New sedation and general anesthesia guidelines: Why the changes?

Abstract

Editor’s note: In Dionne’s commentary (“Raise the Bar for Safe Sedation, Not Barriers for Access to Care,” on page 133) and in this commentary, the authors discuss the latest guidelines for using and teaching sedation and general anesthesia by dentists. Although the authors of both commentaries approach the subject of sedation and general anesthesia from different points of view, their main arguments focus on the concern for patient safety. Hopefully, providing both of these perspectives will afford JADA readers a better and more comprehensive understanding of the very serious issues involved and the challenges ahead. During the October 2016 American Dental Association (ADA) annual meeting, the House of Delegates voted to approve Resolution 37 and update guidelines for the teaching and use of sedation and general anesthesia by oral health care professionals (OHCPs).1American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. Adopted by the ADA House of Delegates, October 2016. Available at: http://www.ada.org/∼/media/ADA/Education%20and%20Careers/Files/anesthesia_use_guidelines.pdf?la=en. Accessed January 15, 2017.Google Scholar, 2American Dental Association. Guidelines for teaching pain control and sedation to dentists and dental students. Adopted by the ADA House of Delegates, October 2016. Available at: http://www.ada.org/∼/media/ADA/Education%20and%20Careers/Files/teaching_paincontrol_guidelines.pdf?la=en. Accessed January 15, 2017.Google Scholar The changes to these documents primarily update educational requirements and clinical guidelines for the use of minimal and moderate sedation. First developed in 1971, this update to the ADA’s sedation and general anesthesia guidelines is the latest evolution of a document that has been revised 10 times (most recently in 2012) and further attempts to bring clarity and direction for OHCPs wishing to use these modalities.3Solana K. ADA House of Delegates adopts revisions in sedation, anesthesia guidelines. ADA News. Available at: http://www.ada.org/en/publications/ada-news/2016-archive/november/ada-house-of-delegates-adopts-revisions-in-sedation-anesthesia-guidelines?source=redirect. Accessed January 15, 2017.Google Scholar For minimal sedation via the enteral route, the dosing of medication is now limited to a single dose or multiple doses in which the cumulative amount does not exceed the US Food and Drug Administration’s (FDA) maximum recommended dose (MRD) for unmonitored home use. Supplemental dosing, as described in 2012 in which the total aggregate dose must not exceed 1.5 times the MRD on the day of treatment, is now prohibited and replaced by statements indicating that if cumulative doses exceed the MRD, or if multiple enteral medications are used, that guidelines for moderate sedation must apply. The revisions, including the use of the MRD as a limit, are meant to “guide dosing for minimal sedation” and are “intended to create [a] margin of safety.”1American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. Adopted by the ADA House of Delegates, October 2016. Available at: http://www.ada.org/∼/media/ADA/Education%20and%20Careers/Files/anesthesia_use_guidelines.pdf?la=en. Accessed January 15, 2017.Google Scholar Also, for minimal sedation, the use of nitrous oxide and oxygen analgesia, specifically permitted by the 2012 guidelines when used in combination with a single enteral drug, has changed. Although still allowed, the original language is replaced by a statement advising that nitrous oxide and oxygen analgesia when used in combination with a sedative agent may produce minimal, moderate, deep sedation, or general anesthesia. For moderate sedation, the educational requirements have been revised to recommend a didactic course consisting of 60 hours of instruction and administration of sedation to at least 20 individually managed patients with no distinction made as to the route of medication administration. In other words, in 2012 moderate enteral sedation course duration was separate and different from parenteral, but the 2016 revision outlines training and clinical guidelines based on intended level of sedation, not route of medication administration.Previous guidelines do not and cannot continuously account for the 1 variable that is always changing—our patients. Previous guidelines do not and cannot continuously account for the 1 variable that is always changing—our patients. In addition, for moderate sedation, deep sedation, and general anesthesia, the monitoring of ventilation must now be assisted by capnography and monitoring of end-tidal carbon dioxide (CO2). In the previous document, end-tidal CO2 monitoring was only required for intubated patients and was only suggested for nonintubated patients. Finally, patient evaluation for these 3 deepest levels of sedation and anesthesia should include body mass index and the consideration of patients with obstructive sleep apnea as part of the preoperative risk assessment. Pediatric sedation is now covered by the 2016 update detailed in the “Guidelines for Monitoring and Management on Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016.”4Coté C.J. Wilson S. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016.Pediatr Dent. 2016; 38: 13-39PubMed Google Scholar The intent of the ADA’s revised sedation and general anesthesia guidelines is to improve procedural safety and efficacy.3Solana K. ADA House of Delegates adopts revisions in sedation, anesthesia guidelines. ADA News. Available at: http://www.ada.org/en/publications/ada-news/2016-archive/november/ada-house-of-delegates-adopts-revisions-in-sedation-anesthesia-guidelines?source=redirect. Accessed January 15, 2017.Google Scholar These guidelines are then disseminated to the state boards and can be incorporated into regulations to help fulfill the mandate of every dental board: to protect the public. Tragic outcomes after dental sedation procedures continue to occur, and these outcomes can prompt scrutiny of guidelines and regulations, and ultimately necessitate changes and updates.5Egerton B. Deadly dentistry. Dallas Morning News. Available at: http://interactives.dallasnews.com/2015/deadly-dentistry/. Accessed January 15, 2017.Google Scholar, 6Mirabella L. Mother of teen who died after dental surgery advocates for dental safety. The Baltimore Sun. Available at: http://articles.baltimoresun.com/2013-06-30/news/bs-md-ho-dental-awareness-20130630_1_general-anesthesia-teeth-wisdom. Accessed January 15, 2017.Google Scholar, 7Gillihan E. Family settles wrongful death suit. The Derby Informer. Available at: http://www.derbyinformer.com/news/derby_news/family-settles-wrongful-death-suit/article_4169a3c0-40bc-11e3-8217-0019bb30f31a.html. Accessed January 15, 2017.Google Scholar, 8Family files suit after teen dies following dental procedure. Laredo Morning Times. Available at: http://www.lmtonline.com/import/article_a410a9ba-7095-53f3-a98d-e497f68e51f8.html. Accessed January 15, 2017.Google Scholar, 9Kincade K. Woman sues sedation training firm over husband's death. Available at: http://www.drbicuspid.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=304228. Accessed January 15, 2017.Google Scholar, 10Wong A. Death of Hawaii toddler points to lax oversight of dentists. The Huffington Post. Available at: http://www.huffingtonpost.com/2014/01/21/hawaii-dentists_n_4639409.html. Accessed January 15, 2017.Google Scholar, 11Smith T. Virginia Medicaid agency probes boy's death after dental work. Richmond Times Dispatch. Available at: www.richmond.com/news/article_1fb96026-7d5e-5c82-9c5a-5a4bd4f2be1c.html. Accessed January 15, 2017.Google Scholar It is therefore essential that documents outlining education and best practices stay up-to-date and reflect not only the evolution of medications and monitoring, but also incorporate knowledge gained after review of adverse events.12Donaldson M. Gizzarelli G. Chanpong B. Oral sedation: a primer on anxiolysis for the adult patient.Anesth Prog. 2007; 54: 118-128Crossref PubMed Scopus (50) Google Scholar, 13Academy of General DentistryAcademy of General Dentistry. GD white paper on enteral conscious sedation.Gen Dent. 2006; 54: 301-304PubMed Google Scholar, 14Goodchild J.H. Donaldson M. Calculating and justifying total anxiolytic doses of medications for in-office use.Gen Dent. 2006; 54: 54-57PubMed Google Scholar, 15Dionne R.A. Yagiela J.A. Coté C.J. et al.Balancing efficacy and safety in the use of oral sedation in dental outpatients.JADA. 2006; 137: 502-513Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 16Feck A.S. Goodchild J.H. The use of anxiolytic medications to supplement local anesthesia in the anxious patient.Compend Contin Educ Dent. 2005; 26: 183-191PubMed Google Scholar, 17Goodchild J.H. Donaldson M. The use of sedation in the dental outpatient setting: a web-based survey of dentists.Dent Implant Update. 2011; 22: 73-80PubMed Google Scholar, 18Donaldson M. Goodchild J.H. Recent advances in physiologic monitoring for in-office enteral sedation: co-pulse oximetry and bispectral index monitoring.Dent Implantol Update. 2009; 20: 25-32PubMed Google Scholar In addition, previous guidelines do not and cannot continuously account for the 1 variable that is always changing—our patients. In the last 4 years and beyond, the most important changes clinical OHCPs have faced include providing safe and effective sedation and anesthesia services to a population that is older, sicker, and taking more medications (both licit and illicit). Poor patient selection, even coupled with properly educated OHCPs, safe drugs, and up-to-date monitoring equipment, can still result in unintended and catastrophic outcomes.5Egerton B. Deadly dentistry. Dallas Morning News. Available at: http://interactives.dallasnews.com/2015/deadly-dentistry/. Accessed January 15, 2017.Google Scholar, 6Mirabella L. Mother of teen who died after dental surgery advocates for dental safety. The Baltimore Sun. Available at: http://articles.baltimoresun.com/2013-06-30/news/bs-md-ho-dental-awareness-20130630_1_general-anesthesia-teeth-wisdom. Accessed January 15, 2017.Google Scholar, 7Gillihan E. Family settles wrongful death suit. The Derby Informer. Available at: http://www.derbyinformer.com/news/derby_news/family-settles-wrongful-death-suit/article_4169a3c0-40bc-11e3-8217-0019bb30f31a.html. Accessed January 15, 2017.Google Scholar, 8Family files suit after teen dies following dental procedure. Laredo Morning Times. Available at: http://www.lmtonline.com/import/article_a410a9ba-7095-53f3-a98d-e497f68e51f8.html. Accessed January 15, 2017.Google Scholar, 9Kincade K. Woman sues sedation training firm over husband's death. Available at: http://www.drbicuspid.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=304228. Accessed January 15, 2017.Google Scholar, 10Wong A. Death of Hawaii toddler points to lax oversight of dentists. The Huffington Post. Available at: http://www.huffingtonpost.com/2014/01/21/hawaii-dentists_n_4639409.html. Accessed January 15, 2017.Google Scholar, 11Smith T. Virginia Medicaid agency probes boy's death after dental work. Richmond Times Dispatch. Available at: www.richmond.com/news/article_1fb96026-7d5e-5c82-9c5a-5a4bd4f2be1c.html. Accessed January 15, 2017.Google Scholar In medical practice, there is the common idiom of “matching the right drug, at the right dose and the right time, for the right patient and the right procedure.”19Grissinger M. The five rights: a destination without a map.PT. 2010; 35: 542Google Scholar, 20Goodchild J.H. Donaldson M. Appropriate antibiotic prescribing for the general dentist.Gen Dent. 2009; 57: 626-634PubMed Google Scholar The ADA has historically enhanced this approach by further considering the right setting, the right education, and even the right equipment. Regardless, with all the excellent intentions and iterations of the guidelines for the teaching and use of sedation and general anesthesia by OHCPs, picking the right patients can still be our Achilles’ heel. Epidemiologic data continue to demonstrate that we are an aging population.21Cire B. World’s older population grows dramatically: NIH-funded Census Bureau report offers details of global aging phenomenon. Available at: https://www.nia.nih.gov/newsroom/2016/03/worlds-older-population-grows-dramatically. Accessed January 15, 2017.Google Scholar The authors of this same report further predict that the United States’s 65-and-over population is projected to nearly double over the next 3 decades, from 48 million to 88 million by 2050. Moreover, this older population is retaining their dentition and requiring the expertise of OHCPs much later in life than has been experienced in the past.22Slack-Smith L.M. Hearn L. Wilson D.F. Wright F. Geriatric dentistry, teaching and future directions.Aust Dent J. 2015; 60: 125-130Crossref PubMed Scopus (22) Google Scholar, 23Niessen L.C. Fedele D.J. Aging successfully: oral health for the prime of life.Compend Contin Educ Dent. 2002; 23: 4-11PubMed Google Scholar, 24Razak P.A. Richard K.M. Thankachan R.P. Hafiz K.A. Kumar K.N. Sameer K.M. Geriatric oral health: a review article.J Int Oral Health. 2014; 6: 110-116PubMed Google Scholar Unfortunately, although people are living longer, that does not necessarily mean that they are living healthier. Early studies had estimated that 30% of patients visiting a dental office suffer from at least 1 medical condition.25Smeets E.C. de Jong K.J. Abraham-Inpijn L. Detecting the medically compromised patient in dentistry by means of the medical risk-related history.Prev Med. 1998; 27: 530-535Crossref PubMed Scopus (60) Google Scholar, 26Fenlon M.R. McCartan B.E. Validity of a patient self-completed health questionnaire in a primary care dental practice.Community Dent Oral Epidemiol. 1992; 20: 130-132Crossref PubMed Scopus (20) Google Scholar The Centers for Disease Control and Prevention has reported that, “As of 2012, about half of all adults—117 million people—had 1 or more chronic health conditions. And 1 of 4 adults had 2 or more chronic health conditions.”27Centers for Disease Control and Prevention. Chronic disease overview. Available at: http://www.cdc.gov/chronicdisease/overview/. Accessed January 15, 2017.Google Scholar Further complicating the medical status of patients is that polypharmacology is becoming the norm as patients get into their sixth, seventh, and eighth decades of life, requiring more medications to treat their different concurrent chronic diseases.28Gujjarlamudi H.B. Polytherapy and drug interactions in elderly.J Midlife Health. 2016; 7: 105-107PubMed Google Scholar, 29Panagioti M. Stokes J. Esmail A. et al.Multimorbidity and patient safety incidents in primary care: a systematic review and meta-analysis.PLoS One. 2015; 10: e0135947Crossref Scopus (62) Google Scholar It is therefore essential that OHCPs undertake a comprehensive review of every patient’s medical as well as pharmacologic history before any procedure. This written and verbal review needs to include an emphasis on both licit and illicit medication use as well as any complementary and alternative medications. Among adults 65 years or older, 40% take 5 to 9 medications regularly and 18% take 10 or more medications.30Slone Epidemiology Center at Boston University. Patterns of medication use in the United States 2006: a report from the Slone survey. Available at: http://www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdf. Accessed January 15, 2017.Google Scholar, 31Jamsen K.M. Bell J.S. Hilmer S.N. et al.Effects of changes in number of medications and drug burden index exposure on transitions between frailty states and death: the Concord Health and Ageing in Men Project Cohort Study.J Am Geriatr Soc. 2016; 64: 89-95Crossref PubMed Scopus (74) Google Scholar, 32Qato D.M. Wilder J. Schumm L.P. Gillet V. Alexander G.C. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011.JAMA Intern Med. 2016; 176: 473-482Crossref PubMed Scopus (364) Google Scholar Furthermore, considering that nearly 70% of these people do not discuss their computer-aided manufacturing use with their primary care providers, OHCPs should ask all patients about their medication use, particularly when prescribing medications and when considering the patients’ overall sedative or anesthetic plan.33Nutrition Business Journal. NBJ's Supplement Business Report 2012. Available at: http://www.newhope.com/research-and-insights/supplement-business-report. Accessed January 15, 2017.Google Scholar Finally, older adults are 7 times more likely than younger adults to experience adverse drug events that require hospitalization, underscoring the importance for all prescribers to carefully consider potential drug interactions and use available resources to mitigate risk (for example, Lexicomp, Micromedex, Clinical Pharmacology).34Budnitz D.S. Pollock D.A. Mendelsohn A.B. Weidenbach K.N. McDonald A.K. Annest J.L. Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.Ann Emerg Med. 2005; 45: 197-206Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Evaluating the medical stability and appropriateness for sedation and anesthesia services for patients as described above may create a confusing milieu of disease states, medications, and potential drug interactions. In these situations, the OHCP must consider several factors: the preoperative fitness of the patient together with the planned sedative or anesthesia protocol, the setting where treatment will be performed, the availability of monitoring equipment, the potential for adverse events, and the ability to rescue the patient should an adverse event occur.35Goodchild J.H. Glick M. A different approach to medical risk assessment.Endo Topics. 2003; 4: 1-8Crossref Google Scholar It is not enough to simply select inherently safe medications and expect a wide therapeutic margin to mitigate procedural risk. The ADA has addressed this in the revised clinical guidelines by stressing the evaluation of preoperative medical status, including implementation of the American Society of Anesthesiologists Physical Status Classification,36American Society of Anesthesiologists. ASA Physical Status Classification System. Available at: https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. Accessed January 15, 2017.Google Scholar and consideration of the patient’s body mass index and the other airway-associated risk factors such as obstructive sleep apnea. Because the definition of both minimal and moderate sedation involves a patient who can maintain a patent airway without assistance, consideration of airway-associated risk factors is prudent and warranted. Respiratory depression and interruptions in breathing are the most likely sedation and anesthetic mishap, and the prudent OHCP should be vigilant in airway maintenance, both through patient selection and the use of appropriate monitoring.37Weaver J.M. The ADA’s new emergency airway course for sedationists.Anesth Prog. 2010; 57: 137-138Crossref PubMed Scopus (5) Google Scholar To this end, capnography and end-tidal CO2 monitoring should add additional safety for moderate sedation. In most cases in which minimal or moderate sedation techniques are used, the use of benzodiazepines as first-line medications continues to be recommended given their long history of efficacy and safety.38Berthold C. Enteral sedation: safety, efficacy, and controversy.Compend Contin Educ Dent. 2007; 28: 264-271PubMed Google Scholar, 39Sebastiani F.R. Dym H. Wolf J. Oral sedation in the dental office.Dent Clin North Am. 2016; 60: 295-307Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar From a historical perspective, it is important to understand that the term maximum recommended dose is established as a part of the FDA approval process onto the US Pharmacopeia. It serves as a maximum dose, either given singly or as a cumulative amount for unmonitored home use, and continues to be part of the sedation and anesthesia guidelines. Although not expressly noted, the mention of MRD in the minimal sedation guidelines relates primarily to triazolam. When triazolam was approved in 1982, the indication was for the treatment of short-term insomnia (it has never received formal approval by the FDA for the indication of procedural sedation in dentistry). For the indication of insomnia and through subsequent FDA reviews, the MRD was established at 0.5 milligrams.40Cowley G. Sweet dreams or nightmare? Newsweek. Available at: http://www.newsweek.com/sweet-dreams-or-nightmare-203042. Accessed January 15, 2017.Google Scholar, 41Halcion triazolam tablets. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/017892s038lbl.pdf. Accessed January 15, 2017.Google Scholar How then should an MRD established for insomnia be interpreted to serve as the maximum dose for minimal dental sedation? The FDA’s Web site indicates that per dose maximums for diazepam and lorazepam are 10 mg and 2 mg, respectively.42Valium brand of diazepam tablets. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/013263s083lbl.pdf. Accessed January 15, 2017.Google Scholar, 43Ativan (lorazepam) tablets. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2007/017794s034s035lbl.pdf. Accessed January 15, 2017.Google Scholar The equivalent dose of triazolam to 10 mg diazepam and 2 mg lorazepam is 0.5 mg, which may provide some empiric guidance and predict an anticipated level of central nervous system (CNS) depression for dental sedation.41Halcion triazolam tablets. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/017892s038lbl.pdf. Accessed January 15, 2017.Google Scholar, 44Repchinsky C.A. Welbanks L. Bisson R. Hachborn F. Canadian Pharmacists AssociationCompendium of Pharmaceutics and Specialties: The Canadian Drug Reference for Health Professionals. Canadian Pharmacists Association, Toronto, Canada2002Google Scholar There have been theoretical attempts to define minimal and moderate enteral sedation dosing, and clinical reports detailing the CNS depression of triazolam on dental patients.15Dionne R.A. Yagiela J.A. Coté C.J. et al.Balancing efficacy and safety in the use of oral sedation in dental outpatients.JADA. 2006; 137: 502-513Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 45Jackson D.L. Milgrom P. Heacox G.A. Kharasch E.D. Pharmacokinetics and clinical effects of multidose sublingual triazolam in healthy volunteers.J Clin Psychopharmacol. 2006; 26: 4-8Crossref PubMed Scopus (16) Google Scholar, 46Pickrell J.E. Hosaka K. Jackson D.L. Heima M. Kharasch E. Milgrom P.M. Expanded studies of the pharmacokinetics and clinical effects of multidose sublingual triazolam in healthy volunteers.J Clin Psychopharmacol. 2009; 29: 426-431Crossref PubMed Scopus (3) Google Scholar, 47Donaldson M. Goodchild J.H. Maximum cumulative doses of sedation medications for in-office use.Gen Dent. 2007; 55: 143-148PubMed Google Scholar, 48Young E.R. Mason D. Triazolam an oral sedative for the dental practitioner.J Can Dent Assoc. 1988; 54: 511-514PubMed Google Scholar Although the available research is insufficient to clearly delineate the appropriateness of the MRD for minimal sedation, it should be considered suitable for 2 important reasons. First, for OHCPs with the smallest amount of sedation training, it creates a definitive maximum dose that when patient factors and potential drug interactions are accounted for, should provide a reasonable safety margin. Second, because drug effect and psychomotor impairment do not cease at the conclusion of dental treatment but wane over time, the MRD as an intended maximum dose for unmonitored home use can create additional safety for patients who have been dismissed and are no longer directly supervised by the dental team. The other significant change with the approval of Resolution 37 relates specifically to moderate sedation where the route of administration is no longer a differentiating factor. Although the oral administration of medications is inherently the safest route given the first-pass effect, enterohepatic circulation, and even the presence of the P-glycoprotein pump throughout the intestinal epithelium, it does have its limitations in regard to predictability both in onset of effect and profundity of response. Drug latency allows for blunted responses, which may give the OHCP time to recognize and manage adverse outcomes, but interpatient variability still makes predictability of response a challenge. The intravenous administration of sedative medications, though much more predictable and titratable, is also more immediate in onset, forcing the OHCP to recognize and mange adverse outcomes immediately should they occur. There may be OHCPs who will disagree with additional training and expense to deliver the same level of sedation they have always provided,49Dionne R.A. Proposed guideline revisions for dental sedation and general anesthesia: why target the safest level of sedation?.Compend Contin Educ Dent. 2016; 37: 546-552PubMed Google Scholar but this guideline change speaks specifically to the philosophy of “[a]ll dental personnel involved in patient management should be adept in monitoring vital signs and in recognizing and managing life-threatening emergencies, including the ability to rescue the patient from an unintended lapse into a deeper level of CNS depression.”50Malamed S.F. Sedation: A Guide to Patient Management.5th ed. Mosby Elsevier, St. Louis, MO2009: 140-141Google Scholar The inherent differences between enteral and parenteral aside, once patients achieve a level of moderate sedation then the same level of caution to prevent unintended deepening of sedation or compromise in airway patency must apply, regardless of route of drug administration. Patients sedated to a moderate level either via oral triazolam or an intravenous benzodiazepine are equally at risk of experiencing airway-associated morbidity, so the training required to provide this level of sedation to an increasingly compromised patient population should be the same. The approval of Resolution 37 and the recently updated guidelines for the teaching and use of sedation and general anesthesia by OHCPs will not be the last iteration for this evolving document. Sedation and general anesthesia services in the dental office are essential for the treatment of dental patients, and our profession should never stop striving for improved efficacy and safety (Box). To that end, the ADA should be commended for continuous and timely updates to the guidelines for the teaching and use of sedation and general anesthesia by dentists.BoxKey takeawaysTabled 1⁃ The most important determinant for safety of dental sedation and general anesthesia is appropriate patient selection and deselection (referral).⁃ The maximum recommended dose for unmonitored home use is the best surrogate for these same medications in procedural sedation. However, these maximum dosages should serve as the ultimate guardrail and should not be considered target doses; rather, do not exceed doses.⁃ More educational opportunities, both didactic and clinical, must be made available for oral health care providers to achieve and maintain competency in providing sedation and anesthesia.⁃ For moderate sedation, the educational requirements should be based on the intended level of sedation and appropriate selection and management of these patients and should not be specifically focused on the route of medication administration. Open table in a new tab Tabled 1⁃ The most important determinant for safety of dental sedation and general anesthesia is appropriate patient selection and deselection (referral).⁃ The maximum recommended dose for unmonitored home use is the best surrogate for these same medications in procedural sedation. However, these maximum dosages should serve as the ultimate guardrail and should not be considered target doses; rather, do not exceed doses.⁃ More educational opportunities, both didactic and clinical, must be made available for oral health care providers to achieve and maintain competency in providing sedation and anesthesia.⁃ For moderate sedation, the educational requirements should be based on the intended level of sedation and appropriate selection and management of these patients and should not be specifically focused on the route of medication administration. Open table in a new tab The new ADA guidelines for the teaching and use of sedation and general anesthesia by OHCPs outline 3 levels of sedation and general anesthesia and encourage OHCPs to embrace education, monitoring, and patient assessment as principal means of ensuring patient safety. For minimal sedation, the maximum recommended dose for unmonitored home use is the correct surrogate as the ultimate guardrail for these same medications in procedural sedation, but they should not be considered target doses, rather, do not exceed doses. Educational requirements for moderate sedation should be based on the intended level of sedation, and appropriate selection and management of these patients, and not simply the route of medication administration. No single drug is truly safe and no single level of sedation or anesthesia is appropriate for all patients, therefore OHCPs must understand and appreciate limitations based on patient, drug, and procedural factors and the appropriateness of referral.