Agd house of Delegates (hod) Policy Manual



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Educational Objectives for the Provision of Dental Implant Therapy by Dentists



INTRODUCTION
In February 2009, the Academy of General Dentistry (AGD) created an Implantology Task Force (ITF) comprised of nine general practitioners with substantial dental implant experience.
The purpose of the ITF was to review the current state of dental implant training in the United States and formulate guidelines. These guidelines would delineate the objectives that are recommended in coursework for educating dentists about safe and appropriate dental implant therapy.
Various dental implant reference materials were reviewed, and pertinent information gleaned from these sources aided in the construction of this document.
Additionally, the observations and experiences of the members of the ITF, many of whom are educators in implant dentistry, were used to develop these training objectives.
It is not the purpose of these Educational Objectives to define a curriculum for dental implant therapy. Rather, these objectives are to be used as guidelines for educational providers to develop curricula that will adequately prepare dentists for providing safe and appropriate dental implant therapy.
There are a variety of educational outlets available to provide dentists with the necessary training in dental implant therapy. These outlets include, but are not limited to, university-based sources, hospital-based sources, dental organizations, manufacturer-sponsored courses, private individuals, and commercial training centers.
All providers of dental implant continuing education (CE) should be AGD PACE- or American Dental Association (ADA) CERP-approved.
Dental implant therapy can be accomplished successfully by all licensed dentists who have received adequate training. No manufacturer, university, hospital, or provider of CE should limit any licensed dentist from having access to the specific knowledge base or materials needed to provide quality care through the provision of dental implant therapy.
As a “prosthetic discipline with a surgical component,” the placement of dental implants is part of the practice of general dentists and specialists alike who have attained the appropriate education.1
Dentists performing the surgical placement of dental implants should have an understanding of the final prosthetic goal of each case and the various elements of the restorative process.
Dental implants provide support for restorations that substitute for missing dentition. Dental implant therapy restores the patient’s function, form, and esthetics, as well as comfort and longevity, and has become the tooth replacement methodology of choice for many patients. Additionally, dental implant therapy facilitates the health and preservation of the remaining oral structures.
In anticipation of untoward circumstances that may occur during the treatment process or after the restorative phase has been completed, dentists should have attained the education necessary to be familiar with interventions needed to manage those circumstances.
GLOSSARY
Autogenous graft

Hard or soft tissue harvested from one or more sites and transplanted to another site or other sites in the same individual.2


CERP

“Recognizing the need to offer its members and the dental community a way to select continuing education (CE) with confidence, to assist regulatory agencies and other organizations responsible for approving credit, and to promote the continuous improvement of CE, the American Dental Association Continuing Education Recognition Program (ADA CERP) was established in 1993. Through an application and review process, the ADA CERP evaluates and recognizes institutions and organizations that provide continuing education (CE).”3


Dental implant

A dental implant is an alloplastic material or device that is surgically placed into or onto orofacial tissues and used for anchorage, functional, therapeutic, and/or esthetic purposes.2


Dental implant prosthesis

Syn: Dental implant restoration. “Any prosthesis (fixed, removable, or maxillofacial) that utilizes dental implants in part or whole for retention, support, and stability.”2
Dental implant therapy

Syn: Implant dentistry, oral implantology. The field of dentistry dealing with the diagnosis, surgical placement, prosthetic reconstruction, and maintenance of dental implants.2
Exogenous graft

Hard or soft tissue derived from outside the patient’s body.2


Familiarity

“A simplified knowledge for the purposes of orientation and recognition of general principles.”4


PACE

“The Academy of General Dentistry (AGD) Program Approval for Continuing Education (PACE) was created to assist members of the AGD and the dental profession in identifying and participating in quality continuing dental education (CDE). The program provider approval mechanism is an evaluation of the educational processes used in designing, planning, and implementing continuing education.”5


DENTAL IMPLANT VARIATIONS

Dentists involved in the practice of implant dentistry should have a familiarity with the various dental implants and dental implant restorations that are presently available, even though the dentists may be placing and/or restoring only one brand or modality.


This familiarity may aid in the recognition of a dental implant device either clinically or radiographically and allow for maintenance protocols. Additionally, familiarity with the various dental implants and dental implant restorations will aid the dentist in exercising his or her professional judgment to treat the patient or make an appropriate referral.

DENTAL IMPLANT CASE TYPES6
Current literature indicates that surgery may be divided into two case types: straightforward and complex.
The type of case is not an absolute measure. After completion of adequate coursework in dental implant therapy, the dentist should be able to assess the case type and make treatment or referral decisions accordingly.
Dental implant therapy, regardless of case type, may be performed safely by an appropriately trained dentist, and these case types are not determinative of need for referral.7
The following attributes of straightforward and complex cases are indicative but not singularly determinative of the respective case types, and are presented below by interpretation of and/or citation of current literature:6
Straightforward case:

Perception of Case: The end prosthetic result and treatment protocols are readily understood.

Tooth Position: Adequate identifiable anatomical landmarks exist to determine optimal tooth position.

Dental Implant Surgery: The dental implant surgery procedure has minimal anatomical risks and can be carried out without the need for significant hard or soft tissue grafting.

Occlusion: The teeth can be replaced without significant alteration to the patient’s existing anatomic structures.

Complex case:

Perception of Case: The end prosthetic result and treatment protocols cannot be readily determined without extensive diagnostic and planning techniques and may include multiple stages to achieve the desired outcome.

Tooth Position: Minimal identifiable anatomical landmarks require more extensive diagnostic procedures to determine the optimal tooth position for esthetics and function.

Dental Implant Surgery: The dental implant surgery is a more challenging procedure with notable anatomical risks and may require significant hard or soft tissue grafting.

Occlusion: A deterioration of the patient’s anatomic structures requires significant treatment planning to adequately restore the occlusion.
EDUCATIONAL OBJECTIVES
Educational objectives for the straightforward placement of dental implants:
A dentist who intends to engage in the straightforward placement of dental implants should have attained education that includes the educational objectives listed below. The dentist should be familiar with the procedures involved in the assessment, planning, placement, restoration, and maintenance of dental implants.6


  1. Anatomy of the maxilla and mandible.

  2. Pathological processes that occur in the maxilla and mandible.

  3. Healing processes that occur following surgery and how to manage postoperative untoward circumstances.

  4. Diagnostic imaging of the mandible and maxilla, and how to interpret the findings from these examinations.

  5. Clinical assessment of a patient’s suitability for dental implants and the medical conditions that could preclude a patient from dental implant therapy or complicate surgery.

  6. Infection control and aseptic techniques as applied to dental implant surgery.

  7. Techniques involved in harvesting autogenous bone from oral sites for augmentation during dental implant placement.

  8. The use of exogenous bone, bone substitutes, and/or soft tissue for augmentation in the placement of dental implants.

  9. The use of appropriate pharmaceutical agents in relation to implant dentistry.

  10. The dental implant options available and their indications and contraindications.

  11. Patient informed consent and how to obtain it prior to dental implant placement.

  12. Clinical and laboratory protocols for dental implant therapy, including:

    1. An understanding of the clinical techniques for conventional dental implant restorative procedures.

    2. An understanding of the pre-surgical laboratory procedures and techniques used to provide dental implant therapy.

    3. An understanding of the laboratory techniques used to construct implant-supported prostheses.

    4. An understanding of the clinical restorative procedures involved in straightforward dental implant-supported restorations.

    5. A recognition of technical and cosmetic limitations of implant dentistry.

  13. Long-term maintenance of dental implants and dental implant restorations.

  14. Proper documentation of all clinical activity.6

  15. Assessment of the occlusion and its relevance in relation to the proposed treatment and longevity of the prosthesis.8

  16. Interventions and approaches to manage potential complications.


Additional guidelines for complex dental implant therapy:6
Experience in the straightforward placement and/or restoration is a prerequisite for complex dental implant therapy.
A dentist should have attained an adequate level of surgical experience and the ability to provide follow-up care to patients who require the placement of dental implants with hard and soft tissue augmentation.
Before complex placement is attempted, a dentist also should have attained the knowledge of the prosthetics necessary for the substantial occlusal alterations that are often needed in restoring and maintaining complex cases.
As dentists advance through the developmental stages of skill acquisition, it would be advantageous for them to seek the assistance and guidance of more experienced dentists to serve as mentors.
DISCLAIMERS
Dental implant therapy may be performed safely by an appropriately trained dentist. These Educational Objectives are not intended to limit the training or practice of dentists in dental implant therapy, nor are they intended to make any representations regarding the qualifications or abilities of any individual dentist or dental specialty.

The AGD expressly disclaims any and all liability arising out of or in any way related to the use, transmission, reliance, or interpretation of these Educational Objectives or any part thereof.


REFERENCES
1. Zablotsky M. The periodontal approach to implant dentistry. J Calif Dent Assoc 1991 December;19(12):39-43.

2. Jalbout Z, Tabourian G, eds. Glossary of implant dentistry II. Upper Montclair, NJ: The International Congress of Oral Implantologists (ICOI):2008.

3. ADA Continuing education recognition program (ADA CERP). Available at: www.ada.org/prof/ed/ce/cerp/index.asp. Revised April 2008.

4. American Academy of Implant Dentistry. Standards for the advanced education programs in implant dentistry. Revised February 2007.

5. AGD PACE Guidelines. Available at: www.agd.org/files/education/pace/guidelines.pdf. Revised January 2009.

6. Faculty of General Dental Practice (UK), The Royal College of Surgeons of England. Training standards in implant dentistry for general dental practitioners. Available at: www.fgdp.org.uk/pdf/training_stds_imp_dent_guide_2008.pdf. Accessed November 2008.

7. Academy of General Dentistry. General guidelines for referring dental patients to specialists and other settings for care. Revised July 2007.

8. Academy of Osseointegration; Committee for the Development of Dental Implant Guidelines; American Academy of Periodontology, Iacono VJ, Cochran SE, Eckert MR, Wheeler SL. Guidelines for the provision of dental implants. Int J Oral Maxillofac Implants 2008 May-Jun;23(3):471-473.


The AAID’s Guidelines for MaxiCourses® (2008) also served as a resource for this document.
Respectfully submitted by:
John P. DiPonziano, DDS, MAGD (Chair)

Russell A. Baer, DDS

Walter C. Chitwood, Jr., DDS

Richard W. Dycus, DDS, MAGD

Leonard R. Machi, DDS, FAGD

Emile Martin, DDS, MAGD

Richard J. Ringrose, DDS, MAGD

Berry Stahl, DMD

Roger D. Winland, DDS, MS, MAGD
Staff Support:

Daniel Buksa, JD, Associate Executive Director, Public Affairs

Srini Varadarajan, Esq., Director, Dental Care Advocacy
Adopted HOD 7/09

POLICY STATEMENT ON TREATMENT OF MEDICALLY COMPROMISED DENTAL PATIENTS


With the aging of the population and the spread of infectious diseases, dentists will encounter growing numbers of medically compromised patients, including those with infectious diseases. The general dentist, as primary dental care provider, plays the key role in providing and coordinating dental care for such patients. In this role dentists have responsibilities to all patients, staff and other parties which they are ethically bound to fulfill.
Responsibilities to the Medically Compromised Patient
o To treat the patient with kindness and compassion, regardless of the nature of the patient's condition.
o To be sufficiently educated to evaluate the dental health of a medically compromised patient and to consult with physicians, when necessary, regarding the patient's medical status.
o To provide appropriate treatment within the dentist's realm of competence.
Responsibilities to Dental Staff
o To ensure that staff are trained in emergency care, the management of special health conditions and the management of medically compromised patients.
o To advise staff of the health status of each patient so they may employ appropriate procedures and avoid procedures that may place themselves or the patient at unnecessary risk.
o To ensure that all staff members are properly educated so they understand that infection control measures, including barrier techniques are in place and practiced routinely to protect them against disease. With this understanding they can properly render compassionate care to a medically compromised patient.
Responsibility to Other Parties
o Dentists must observe state and/or federal laws and regulations that require providers to protect the confidentiality of the patient.
Ethical Considerations for Treating HIV Positive Patients
The Academy believes that dentists are obligated to observe the American Dental Association's Principles of Ethics and Code of Professional Conduct in the treatment of all patients including those who are medically compromised, of which HIV positive patients are a part."
Adopted HOD 7/92

Academy of General Dentistry

White Paper on Enteral Conscious Sedation

Enteral Conscious Sedation White Paper

I. Introduction

A. AGD Policy Statement on the Use of Enteral Conscious Sedation in Dentistry


B. AGD Statement of Purpose

In recognizing the importance of controlling anxiety and pain in dental patients, the AGD believes all dentists should have adequate access to training in enteral conscious sedation and the availability to practice this modality.


Training may be received through pre- or post-doctoral education or in a continuing education program.
II. Definitions
Sedation: A depressed level of consciousness. Because sedation incorporates a continuum of central nervous system (CNS) depression, specific levels are defined:
Anxiolysis (minimal sedation): The diminution or elimination of anxiety. This may be accomplished by the use of medication that is administered in an amount consistent with the manufacturer’s current recommended dosage and/or judgment on the part of the clinician with or without nitrous oxide and oxygen.
When the intent is anxiolysis only, the definition of enteral conscious sedation and the training and performance standards described herein do not apply.
Conscious Sedation (moderate sedation): A minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or non-pharmacological method or a combination thereof.
In accord with this particular definition, the drugs and/or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Further, patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of conscious sedation.i


Enteral Conscious Sedation: Any technique of conscious sedation in which the sedative agent is absorbed through the gastrointestinal (GI) tract or oral mucosa (e.g., oral, rectal, or sublingual).
Deep Sedation: An induced state of depressed consciousness accompanied by partial loss of protective reflexes, including the inability to continually maintain an airway independently and/or to respond purposefully to physical stimulation or verbal command, and is produced by a pharmacological or non-pharmacological method or combination thereof.ii
Patient management at this level of sedation is beyond the scope of this document and mandates advanced formal training in general anesthesia.
Maximum Recommended Dose (MRD): Maximum recommended single dose of a medication that can be prescribed for a particular indication.
American Society of Anesthesiologists (ASA) Physical Status Classification Systemiii:



ASA Physical Status Classification

ASA Definition

AGD Recommendations pertaining to sedation

I

A normal healthy patient

Normal sedation protocol



II

A patient with a mild systemic disease

Normal sedation protocol is generally indicated with consideration for modification of sedation protocol



III

A patient with severe systemic disease

Normal sedation protocol may be indicated after serious consideration for modification of sedation protocol



IV

A patient with severe disease that is a constant threat to life

Invasive dental care (elective or emergency) is not indicated in the dental office setting



V

A moribund patient who is not expected to survive without the operation

Not Applicable

VI

A declared brain-dead patient whose organs are being removed for donor purposes

Not Applicable


Treatment Modifications per ASA Physical Classification System:
Modification of sedation protocol for medical risk patient (ASA II, III)iv

• Recognize the patient’s degree of medical risk.

• Complete medical consultation before dental therapy, as needed.

• Schedule the patient’s appointment at a time of day when their stress will be least.

• Monitor and record preoperative and postoperative vital signs.

• Use sedation regimen with minimal potential for causing physiologic disturbances.

• Administer adequate pain control during therapy.

• Ensure length of appointment does not exceed the patient’s limits of tolerance.

• Follow up with postoperative pain and anxiety control.

• Telephone the higher medical risk patient later on the same day that treatment was delivered.

• Arrange the appointment for the highly anxious or fearful, moderate-to-high-risk patient during the first few days of the week when the office is open for emergency care and the treating doctor is available.

III. Training Requirements

A. General Guidelines
1. All persons involved in the management of sedation patients must hold a currently valid Basic Life Support (BLS or CPR) for Healthcare Providers card.
2. An adult enteral sedation course shall consist of a minimum of twenty hours of didactic training that meets the requirements of the ADA's "Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry" and has twenty sedation experiences. This training may consist of videotaped cases of actual sedations, which may be edited to emphasize important clinical concepts. 
B. Pediatric Guidelines
1. An additional six hours of training in pediatric enteral conscious sedation emphasizing physiology, metabolism, anatomy and pharmacological considerations are required for the use of enteral conscious sedation in patients under 13 years of age or less than 90 pounds.
2. It is suggested that practitioners who provide enteral conscious sedation maintain current certification in Pediatric Advanced Life Support (PALS).
C. The Essential Knowledge Emphasized in Each Course
1. All dentists administering enteral sedation must have a sufficient and current knowledge-base of the drugs he/she is administering, including the pharmacology, indications, contraindications, dosing, adverse reactions, interactions and their management.
D. Continuing Education
1. Nine hours of PACE and/or CERP approved courses directly related to the clinical use of enteral sedation every three years.  In addition, BLS (CPR) is required to be current.
IV. Sedation Medications and Usage
A. Medications
1. Only those medications and techniques with which the practitioner is thoroughly familiar should be used.
B. Dosages
1. Single Dosages
a. No single dosage administration should exceed a single MRD in one dose for that particular drug.
2. Multiple Dosages
a. Any medication that is used in multiple dosing beyond the MRD in aggregate should be capable of being reversed.
1. The interval between dosing must be adequate to permit evaluation of the CNS depressant effects of previously administered medication(s).
2. No additional sedative medication(s) should be given when acceptable sedation is noted as judged by patient or dentist.
C. Multiple Agents

1. Use of additional enteral conscious sedation medications and or inhalation sedation (i.e. N2O-O2) should be done with caution due to the possible occurrence of a greater level of CNS depression than desired.


2. Local anesthesia dosing limits must be clearly understood and adhered to in order to prevent additive toxicity.
V. Monitoring
A. The following systems must be monitored during the sedation appointment (as described below) to ensure the safety of the patient during enteral conscious sedation.
1. Central Nervous System (CNS)
a. Patient responsiveness to verbal command must be assessed every five minutes following the administration of the medication until appropriate discharge criteria are met.

2. Respiratory System


a. Auscultation of the airway prior to the sedation drug being administered in addition to use of continuous pulse oximetry commencing at the time a clinical effect of the sedation medication is first manifested and continuing until appropriate discharge criteria are met.

3. Cardiovascular System (CVS)

a. Blood pressure and heart rate must be assessed every 15 minutes commencing at the time a clinical effect of the sedation medication is first manifested and continuing until appropriate discharge criteria are met.
VI. Documentation
A. At a minimum, an enteral conscious sedation record must include the following:
1. Review of patient’s medical and pharmacological history sufficient to enable the dentist to assign an ASA status and to assess risk factors in relation to sedation including any adverse reactions to medications.
2. Physical evaluation to include patient’s age, weight and height; general appearance, noting obvious abnormalities; and visual examination of the airway, such as range of motion, loose teeth, potential obstruction from large tongue, tonsils, etc.
3. Informed consent for enteral sedation must include risks and alternatives and be signed by the patient, parent or legal guardian prior to the administration of CNS depressive medications by the patient, parent or legal guardian. A separate signed consent form is required for each visit.
4. The sedation record should be time based and should include the information described in Appendix I (attached).
VII. Discharge Protocol
A. Discharge Criteria for the Patient

1. Conscious and oriented


2. Vital signs are stable
3. Ambulatory with minimal assistance
B. Discharge Responsibility

1. Patient must be discharged from the office into the care of a responsible adult who has a vested interest in the health and safety of the patient. Written and verbal instructions must be provided, that include an admonition for the patient not to operate a motor vehicle or any dangerous equipment for a minimum of 18 hours or longer if drowsiness or dizziness persists


2. Privacy information/HIPPA form for the escort to sign, if applicable.
C. Administration of Reversal Agents
1. If a reversal agent is administered before discharge criteria have been met, the patient must be kept in a monitored environment for minimum of two hours. Routine discharge criteria must also be met.
D. Post-operative Analgesia
1. With respect to post-operative analgesia, nonsteroidal anti-inflammatory drugs (NSAIDs) should be encouraged.
VIII. Emergency Management

A. Responsibility of the Dentist

1. The dentist is responsible for the anesthetic management, adequacy of the facility, and treatment of emergencies associated with the administration of enteral conscious sedation, including immediate access to appropriate pharmacologic antagonists and properly sized equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.v



APPENDIX I
Sedation Record for Enteral Conscious Sedation
An enteral conscious sedation record should include the following information:


  • Patient name

  • Date of procedure

  • Verification of accompaniment for discharge

  • Preoperative blood pressure, heart rate, and oxygen saturation

  • ASA status

  • Names of all medications administered

  • Doses of all medications administered

  • Time of administration of all medications

  • List of monitors used

  • Record of systolic and diastolic blood pressure, heart rate, oxygen saturation and level of consciousness at 15-minute intervals

  • Time of the start and completion of the administration of the enteral/sedation

  • Time of the start and completion of the dental procedure

  • Recovery period

  • Discharge criteria met: oriented, ambulatory, vital signs stable (record of blood pressure, heart rate, oxygen saturation)

  • Time of discharge

  • Name of the professional responsible for the case

  • A notation of any complications or adverse reaction



References
¹American Dental Association. Guidelines for the Use of Conscious Sedation, Deep Sedation, and General Anesthesia for Dentists. Available at: http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf. Accessed November 9, 2005.
²Ibid.
³American Society of Anesthesiologists. ASA Physical Status Classification System. Available at: http://www.asahq.org/clinical/physicalstatus.htm. Accessed November 9, 2005.

4Malamed SF. Medical emergencies in the dental office. 6th edition 2006. C.V. Mosby, St. Louis.
5American Dental Association. Guidelines for the Use of Conscious Sedation, Deep Sedation, and General Anesthesia for Dentists. Available at:

http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf. Accessed November 9, 2005.



Handling Legislation Regarding General Anesthesia and Sedation Guidelines

REGARDING BOTH GENERAL ANESTHESIA AND IV SEDATION
1. All dentists, regardless of specialty status, should be deemed qualified to render particular modalities of pain control based upon the same qualifications. membership in a specific organization must not be used as a basis for permitting any individual to perform a given modality of pain control.
2. Part One of the ADA's Guidelines should be implemented as a basis for preparing dental school undergraduates to render appropriate pain and anxiety control measures.
3. The dentist must report to the State Board of Dental Examiners any mortality or any incident occurring in the office which results in temporary or permanent, physical or mental injury requiring hospitalization of said patient that is the direct result of dental general anesthesia or sedation.
4. The dentist is responsible for ensuring that the dental office is properly equipped and maintained to safeguard the patient's overall health. The dentist should be prepared to undergo an inspection and evaluation of the facility, equipment, personnel, and procedures used in the office. At least one of the individuals conducting the inspection should be a general dentist qualified to administer general anesthesia and IV sedation, wherever possible.
REGARDING GENERAL ANESTHESIA
1. All dentists not covered by a grandfather clause who wish to administer general anesthesia must complete education equivalent to the number of general anesthesia training hours required in the current oral surgery residency programs. These hours may be acquired on either a full time or part time basis. Dentists qualified under this section shall be encouraged to take refresher courses.
2. Laws enacted must contain a permanent grandfather clause. Demonstration by a general practitioner that he/she has been administering general anesthesia successfully on a regular basis for the last five years shall qualify that dentist as meeting the necessary educational requirements for grandfathering.
3. The dentist is responsible for seeing that an adequately trained individual is with him or her to continuously monitor the patient under general anesthesia.
4. A dentist who has not been trained in administering general anesthesia may obtain a special permit to have general anesthesia administered in his/her office providing he/she has an anesthesiologist, or a certified registered nurse anesthetist or the equivalent on the premises until such time as the patient regains consciousness.
5. A dentist who wishes to administer general anesthesia in his/her office should possess a current certificate in Advanced Cardiopulmonary Life Support issued by the American Heart Association, the American Red Cross, or an equivalent agency sponsored cardiopulmonary resuscitation course with recertification every two years.
REGARDING SEDATION
1. Sedation can be learned on a CDE basis with reference to the course content described in Part III of the ADA's Guidelines. The time and type of training should be subject to the approval of the Dental Board. This allows for a variety of programs in the same state so that dentists may select the program most appropriate to their backgrounds.
2. There is enough evidence to indicate that the clinical and didactic material for sedation can be learned in the undergraduate and graduate levels, and through CDE on a continuous or incremental basis. It is helpful if the course can be conducted in a hospital or dental school environment. Consideration should be given to providing the course on an incremental basis so that it will be available to more of the practicing profession.
3. Laws enacted must contain a permanent grandfather clause. Demonstration by a dentist that he/she has been administering sedation successfully on a regular basis for the last three years shall qualify that dentist as meeting the necessary educational requirements for grandfathering. Grandfathered dentists should be encouraged to take periodic refresher courses.

Revised HOD 5/87

Revised HOD 7/94

Handling Legislation Regarding General Anesthesia and Sedation



1. All dentists, regardless of specialty status, should be deemed qualified to render particular modalities of pain control based upon the same qualifications. Membership in a specific organization must not be used as a basis for permitting any individual to perform a given modality of pain control.
2. Part One of the ADA's Guidelines should be implemented as a basis for preparing dental school undergraduates to render appropriate pain and anxiety control measure.
3. The dentist must report to the State Board of Dental Examiners any mortality or any incident occurring in the office which results in temporary or permanent, physical or mental injury requiring hospitalization of said patient that is the direct result of dental general anesthesia or sedation.
4. The dentist is responsible for ensuring that the dental office is properly equipped and maintained to safeguard the patient's overall health. The dentist should be prepared to undergo an inspection and evaluation of the facility, equipment, personnel and procedures used in the office. At least one of the individuals conducting the inspection should be a general dentist qualified to administer general anesthesia and IV sedation, wherever possible.
Regarding general anesthesia
1. All dentists not covered by a grandfather clause who wish to administer general anesthesia must complete education equivalent to the number of general anesthesia training hours required in the current oral surgery residency programs. These hours may be acquired on either a full time or part time basis. Dentists qualified under this section shall be encouraged to take refresher courses.
2. Laws enacted must contain a permanent grandfather clause. Demonstration by a general practitioner that he/she has been administering general anesthesia successfully on a regular basis for the last five years shall qualify that dentist as meeting the necessary educational requirements for grandfathering.
3. The dentist is responsible for seeing that an adequately trained individual is with him or her to continuously monitor the patient under general anesthesia.
4. A dentist who has not been trained in administering general anesthesia may obtain a special permit to have general anesthesia administered in his/her office providing he/she has an anesthesiologist, or a certified registered nurse anesthetist or the equivalent on the premises until such time as the patient regains consciousness.
5. A dentist who wishes to administer general anesthesia in his/her office should possess a current certificate in Advanced Cardiopulmonary Life Support issued by the American Heart Association, the American Red Cross, or an equivalent agency provided cardiopulmonary resuscitation course with recertification every two years.
Regarding sedation
1. Sedation can be learned on a CDE basis with reference to the course content described in Part III of the ADA's Guidelines. The time and type of training should be subject to the approval of the Dental Board. This allows for a variety of programs in the same state so that dentists may select the program most appropriate to their backgrounds.
2. There is enough evidence to indicate that the clinical and didactic material for sedation can be learned in the undergraduate and graduate levels, and through CDE on a continuous or incremental basis. It is helpful if the course can be conducted in a hospital or dental school environment. Consideration should be given to providing the course on an incremental basis so that it will be available to more of the practicing profession.
3. Laws enacted must contain a permanent grandfather clause. Demonstration by a dentist that he/she has been administering sedation successfully on a regular basis for the last three years shall qualify that dentist as meeting the necessary educational requirement for grandfathering. Grandfathered dentists should be encouraged to take periodic refresher courses.

National Health Care Reform Position Paper



EXECUTIVE SUMMARY
Reform to our nation's health care system will require a significant restructuring of the current delivery system. However, the Academy believes these changes should be incremental and should build upon the strengths of our current system.
The Academy of General Dentistry believes that any health care reform plan must require insurers to offer a minimum benefits package, which would be developed and updated yearly by an independent, federally established commission. Community rating would replace experience rating, pre existing condition exclusions would be prohibited and purchasing corporations or networks would be established to allow the pooling of good and bad risks. In addition, a national risk pool would be established for eligible individuals.
Employers would be encouraged to offer a basic benefits package to all employees. In addition, strong incentives would be developed to promote the purchase of a comprehensive benefits package, which includes dental services. Employers would be required to continue to offer, but not pay for, coverage to employees who have been fired, laid off or have quit.
Medicaid could be expanded and made more efficient through a system of vouchers and subsidies and aggressive anti fraud measures. Uniform eligibility standards and a uniform basic benefits package and catastrophic care, could be established and could be provided through managed care systems that operate on a group model or on a clinic type (staff model) of delivery system.
Employees would be required to share in premium costs. Incentives would be developed to encourage providers to practice in currently underserved areas and extensive professional liability reforms would be implemented. Administrative costs and waste in the health delivery system would be reduced, and living wills would be recognized.

STATEMENT OF GUIDING PRINCIPLES
The Academy of General Dentistry believes that the following principles must be the ultimate goal of any health care reform plan. It acknowledges that these goals may not be immediately achievable. However, it affirms that these goals must be the guiding principles behind any reform plan.
The Academy believes that any health care reform plan must:
1. Provide access to basic health care for all legal residents of the United States, regardless of income.
2. Control escalating health care costs.
3. Provide high quality health care.
4. Build upon the strengths of the current system.
5. Be based on an equitable tax policy.
6. Preserve our pluralistic financing, reimbursement and delivery systems to allow patients the freedom to choose their health care providers and the manner in which their health care benefits are delivered.
7. Be adequately funded.
8. Include a preventive component.

Rx FOR CHANGE
The Academy of General Dentistry supports incremental reforms to our nation's health care system that will build upon its current strengths while increasing access and decreasing costs. While gaining control of costs is crucial, the Academy notes that the high quality of health care currently available in the United States should not be compromised in any way.
The U.S. Department of Commerce estimates in its U.S. Industrial Outlook 1993 that, during 1992, of the $838.5 billion spent on national health expenditures, $40.4 billion was spent on dentists' services, compared to $157.1 billion on physicians' services.
The Commerce Department also found that outlays for physicians' services, home health care, hospital care and nursing home care rose at significantly higher rates between 1987 and 1992 than for dentistry. In fact, the increase in outlays for dentistry has been lower than nearly every other area of health care. Dentistry is one of the few areas where expenditures are still increasing at single digit rates. For example, the Commerce Department reports that from 1991 to 1992, spending for dentistry rose 9.0 percent, while spending for physicians' services rose 10.6 percent during the same time period.
The Academy's position on health care reform addresses the issue in two parts: (1) broadening access to care and (2) controlling costs.
I. Broadening access to care.
Despite the fact that the United States spends more per capita    and a greater proportion of its gross domestic product    than any other industrialized nation in the world on health care, millions of individuals are falling through the cracks in our health care system.
Two reports    one released in December 1992 and the other in January

1993    although arriving at different figures, both confirm that the number of individuals without health insurance coverage is steadily increasing, ranging from 35.4 million to 36.6 million in 1991. Surprisingly, nearly three fourths of all uninsured Americans are workers or their dependents, according to a September 1992 General Accounting Office report.


The Academy believes that access to care could be improved by:
1. Requiring private insurers to offer a federally established minimum package of health care benefits.
An independent commission may be formed to develop and update yearly a minimum benefit package that all private insurers would be required to offer. The independent commission should include representatives from all participants of the health care system: dentists, physicians, hospitals, government, business, labor, consumers and insurers. This package should be weighted toward preventive benefits since these services are most cost effective.
2. Creating incentives for employers to provide comprehensive benefits packages to their employees.
More favorable circumstances should be created for employers to provide comprehensive health benefits, including dental services, voluntarily. Incentives should include providing employers with the choice of a tax credit or deduction to encourage them to purchase the basic benefits package. The tax credit/deduction should be the same for both large and small businesses.
The importance of a health care tax credit/deduction is dramatically highlighted by a January 1993 report released by Communicating for Agriculture (CA), a national rural non profit advocacy organization. CA found that the loss of the 25 percent deduction for the cost of health insurance benefits for the self employed is likely to lead to an additional 400,000 uninsured individuals.
However, given the current political and financial climate, the Academy recognizes that a full 100 percent deduction or tax credit may not be feasible. Therefore, the Academy stresses that whatever limit is finally established be equitable. Large and small businesses, incorporated firms and self employed individuals should all be given an equal deduction.
The Academy also believes that funds raised by limiting the deductibility of health insurance benefits should be used to expand access to health care, not to build highways or for any other reason.
3. Encouraging employers to offer a basic benefits package to all employees.
Employers should offer a basic benefits package to all employees. To encourage this, no employer should be allowed to deduct any part of his/her health insurance premiums unless he/she offers the basic package to all employees. This will discourage large employers from offering health benefits only to upper management, and it will discourage small employers from only purchasing health insurance for themselves.
4. Giving temporarily unemployed persons continued coverage at group rates, and making premium payments tax deductible up to the maximum allowable limit.
This would provide a much needed safety net for United States workers. Employers should be required to offer, but not pay for, a basic package for this group at regular group rates. This coverage should be offered regardless of the reason for the individual's unemployment. For example, an employer must not be allowed to deny continued coverage simply because a person was fired, laid off or has quit. The payments made for health insurance by the individual should be tax deductible up to the maximum allowable limit.
5. Reforming the insurance market to assure affordable basic benefits for small groups.
Reforms to the insurance industry are fundamental to any solution to the health insurance problem. Establishing community rating in place of experience rating would reduce the cost of health insurance and make fees more stable from year to year for small businesses and uninsurables by spreading risks. Consequently, if an employee in a small business finds it necessary to utilize health benefits in a given year, he/she won't necessarily increase the rates for his/her company. This, in turn, will encourage more small businesses to provide health insurance benefits to their employees.
Other necessary reforms include prohibiting pre existing condition exclusions and developing purchasing corporations or networks to allow the pooling of good and bad risks within small employer pools.
In addition, self employed persons, unemployed but self sufficient persons, and adult students should be combined into a national risk pool with coverage provided by private insurers at rates no greater than 125 percent of the group rate for comparable coverage.
6. Reforming Medicaid.
Medicaid should be expanded and made more efficient to reduce costs and to improve access to health care. There should be uniform eligibility standards across the nation, and a standard benefits package should be developed. The standard benefits package should include a long term and catastrophic care insurance benefit and preventive services. These benefits should be provided to Medicaid recipients through cost effective managed care systems that operate on a group model, staff model or clinic type of delivery system.
Medicaid should be expanded to include all categorically impoverished persons, and should cover workers who are not covered under their employer's insurance plans. Low income individuals should receive assistance in purchasing the basic package of Medicaid benefits through a series of vouchers and subsidies on a sliding scale based on income. The poorest individuals should receive a non transferable voucher for the purchase of the coverage, and other low income individuals should receive a subsidy to assist them in purchasing the basic benefit package. This expansion should be paid for by both the federal and state governments.
Medicaid fees should be made comparable to Medicare, and providers must be adequately compensated. Properly compensating health care providers will prevent cost shifting and ensure a high standard of care. The importance of adequate funding is highlighted by an April 1992 report released by the Healthcare Financial Management Association (HFMA). HFMA found that reimbursement shortfalls from Medicare and Medicaid are comprising an increasingly larger share of hospital cost shifting. In 1989, the estimated level of under compensated care from public payers    $11.2 billion    was "reasonably close" to the cost of unsponsored care provided to patients in the form of bad debt and charity care    $8.9 billion. By 1992, however, the study estimated that undercompensated care from public payers would reach $22.7 billion compared to about $11.9 billion for unsponsored care.
* Aggressive measures should be taken to eliminate fraud and corruption. For example, a data base of all final adverse actions and certain fraud investigations against health care practitioners should be established. However, such a system must ensure patient confidentiality. The importance of anti fraud measures is highlighted by testimony presented to Congress in February 1993 by William Mahon, executive director of the National Health Care Anti Fraud Association, who said that health care fraud and abuse could cost the nation as much as $94 billion in 1993.
The reformed Medicaid should be transferred to the private sector with at least one hospital medical surgical dental benefit plan or carrier in each state.
7. Instituting a federally supported system of financial incentives for providers in underserved areas.
Financial incentives, such as loan forgiveness, would make less desirable geographic and socio economic areas more attractive to health care providers, and would thereby increase the availability of quality health care to all residents.
* The Board recommended that the third sentence in this paragraph be amended to read "... must ensure patient confidentiality and provider due process." The Board also recommended that the entire paragraph be moved to the last page of the paper, numbered as item 6, and given the title "Eliminating Fraud and Corruption."
II. Controlling escalating health care costs.
Controlling escalating costs is crucial to reducing the burgeoning deficit. In addition, reducing health care costs is one factor that will help United States firms successfully compete in the global marketplace.
According to a September 1992 General Accounting Office report, a survey of medium and large firms found that employer and employee health benefit costs grew at an average annual rate of 16 percent over the past four years. And, small firms have been experiencing even larger increases.
The Academy believes costs could be controlled by:
1. Implementing tort/professional liability reforms.
Any professional liability reforms must enhance the injured individual's ability to obtain fair compensation and at the same time protect doctors from predatory and unjustified law suits. Tort reforms should include establishing mandatory periodic payments of substantial awards for damages, imposing a ceiling on non economic damages, implementing mandatory offsets of awards for collateral sources of recovery, limiting attorney's contingency fees, imposing a statute of limitations on health care related injuries, devising alternative methods of resolving disputes and requiring medical facilities to use risk management practices.
The National Medical Liability Reform Coalition found in a February 1993 report that the nation's health care system could save as much as $76 billion over the next five years by reducing or eliminating the practice of "defensive medicine" through implementing reforms such as these.
2. Limiting administrative costs.
Simplifying administrative procedures and making insurance forms uniform would reduce costs significantly. In addition, implementing an electronic claims processing system would streamline the process, thereby reducing costs. A November 1990 report by Families USA Foundation and Citizen Action estimated that $52.8 billion could be saved by simplifying the insurance administrative system of private health insurance.
3. Reducing oversupply of hospital beds and duplicative expensive technology.
Unused hospital beds provide no benefit and contribute to the drain on our limited resources. Reducing the oversupply of beds would help to reduce costs as would reducing duplicative technology. A June 1991 General Accounting Office report found that the medical "arms race" is a significant contributor to rising health care expenditures. One example the report gave was of a county in Pennsylvania. In this county, a hospital and a group of radiologists each acquired MRI machines. But another MRI machine also serving local residents was already available in the next county. As a result, a small area had three sophisticated diagnostic machines, each costing $1.5 million. With those machines, physicians apparently performed more MRI scans per resident than were done in all of Philadelphia and many other hospitals in the state.
4. Requiring employees to share in premium costs, but make employees' contributions deductible up to the maximum allowable limit.
Requiring employees to share in premium costs is an easy way to promote wiser consumer choices. Additionally, copayments would help to encourage greater personal responsibility on the part of the patient, and to decrease frivolous use of the health care system without unduly burdening those who truly need to use it.
5. Recognizing living wills in law.
By respecting the wishes of our terminally ill patients and legally recognizing living wills, we could reduce health care expenditures for the terminally ill.

Adopted HOD 7/93


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