A number of years ago, the American Society of Dentist Anesthesiologists petitioned the American Dental Association's Commission on Dental Accreditation (CODA) to accredit its affiliated dentist anesthesiologist residency programs. After considerable debate within the Commission and among the broad-based dental communities of interest, CODA eventually voted to develop an accreditation process that would incorporate dentist anesthesiology residencies. The next step was to create standards that anesthesia programs would have to meet to become accredited. The communities of interest in dentistry, including opportunities at multiple forums where any ADA member could provide input, again subjected these proposed standards to review. The CODA finally voted to accept these standards with minor revisions at their January 2007 meeting. Current dentist anesthesiologist residency programs and institutions that are in the process of developing new programs are now being asked to submit an application for accreditation. The process starts with an internal self-evaluation by each program, based on the CODA application guidelines, and ends with a vote by the CODA after a report from their site visiting team is received.
According to the CODA standards document, “Advanced Dental Education Programs in Dental Anesthesiology are educational programs designed to train the dental resident, in the most comprehensive manner, to use pharmacologic and nonpharmacologic methods to manage anxiety and pain of adults, children, and patients with special care needs undergoing dental, maxillofacial, and adjunctive procedures, as well as to be qualified in the diagnosis and nonsurgical treatment of acute orofacial pain and to participate in the management of patients with chronic orofacial pain.” The resident MUST be trained to the highest level to be “proficient in the administration of local anesthesia, sedation, and general anesthesia, as well as in psychological management and behavior modification as they relate to anxiety and pain control in dentistry” and be “proficient in managing perioperative emergencies and complications related to anxiety and pain control procedures, including the immediate establishment of an airway and maintenance of ventilation and circulation.”
In order to accomplish these lofty goals and others, the standards are quite rigorous and highly detailed. For instance, each resident MUST do a minimum of 500 deep sedations/general anesthetics, 200 of which MUST be intubated general anesthetics, and at least 50 MUST be nasotracheal intubations and 20 cases MUST incorporate advanced airway techniques such as fiber-optic intubation, laryngeal mask airway, etc. A minimum of 100 cases MUST be for children 6 years old or younger and 50 cases MUST be for special-needs patients. Current dentist anesthesiologist programs that are unofficially accredited by the American Dental Board of Anesthesiology can meet these criteria.
The program MUST be a minimum of 24 months' duration, although half of the existing programs already exceed that standard. The program MUST include at least 12 months of full-time anesthesia administered in the operating rooms of a hospital that provides trauma and/or emergency surgical care, with up to 3 months of credit given for anesthesia experience in a hospital or university-affiliated ambulatory surgery center if the complexity of the cases is generally equivalent to those in the main hospital. At a minimum, a total of 18 months over the 2-year period MUST be devoted exclusively to clinical training in anesthesiology. Experience in the administration of deep sedation/general anesthesia and other forms of pain and anxiety control for ambulatory dental patients MUST be provided. A comprehensive didactic program is also required. The dentist anesthesiologist completing this comprehensive residency MUST meet the CODA's definition of being clinically proficient—“The level of knowledge, skills, and values attained when a particular activity is accomplished in more complex situations, with repeated quality and with a more efficient utilization of time.”
There are three major benefits to the profession that will be derived from the accreditation of dentist anesthesiologist residency programs.
1. Since there is a huge increased need and demand for dentists to provide advanced sedation and anesthesia services for other dentists, accreditation should provide increased funding opportunities to support more residents and residency programs to meet that need and demand.
2. Accreditation by dentistry helps cement anesthesia at its highest level as being within the scope of dental education and within the scope of the clinical practice of dentists.
3. Finally, accreditation keeps the highest level of anesthesia education within the control of dentistry and maintains our ability to control the quality of anesthesia training that dentist anesthesiologists receive to protect the safety of the public that we serve. State dental boards now have an appropriate measuring stick to judge the adequacy of anesthesia training for dentist anesthesiologists. They should now recognize that future dentist anesthesiologists must be graduates of CODA-accredited training programs to be eligible for anesthesia permits (with, of course, traditional grandfathering for those who completed training prior to accreditation.)
Common sense dictates that if a special-needs child has a space maintainer fabricated by a graduate of a CODA-accredited dental technology program, and if the device is seated by a graduate of a CODA-accredited pediatric dentistry program who is assisted by a graduate of a CODA-accredited dental assisting program, then the dentist anesthesiologist who provides the general anesthesia (and in whose hands the life of the child is held) must also be a graduate of a CODA-accredited anesthesia program.
Although this process took many years to come to fruition, it demonstrates that dentistry does eventually change with the times. The Commission on Dental Accreditation should be applauded for its efforts to develop and implement accreditation of dentist anesthesiologist residency programs.