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Risk management in Dental offices-Conscious Sedation

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What is Conscious Sedation in Dentistry?

A Technique used during dental treatment for patients with high anxiety and fear of the Dental treatments.

Conscious Sedation incorporates the use of drug or drugs through different administration path such oral administration, nasal or IV infusion.

Used to suppress the Central Nervous System (CNS) enabling the dentists to carry out treatment. During this procedure, verbal contact with the patient is maintained throughout.

Conscious Sedation allows the patient to maintain a patent airway independently and continuously.

The important aspect of the technique and drugs used for Conscious Sedation is that the margin of safety should be wide enough to avoid the likeliness of loss of consciousness.

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Methods of Conscious Sedation:

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Administration through nasal pathway.

Nasal canula used; no extra intervention is required.

Mixture of Nitrous Oxide and Oxygen is used.

Oral sedation uses anxiolytic agents before the treatment starts.

Benzodiazepines are used as oral sedation medications.

The drug used are administered through venous pathway.

Benzodiazepines, Ketamine and Propofol are the agents used commonly.

Indications of Conscious Sedation

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Dental Phobia and anxiety

Traumatic and long procedure

Medical conditions aggravated by stress such as Asthma, Angina and Epilepsy

Children more than 1 year of age

Mentally challenged individuals.

Ineffective Local Anesthesia due to any reason.

Advantages to this procedure

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The advantages to this procedure definitely overlook the cautiously avoidable complications. Since the dental procedures are mostly elective in nature, the patients are benefitted even though they have high anxiety or fear of a dental setting, challenged mental condition and long and major surgical procedures. For the dentists and the practice, the main advantage is having an additional feather in the cap for providing such treatment option which is inclusive of all patient conditions. Not to mention, the technique also makes the job of the dentist easy since the behavioral management is taken care of due to CNS depression.

Preparation for the procedure: A handy checklist....

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Consent for treatment in writing for all treatments under Conscious Sedation; In case of children, the consent must be obtained from the parents or legal guardian.

Presedation check-up: Only healthy patients or patients with mild systemic diseases could be ideal candidates for this procedure, as per the American Society of Anesthesiologists (ASA).

Detailed airway examination checking for any abnormal airway obstructions.

In case of any underlying medical or surgical condition, the physician’s/specialist’s opinion should be considered.

Presedation fasting; it is a controversial topic, however fasting rule of 2-4-6 (2 hours of liquids, 4 hours of breast milk and 6 hours of solids) is recommended for elective procedures.

Operating room/facility should have monitoring and resuscitation equipment and personnel.

Monitoring equipment such as ECG, pulse oximeter, NIBP, BP monitoring, defibrillator should be available in working condition.

Crash cart for emergency drugs and equipment should be available and ready.

Availability of appropriate size of suction catheter, adequate oxygen supply, functioning flow meters, and tubing for oxygen delivery to patient, and airway-equipment.

Challenges in Dental Conscious Sedation

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Proper patient evaluation before planning of the procedure.

Screening the patient for being eligible to undergo the dental treatment under Conscious Sedation, such as recording of medical history.

Patient communication before, during and post procedure.

Shared pathway between the dentist and the anesthesiologist.

Phobia and Anxiety of the dental procedure.

Coexisting systemic medical diseases such as cardiac anomalies, mental instability, and epilepsy.

Chances of arrhythmias during surgery.

Enlarged tonsils and adenoids in children leading to airway obstruction.

Chances of Vasovagal syncope due to the resting position in the dental chair.

Maintaining the inventory for the procedure.

Emergency crash cart maintenance.

Risks associated with Conscious sedation

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For the patients

For the providers

For the dental practice

Main risks are medical issues during or post surgery if the procedure sees any lapses due to the certain reasons.

Malpractice claims if any complication occurs.

Provider’s liability.

Drowsiness, dry mouth, headache, and memory loss are some of the post surgery symptoms.

Claims regarding the negligence.

Reputational damage.

Loss of consciousness, over sedation, hypoventilation, cardiac arrest are some of the complications.

Reputational risk.

Non-compliance with the governing bodies.

Loss of licensure.

Licensure issues.

Financial loss due to fines and penalties.

Penalties and fines.

Legal risks through lawsuits against the practice and the providers.

There are no rows in this table

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Risk Management Strategy

Risk avoidance

Risk can be avoided through avoiding practice violations, such as practicing without a credible license, or prescribing/suggesting conscious sedation without therapeutic purposes.

Avoiding malpractice risks through careful patient selection for the procedure under conscious sedation. Evaluation as per the ASA guidelines and a specialist or physician report can be seeked out before making the decision for patients with underlying medical conditions.

Proper education and training regarding the technique. Not limiting it to the dentists, but also the dental auxiliaries should also be trained for the same to reduce the risk of any error event.

Maintaining adequate supply of the drugs for emergency purposes and the having all the equipment ready in working condition for the resuscitation, as per the requirements.

Risk reduction

Proper patient communication including verbal and written communication explaining the procedure, the advantages, disadvantages, alternatives, outcomes and complications related to it.

Detailed patient records documentation starting from detailed patient’s medical history. Patient’s dental records, treatment plan, treatment options, diagnostic reports, medications, allergies and adverse reactions, and so on. Informed consent and informed refusal documents should also be documented with the patient’s signature.

Proper office management. It includes a proper flow of operations, proper billing, proper triage and patient scheduling, proper patient discharge notification and detailed procedures and policies are to be maintained by every employee.

Dental record management.

Precautionary policies to be framed in detail and should be adhered to by the staff. These also include basic precautions in a dental setting such hygiene maintenance, disinfection of the operatories, PPE use by the staff, sanitation of the equipment, avoiding cross infection.

Precautionary actions can also be taken in the very beginning with the design of the office.

Adequate supply of the gases, drugs and other equipment and material used for the procedure. As mentioned before, a crash cart should be maintained on a regular basis for any emergencies.

Dentists and staff trained to resuscitate if such a situation occurs.

Risk transfer

Referring the patients to the specialists or other providers where there is a doubt in considering the patient eligible, is a better option than taking a risk.

Insurance policies can be bought to protect the practice and dentists from the liabilities. Some examples are Business owners policy, General liability insurance, medical malpractice insurance, claims-made policy, etc.

Risk management as per the ASHRM domains

Domain

Risks

Risk management tactics examples

Operational

documentation error; faulty medical records; staffing

Proper detailed education and training of the staff; having on call staff as back up

Clinical/patient safety

mistakes during the procedure; improper administration of drugs.

Proper detailed education and training of the staff entailing the procedure.

Strategic

supplier relations, referring doctors relations, marketing, reputational risks.

Maintaining a proper contract based relation with the stakeholders.

Financial

Low return on investment, losses due to malpractice claims, penalties or fines if incurred

proper investment planning and funding, and practicing risk avoidance and reduction strategy.

Human capital

malpractice, shortage of staff, injuries

employee retention incentives and workers compensation for injuries, vaccinations.

Legal/regulatory

Malpractice claims, licensure

practicing risk avoidance strategy

Technology

failure of monitoring systems, emergency equipment malfunction

Regular designated tests to make sure everything is functioning.

Hazard

natural calamities; facility hazard

insuring the practice against them.

There are no rows in this table

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Sources

Enterprise Risk Management - ASHRM. https://www.ashrm.org/system/files?file=media/file/2019/06/ERM-Tool_final.pdf.

AIS, Team. “A Guide to Dental Risk Management.” Advantage Insurance Solutions, 7 Apr. 2022, https://www.teamais.net/blog/a-guide-to-dental-risk-management/.

Kapur, Arpita, and Vinay Kapur. “Conscious Sedation in Dentistry.” Annals of Maxillofacial Surgery, U.S. National Library of Medicine, 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327823/#:~:text=Conscious%20sedation%20is%20a%20technique,throughout%20the%20period%20of%20sedation.

BS;, Jackson DL;Johnson. “Conscious Sedation for Dentistry: Risk Management and Patient Selection.” Dental Clinics of North America, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/12436831/.