Children visiting the dentist may require anesthesia for a variety of common procedures from cavities to tooth extractions. When the dentist informs parents that their child will require anesthesia, many parents may not fully understand the dangers. There are some important questions that should be addressed. What type of anesthesia? Who will be administering the anesthesia and what is their level of education and expertise?
There have been several cases that highlight the dangers of pediatric dental anesthesia. In California, the deaths of children such as Caleb Sears are serving as a wake-up call for dental and medical professionals from across the state.
Caleb’s tragic death inspired his family to push for new legislation regarding the administration and monitoring of anesthesia for children. This led to the passage of AB 2235 by former Assembly Member Tony Thurmond (D-Richmond). The law, known as Caleb’s Law Part I, required that the Dental Board of California (DBC) review and report on the dental anesthesia laws and regulations.
They then proposed AB 224, Caleb’s Law Part II. This bill would have required a separate and independent anesthesia provider for young children who needed general anesthesia or deep sedation. The bill was sponsored by the California Society of Anesthesiologists (CSA), the American Academy of Pediatrics-California Chapter (AAP-CA), and the California Society of Dentist Anesthesiology (CSDA).
Unfortunately, this bill was never passed due to opposition from CALOMS and the CDA. The CDA argued that such a bill would deny children access to important procedures and raise costs. After adding several amendments, Governor Brown signed SB 501 into law in October 2018. Although there is still progress to be made, there certainly are some wins from this law. Now adverse events to the DBC must be recorded, and these records maintained for 15 years. There are standardized levels of ASA and CMS terminology for anesthesia and sedation. Dentists also need a pediatric endorsement for the general anesthesia permit. Unfortunately this legislation still fails to ensure that children under anesthesia at the dentist are receiving the same quality of anesthesia care that they would in a medical office, surgicenter or hospital operating room.
More and more dental procedures that require general anesthesia are taking place at dental offices. There are several reasons behind this. It may be more cost effective for dentists to perform the surgery in their office rather than at a hospital. Additionally, many dentists don’t have hospital privileges nor want to deal with the inefficiency and bureaucracy typical of many hospitals. These factors and others have contributed to the trend towards administering pediatric anesthesia at dental offices.
In California, dentists and oral surgeons are not required to have a second person in the room devoted solely to administering anesthesia and monitoring the patient. In medical practices, you need a qualified anesthesiologist on hand if the patient requires deep sedation or general anesthesia. After all, a surgeon can’t perform a procedure and perform anesthesia at the same time!
At dental offices, dentists and oral surgeons are allowed to supervise a “dental sedation assistant” while they operate. Becoming a dental sedation assistant is not like becoming an anesthesiologist or anesthesiologist assistant. To become a dental sedation assistant, you don’t need a college degree. You only need 40 hours of didactic education, 28 hours of laboratory instruction, and one year of experience.
Administering anesthesia is always accompanied by some degree of risk. Children are NOT small adults. Pediatric anesthesia requires special knowledge and has unique challenges. Pediatric patients have a fixed stroke volume, higher oxygen consumption and a lower functional residual capacity in the lungs, they desaturate more rapidly than adults when the airway is compromised.
Children, especially any with developmental delays, are often safest under deep sedation administered by a qualified anesthesiologist. Children are also difficult to control, even as anesthesia is administered. To combat this, some oral surgeons or dentists use a combination of oral, intranasal, and IV medications. Because of this, some children have stopped breathing during their procedures. If they aren’t closely monitored, the issues may not be caught in time. This leads to brain damage or death.
In dental offices, the staff are usually ill-prepared to handle a resuscitative situation. There are no national training standards, only recommended guidelines. As long as the dentist meets the requirements of his or her own state dental board, they can perform sedation and anesthesia without a physician or dental anesthesiologist. According to Dr. Herlich, DMD, MD, a doctor and dentist who works with the American Society of Anesthesiology (ASA) and the ADSA, “dental boards and dental offices do not have to follow ASA standards of care.”
Pushing for restrictive legislation may seem like our best hope. However, such an action cannot be taken lightly. Most dental surgery providers will not want to hire a separate anesthesia provider, and instead oral surgery services may stop being provided. By eliminating the ability for even qualified oral surgeons with anesthesiologists to provide anesthesia in their office, patients will be forced to go to the hospital for procedures. There is often a long wait period required for dental surgeries at hospitals, and people might not be able to receive or afford the care they need. There are also very few MD or Dental Anesthesiologists and even less CRNA’s who routinely perform dental office anesthesia.
No parent should lose a child from a preventable anesthetic complication during a routine dental procedure. Unfortunately, there is no perfect solution. However, parents and the public need to be better educated about the flaws in the system and advocate for policies that will make it safer for every child to receive the best possible anesthesia care at their dentist’s office.