTION:
• Colorless inhalation anesthetic with a
slightly sweet odor. Note: Shipped as
a liquefied compressed gas.
• Molecular weight: 44.0 g/mol
• Boiling point: -127 degrees F
• Solubility: (77 degrees F)
0.1% Vapor Pressure
• Nonflammable gas, but supports
combustion at elevated temperatures.
• Incompatibilities & reactivities:
Aluminum, boron, hydrazine, lithium,
hydride, phosphine, sodium
TARGET ORGANS
• Respiratory system, central nervous
system, reproductive system
SYMPTOMS OF OVEREXPOSURE
• Dyspnea (breathing di culty),
drowsiness, headache, asphyxia,
reproductive e ects, liquid frostbite
Nitrous oxide allows
pediatric dentists to
be superheroes!
TheNationalInstituteforOccupationalSafetyandHealth(NIOSH)
https://www.cdc.gov/niosh/npg/npgd0465.html

As pediatric dentists, our role is akin to that of superheroes, and nitrous
oxide sedation is the extraordinary power that gives us an alternative to
other more advanced behavioral-management techniques such as
protective stabilization, deep sedation, and general anesthesia. Since its
discovery more than 170 years ago, nitrous oxide has had an impeccable
safety track record. With the Internet, every parent now has the potential
to become an “expert.” Consequently, we receive inquiries daily about
safety concerns, including questions about fluoride, radiographs,
sedation, and more. Fortunately, nitrous oxide is well accepted by
parents, mainly due to its excellent safety record, rapid onset of action,
short duration, reversibility, and titratability.
This colorless and virtually odorless gas—the one that allows us to
provide safe and effective analgesia and anxiolysis while treating
challenging children—deserves our deep appreciation. Nitrous oxide
allows us as pediatric dentists to enhance the effectiveness of our
communication and improve patient cooperation in anxious children.
How fortunate we are that Horace Wells introduced dentistry to nitrous
oxide’s amazing superpower qualities, allowing us to fulfill our role as
superheroes in our patients’ eyes!
3.
Analgesia, anxiolysis,
and euphoria, Oh my!
Nitrous oxide has multiple
mechanisms of action that lead
to central nervous system
depression and euphoria. While
the mechanism by which nitrous
oxide acts upon the nervous
system is not fully understood,
the analgesic and anxiolytic
effects are thought to be similar
to those of opioids and
benzodiazepines, respectively.5
Nitrous oxide—when used in
conjunction with communicative
behavior guidance techniques—is
especially effective in helping
children learn to cope with their
fears, anxieties, and the stress
associated with dental treatment.
2.
Titrate, titrate, titrate!
Initially, 100 percent oxygen
should be administered for 1–2
minutes followed by titration of
nitrous oxide in intervals of 10
percent until the desired
sedation is achieved, with most
patients requiring 30–40
percent nitrous oxide. The
concentration of nitrous oxide
should not routinely exceed 50
percent. During treatment,
monitoring the status of the
following items will help you
to select the appropriate
concentration of nitrous oxide:
a) patient’s respiratory rate and
rhythm, b) patient’s response to
commands, and c) level of
patient’s consciousness.3
1.
Nitrous oxide is
nearly an ideal
anesthetic agent.
Nitrous oxide has many
characteristics of an ideal
anesthetic agent. It has a great
track record in terms of safety
due to the fact that it can be
delivered in a noninvasive
manner, it lacks serious side
effects, it’s simple to use, and has
rapid onset and quick recovery.7
For these reasons, nitrous oxide
has many health-care
applications including fracture
reduction, laceration repair,
otologic procedures, labor pain
relief, and of course, pediatric
dentistry treatment.
1. Gifford EE. Horace Wells discovers pain-free dentistry. Retrieved from: https://connecticuthistory.org/
horace-wells-discovers-pain-free-dentistry.
2. Wilson S, Gosnell ES. Survey of American Academy of Pediatric Dentistry on nitrous oxide sedation: 20
years later. Pediatr Dent 2016;38:385—392.
3. American Academy of Pediatric Dentistry. Guideline on use of nitrous oxide for pediatric dental
patients. Pediatr Dent 2016;38:211—215.
4. Clark MS, Brunick AB. Handbook of nitrous oxide and oxygen sedation. 4th edition, Mosby, 2015.
5. Wright GZ, Kupietzky A. Behavior management in dentistry for children. 2nd edition, Wiley Blackwell,
2014.
6. Levering NJ, Welie JVM. Current status of nitrous oxide as a behavioral management practice routine
in pediatric dentistry. Dent Child 2011;78:24—30.
7. Klein U, Robinson TJ, Allshouse A. End-expired nitrous oxide concentrations compared to
flowmeter settings during operative dental treatment in children. Pediatr Dent 2011;33:56—62.
References
3.
2.
1.
Nitrous oxide is
nearly an ideal
anesthetic agent.
2014.
References
30 Shift Magazine / Fall 2017
3.
2.
1.
Nitrous oxide is
nearly an ideal
anesthetic agent.
2014.
References

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of dentistry or AGD endorsement. 5/1/2016
to 4/30.2018. Provider ID 358727

TAKING
LIFE IN
STRIDEAlex’s mom, an RDA, shares her
experience facing her own son’s
dental work under general anesthesia
from a mother’s perspective.
By Jessica Harrison, RDA
TAKING
LIFE IN
STRIDEFrom a mother’s perspective, Alex’s
mom, an RDA, shares her experience
facing her own son’s dental work
under general anesthesia.
By Jessica Harrison, RDA

www.sprigusa.com / Fall 2017 33www.sprigusa.com / Fall 2017 33

hen you found out your son, Alex,
needed crowns, what went through your
mind, knowing what you know as an RDA?
JESSICA
As soon as Alex's second primary molars started to erupt, I noticed they
had hypoplasia (defective enamel formation.) I watched these four
teeth closely as they erupted. When Alex was almost 3 years old, and as
soon as the molars had erupted fully, I knew it was time to cap those
teeth with crowns. Being a mom as well as an RDA and knowing what I
do about the importance of prevention, I found it hard to face the
reality that my own child needed dental treatment. Yet, in Alex's case,
since the hypoplasia on his teeth resulted from uncontrollable causes,
there was no way for me to have prevented the condition. All I could do
was to make sure his teeth would be treated correctly.
With your background assisting with
general anesthesia on a monthly basis in the
dental o ce, did that experience a ect
your decision on how and where Alex would
be treated?
JESSICA
I have watched children go under sedation for over 15 years.
I have also seen kids in the dental office undergoing treatment and
experiencing unpleasant situations which could have been avoided if
their parents had chosen to request sedation. My son Alex is young, and
I did not want him to be "traumatized" if the visit did not go well. I have
seen that happen far too many times. Previously, my older son Jordan
had a small occlusal cavity on #L. I decided to treat him in the dental
office, but the visit did not go well. Let’s just say it has taken him three
years to finally be at ease during his routine visit to take X-rays and do a
prophy. I did not want Alex to have that kind of experience.
As soon as I knew Alex would need treatment, I was 100 percent in
favor of choosing sedation for him. If I was not experienced in the use
of anesthesia, then I may have felt differently and not wanted my son
sedated. I probably would have wanted to see how the treatment would
go in the dental office without sedation. However, due to my previous
experience as a RDA, I did not even consider having Alex's dental
treatment attempted while he was unsedated. I wanted his future
cleaning visits to continue to go well without creating any fear on his
part. He is a very wiggly little boy, and I know he would have had
trouble holding still for treatment. As a dental professional, I know that
when kids do not hold still, the dentist has a difficult time doing the
dental work and achieving 100 percent ideal results. So, I put my full
trust in the sedation process with the knowledge that my son would
have no idea of what happened and would continue to experience easy
routine cleanings in the future.
W

How did your experience with Alex in the
hospital di er from your own experience
being part of the anesthesia team o ering
sedation in an o ce setting? Why did you
choose one location over the other?
JESSICA
I chose for my son to have sedation done at Kaiser Permanente Medical
Center, and it went flawlessly. Seizures run in our family, and since he has
experienced one seizure already, I felt safer with him being sedated in the
hospital instead of receiving IV sedation in my office. I also have Kaiser
Insurance, so my co-pay was not that much. My experience as a mom with
Alex in the hospital was good. I knew the steps that the nurses, dentist, and
anesthesiologist would take. I understood why they were checking his
vitals. I knew what was going to happen once he was wheeled away from
me on the gurney. Prior to this experience, when I was part of the
anesthesia team, I did not empathize that much personally with the
patient’s parents because I had not been through it myself. Now that I have
had my own experience with my child being sedated for dental treatment,
I can sympathize more fully with parents.
When you saw Alex in recovery after the
procedure, how did that make you feel? What
was going through your mind?
JESSICA
I was happy to see Alex once he was in recovery. I had full confidence in
the staff at Kaiser and prayed for no complications. I know from an
assistant’s viewpoint, it is best to just let the child wake up on his own,
slowly. I have seen many parents start to rock their children trying to rush
them awake. My husband and I just sat there quietly with Alex, and once
he started to wake up on his own, then we were right there to assure him.
He woke up with no tears. The nurse gave him a popsicle, and he left
happy. He even wanted to go to the park later that day.
How has your personal experience with Alex
going through his anesthesia changed the way
you interact with other parents whose
children are preparing for sedation?
JESSICA
After my positive experience with my own son’s sedation, I am even more
in favor of using sedation than I was before. I would not want to put a child
through the fearful experience of unsedated treatment when there is such
an easier way. In my opinion, children should have as positive a dental
experience as possible. Now when I talk to parents, I am able to share with
them my own experience and am better informed to advise them
regarding the benefits of treating children with sedation. I am a parent
first and a dental professional second. Sedation/anesthesia can be scary for
both patients and their parents. The media have not helped the situation. I
always recommend that parents educate themselves in advance. I urge
them to ask questions and not rely only on news stories, since the
information they report may not always be accurate.

Thank you to the entire Harrison
family for sharing your story.
Mr. and Mrs. Harrison, along with their three beautiful children, live
in Folsom, California. Mr. Harrison is a police officer with the Los
Rios Police Department at the Folsom Campus.

F A C E B O O K . C O M / S P R I G
T W I T T E R . C O M / S P R I G
Y O U T U B E . C O M / S P R I G
WE’D LOVE
TO CONNECT
WITH YOU.
U S A
U S A
U S A
I N S T A G R A M . C O M / S P R I G U S A

BACK TO
BASICS
By Thomas E. Lenhart, DMD
UNDERSTANDING TREATMENT OPTIONS
FOR IN-OFFICE SEDATION
Does this ever
happen at
your office?

oung children 2–5 years of age are cognitively,
emotionally and/or physically unable to
consistently follow commands and
instructions or to adequately control their
emotions.1 The two main approaches to
behavioral management in this age group are
non-pharmacologic and pharmacologic. In the past, non-
pharmacologic behavioral management techniques were
the most frequently used as a means by which the
pediatric dentist could safely and efficiently provide
treatment and leave the young child with an emotionally
and physically positive experience. The most common
non-pharmacologic behavioral management techniques
utilized are communication, humor, behavioral shaping,
voice control, hypnosis, coping skills, aversive
conditioning, distraction, and physical restraint.2,3
As an office-based, mobile anesthesiologist and educator
for more than 20 years, I have seen a definitive shift in the
choice of behavioral-management techniques adopted by
dentists when treating children in the 2–5-year age group.
Over the last few decades, child behavior (which is
increasingly difficult to control) along with changes in
parental expectations have resulted in the restraint
forms of non-pharmacologic behavioral management
becoming almost obsolete.
Today, pharmacologic behavioral management is the new
standard/norm governing patient care in pediatric
dentistry. The standard I am referring to is the use of oral
conscious sedation or general anesthesia. An estimated
100,000–250,000 pediatric dental sedations are
performed each year in the United States.4 This treatment
norm provides comfort, pain relief, and anxiolysis. It also
minimizes psychological trauma related to dental surgery.
The major objectives of sedation are to alter the child’s
awareness, ensure intact reflexes (including the muscles of
the airway), maintain normal vital signs (heart rate,
respiration rate, blood pressure, temperature), increase
the patient’s pain threshold, and produce amnesia in order
to allow the dentist to effectively and successfully
complete treatment.
Y

CASE SELECTION TOOLS
Patient selection is the most important step in
minimizing the risk of sedation for children.
Pediatric dentists need to use all assessment tools
available to develop criteria which will allow them
to choose the proper treatment location, type of
sedation to be used, appropriate medications, and
route of administration. The major tools available
to ensure proper patient selection include: 1) a
thorough review of the child’s medical history, 2) a
review of systems, 3) a focused physical exam, 4)
ASA risk classification, and 5) airway evaluation.
Medical History:
The purpose of a medical history is to gather as
much information about your patient as possible.
One complicating factor in obtaining an accurate
medical history is due to the current trend of
parents not being forthcoming when reporting
their child’s past or present health history and
related medical problems. This reluctance of
parents to disclose health problems may be due to
issues relating to insurance exclusions or fear of a
potential increase in premiums. Because of these
factors, it is important, especially when your
assessment warrants it, to request a recent history
and physical—along with any test or lab results—
from the patient’s pediatrician.
Review of Systems:
This next tool presents a list of questions, arranged
by organ system, designed to uncover any existing
dysfunction or disease. The review gives a pediatric
dentist an opportunity to discover any subjective
symptoms that parents either forgot to describe or
considered relatively unimportant at the time they
filled out the medical history form. In summary,
this review serves as a tool enabling a dentist to
reveal omissions, inconsistencies, or patient co-
morbidities not previously mentioned.
Focused Physical Exam:
This exam is used to build on the information
gathered during the medical history and review of
systems. The first step in a proper physical exam is
to obtain the child’s base-line vital signs such as
heart rate, respiratory rate, blood pressure and
temperature along with the knowledge of the
normal values associated with patients of that
specific age.
The next step is to auscultate the child’s heart and
lungs with a quality stethoscope in order to rule out
dysrhythmias, murmurs, congenital heart defects,
stridor, croup, congestion, or decreased breath
sounds. Remember, you don’t need to be a
cardiologist, but you do need to know normal
sounds from abnormal sounds. I recommend that
you execute a YouTube.com search for “heart and
lung sounds.”
The most common reasons to cancel a child’s
scheduled sedation procedure include the
following: an undiagnosed heart murmur or
murmur greater than a grade II/VI, an upper
respiratory infection (URI), cough, cold, flu and/or
fever within two weeks of the scheduled procedure.
Remember to ask specific questions. This history is
critical in avoiding intra-operative airway
complications.
ASA Risk Classification:
This tool provides a means of assessing the child’s
overall physical health or "sickness" prior to
sedation. It is also a predictor of whether or not the
child should be treated in an office-based setting.
My personal opinion is that only ASA I & II patients
should be sedated in an office-based setting.
I will highlight three topics
that, if properly attended to, I
believe can dramatically
increase the overall safety and
effectiveness of procedural
sedation and/or general
anesthesia associated with
children in the office-based
dental setting: 1) case selection
tools for use in identifying
patients eligible to receive
sedations, 2) choosing the
appropriate type of sedation,
and 3) recognition and
management of complications
associated with sedation.

Airway Evaluation:
“Airway, Airway, Airway.” NEVER forget this
phrase. This emphasis on maintaining an open
airway takes priority over everything else we do.
From my perspective, without a patent airway, the
teeth do not matter. Why do I say this? Children’s
anatomy and physiology inherently increases their
risks during sedation. They very quickly
desaturate, becoming hypoxic, cyanotic, and
bradycardic, which leads to cardiopulmonary
arrest. Sometimes the slightest increase in the
opening of the mouth or the slightest change in
head positioning can partially or completely block
the child’s airway during the surgical procedure
without a dentist realizing it.
I start my airway evaluation with an overall
assessment of the head. I ask myself the following
questions: Is there any craniofacial dysostosis or
syndromic features? Does the child have any facial
asymmetries? Does the child have full range of
motion of their neck? I have the child look up,
down, left and right in order to evaluate full
extension and flexion of the neck. What is the
maximum opening of the mouth? Is there any
limitation to opening or closing of the mouth? Is
the child a mouth breather? Do they have rhinitis?
What is the thyroid mental distance?
I will then have a child open his mouth and stick
out his tongue without saying “awwh” in order to
assess his Mallampati classification. This
evaluation is a good predictor of obstruction,
apnea, and/or difficult airway. It is best to avoid
oral sedation on children with a Class III or IV
Mallampati classification.
Finally, I will assess the patency of the child’s nose.
Is the child congested? One can only imagine how
difficult it must be to move air in and out through
a partially obtunded airway.
Medical History
Review of Systems
Focused Physical Exam
ASA Risk Classification
Airway Evaluation

CHOICES TO MAKE—
ORAL SEDATION OR
GENERAL ANESTHESIA?
When making a decision regarding sedation options
for a pre-cooperative young child with extensive
dental decay, the pediatric dentist must most often
choose between treatment under oral conscious
sedation with passive restraint or general anesthesia.
What are the factors to consider when making such a
decision?
Choosing an Anesthetic Agent:
The common oral medications used to sedate fearful
or uncooperative children have not changed much in
the past 50 years. Many of these medications are
antiquated with narrow margins of safety. Newer
medications, like midazolam, have a shorter duration
of action and a high incidence of paradoxical
reactions.
One of the challenges when choosing oral sedation
over general anesthesia involves predictably dosing a
child whose physiology is being greatly affected by
“fight or flight” responses. When delivering sedatives
orally, a child is often under stress which may affect
the efficiency of the medication being absorbed in
the stomach. Because the stomach’s emptying time is
adversely affected by the stress of preop procedures,
medications are often much less predictably
absorbed, and their therapeutic effects are often
delayed. As a result, practitioners may be tempted to
administer a second dose. This may lead to an
unanticipated deeper level of sedation than originally
planned. Why is this the case? When the child begins
to calm down under the effect of the sedation, and
the “fight or flight” reflex subsides, the GI system
relaxes, and both doses kick in, potentially deepening
the sedation to dangerous, unintended levels.
General anesthesia on the other hand, delivered via
inhalation, intramuscularly, or intravenously, exhibits
much more predictable absorption results, unaffected
by the potential “shut down” of the GI system
observed with oral sedation.
Choosing the Mode of Anesthesia
Delivery:
When oral conscious sedation is not an appropriate
option or is ineffective, general anesthesia is the
preferred choice. Induction of general anesthesia is
most often accomplished using one of three methods:
1) inhalation, 2) intramuscular, or 3) intravenous. All
three of these administration routes are more
effective than using oral sedation because they allow
medications to avoid the first-pass effect in the liver.
This reality allows them to act much more
predictably regardless of the patient’s level of
cooperation. After induction, anesthesia maintenance
is also more easily controlled because medications
can be injected directly into the circulatory system.
These intravenous medications can be titrated to
elicit the desired effect, or, if necessary, they can be
reversed. Newer medications have very rapid onset
and elimination times, making them ideal for use in
the outpatient dental setting.
Choosing the Setting for Delivering
Anesthesia:
When considering whether it is safe to administer
general anesthesia in an office setting, a dentist
anesthesiologist typically considers minimum
physical eligibility criteria. These may require that a
child be at least 18 months to 2 years of age and 10–12
kg in body weight. Manifestations of the following
conditions in young patients should be seen as
contraindications when considering giving them
sedation in an office setting: 1) uncontrolled asthma,
requiring multiple medications and the use of a
rescue inhaler daily/weekly, 2) syndromes whose
physical characteristics could result in a
compromised airway or difficulty intubating if an
emergency were to arise, 3) a prior history of open-
heart surgery, 4) a recent diagnosis of DM type I, as
patients often manifest large swings in blood glucose
levels during the first few months/years after initial
diagnosis, or 5) potentially complicating airway
factors such as a history of tracheo/laryngeal malacia
or a lengthy stay in the NICU requiring prolonged
intubation resulting in trachea atresia.
When considering the safety of office-based sedation,
additional questions to weigh include these: 1) Is the
child currently under treatment with chemotherapy
drugs? 2) Has she been diagnosed with a bleeding
disorder? 3) Is there even a suspicion that he has a
pseudocholinesterase deficiency? A positive response
to any of these questions should cause a practitioner
to think carefully when deciding on the best location
for treatment. Remember, it is always wise and
prudent to involve your medical colleagues when
making decisions based upon your patients’ medical
conditions. Often physicians will have additional
information and recommendations that will assist
you in arriving at a treatment decision.
If a child fails to meet any of the above criteria,
manifests any of the contraindicating conditions, or
has any other issue that you feel could compromise
the safety of treatment in an office setting, your
wisest choice is to consider performing the dental
procedure at a surgery center or in a hospital
operating room.
Challenges when
choosing oral sedation
over general anesthesia
involve predictably
dosing a child whose
physiology is being
greatly affected by “fight
or flight” responses.

Summary Criteria for Choosing
Oral Sedation or General Anesthesia
in the Office Setting:
When deciding on the type of sedation to use—
oral sedation or general anesthesia—I generally
recommend making the decision based on the
following criteria:
RECOGNITION AND
MANAGEMENT OF
COMPLICATIONS
We all know that sedation has inherent risks due
to numerous factors such as airway complications,
physical status changes, drug sensitivities,
tolerances, etc. Also, we recognize that the level of
sedation is not a static, fixed state, but exhibits a
sliding continuum depending on surgical
stimulation.5 For example, oral sedation can have a
wide variability of efficiency regarding onset of
action and duration of action due to the route of
administration and the first-pass effect through
the liver. Emergencies can and do happen in the
office-based setting for sedation. Being aware and
prepared is vital.
Common problems associated with sedation are
respiratory and/or cardiovascular in nature. The
most common problems associated with pediatric
sedation are respiratory: respiratory depression
due to hypoventilation or airway obstruction,
laryngospasm, bronchospasm, or aspiration.
Common cardiovascular problems include
syncope, hypotension, hypertension, bradycardia,
or tachycardia. A practitioner and his/her team is
only as safe as they are prepared. Regular
continuing education in medical emergency
management and routine checks of all emergency
equipment and medications are vital for any
practice providing sedation/general anesthesia for
their patients. Only through proper monitoring,
situational awareness, access to emergency
equipment and training, and participating in mock
emergency drills will we decrease the risk of
morbidity or mortality of our pediatric patients.
We owe it to our patients and their families to
practice each and every day with the upmost of
care and safety.
Choices and Parental Informed Consent:
As the controversy increases relative to the possibility of
whether certain medications given to young children effect
brain function and cognitive development,6 obtaining
informed parental consent prior to delivering sedation or
general anesthesia is imperative.
Pediatric dentists must be sure to adequately inform parents
of the various options available for treatment, including
discussing non-pharmaceutical options as possible
modalities, even when their own clinical evaluation might
indicate otherwise.
• When to Use Oral Sedation
Mild to moderate anxiety
Fearful but cooperative patient
Short treatment time
No history of any significant
medical conditions
ASA I or II stable
Normal focused physical exam
Mallampati score I or II
• When to Use General Anesthesia
Moderate to severe anxiety
Fearful and combative patient
Moderate to long treatment time
Behaviorally or intellectually
disabled
ASA I or II stable
Normal focused physical exam
Mallampati score I–IV
(No obstructive sleep apnea)

Conclusion
Recently, reports have highlighted a
disproportionate increase in the number of cases
nationally that have resulted in the death or
permanent neurologic damage of children being
treated by dentists and involving oral conscious
sedation, moderate to deep sedation or general
anesthesia.7,8,9,10 These incidences have involved
various anesthesia providers, different surgical
settings, different levels of sedation, different
airway approaches, and different anesthesia
delivery models. So, my question is “Why?”
Although I don’t have a definitive answer, this
question should concern all of us involved in
pediatric sedation and stimulate a renewal of our
commitment to following the sedation guidelines of
the AAPD and to doing everything we possibly can
to ensure the safety of our pediatric patients.
The dental profession faces a dilemma. We
understand that early childhood caries are
associated with pain, tooth loss, impaired growth,
decreased weight gain, failure to thrive, and
negative effects on quality of life such as problems
with eating, speaking, playing, and learning. As
healthcare providers, we understand that not
treating or extracting carious teeth can result in
serious complications, including emergency-room
visits, hospitalization, and/or death. On the other
hand, we also understand that sedation itself carries
inherent risks. Our challenge? How can we reduce
the risks associated with moderate to deep sedation
and/or general anesthesia for children undergoing
dental procedures? My recommendation is that we
go back to the basics and re-familiarize ourselves
with pediatric airway anatomy and physiology,
sedation pharmacology, and the recognition and
management of complications associated
with sedation.
References
1. Anthonappa RP,Ashley PF,Bonetti
DL,Lombardo G,Riley P.Non-pharmacological
interventions for managing dental anxiety in
children (Protocol).Cochrane Database of
Systematic Reviews2017, Issue6. Art. No:
CD012676. doi: 10.1002/14651858.CD012676.
2. Sheller B. Challenges of managing child
behavior in the 21st century dental setting.
Pediatr Dent 2004; 26(2): 111–13.
3. Law CS, Blain S. Approaching the pediatric
dental patient: A review of nonpharmacologic
behavior management strategies. J Calif Dent
Assoc 2003;31(9):703–13.
4. Nelson TM, Xu Z. Pediatric dental sedation:
challenges and opportunities. Clin Cosmet
Investig Dent 2015; 7: 97–106.Published online
2015 Aug 26.doi:10.2147/CCIDE.S64250.
5. Becker DE, Haas DA. Management of
complications during moderate and deep
sedation: respiratory and cardiovascular
considerations. Anesth Prog 2007 Summer;
54(2): 59–69.
6. Sun L. Early childhood general anaesthesia
exposure and neurocognitive development. Br J
Anaesth 2010 Dec; 05(Suppl 1): i61–i68.doi:
10.1093/bja/aeq302. PMCID:PMC3000523.
7. Chmura C, Roher C, Horn M, Rojas J. “Dental
anesthesia under scrutiny after child dies.”
https://www.nbcbayarea.com/news/local/
dental-anesthesia-under-scrutiny-after-child-
dies-381594491.html. Bay Area NBC News, June
2, 2016.
8. Recede K, McLaren G. “California girl dies
during dental procedure, family says.” http://
fox40.com/2017/06/15/3-year-old-stockton-girl-
dies-during-dental-procedure. Health, Fox
News. June 16, 2017.
9. WFTV 9 ABC News. “9 Investigates teenager’s
death after routine dental procedure.” http://
www.wftv.com/news/9-investigates/9-
investigates-teenagers-death-after-routine-
dental-procedure/285179265. May 16, 2016.
10. Bradford H. “Dental sedation responsible for
at least 31 child deaths over 15 years.” http://
www.huffingtonpost.com/2012/07/13/dental-
sedation-child-deaths_n_1671604.html.
Huffington Post, July 13, 2012.
My recommendation…
Re-familiarize ourselves with pediatric airway anatomy and physiology,
sedation pharmacology, and the recognition and management of
complications associated with sedation.
“ Thomas E. Lenhart, DMD

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We all have questions, but sometimes it’s difficult to find reliable answers. With
sedation and general anesthesia recently featured so prominently in national
news, Shift magazine goes behind the scenes in an interview with a past
president of the American Society of Dentist Anesthesiologists to discover
answers to some important questions dealing with dental anesthesia and
related issues involving patient safety in pediatric dentistry.
Got
questions
about
anesthesia?

QUESTIONS BY Shift magazine ANSWERS BY Michael Mashni, DDS
Shift magazine
1. With recent nation-wide news stories
reporting sedation-related tragedies in
dental o ces, are the risks for in-o ce
anesthesia going up? Or is it still safe?
MM
We are all concerned when we read reports of poor
outcomes occurring in dental offices. Of course, even a
single poor outcome is one too many. One problem we face,
however, is that the facts are rarely available for the experts
to review. Furthermore, we don’t have access to a centrally
maintained database which allows us to track all outcomes.
Much of what we know regarding the circumstances
surrounding reported poor outcomes is based on what we
hear from the media or from attorneys pleading the case for
their clients.
The safety of anesthesia will always be questioned after any
poor outcome, and hopefully we can all take the opportunity
to review how we practice and explore how we can improve
the safety of the patients we treat. We must continually ask
ourselves probing questions. How can we learn from these
cases to determine what went wrong? And how can we
prevent the same problems from occurring again?
Many factors can affect the safety of anesthesia. Safety is
related to the training of the individual anesthesia provider,
his/her experience (particularly with pediatric patients),
and coexisting or current medical conditions such as a
concurrent upper-respiratory-tract infection. Additional risk
factors include such things as food in the stomach, length of
the procedure, and even the common sense of the provider.
If an anesthesia provider determines that a patient would be
put at increased risk while undergoing anesthesia, then
treatment may need to be referred to a hospital or surgery
center, depending on the specific circumstances. In many
cases, however, children can still be safely treated in the
dental office by practitioners who are properly trained and
prepared.
Shift magazine
2. What are the di erences between
using a medical anesthesiologist vs. a
dental anesthesiologist? Are they
trained di erently?
IN A
RECENT
UPDATE:STATISTICS FROM A
2014 ASA CONVENTION*
• In data from from more than 3.2 million
cases of anesthesia use between 2010
and 2013, the rate of complications
decreased from 11.8 percent to 4.8
percent. The most common minor
complication was nausea and vomiting
(nearly 36 percent) and the most
common major complication was
medication error (nearly 12 percent).
• The death rate remained at three
deaths per 10,000 surgeries/
procedures involving anesthesia.
• Among the other ﬁndings:
complication rates were not higher
among patients who had evening or
holiday procedures; patients older
than 50 had the highest rates of
serious complications; and healthier
patients having elective daytime
surgery had the highest rates of
minor complications.
In a recent update, Dr. Jeana Havidich, an
associate professor of anesthesiology at
Dartmouth-Hitchcock Medical Center in New
Hampshire, presented the above preliminary
data at an American Society of Anesthesiologist
convention in October 2014.
(theanesthesiaconsultant.com)
*

MM
Physicians and dentists each travel a different pathway prior
to their anesthesia training. Physician anesthesiologists are
well trained in all aspects of anesthesia. Historically, dentists
have trained side by side with physician colleagues in the
same program. When this practice was no longer an option,
training programs for dentists developed with rotations in
the anesthesia departments of hospitals and medical centers,
but also concentrating on treating patients for dental
reasons, and more specifically, in the dental office setting.
Prior to the accreditation of dental anesthesia training
programs, the training varied by location and school. Now,
however, set standards exist which all dental anesthesiology
training programs must follow. Currently, the length of such
training is three years. These programs maintain high
minimum standards for treatment of pediatric patients and
train dentists in providing outpatient anesthesia in a dental
office. Both physician anesthesiologists and dentist
anesthesiologists are qualified to treat patients in the office
setting. We may conclude that all anesthesia providers—
whether trained via a medical or dental track—must be
properly qualified to work in a dental office setting that will
ensure the safety of patients.
Shift magazine
3. With increasing scrutiny becoming
the norm, should I as a pediatric dentist
be requesting a medical clearance on
all my sedation cases, or is it ok to just
let the anesthesiologist do the H&P?
MM
That is a good question. A medical history and a focused
physical evaluation (H&P) must be performed on each
patient prior to administering anesthesia. One purpose of
the medical history is to review the medical systems and
determine if more questions need to be answered or more
tests performed. Routine lab tests or chest x-rays used to be
standard prior to surgery, but this practice has long been
abandoned as these procedures rarely altered treatment,
unless they revealed an existing contraindication. Medical
clearance by itself may not be helpful and may only give a
false sense of security.
After reviewing a medical history and/or evaluating the
patient, if you determine that a consult is necessary, then
you should absolutely obtain one prior to treatment. Just as
routine laboratory tests or chest x-rays are not necessary, a
medical consult is not necessary for every patient. A medical
consult should be directed towards addressing specific
conditions and not be a general request for “clearance.” A
note from a physician which only indicates “ok to treat” is
worthless. A child with a failing heart may be “ok to treat”
for the purpose of repairing the cardiac defect. This does not
mean the patient would be ready for dental treatment in an
office-based setting.
Shift magazine
4. Do any statistics demonstrate
whether it is safer to have my patient
intubated vs. using an open-airway
technique?
MM
Both techniques have been used safely and successfully for
many years. I am not aware of any studies comparing the
two modes of practice. Medicine has tended to intubate
patients and more recently adopted a practice of using
supraglottic airways such as a laryngeal mask airway.
Dentistry, on the other hand, has a strong history of
utilizing an open-airway technique.
The main benefit of intubation is achieving a protected
airway. The downside of using an intubation technique is the
potential soreness or trauma it may cause. These results,
however, are infrequent, particularly when performed by
skilled providers.
When using an open-airway technique, the anesthesiologist
must manage the airway. My observation is that patients
wake up more smoothly following an open-airway procedure.
My friends who choose to intubate their patients would
disagree. So, the debate continues….
Shift magazine
5. What are some important factors to
consider when choosing an anesthesia
provider to assist my practice?
MM
Safety is your number one consideration; but it is also
number two, three, and four! Start with the provider’s
training. Make sure the anesthesiologist completed an
anesthesia residency either in medicine or dentistry. Look at
the amount of training and experience the provider has had
with pediatric patients. Kids are not small adults and
shouldn’t be treated as such.
Board certification in anesthesia by the American Dental
Board of Anesthesiology (dentists) or the American Board of
Anesthesiology (physicians) is verification of training at the
highest level. For dentists, active membership in the
American Society of Dentist Anesthesiologists indicates the
highest level of ongoing training in anesthesia for dentistry.
Make sure the provider has experience or training in
providing sedation in the dental office setting. Ask for
references from other dentists or physician colleagues.
Shift magazine
6. With the rising cost of medical
insurance deductibles, do you foresee
more people opting to request in-o ce
sedation for dental procedures in the
future?

MM
There is no question that in-office anesthesia is more cost
effective than performing procedures in a surgery center or
a hospital. Since I began my training in anesthesia in the
early 1990’s, I have observed pressure to move anesthesia
outside the hospital to ambulatory settings. However, cost
savings should not be the only consideration. As discussed
above, safety is our first priority, and if a patient’s needs
require the use of a surgery center or hospital operating
room, then finances shouldn’t dictate that treatment be
performed in a dental office.
This being said, anesthesia provided in ambulatory centers
and even in dental offices has a long track record of safety.
Advances in medicine will only improve this record. New
devices such as bluetooth precordial stethoscopes, video
laryngoscopes, vein finders, and supraglottic airways have
been developed. These instruments have become widely
available since my training and all give me tools that help
me treat patients more safely in ambulatory settings. I
cannot foresee a decrease in utilization of in-office
anesthesia.
Shift magazine
7. If I currently use oral sedation in my
o ce, are there reasons I should
consider inviting an anesthesiologist to
partner with me in providing in-o ce
sedation?
MM
My opinion is that minimal sedation—more specifically,
sedation administered by the oral route—is the most
underutilized tool in dentistry. A divide exists between
medicine and dentistry regarding providing sedation and
anesthesia for potentially painful or uncomfortable
procedures. I once had a chalazion (blocked duct in my
eyelid) for which my ophthalmologist recommended
treatment in the hospital operating room despite most
ophthalmologists performing such treatment under local
anesthesia in the office. I’m told this procedure involves
only a simple excision, yet my medical insurance authorized
the anesthesia in the hospital without question.
I never had the procedure performed, but compare this
simple chalazion procedure to a dental procedure requiring
you to do several pulpotomies, seat a number of SSCs, and
maybe even perform an extraction. Why is it that in
dentistry we expect patients to just grin and bear it?
Pediatric dentists or others with training in minimal
sedation, should continue providing sedation services as
long as the treatment falls within the scope of both the
dentist’s training and the AAP/AAPD guidelines (AAP/AAPD
Guidelines for Monitoring and Management of Pediatric
Patients Before, During and After Sedation for Diagnostic
and Therapeutic Procedures: Update 2016).
If done within the guidelines for minimal and moderate
sedation, failures can be expected. If you experience a 100
percent success rate using minimal sedation, then you are
either ultra conservative and lucky with your patient
selection or you are overdosing a small percentage of your
patients. An anesthesiologist is available for the patients
that require deeper levels of sedation.
Shift magazine
8. Where do you see in-o ce sedation
moving in the future, and how can
dental professionals help ensure this
option will be available for future
generations of pediatric dentists?
MM
In-office sedation is growing due to the strong safety record
and the current demand. By choosing appropriate patients
that can be treated in the office by minimal sedation and
utilizing a qualified anesthesiologist, dentists will be
providing a much-needed and safe alternative to a surgery
center or hospital. As a profession, we need to continue to
improve outcomes and continuously look at our processes
and procedures to see how we can improve, even if we think
we are doing a good job as it is now. Poor outcomes will
always prompt a review and sometimes new regulations and
laws. Tracking outcomes data will either establish our
practices as safe or show us how to improve. Poor outcomes
will always prompt a review and sometimes may result in
new regulations being adopted and/or new laws being
passed. This is the best defense we have against reflex moves
that would place limits on anesthesia in the dental office.
For dentists, active membership in the American
Society of Dentist Anesthesiologists indicates the
highest training in anesthesia for dentistry.
Send us an email at editor@sprigusa.com. If there is interest,
we can make this forum a regular part of Shift magazine.
additional
questions
about
anesthesia
topicsrelated
Got
?

Safety in Pediatric
Procedural Sedation
By Sarat “Bobby” Thikkurissy, DDS, MS
Navigating
Icebergs

When any one asks me how I can best describe my experiences
of nearly forty years at sea, I merely say uneventful. Of course, there
have been winter gales and storms and fog and the like, but in all my
experience, I have never been in an accident of any sort worth speaking
about.... I never saw a wreck and have never been wrecked, nor was I
ever in any predicament that threatened to end in disaster of any sort.
I will say that I cannot imagine any condition which could cause a ship
to founder. I cannot conceive of any vital disaster happening to
this vessel. Modern shipbuilding has gone beyond that.
Captain E. J. Smith (HMS Titanic)
“

rony aside, the quote on the previous page
belies our inability to plan for unexpected
adverse outcomes. It would seem
complacency is an inevitable by-product of
success, but one achieved at grave cost.
Procedural sedation is a vital part of the
behavior management continuum advocated
and practiced by the American Academy of
Pediatric Dentistry (AAPD) and its members.
Every day thousands of children are sedated
safely and without harm across the country. In
spite of sedation’s safety track record, it is the
unexpected outcome—a death, hospitalization,
and the like—that drive us to analyze and re-
analyze our processes in an attempt to keep our
children safe. In weighing the option to use
procedural sedation, we truly must strive to
achieve a standard of “zero tolerance” for
adverse outcomes.
The AAPD is committed to making safety the
key factor in determining all its
recommendations regarding the therapies and
care provided by its members. This
commitment has been underscored when
formulating its best practices, developing its
continuing education courses, designing its
webinars, and drafting its operating principles.
In 1818, The Lady’s Magazine published a sidebar
on the foundations of basic-skills-oriented
education programs emphasizing reading,
writing, and arithmetic—the Three R’s. Along
this same line of thinking, I’d like to put
forward the “Three A’s” for basic-sedation skills:
Assumptions, Assessment and Awareness. I will
frame these skills within the parameters of our
current AAPD guidelines.
ASSUMPTIONS
1. Assume parents will fib.
I may have taken this assertion from the TV series “House,” but
it’s true none-the-less. Because parental assessments are not
always reliable, be sure to rely on your physician colleagues to
obtain a history and physical (H&P) when scheduling
procedural sedation of children. While I have participated in
research demonstrating that physician H&Ps are dubious at
times, the point is that someone (either the dentist or
physician) is objectively assessing the child’s health.1 The AAPD
guidelines do an excellent job of not only outlining basic
components of assessment but also highlighting areas that
impact sedation—items such as BMI/obesity, history of
prematurity and associated airway illness during early
childhood, and a review of systems. The adage “never treat a
stranger” comes to mind. In summary, know your patient.
2. Assume parents will not understand.
The AAPD clearly states that informed consent is the “process
of providing patients/parents with relevant information
regarding diagnosis and treatment needs so that an educated
decision regarding treatment can be made.” Requiring informed
consent compels discussion of risks, benefits, and alternatives
to any therapy. A compelling reason must exist before making a
decision to use pharmacologic therapy (sedation or general
anesthesia). In a time when insurance companies attempt to
drive clinical decision making, practitioners must be the ones
who step back, examine risks to the child, and, using this
assessment as their guiding “north star,”2 plan for appropriate
procedural sedation to which parents give consent.
Additionally, health literacy can impact a parent’s ability to
understand written documents. According to the National
Assessment of Adult Literacy, the understanding of 14 percent
of adults (30 million people) falls below the basic level of health
literacy.3 This fact underscores the importance of drafting a
carefully worded, easily understood consent form and
discussing it adequately with a child’s parents before
administering sedation or general anesthesia.
3. Assume the family will get stuck in traffic!
Flippancy aside, an issue of constant discussion and debate is
whether children can be dosed with “anxiolytics” at home. The
AAP/AAPD guidelines clearly state that “The administration of
sedating medications at home poses an unacceptable risk.”4
Case reports indicate that children have been given
medications at home which induce an unexpected depth of
sedation and lead to tragic situations which result in the worst
of all imaginable outcomes, a child’s death. It is worth noting
that the AAPD guidelines adopt the American Academy of
Pediatrics (AAP) definition5 of “pediatric,” i.e. all patients aged
18 and under. Both AAP and AAPD guidelines apply to this
entire age group.
ASSESSMENT
1. Assess ventilation.
Studies have demonstrated as much as a 200-second diagnostic
lead time when using capnography testing to detect apnea as
compared to using a pulse oximeter alone. The American
Society of Anesthesiologists (ASA) and the American Society of
Dentist Anesthesiologists list capnography as the standard of
exhaled carbon dioxide assessment. The AAP/AAPD
recommend capnography as the preferred measure of
Safety in Pediatric Procedural Sedation
I
The key preventive measure
is to assess the quality of ventilation,
because evidence of impaired
ventilation will typically precede
oxygenation problems noted on
the pulse oximeter.

,
“Mr. Ismay, it was under your directive
that we were traveling through an ice
field at the arrogant speed of twenty-one
knots! I am the master of this vessel and
I have been too complacent! “
Titanic — 1997 ﬁlm
Captain E. J. Smith (HMS Titanic)

ventilation, although replaceable with amplified pre-tracheal
stethoscope, if appropriate, and purposeful bi-directional
communication is present. The key preventive measure is to
assess the quality of ventilation, because evidence of impaired
ventilation will typically precede oxygenation problems noted
on the pulse oximeter. In many cases, the anatomy of a young
patient will lead to upper airway obstruction caused either by a
forward-tilted head, or most commonly, the tongue, which
exhibits a relative macroglossia in a child.
2. Assess your staff.
In private offices, particularly in rural areas, 911/first-responder
response times may be variable. Therefore, dentists and their
staff are the key link ensuring the patient’s survival. Early
identification of respiratory or cardiovascular problems and
high-quality basic life support and airway management are
essential in successful rescue of the patient. This is where
running mock codes, or testing office preparedness is key. The
importance of dental office staff in an emergency cannot be
overstated, as their skills are essential to ensure successful
outcomes. The AAP/AAPD guidelines have distinct sections
relating to on-site preparedness and facility requirements.
Visit the Society for Pediatric Anesthesia website at
www.pedsanesthesia.org/critical-events-checklists where
you may download multi-lingual emergency checklists.4
3. Assess the child.
This concept cannot be reinforced enough. On several
occasions a dental team has been so focused on treatment
of the tooth that they failed to realize the child had stopped
breathing. The AAP/AAPD guidelines underscore that “If
sedating medications are administered in conjunction with
an immobilization device (i.e., protective stabilization),
monitoring must be used at a level consistent with the level
of sedation achieved.” This underscores a point that is
fundamental in pediatric sedation—children exhibit variable
responses to sedative medications. All providers must prepare
to rescue the child from one sedation level deeper than was
intended. There is no such thing as “only Versed.” Even when
using Versed alone, a patient may require resuscitation or
rescue. A basic principle taught in Basic, Advanced Cardiac,
and Pediatric Advanced Life Support (BLS/ACLS/PALS)
training courses is to treat the patient, not the monitor. Even
if the pulse oximeter reads 100 percent, is the child cyanotic? Is
she obstructing? Understand what “normal” is, and then
constantly be alert for signs indicating that a deviation from
normal is occurring. If a deviation does occur, be prepared to
act swiftly and without hesitation.
AWARENESS
1. Be aware of potential adverse events.
The American Dental Association, AAPD, ASA and a host of
other organizations have affirmed the importance of
AMERICAN
ACADEMY OF
PEDIATRIC
DENTISTRY
RESOURCES ON
PROCEDURAL
ANESTHESIA AND
SEDATION
R
Guideline for Monitoring
and Management of Pediatric
Patients During and After
Sedation for Diagnostic and
Therapeutic Procedures
www.aapd.org/media/
policies_guidelines/g_sedation.pdf
Policy on the Use of Deep
Sedation and General Anesthesia
in the Pediatric Dental Office
www.aapd.org/media/
Policies_Guidelines/P_Sedation1.pdf
Guideline on Use of Anesthesia
Personnel in the Administration
of Office-based Deep Sedation/
General Anesthesia to the
Pediatric Dental Patient
www.aapd.org/media/
Policies_Guidelines/
G_AnesthesiaPersonnel1.pdf
Guideline on Use of Local
Anesthesia for Pediatric
Dental Patients
www.aapd.org/media/
Policies_Guidelines/
G_LocalAnesthesia2.pdf
All providers must prepare
to rescue the child from one
sedation level deeper than
was intended.

Shift magazine - Fall 2017

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