Pediatric dental anesthesia: The Dental Board gets it wrong

4th January, 2017

Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

A surgeon can’t do an operation and at the same time direct the actions of a registered nurse or a medical assistant to administer deep sedation or general anesthesia. Even we, as physician anesthesiologists, must involve a second, qualified anesthesiologist or nurse anesthetist if a patient needs deep sedation or general anesthesia while we perform an interventional procedure.

Yet dentists and oral surgeons across America are permitted to supervise a “dental sedation assistant” or “dental anesthesia assistant” who is administering sedative or anesthesia medications while they operate. In California, a dental assistant needs only to complete one year of experience, 40 hours of didactic education, and 28 hours of laboratory instruction to become a dental sedation assistant. No college degree is necessary, and in many states, the requirements are even less.

There has been a smoke screen of confusion around dental office practices partly because the dental regulations haven’t conformed to standard terminology. Instead of using the terms that we’re accustomed to – minimal, moderate, and deep sedation – the DBC has used different terms:

Adult oral conscious sedation

Pediatric oral conscious sedation

Parenteral conscious sedation

Under the umbrella of “parenteral conscious sedation”, there has been no limit to the powerful anesthesia medications that dentists and oral surgeons could use, including propofol, ketamine, fentanyl, methohexital, and midazolam. As long as the patient isn’t intubated, the anesthetic technique (in the DBC’s view) is still “conscious sedation”.

The concept of “conscious sedation” is often unrealistic in a child of pre-cooperative age, or a child of any age who suffers from developmental delay. The child will be safest either fully awake or completely asleep under deep sedation or general anesthesia in the hands of a qualified anesthesiologist. For extensive dental work, airway protection with an endotracheal tube is usually indicated. In any “in-between” stage of anesthesia or sedation, the child may become paradoxically excited or simply unable to cooperate and hold still.

In attempts to control children, some dentists and oral surgeons have “stacked” oral, rectal, intranasal, and/or IV medications to the point that children have stopped breathing either during their procedures or during the recovery period. With inadequate monitoring, these problems haven’t been recognized in time to reverse the rapid descent toward death or irreversible brain damage.

The legislature is paying attention

After tragic cases made headlines in California and nationally, State Senator Jerry Hill demanded that the DBC review California’s laws and regulations concerning pediatric dental anesthesia, and determine if they are adequate to assure patient safety. Several public hearings took place, with families of dead or permanently injured children making emotional pleas for change.

The oral surgery and dental lobbies have resisted any revision to current laws and regulations, arguing that the single operator-anesthetist model has a long history of generally safe use. However, there is no reliable database where outcomes and complications of dental and oral surgery procedures have been consistently recorded, and the DBC has discarded or redacted many records after complications were reviewed.

It seems clear that the most powerful motivator against change is the fact that the single operator-anesthetist currently can bill patients and insurers for performing the procedure and for administering anesthesia.

The most recent DBC recommendations

In a day-long meeting on December 1, 2016, in San Francisco, the DBC heard further testimony and voted on recommendations to send to the California Legislature. These recommendations included revising the current permit structure to reflect the national standard terminology of minimal sedation, moderate sedation, and deep sedation/general anesthesia. The Board also supported improvement of data collection related to pediatric dental anesthesia.

In a move that came as a surprise to many observers, Steven Morrow, DDS, the President of the DBC, came out in favor of requiring a separate “general anesthesia permit holder”, in addition to the operating dentist or oral surgeon, for any child under the age of 7 who needs general anesthesia. A general anesthesia permit can be granted by the DBC, upon application, to a physician anesthesiologist, a dentist anesthesiologist, an oral surgeon, or a dentist who demonstrates additional training in anesthesia. After debate, Dr. Morrow’s motion was adopted by a 13-2 vote of the Board.

While these new recommendations represent some progress in the face of vocal opposition by dentists and oral surgeons, they are dangerously inadequate.

They would still permit a single operator-anesthetist to give general anesthesia to older children, or “moderate sedation” to very young children.

They imply that a dental assistant or a dental sedation assistant has sufficient education to be trained in and perform Pediatric Advanced Life Support (PALS). The delivery of PALS care involves knowledge of pharmacology and medicine well beyond their scope, and is intended for people with the educational level of physicians, dentists, nurses, pharmacists, and emergency medical technicians (EMTs).

They imply that training in PALS is equivalent to years of professional, post-graduate training in anesthesiology.

The latest DBC recommendations don’t consider other factors – such as developmental delay, obesity, apnea, or enlarged tonsils – that may increase the risks of sedation and anesthesia in children of any age. They don’t acknowledge the common-sense fact that children with serious health issues, very young children, or children of any age who need extensive work such as full-mouth rehabilitation, are likely to be safest in a surgery center or hospital with a dedicated anesthesia team rather than in an office setting.

Next steps

We will continue to monitor developments closely as the California Legislature considers the DBC recommendations, and as new legislation concerning pediatric dental anesthesia is drafted. We dispute the Dental Board’s flawed assertion that “moderate sedation” for a toddler’s dental procedure is no different in terms of risk from moderate sedation in a conscious, cooperative, healthy, 12-year-old. Every parent knows what a challenge it can be to get a small child through a haircut, let alone a dental procedure.

We also disagree fundamentally with the argument that more stringent safety requirements for pediatric dental anesthesia could decrease access to care. If the DBC did not require – and derive income from – issuing its own general anesthesia permits, then it would be far easier for any licensed physician anesthesiologist or nurse anesthetist to provide care to children in dental and oral surgery offices. The Legislature should require insurers to pay for necessary anesthesia services for children in dental offices as well as in surgery centers and hospitals.

The best solution of all is for fewer children to need dental procedures extensive enough to require sedation and anesthesia beyond the level of minimal sedation with nitrous oxide. This will require education of parents to encourage better oral hygiene and consistent, early, preventive dental care. It will also require the Legislature to approve better payment rates for Denti-Cal, so that low income is less of a barrier to obtaining preventive dental care.

Our advocacy on this important issue will benefit few of us directly, but I can think of no more important effort that we could make on behalf of children everywhere.

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