March 2017 Volume LII Number 2
Pediatric Dentistry at the 2016 ADA Annual Meeting
During the ADA’s 2016 Annual Meeting in Denver, Colo., the AAPD hosted a reception for members serving as delegates in the ADA House, pediatric dentistry speakers, and representa- tives from other dental partner organizations. The AAPD Executive Committee held a meet- ing with leadership of the Academy of General Dentistry and we also met with leaders of the Dental Specialties Group, which consists of the nine ADA-recognized dental specialties. As is done every year, we reviewed resolutions of interest to pediatric dentistry being considered by the ADA House of Delegates.
ADA Annual Meeting
Resolution 37H–Revision of Sedation/ Anesthesia Guidelines
This resolution was approved:
Resolved, that the Guidelines for the Use of Sedation and General Anesthesia by Dentists (Trans.2012:468) and the Guidelines for Teaching and Pain Control and Sedation to Dentists and Dental Students (Trans.2012:469) be amended as presented in Appendix 1.
In 2015 the resolution was referred back to committee, and the 2016 version had a significant modification related to the joint AAPD/American Academy of Pediatrics seda- tion guidelines. The ADA guidelines defer to our guidelines for pediatric populations, meaning their guidelines are focused on adults. With this in mind, AAPD President Jade Miller made the following statement before the ADA Reference Committee:
I would like to give a perspective on the Joint Seda- tion and Anesthesia Guidelines of the American Academy of Pediatric Dentistry and American Academy of Pediatrics. My particular focus will be on ventilation monitoring. I hope to provide a better understanding of our reasoning behind the guidelines in this area. The document was updated this year, 2016. The guidelines are used by both organizations as sedation and anesthesia guidelines for pediatric patient care by both physicians and dentists.
First, we want to acknowledge and thank the ADA and CDEL for recommending a change from last year’s proposal, namely to defer to the existing AAPD/AAP Guidelines for pediatric patients. We feel this is appropriate and in the best inter- est of children’s safety.
The AAPD would like to point out in monitoring ventilation where our guidelines and the proposed ADA Guidelines are in alignment and where they de- part. An important perspective to understand is that when it comes to sedation there are the differences in the sedation of children for dental procedures in the office compared to adults. Pediatric sedation, in most cases utilizing an oral sedation regimen, is usually at a minimal to moderate sedation level. We believe that adult dentistry, often utilizing an IV regimen, may trend toward more moderate to deeper sedation levels. Because of that, it is in the area of ventilation monitoring we allow limited provider discretion when sedating pediatric patients.
As we testified last year on the 2015 proposal, and as included in our current updated guidelines, for mod- erate sedation 2 of 3 means of monitoring ventilation must be met. Those are:
1. Capnography—measuring ETCO2—that is preferred.
2. Precordial/pretracheal stethoscope. The amplified version is preferred. Or 3. Bidirectional communication with the patient. Let me emphasize the term communication. It is not a groan. It is communication, the provider seeking a response and the child responding appropriately.
Again, two of these three parameters must be met.
The definition of moderate level of sedation is a purposeful patient response, which may require a mild stimulation to obtain an appropriate response. Therefore, in our guidelines if the pediatric patient is not talking and/or not responding appropriately, capnography is required in addition to a precordial/ pretracheal stethoscope. If the patient is respond- ing appropriately and the dentist is monitoring ventilation via a precordial/pretracheal stethoscope, capnography is not required but must be available. Again, this is premised on the original intended level of sedation being in the minimal to moderate range. Our recommendations for deep sedation/anesthesia do mandate capnography.
The AAPD believes this allows appropriate provider discretion while achieving patient safety, which is clearly paramount.
The other area I would like to point out that is more unique to pediatric patients is cooperation and behavior elements. This tends to be less of a variable in adult sedation. Children may be at times become upset, moving around or tend towards mouth breath- ing. In those situations, when you talk to the child and they clearly respond appropriately, capnography may prove more of a distraction than an aid to patient safety. The technology is not there to provide a con- sistent, valid read-out in such a patient. This creates an algorithmic nightmare of: (1) reaffixing instru- mentation, (2) ignoring the reading, or (3) instituting unnecessary and perhaps deleterious emergency measures.
Resolution 65H–Amendment to Section 5.H. of the ADA Principles of Ethics and Code of Professional Conduct
This resolution was approved:
Resolved, that Section 5.H. of the ADA Principles of Ethics and Code of Professional Conduct be amended as set forth below (additions underscored, deletions
5.H. ANNOUNCEMENT OF SPECIALIZATION AND LIMITATION OF PRACTICE.
This section and Section 5.I are designed to help the public make an informed selection
between the prac- titioner who has completed an accredited program beyond the dental degree and a practitioner who has not completed such a program. A dentist may ethi- cally announce as a specialist to the public in any of the The dental specialties recognized by the Ameri- can Dental Association including and the designation for ethical specialty announcement and limitation of practice are: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, peri- odontics, and prosthodontics., and in any other areas of dentistry for which specialty recognition has been granted under the standards required or recognized in the practitioner’s jurisdiction, provided the dentist meets the educational requirements required for recognition as a specialist adopted by the American Dental Association or accepted in the jurisdiction in which they practice.* Dentists who choose to announce specialization should use "specialist in" or "practice limited to" and shall devote a sufficient portion of their practice to the announced specialty or specialties to maintain expertise in that specialty or those specialties, Dentists whose practice is devoted exclusively to an announced specialty or specialties may announce that their practice "is limited to" that specialty or those specialties. limit their practice exclu- sively to the announced dental specialties, provided at the time of the announcement such dentists have met in each recognized specialty for which they announce the existing educational requirements and standards set forth by the American Dental Association. Den- tists who use their eligibility to announce as specialists to make the public believe that specialty services ren- dered in the dental office are being rendered by quali- fied specialists when such is not the case are engaged in unethical conduct. The burden of responsibility is on specialists to avoid any inference that general practitioners who are associated with specialists are qualified to announce themselves as specialists.
*completion of an advanced educational program accredited by the Commission on Dental Accredita- tion, two or more years in length, as specified by the Council on Dental Education and Licensure, or being a diplomate of an American Dental Associa- tion recognized certifying board for each specialty announced.
The AAPD recommended that the following clarifying statement be added at the end of the above paragraph, due to the unique nature of pediatric dentistry as an age-defined specialty:
"In the case of the age-defined specialty of pediatric dentistry, a general practitioner may announce as a General Dentistry practice limited to children, but shall not announce as a General Dentistry practice limited to pediatric dentistry as the latter statement implies specialty status." Disappointingly, this statement was not adopted by the ADA Reference Committee.
Resolution 12RC–Proposed New Policy on Comprehensive ADA Policy Statement on Inappropriate or Intrusive Provisions and Practices by Third Party Payers
This resolution was adopted with the directive that:
. . . this policy be communicated to the National As- sociation of Dental Plans (NADP) and dental benefit companies to encourage consideration of this policy in the design and revision of each carrier’s dental plan products.
This resolution was strongly supported by the AAPD. It identifies a number of objectionable third party payer policies that interfere with treatment decisions made be- tween doctor and patient. The policy is discussed in detail in the Coding Corner on page 44 of this PDT issue.
AAPD Member Speakers
The following AAPD members made CE presentations during the ADA Annual Meeting:
Kevin Donly presented the AAPD sponsored course in the "Specialty Pavilion" on Update on Caries Remineralization Agents.
Marvin Berman presented on Garden of Tips for Effective Pediatric Dentistry and Special Patients-Special Dentists, Opportunity Calls.
Charles S. Czerepak co-presented on Maintaining Your Viability as a Medicaid Provider.
Gregory L. Psaltis presented on Primary Pulp Therapy and Stainless Steel Crowns are a Snap.
Sidney A. Whitman co-presented on Maintaining Your Sanity and Practice Viability as a Medicaid Provider.
J. Timothy Wright co-presented on ADA Clinical Practice Guidelines: The Most Effective Treatment in Dentistry.
AAPD Member Delegates and Alternates
We thank those AAPD members who served in the 2016 ADA House of Delegates:
1ST DISTRICT (CONN., MAINE, MASS., N.H., R.I., VT.) Delegate
Jonathan D. Shenkin (Augusta, Maine)
Loren C. Baim (Glens Falls, N.Y.)
Gary L. Creisher (Kennebunk, Maine)
Erik Johnson (Van Buren, Maine)
Jay Skolnick (Webster, N.Y.)
2ND DISTRICT (N.Y.)
Margaret Madonian (Liverpool, N.Y.)
Lauro F. Medrano-Saldana (Brooklyn, N.Y.)
Loren C. Baim (Glens Falls, N.Y.)
Jay Skolnick (Webster, N.Y.)
4TH DISTRICT (AIR FORCE, ARMY, DEL., D.C., MD., NAVY, N.J., PHS, P.R., VETERANS AFFAIRS, VIRGIN ISLANDS)
Mark A. Vitale (Edison, N.J.)
Sidney A. Whitman (life member) (Hamilton Square, N.J.)
5TH DISTRICT (ALA., GA., MISS.)
James I. Lopez (Columbus, Ga.)
Robert David Bradberry (Marietta, Ga.)
Erik H. Wells (Athens, Ga.)
6TH DISTRICT (KY., MO., TENN., W. VA.)
K. Jean Beauchamp (Clarksville, Tenn.)
7TH DISTRICT (IND., OHIO)
Terry G. Schechner (Valparaiso, Ind.)
8TH DISTRICT (ILL.)
Victoria A. Ursitti (Arlington Heights, Ill.)
9TH DISTRICT (MICH., WISC.)
Martin J. Makowski (Clinton Township, Mich.)
10TH DISTRICT (IOWA, MINN., NEB., N.D., S.D.)
Valerie B. Peckosh (Dubuque, Iowa)
James D. Nickman (North Oaks, Minn.)
11TH DISTRICT (ALASKA, IDAHO, MONT., ORE., WASH.)
Linda Edgar (affiliate member) (Federal Way, Wash.)
Bernard J. Larson (Mount Vernon, Wash.)
Hai T. Pham (Aloha, Ore.)
John L. Gibbons (Tacoma, Wash.)
Jane Gillette (affiliate member) (Bozeman, Mont.)
Olga L. Ortuzar (Everett, Wash.)
Sarah Post (Eugene, Ore.)
12TH DISTRICT (ARK., KAN., LA., OKLA.)
John T. Fales, Jr. (Olathe, Kansas)
Timothy R. Fagan (Enid, Okla.)
Nick Rogers (affiliate member) (Arkansas City, Kansas)
Cindi Sherwood (Independence, Kan.)
13TH DISTRICT (CALIF.)
Claudia Masouredis (San Francisco, Calif.)
Joseph P Sciarra (Woodland Hills, Calif.)
Sharine V. Thenard (Alameda, Calif.)
14TH DISTRICT (ARIZ., COLO., HAWAII, NEV., N.M., UTAH., WYO.)
Karen D. Foster (Aurora, Colo.)
Jeffrey A. Kahl (Colorado Springs, Colo.)
Kirk J. Robertson (Flagstaff, Ariz.)
Lynn Fujimoto (Aiea, Hawaii)
15TH DISTRICT (TEXAS)
Rita M. Cammarata (Houston, Texas)
Charles W. Miller (Arlington, Texas)
Paul A. Kennedy, III (Corpus Christi, Texas)
Adam C. Shisler (Houston, Texas)
16TH DISTRICT (N.C., S.C., VA.)
Scott W. Cashion (Greensboro, N.C.)
Roger E. Wood (Midlothian, Va.)
Ronald D. Venezie (Apex, N.C.)
Rocky L. Napier (Aiken, S.C.)
17TH DISTRICT (FLA.)
Suzanne Thiems-Heflin (Gainesville, Fla.)
13TH DISTRICT TRUSTEE (EX-OFFICIO MEMBER OF HOUSE)
Lindsey A. Robinson (Grass Valley, Calif.)
Click here for a PDF version of this article.