Dept of Medical Education

1 Wyoming Street
Dayton, OH 45409

"Medical Emergencies, Local Anesthesia and Moderate Sedation in

Dental Practice"

Presented by the Miami Valley Hospital Department of Medical Education

[ Notice: The completion of this entire series fulfills the Ohio State Dental Board Requirements for
training in Intravenous Sedation. Dentists from other states should confirm the course approval
with their state dental board. You may need to provide them a copy of this syllabus.]

Note to State Dental Boards: See page 10 for description of clinical IV experiences in Module 5.

This document details a series of courses (modules) that address management of office medical
emergencies, Advanced Cardiac Life Support (ACLS), and moderate (conscious) sedation in dental
practice. The complete series fulfills the "Guidelines for Teaching Pain and Anxiety Control" as adopted by
the American Dental Association and the American Dental Society of Anesthesiology. Courses in this
series include:

Session 1 Module 1 - Medical Emergencies in Dental Practice (8 hr)

Module 2 Local Anesthetics and PO/Nitrous Oxide Sedation (16 hr)
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Session 2 Module 3 - Patient Monitoring: Physiological and Technical Considerations (8 hr)
Module 4 - Advanced Cardiac Life Support (16 hr)
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Session 3 Module 5 - Intravenous Moderate (Conscious) Sedation (48 hr)
-----------------------------------------------------------------------------------------------------------------------

The entire 5-module sequence is required for those wishing to train in intravenous moderate sedation and
participants must score a minimum of 80% on each modules posttest to continue in the series. Questions
are based on objectives listed on the first page of workbooks provided for each module and are thoroughly
addressed in the prerequisite reading, pretests and seminar lectures.

Modules 1 thru 4 can be taken individually as independent seminars, if topics are of interest to dentists
who do not wish to pursue training in IV Moderate Sedation.

The following pages contain detailed syllabi for each module. Direct any inquiries to the course director.

Daniel E. Becker, DDS

Associate Director of Education

General Dental Practice Residency
Miami Valley Hospital
1 Wyoming Street
Dayton, OH 45409

Telephone: 937/208-2144 E-Mail: [email protected]

1/1/2017 1 Course Syllabus

Course Syllabus: (Module 1)

Medical Emergencies in Dental Practice

Description:

A one day (8 hours) lecture/participation seminar covering principles required for the recognition and
treatment of medical urgencies and emergencies in the dental office. Dentists are encouraged to attend
with at least one office auxiliary. Current American Heart Association certification in BLS for healthcare
providers is strongly encouraged as a prerequisite to this seminar. Prerequisite reading and pretest will be
mailed upon receipt of registration. Laboratory session includes managing simulated emergencies on
human patient simulators (SimMan).

Objectives:

1. Discuss strategies for prevention of medical emergencies including office/staff preparedness and
appropriate patient evaluation.
2. Describe components of a primary assessment and demonstrate proper use of equipment and devices
for respiratory and cardiovascular assessment and support.
3. Explain the actions, effects, indications and doses for useful emergency drugs and demonstrate their
preparation and administration.
4. Describe the pathogenesis and appropriate protocols for managing urgencies and emergencies that
may present during dental treatment.

Method of Evaluation:

1. Written posttest covering prerequisite reading and lectured material.

2. Laboratory checkoffs on airway management, vital signs and drug preparation.

Prerequisite Reading: (See Course Workbook)

1. Becker DE, Rosenberg MB, Phero JC. Essentials of Airway management, oxygenation and
ventilation Part 1: Basic equipment and devices. Anesth Prog. 2014;61(2):78-83.
2. Becker DE. Emergency Drug Kits: Pharmacological and Technical Considerations. Anesth Prog.
2014;61(4):171-79.
3. Becker DE. Management of Medical Urgencies and Emergencies (Topic Monograph)

1/1/2017 2 Course Syllabus

 Laboratory Activities

Airway / CPR
Oxygen Tanks/Regulators / Oxygenation
Turn on O2 Tank / Operate Flow Meter
Remove regulator and reattach
Place Nasal Cannula on Partner ( Calculate ~FIO2)

Positive Pressure Ventilation

Demonstrate Oropharyngeal Airway Insertion
1 person BVM ventilations: (Apnea with pulse)
2-person BVM ventilations: (Apnea with pulse)

2-Person CPR with BVM (May use 2-person BVM)

Non-intubated Patient (30:2)

Drug Preparations
Demonstrate EpiPen
Prepare syringes from Amps, SDV & MDV

Emergency Simulations (SimMan)

Perform Primary Assessment (Simultaneous Actions by Team)
Determine Consciousness
Assure Airway Patency and Breathing
Provide Supplemental Oxygenation or Ventilations
Assess Pulse and Blood Pressure

Recognize and Manage Selected Complications

1/1/2017 3 Course Syllabus

Course Syllabus: (Module 2)

Oral and Nitrous Oxide Sedation

Description:
A two day presentation of essential information required for the safe and effective use of nitrous oxide
and sedative/anxiolytics administered PO for management of the anxious dental patient. Local
anesthesia is reviewed and emphasized as the foundation upon which all minimal and moderate
sedation regimens are employed. Prerequisite reading and pretest are mailed upon receipt of
registration.

Module 1, Medical Emergencies, is encouraged as prerequisite for this seminar.

Objectives:
1. Define various terms related to pain and anxiety, and distinguish dated Guedel stages of general
anesthesia with the more contemporary concept of anesthetic components.
2. Characterize 5 levels of sedation identifying clinical features that distinguish minimal, moderate and
deep sedation.
3. Contrast respiratory and cardiovascular changes that accompany the various sedation levels and
general anesthesia.
4. Describe fundamental principles of pharmacodynamics and pharmacokinetics that provide the basis
for the safe and effective use of sedation regimens.
5. Explain the mechanism of action for benzodiazepines and the principal pharmacokinetic parameters
by which they are compared.
6. Describe the actions and effects of antihistamines and opioids, and note their disadvantages
compared to benzodiazepines alone for enteral sedation.
7. Explain the mechanism of action for local anesthetics including their chemical properties that
determine onset and duration.
8. Discuss potential adverse effects of local anesthetics and their maximum dosages, including
calculations for each component found in various conventional formulations.
9. Describe essential pharmacological properties of vasopressors including their dosages,
cardiovascular influences and potential drug interactions.
10. Define MAC and explain how it is altered by other drugs and patient variables.
11. Distinguish the analgesic and anesthetic actions of nitrous oxide, and describe essential
pharmacological features including distribution to air-filled spaces and influences on respiratory and
cardiovascular function.
12. Discuss putative mechanisms that may account for toxic influences of nitrous oxide following chronic
exposure and offer strategies for reducing nitrous oxide exposure to healthcare providers.
13. Describe the components and function of nitrous oxide/oxygen delivery systems.
14. Describe appropriate monitoring for patients receiving nitrous oxide and/or enteral sedation.
15. Discuss relative contraindications and management of complications associated with nitrous oxide
and/or enteral sedation, including the pharmacology and appropriate use of flumazenil for
benzodiazepine reversal.
16. Describe appropriate regimens for enteral sedation, addressing special considerations for geriatric,
obese and pediatric populations, and explain the hazards of combination regimens administered by
PO, submucosal or IM routes.
17. Describe appropriate medical evaluation, patient instructions, records and discharge criteria when
providing moderate sedation.

1/1/2017 4 Course Syllabus

Method of Evaluation:

1. Written posttest covering prerequisite reading and lectured material.

2. Laboratory and clinical check-off for IM injection, airway management, monitoring, and management
of simulated complications.

Prerequisite Reading:
1. Becker DE. The Pharmacological Basis of Sedation. (Topic Monograph.)
2. Becker DE. Anxiolytics and Sedative-Hypnotic Drugs. (Topic Monograph.)
3. Becker DE, Reed KL. Local anesthetics: Review of Pharmacological Considerations. Anesth Prog
2012;59(2):59:90-102.
4. Becker DE, Rosenberg M. Nitrous oxide and the Inhalation Anesthetics. Anesth Prog 2008 55:124-131
5. Becker DE. Patient Monitoring and Managing Complications. (Topic Monograph)

Laboratory Activities

IM Injections
Discuss needle gauges and lengths
Drug Preparation (Sterile Normal Saline)
Prepare syringe from MDV
Drug Administration (IM Deltoid)
Select & Prepare Site
Z-Track Administration

Airway Adjuncts / Ventilation

Ventilation
1 person BVM ventilation of Manikin
2 person BVM ventilation of Manikin
Airway Adjuncts
Oropharyngeal Airways: Size, Insertion & BVM
Supraglottic Airways: Size, Insertion & BVM

Emergency Simulations (SimMan)

Perform Primary Assessment (Simultaneous Actions by Team)

Determine Consciousness
Assure Airway Patency and Breathing
Provide Supplemental Oxygenation or Ventilations
Assess Pulse and Blood Pressure
Recognize and Manage Complications

1/1/2017 5 Course Syllabus

Course Syllabus: (Module 3)

Physiological and Technical Aspects of Patient Monitoring

Description:

A one day (8 hour) lecture/laboratory seminar covering the general principles of autonomic, respiratory
and cardiovascular physiology essential to properly monitor and assess the sedated patient. Requisite
methods of patient monitoring are presented, including practical experiences in their use. This course is
one in a series of courses designed for training in intravenous moderate sedation. However, it is also useful
as preparation for training in Advanced Cardiac Life Support or as general review for those already trained
in sedation and anesthesia. Prerequisite reading and pretest are mailed upon receipt of registration.

Objectives:

1. Describe the rationale for patient monitoring and distinguish the ADA Guidelines for monitoring
patients receiving moderate sedation from those receiving deep sedation and general anesthesia.
2. Describe the autonomic control of vital organ systems.
3. Explain general principles of synaptic transmission, including synthesis and termination of
cholinergic and adrenergic neurotransmitters.
4. Describe the actions, effects and indications for prototypic drugs that mimic and inhibit autonomic
control.
5. Explain basic principles of ventilation, perfusion and gas transport, including the oxygen-hemoglobin
dissociation curve and information provided by arterial blood gases.
6. Define selected respiratory volumes and capacities.
7. Distinguish hypercapnic and hypoxemic mechanisms that control ventilation and the manner in which
selected drug classes depress respiration.
8. Describe methods for monitoring respiratory function including the physiologic principles of pulse
oximetry and capnography.
9. Explain the factors that sustain arterial blood pressure, distinguishing those that determine systolic
and diastolic pressures.
10. Describe the cardiac cycle in terms of pressure gradients and ventricular volumes, and distinguish
stroke volume from ejection fraction.
11. Explain the influences of preload, contractility and afterload on stroke volume and subsequent
arterial pressure.
12. Explain principles of coronary perfusion and factors that determine myocardial oxygen consumption.
13. Describe and demonstrate available systems for monitoring cardiovascular function, including
technical aspects of electrocardiography.
14. State the intrinsic rates for the cardiac neural conduction system and explain how these are
influenced by the autonomic nervous system.
15. Correlate the components of an electrocardiogram with the physiologic events in a cardiac cycle.
16. Interpret common atrial and ventricular dysrhythmias from single-lead ECG tracings

1/1/2017 6 Course Syllabus

Method of Evaluation:

1. Written post-test covering prerequisite reading and lectured information.

2. Laboratory exercises in ECG and etCO2 interpretation.

Prerequisite Reading :
1. Becker DE. Basic and clinical pharmacology of autonomic drugs. Anesth Prog. 2012;59(4):159-68.
2. Becker DE, Casabianca AB. Respiratory Monitoring: Technical and Physiological Considerations.
Anesth Prog 2009;56(1):14-20
3. Becker DE. The Cardiovascular System. (Topic Monograph)
4. Casabianca AB, Becker DE. Cardiovascular Monitoring: Technical and Physiological Considerations.
Anesth Prog 2009;56(2):53-60.
5. Becker DE. Fundamentals of ECG interpretation. Anesth Prog 2006;53(2):53-64

1/1/2017 7 Course Syllabus

Course Syllabus: (Module 4)

Advanced Cardiac Life Support

Description:

This course is a standard AHA Advanced Cardiac Life Support provider course, with emphasis on the
dental office setting. (Two days -16 hours) Participants in the complete IV sedation series must complete
this particular course. Certification from other courses is not accepted.

PREREQUISITE: Current BLS certification at Healthcare Provider Level is an ABSOLUTE

requirement!! Participants attending their initial ACLS course are encouraged to
attend Module 3 Physiological and Technical aspects of Patient Monitoring.

CONTENT: Standard content of American Heart Association's curriculum with added

applications and emphasis for the dental office setting; including anaphylaxis,
asthma attack and hypertensive crisis. ALL laboratory sessions include recognition
and management of complications on human patient simulators, SimMan.
Cardiac arrest scenarios are managed using an AED rather than conventional
defibrillators.

EXAMINATION: Standard written exam required by the American Heart Association for successful
completion PLUS 20 Strip ECG Tracing ID and lab checkoffs found on the following
page.

1/1/2017 8 Course Syllabus

 ACLS Airway Testing

Student: _________________________ PASS _______ FAIL _____

Instructor: ________________________

Grading Key:
S = Satisfactory U = Unsatisfactory

Grade
Activity
1st Attempt 2nd Attempt

BVM Ventilation (On Standard Manikins)

Turn on O2 Tank / 10-15 L/min / Connect BVM

BVM ventilations: (Apnea with pulse) Q5-6sec
2-Person BLS: 30:2
(Note: Chest Compressions are always 100/min)

Airway Adjuncts (On Intubation Manikins)

Select and Insert Oral Airway
Select and Insert Nasal Airway
Pre-oxygenate with BVM
LMA Inserted Correctly and Connected to BVM
Confirmation of Placement
Ventilations: (Apnea with pulse) Q5-6 sec
2-Person BLS: (Q 6-8 sec/ compressions uninterrupted)

ACLS Mega Code Testing

(Includes management of medical emergencies in addition to cardiac arrest.)

1/1/2017 9 Course Syllabus

Course Syllabus: (Module 5)

Intravenous Moderate Sedation

Description:

A six-day lecture, laboratory and clinical presentation addressing the safe and effective use of
intravenous sedation in dental practice. The sequential completion of Module 1 (Medical Emergencies),
Module 2 (PO & N2O Sedation), Module 3 (Patient Monitoring) and Module 4 (ACLS provider course)
are an absolute prerequisite for participation in this final module of the complete series in IV moderate
sedation. In addition, each participant must arrange for 8 hours of clinical experience during which he or
she manages and supports the airway of unconscious patients. This can occur in a hospital operating room
or office of an oral surgeon or dentist anesthesiologist approved by the course director. Prerequisite reading
and pretest is included in a workbook provided to each registrant.

Objectives:

1. Compare and contrast the principal pharmacokinetic processes as they pertain to drugs
administered PO, IM and IV.
2. Describe basic principles of pharmacodynamics and distinguish peripheral and central actions and
effects mediated at various receptors.
3. Compare diazepam and midazolam in terms of their pharmacokinetics, pharmacodynamics and
dosage increments for IV sedation.
4. Compare diphenhydramine and promethazine in terms of their pharmacokinetics,
pharmacodynamics and dosage increments for IV sedation.
5. Compare meperidine, fentanyl and nalbuphine in terms of their pharmacokinetics,
pharmacodynamics and dosage increments for IV sedation.
6. Describe and demonstrate technical aspects of intravenous drug administration.
7. Explain and demonstrate appropriate patient assessment, education, monitoring, and sedation
records, including appropriate discharge criteria
8. Describe the recognition and treatment of local and systemic complications that can be associated
with intravenous sedation. Include essential pharmacological features of any drugs indicated.
9. Describe essential aspects for medical evaluation of a patient for intravenous moderate sedation.
10. Demonstrate competent intravenous sedation technique including proper airway management,
monitoring, drug titration, and time-oriented records.

1/1/2017 10 Course Syllabus

Method of Evaluation:

1. Written post-tests that are comprehensive over all prerequisite reading and lectured materials:
Exam 1 covers modules 1-3 and Exam 2 covers modules 1-5 (excluding ACLS).
2. Emergency simulation practical exam on human patient simulator (SimMan)
3. Clinical exam (mock IV sedation on partner using placebo)
4. Competence during IV sedation of clinic patients.
5. Satisfactory completion of 8 hour practicum managing airway of patient under deep sedation and/or
general anesthesia.

Prerequisite Reading
1. Becker DE. Intravenous Sedation: Technical considerations, patient management and nuisance
complications. (Topic Monograph)
2. Becker DE. Pharmacokinetic Considerations for Moderate and Deep Sedation. Anesth Prog 2011;
58(4):166-173
3. Becker DE. Pharmacodynamic Considerations for Moderate and Deep Sedation. Anesth Prog 2012;
59(1):in press
4. Becker DE. Preoperative Medical Evaluation: Part 1: General principles and cardiovascular
considerations. Anesth Prog 2009;56(3):92-102.
5. Becker DE. Preoperative Medical Evaluation: Part 2: Pulmonary, endocrine, renal and miscellaneous
considerations. Anesth Prog 2009;56(4):135-144.
6. Becker DE. Haas DA. Recognition and management of complications during moderate and deep
sedation. Part 1: Respiratory Considerations. Anesth Prog 2011; 58(2):82-92
7. Becker DE. Haas DA. Recognition and management of complications during moderate and deep
sedation. Part 2: Cardiovascular Considerations. Anesth Prog 2011; 58(3):126-138.

Note to State Dental Boards:

Clinical Experiences in IV Sedation:

Each doctor personally administers intravenous sedation to 20 patients while being provided dental
treatment by our general practice residents.

1/1/2017 11 Course Syllabus