A Matter of Life and Death

In this month’s letter, ADEA President and CEO Dr. Rick Valachovic hears from experts in pediatric sedation about efforts to reduce adverse events in the dental office.

You’ve read the headlines or heard them on TV, and if you’re like me, the stories seem surreal. How, you wonder, could this happen again?

While deaths in the dental office are exceedingly rare, they do occur, and it’s especially troubling when a child’s life is lost. The good news is, we know a lot about why this happens, and we can do a great deal to prevent future tragedies.

I recall the bygone days when hospitalization and general anesthesia were often required to treat the youngest patients. The ability to sedate children in the dental office was a major advancement, but it is not without serious associated risks. Studies show a low but persistent rate of life-threatening respiratory events induced by sedation, and the size of children’s airways makes them especially vulnerable to complications that can end in death.

A 2013 study revealed 44 media reports of such events between 1980 and 2012. How does that compare with the number of children sedated for dental procedures during those decades or today? No one knows for sure, but observers agree that the use of pediatric sedation is on the rise.

One such observer is Stephen Wilson, D.M.D., M.A., Ph.D., Chief Dental Officer at Blue Cloud Pediatric Surgery Centers and author of the first textbook solely devoted to pediatric sedation for dental procedures. Steve also served for three years on the ADEA Board of Directors. He published a study in 2001 on the use of procedural sedation (referred to as “conscious sedation” to reflect that patients remain more responsive compared with an unresponsive state when under general anesthesia). He found an increased use of procedural sedation compared with the preceding decade, a trend that he believes continues to this day. Why? A multitude of reasons—early childhood caries are on the rise, with parents eager for treatment; many preschool-aged children are ill equipped to sit still for dental procedures; some school-aged children are paralyzed by fear and anxiety in the dental setting; and more.

“I think sedation is increasing to meet a need that’s out there, and that’s appropriate,” Steve told me. The occurrence of adverse events, he believes, boils down to inadequate training—in both sedation and rescue techniques.

“General practitioners receive very little if any didactic or clinical sedation experiences in dental schools,” Steve told me. “When they graduate and go out into practice, they’re basically using sedation for the first time on their own. They’re essentially self-taught, so they may not be aware of guidelines or procedures or even basic pharmacology, and consequently, they get into trouble.”

To make matters worse, when trouble occurs, providers may not be prepared to intervene effectively while they wait for emergency services to arrive.

“We have this model in dentistry where the person doing the surgery is also the person who is supposed to be providing the anesthesia and monitoring the patient’s safety. You really can’t do both safely,” says Paul Casamassimo, D.D.S., M.S., Professor Emeritus in the Division of Pediatric Dentistry at The Ohio State University College of Dentistry.

In recent years, Paul and Steve have been involved in developing and editing the pediatric sedation guidelines jointly issued by the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD). Paul also led the task force that revised the Accreditation Standards for Advanced Specialty Education Programs in Pediatric Dentistry about a decade ago. In 2017, the Commission on Dental Accreditation reissued those standards, which now require students and residents to complete a minimum of 50 patient encounters in which sedative agents other than nitrous oxide are used. In at least half of those cases, residents must act as the sole primary operator. Observing sedative procedures doesn’t count.

These requirements represent vastly more preparation than the typical general dentist receives in a weekend CE course on sedation, no matter how high the quality may be, and Paul feels it’s warranted.

“Someone who might be mildly sedated can go into moderate to deep sedation just because of their physiology, and dentists have to be able to handle those types of unexpected effects,” Paul told me.

He is pleased that the sedation standards for pediatric dental residents have been strengthened, and he praises the sedation training oral and maxillofacial surgeons receive. But Paul notes with concern that sedation training is not a standard feature of most general practice residencies, nor is it included in the typical predoctoral curriculum. Meanwhile, the practice standards for dentists who use sedation vary substantially from state to state.

There are exemplars, including Paul’s state of Ohio. The state’s dental board lays out stringent criteria that dentists must meet before receiving a permit to provide deep sedation or general anesthesia. Requirements include completing accredited graduate-level training and passing an onsite facility evaluation to ensure that appropriate personnel, drugs and equipment are in place to monitor and rescue patients.

States can also help ensure patient safety by requiring dental offices to become certified through the American Association for Accreditation of Ambulatory Surgery Facilities and by bolstering their Medicaid programs. Low reimbursement rates for publicly funded pediatric dental visits make it difficult for families to find willing providers, Steve says, let alone dentists who are well trained in sedation and skilled in managing young children.

This is an art in and of itself, as anyone who has worked with very young children can tell you. In Paul’s view, detailed in a 2015 article in the Journal of Dental Education, problems associated with pediatric sedation arise in part from how little exposure most dentists and dental students have to treating very young children, especially those with complex needs. “If you’re going to practice family dentistry,” Paul believes, “you’ve got to be able to take care of kids from one year of age and people with special needs, and the training needs to reflect that.”

He thinks raising the training standards for specialty programs and for dentists who want to provide sedation is probably the best avenue for improving safety. As far as predoctoral students are concerned, he’d like to see elective opportunities that meet state dental board criteria for those who want to provide sedation. Absent that training, he recommends communicating that sedation is not in the realm of general dental care and putting “the fear of God, so to speak,” in future dentists who see sedation as a simple procedure.

I appreciate Paul’s sentiments. In an ideal world, all children who need sedation would be referred to highly trained specialists, but there simply aren’t enough of those specialists to go around. And the alternative—general anesthesia in a hospital operating room—comes with its own set of problems as I learned firsthand during my pediatric residency at Children’s Hospital Medical Center in Boston. I, for one, am glad that we now have the option of sedating children who need care in outpatient settings. The question is, what more can we do to ensure that providers are well trained in sedation and in rescue techniques?

Steve has given a lot of thought to what comprehensive training might look like. On the didactic side, he would like all dental schools to give predoctoral students a common foundation by:

• Familiarizing them with the AAP/AAPD pediatric sedation guidelines.
• Having them review morbidity and mortality case studies to understand that almost all sedation-related cases involve the respiratory system or overdosing with local anesthetics.
• Teaching them about physiologic monitoring devices, such as pulse oximeters and capnographs.
• Emphasizing the need to have a person in the operatory whose only task is to monitor patients during deeper levels of sedation and intervene to rescue if problems arise.
• Explaining the implications of the sedation routes (oral, intranasal, intravenous).
• Offering simulation training in advanced life support and rescue.

This last item is costly and time-consuming, but has been shown to be more effective than didactic education alone, and on most of our campuses, simulation centers are already in place. At present, general practitioners and some specialists receive very minimal training in this area, sometimes as little as a basic course in CPR.

Steve acknowledges the challenge of adding to an already packed curriculum, but he points out that “Sedation is the one aspect of dentistry we do that can be life-threatening to the patient.”

Can sedation emergencies be eliminated? Probably not, but we can prepare ourselves better to deal with them when they happen. We can start by considering curricular changes such as Steve suggests, by supporting legislative and regulatory efforts that would improve safety and by reducing barriers to care that allow children’s dental problems to become acute.

Paul tells me that the AAP, AAPD and other dental and medical specialty organizations are working in concert to eliminate deaths from pediatric dental sedation. It’s time for the dental education community to seriously consider what more we can do to ensure that providers are well-trained in sedation and rescue techniques.