John R. Ayre Jr., DDS
Dental sedation is commonly administered for the treatment of anxious children. It is one of the hallmarks of training for pediatric dentists. It is estimated that between 10% and 20% of children and special needs adults will require pharmacosedation to safely and efficiently complete dental treatment.1,2 Children and the elderly present the highest risk and lowest error tolerance in patient safety during sedation procedures. Although rare, the most serious adverse outcomes of sedation are brain damage and death.3,4 No one should die from visiting the dentist.
Incidence of adverse events in the US
A number of severe adverse events have occurred in the United States during the past five years. In response, state legislatures have told their dental boards to investigate dental anesthesia–related deaths and mishaps. These panels are composed of dental anesthesiologists, oral surgeons, pediatric dentists, and general dentists. All are actively licensed and practicing dentists who frequently perform in-office sedation. Many teach sedation/anesthesia in dental schools.
The panels reviewed deidentified data compiled during board investigations that were involved in patient mortalities and patient harm during or following dental treatment in which sedation/anesthesia was administered. They evaluated substance and application of emergency protocols related to the administration of the sedation/anesthesia. They also reviewed other state laws and rules and scientific literature.
In 2016, a Texas panel performed an intensive review of 78 cases.5 Nineteen were determined to have been mishandled, six were identified as major events (death or permanent injury), and four of the six were children under eight years of age. An additional 13 were categorized as mishaps (adverse events without permanent injury).
Between 2011 and 2016, five deaths and one brain injury occurred that were directly related to sedation/anesthesia.It was revealed that oral and maxillofacial surgeons, pediatric dentists, and dental anesthesiologists perform approximately 411,000 sedation/anesthetics annually in Texas. Adding all licensed Texas dentists, the total number of sedation procedures is estimated to be between 500,000 and 1,000,000 annually.
Texas is not alone. A July 2016 pediatric anesthesia study undertaken by the Dental Board of California found that between 2010 and 2015, nine pediatric deaths were noted from various combinations of local anesthetic, sedation, and general anesthesia.6 Fifty-six additional pediatric hospitalizations were also described, many of which are still being investigated.
Key findings from these reviews include:
• The incidents were varied and occurred in office settings, outpatient surgical centers, and hospitals.
• They occurred in the presence of highly trained dentists, nurse anesthetists, and medical anesthesiologists.
• No one type of provider or sedation delivery model had better outcomes, i.e., oral sedation was no safer than IV or general anesthesia.
• The nature of the mishaps was varied but included drug overdoses and the patients becoming more sedated than anticipated.
• There were cases of premature discharge.
• There was poor drug selection.
• There was poor management in the early stages of a developing urgency that allowed the condition to deteriorate to an emergency.
• There were delayed calls to 911.
Response at the state level
Dental board requirements and state laws are changing in response to these accidents. Although pediatric dental sedation has an excellent safety record, adverse outcomes sometimes occur in apparently healthy patients, indicating that there may be inherent risk in sedation and general anesthesia. Nevertheless, it is important to continue efforts to improve outcomes for all patients who receive sedation and general anesthesia for dental treatment.6
Presently, 25 states have special requirements for pediatric patients, and nine states have a separate permit for sedation of pediatric patients. Later this year it is anticipated that Texas and California will mandate updates to staff requirements, educational requirements, and monitoring standards in an effort to improve the safety of pediatric dental anesthesia and sedation. For example, dentists will be required to use precordial stethoscopes and capnography as part of patient monitoring. For the treatment of children under seven years of age, it will also be necessary to have a separate staff member trained in patient monitoring dedicated to that task.
