Anesthesia complications suspected; state rules differ
The highly publicized deaths of two children who died after an in-office dental procedure performed by a dentist and an oral surgeon, respectively, have many questioning whether national guidelines or individual state dental board requirements need to be strengthened when it comes to administering general anesthesia to a pediatric population. The cause of both fatalities is suspected by some to be related to anesthesia.
“The educational and training requirements to administer sedation and anesthesia are regulated by individual state dental boards,” said dentist anesthesiologist Joel M. Weaver, DDS, PhD, a spokesman for the American Dental Association (ADA) and emeritus professor at the Ohio State University, in Columbus. Dr. Weaver is a past president of the American Society of Dentist Anesthesiologists, American Dental Board of Anesthesiology and American Dental Society of Anesthesiology, which are the three major organizations for anesthesiology in dentistry.
“Because sedating children is very different from sedating adults,” Dr. Weaver said, “many state dental boards require the dentist who sedates a child 12 years and younger to qualify for a special moderate sedation or anesthesia permit.”
ADA Guidelines Not Specifically Pediatric
Dr. Weaver said some state dental board rules and laws closely follow the principles outlined in the ADA guidelines, which for deep sedation or general anesthesia include an advanced education program accredited by the ADA Commission on Dental Accreditation and current certification in Basic Life Support for Healthcare Providers.
The ADA guidelines list the minimal number of individuals required for each of the various levels of sedation, as well as for general anesthesia. “For minimal and moderate sedation, the sedation-trained dentist needs an assistant who is trained in Basic Life Support for Healthcare Providers, in case of an emergency,” Dr. Weaver said. For deep sedation and general anesthesia, the anesthesia-trained dentist needs the same type of assistant, plus another assistant “whose duty is to monitor the patient and the monitoring equipment to assure that the patient’s vital signs are stable throughout the procedure.”
Dr. Weaver said the ADA’s anesthesia and sedation guidelines are updated periodically to conform to new scientific findings and evolving technology. However, the association does not have guidelines specific to a pediatric population, but defers to the American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.”
“Dentists enter the profession to help people and provide care,” Dr. Weaver said. “Our commitment to safety is apparent in the educational resources offered by the ADA.”
Dr. Weaver said the rules and laws adopted by individual states are enforced by each state dental board. “State dental boards are the appropriate entity to collect patient complaints because they have the enforcement power over licensed dentists to assure the safety of the public,” he said. The ADA does not collect case information or disciplinary actions regarding sedation or anesthesia, “so it is difficult to judge the degree of enforcement.”
The most recent of the two pediatric patient deaths occurred in March 2016, when a 14-month-old girl stopped breathing after being administered general anesthesia for what started out as a routine cavity-filling procedure at Austin Children’s Dentistry (ACD), in Texas (see sidebar). ACD spokeswoman Sarah Marshall said, “We follow all prescribed guidelines from regulatory authorities of dental practices and will continue to do so. The organization’s primary concern is always for the safety and well-being of patients, staff and the community.”
Ms. Marshall said for all procedures at ACD, the dentists and the anesthesiologist staff are independent contractors. “The 911 tape [of the toddler] confirmed a dentist and anesthesiologist were both present,” she said. “But because of privacy laws and any matters under investigation, I am unable to comment on any specific situations.”
CRNAs: Barriers, and No Pediatric Guidelines
According to Juan Quintana, DNP, MHS, CRNA, president of the American Association of Nurse Anesthetists (AANA), in the state of Texas there are many practice barriers that prevent certified registered nurse anesthetists (CRNAs) from providing anesthesia in a dental office. “If these restrictions were removed, dentists would be more likely to hire CRNAs to administer anesthesia to dental patients rather than perform both the oral surgery and the anesthesia themselves,” Dr. Quintana said. “From my experience as a CRNA, our standard of practice is to assess and evaluate the patient before the procedure and stay with our patient throughout their procedure. CRNAs monitor vital signs, adjust the anesthetic drugs as needed and remain vigilant in case of an emergency. Patients’ safety is our No. 1 priority.”
The AANA does not have specific guidelines or recommendations for a dental office or pediatric dentistry. More generally, however, the association publishes “Standards for Office Based Anesthesia Practice.” Dr. Quintana said, “These standards identify the minimum policies that should be in place, elements of the preanesthesia assessment, monitoring requirements, an assessment checklist of minimum elements for providing anesthesia, and an anesthesia equipment and supplies checklist.”
The AANA also has a document titled “Non-anesthesia Provider Procedural Sedation and Analgesia” for policy development at a facility. “Specifically, this document provides sedation considerations for special populations, including pediatrics,” said Dr. Quintana, who has been a CRNA for nearly 20 years and currently serves as president of Sleepy Anesthesia, an anesthesia practice headquartered in Winnsboro, Texas, which serves several hospitals in the Lone Star State.
The AANA also offers resources for patients, children and parents. “These resources include information on preparation for office-based anesthesia, a parent’s role in preparing their children for surgery and anesthesia, and a children’s educational coloring book,” Dr. Quintana said.
States’ Rules Vary
Dr. Quintana said the dental board rules in many states are modeled after the ADA and AAP/AAPD guidelines. “Each state’s rules may vary, however, concerning specific equipment, supplies and monitoring required for various levels of sedation and anesthesia,” he said. “Overall, every clinician’s focus needs to be on the safety of their patient throughout the procedure. Patient assessment and evaluation, patient monitoring, and the availability of requisite emergency medications, equipment and policies, are important to providing safe patient care in an office-based setting.”
The American Dental Society of Anesthesiology (ADSA) also does not have its own guidelines or recommendations for anesthesia in a dentist’s office. “We defer to the excellent guidelines that the ADA and AAPD/AAP have published,” said Kenneth L. Reed, DMD, president of ADSA, and a dentist anesthesiologist at Solis Surgical Arts, a surgery center in Tarzana, Calif. “Both organizations regularly update those guidelines, and both are due to update them again later this year after a multiyear reevaluation.”
When these guidelines are followed, “there is a phenomenal safety record of sedation and anesthesia in dentistry,” Dr. Reed said. “Almost universally, when an adverse outcome occurs, the guidelines were violated, oftentimes on many fronts.”
Dr. Reed said a certified or dedicated anesthesiologist is not required on-site when anesthesia is given. “Local anesthesia is ‘anesthesia’ that does not require the presence of an anesthesiologist in any medical or dental office,” he said. “The same can be said for inhalation sedation with nitrous oxide and oxygen only or even parenteral moderate sedation that is routinely done safely by dentists and physicians on a daily basis in their offices without a dedicated anesthesiologist.”
Dr. Reed said sedation and anesthesia rules vary by state within dentistry. “Many states accept the ADA guidelines as their state requirements, but others feel they want to write their own,” he said. “There are also no nationwide standards; there are only nationwide guidelines.”
A Watered-Down Bill
The second death that has garnered a lot of media attention is of a 6-year-old boy from the San Francisco Bay Area who, in March 2015, was treated by an oral surgeon in Albany (California) to remove a tooth. The boy was given general anesthesia by the oral surgeon, which the family believes ultimately caused the death.
As a result, the family reached out to their state assemblyman, Tony Thurmond (D-Richmond), who produced a bill—known as Caleb’s Law—that required notifying parents before their child’s oral surgery that there is a greater risk for death when the same oral surgeon performs both surgery and anesthesia. In a statement to Anesthesiology News, the father, Tim Sears, said: “When parents make decisions about anesthesia risks they conflate the more safe practice of medical anesthesiologists with the practice of having an oral surgeon operating as a single operator-anesthetist. The risks vary and parents should know that. I only wish we had known that.”
However, dental groups and lobbyists, including the influential California Dental Association (CDA), fought back, and were successful in watering down the bill by replacing it with a more general warning about the risks from anesthesia.
In response to inquiries, CDA provided the following statement: “The California Dental Association is saddened by the tragic loss of a young life and we extend our heartfelt condolences to the family. CDA is deeply committed to ensuring that dental care is safely and effectively provided every day, to every person. To that end, we are pleased that the Dental Board of California responded immediately to a request from the California Senate Business and Professions Committee to investigate whether the state’s laws, regulations and policies are appropriate to reduce the potential for injury or death from the administration of general anesthesia or deep sedation for pediatric dental patients.”
The statement indicates that CDA “is committed to support actions that ensure children and adults have access to the highest and safest standards of care.” Furthermore, “While the state evaluates the provision of general anesthesia for pediatric dental care, it is important to know that each year in California thousands of children receive anesthesia to protect them from the stress of receiving medically necessary dental treatment. Deaths from anesthesia are rare; the administration of general anesthesia has a strong safety record built upon the significant anesthesia training required and the in-depth, in-person evaluation the dental board must complete before awarding a dentist a permit to provide general anesthesia in California. While these steps support the safe provision of care, continued analysis and evaluation is beneficial to ensure this strong safety record continues into the future, for every patient, every day.”
ASA Can Only Advocate
Being a medical specialty, the American Society of Anesthesiologists (ASA) “has no authority or position regarding dentistry—that would fall under the state dental boards,” said Andrew Herlich, MD, ASA’s liaison to ADA’s Committee on Anesthesia. “Safe anesthesia care is our top priority.”
Dr. Herlich said ASA’s guidelines are the same for any location: a dental office, a physician’s office, an outpatient surgery center, even a hospital operating room. “We advocate for physician-led, team-based anesthesia care, using standard monitoring for patient care,” Dr. Herlich said.
Standard monitoring for moderate and deep sedation and general anesthesia consists of the ability to monitor heart rate, heart rhythm, blood pressure, oxygen saturation and “of course, a way to quantify the patient’s respiration,” he said. “In loose terms, this quantifying means capnography.”
Dr. Herlich said there is no mandate by any authoritative body to require an anesthesiologist on-site when anesthesia is given.
In other words, dentists can perform sedation and anesthesia themselves, without the need for a physician anesthesiologist, as long as the dentist has met the requirements of his or her own state dental board. “We cannot impose our standards to a dental board or dental office,” Dr. Herlich said.
As for a single provider handling both anesthesia and the procedure itself, “it depends on the situation, because there are people that are trained to do both, such as emergency physicians,” Dr. Herlich said. Variations in state policies and rules also “are all over the map.”
Dr. Herlich, a physician anesthesiologist and dentist, as well as a professor of anesthesiology at the University of Pittsburgh School of Medicine, said the specialty of oral surgery “has incredibly high standards and follows the same guidelines as ASA, step by step.”
But even by following ASA guidelines, deaths are still possible in a dental office. “It depends on the choice of patients and choice of location,” Dr. Herlich said. “There are deaths in the operating room.” Moreover, concerning the handful of well-publicized, anesthesia-related deaths, “we do not know the denominator.”
Meanwhile, as new sedative medications are approved and new monitoring devices developed, along with research discovering new and improved sedation and anesthesia techniques, “the safety of sedation and general anesthesia in the dental office will undoubtedly continue to improve,” said Dr. Weaver.
“Office-based anesthesia in a dental office has a long history of safety and efficacy, going back to Horace Wells in 1844,” said Dr. Reed. Fast-forward to the 1980s, when dentists “were providing office-based general anesthesia for outpatient ‘day surgery,’ while medicine was still requiring overnight admissions and hospital stays for the most minor and routine surgery that required general anesthesia. Dentistry has always been at the forefront of office-based sedation and anesthesia, and I do not see that changing in the future.”
Dr. Quintana concluded, “Anesthesia professionals and all clinicians should continue to be vigilant and promote patient safety for patients of all populations and undergoing any type of procedure, no matter how routine. As part of a continuous quality improvement process, clinicians must learn from these tragic events and improve the care provided to their next patients.”