By Mary Otto
A 3-year old Hawaiian girl died in January, a month after she lapsed into a coma while undergoing a dental procedure. The Hawaii Department of Commerce and Consumer Affairs has begun an investigation into what went wrong in the Kailua dental office of Dr. Lilly Geyer. The parents of the dead child, Finley Puleo Boyle, are suing and their lawyer is raising questions about the dentist’s diagnosis as well as the level of sedatives administered to the 38-pound girl. Neither the dentist nor her attorney have commented on the case.
Reporter Susan Essoyan of the Hawaii Star Advertiser has been keeping her readers informed.
Tooth decay, while largely preventable, remains the most common chronic disease of childhood.
An increasing number of children are being placed under sedation or anesthesia for dental care, experts say. Children with diagnoses of extensive decay who may not be able to sit still for care are sometimes placed under general anesthesia before undergoing treatment. Sedation, a drug-induced depression of consciousness, “is increasingly popular and viewed as lower-risk in community settings” such as dental offices, according to a August 2013 report in Pediatric Anesthesia.
The authors of the study, “Trends in Death Associated with Pediatric Dental Sedation and General Anesthesia,” reviewed 44 media reports of American children who died after receiving anesthesia for dental work between 1980 and 2011.
The researchers, led by Helen H. Lee, of the University of Washington’s Department of Anesthesiology and Pain Medicine, called for the establishment of a national database of adverse dental anesthesia outcomes to enable future research into patient safety.
The nonprofit Raven Marie Blanco Foundation was among the resources used by Lee and her colleagues to gather media reports for their study. The organization was founded in 2009 by the parents of an 8-year-old Virginia girl who died after suffering complications during a dental procedure. The group compiles reports of deaths associated with dental procedures on its website and advocates for improved emergency preparedness in dental offices.
A 2012 ABC News investigation into the death of Blanco and several other children raised questions about the patchwork of state requirements related to sedation training for dentists and a lack of emergency preparedness found in practices.
The American Dental Association (ADA) offers guidelines and resources related to sedation and anesthesia for both dentists and patients.
Dental Organization for Conscious Sedation (DOCS) Education maintains a regulatory website designed to help health professionals navigate state rules governing oral sedation.
The American Dental Society of Anesthesiology (ADSA) provides resources, including a patient guide, to dental anesthesia and sedation.
The American Academy of Pediatric Dentistry (AAPD) offers published materials, including a “Policy on the Use of Deep Sedation and General Anesthesia in the Pediatric Dental Office.”
For this tip sheet, AAPD national spokesperson, Stephen Wilson D.M.D., M.A., Ph.D., who is director of the pediatric dentistry division at Cincinnati Children’s Hospital Medical Center, offered to respond to some basic questions about pediatric dental sedation and anesthesia.
Q: What are the types of sedation and anesthesia that are more commonly used in dentistry?
A: I am going to speak primarily about pediatric dentistry because I am a pediatric dentist. However, before I do so, I can tell you that the types and routes of sedations performed in dentistry are oral sedations, intravenous sedations and general anesthesia; and more rarely submucosal, intramuscular, and intranasal. The oral surgeons and dental/medical anesthesiologists primarily do intravenous sedation and general anesthesia.
The routes of administration in which pediatric dentists traditionally are trained and use include oral sedation, submucosal and intranasal. There are a few that have some IV training but it’s very limited. There is one other means of sedation you tend to forget about because it happens so commonly, and that is the use of nitrous oxide or laughing gas. Generally speaking, it is not the route of administration that’s particularly important; it is the dose of drugs used, including local anesthetics.
Q: Which ones of these are used in an office setting?
A: Well, they can all be used in an office setting provided that you have the appropriately trained individual to provide those different types of sedation. Also, the office must have appropriate monitors and back-up safety equipment (e.g., back-up suctioning).
Q: Roughly how often are dental procedures performed under sedation and anesthesia?
A: I don’t really have an idea, but I can tell you it’s a very large number. Laughing gas, especially, happens on a daily basis in hundreds of offices around the United States. Other types of sedations and general anesthesia also happen fairly frequently in offices around the United States. Reasons for the need or use of sedation or general anesthesia include a relatively high caries (cavity) rates in children with estimates of up to 30 percent to 50 percent of children experiencing decay before entering school or during the school years, young children who lack good coping and/or language skills, unusually fearful or anxious children, temperamentally difficult children, medically/psychologically/emotionally challenged children, and probable societal changes and expectations such as differing parenting styles across generations.
Q: Is there licensing, accreditation, or training required?
A: That is a tough question to answer because it is so complex. The bottom line is dental students are generally exposed to these different types of sedation. But that exposure can be didactic, or didactic and clinical, ranging from minimal to fairly significant and the “exposure” could be watching, assisting or even doing a sedation procedure under faculty supervision. The extent of such exposures likely depends on where they went to dental school. The dental specialties such as oral-maxillofacial surgery or pediatric dentistry do receive training in their specialty program; training specifically as it relates to these different types of sedation. But a general dentist who graduates from dental school may have been exposed to just the didactic part of sedation or they may have had some clinical experience in dental school.
Q: What are the normal precautions that are taken? What kind of backup do dentists have when they perform sedation or anesthesia?
A: Again, that is a complicated question because a lot of precautionary issues have to do with our training and a lot have to do with state regulations and state board requirements so it’s not a simple question to answer. But the bottom line is the public should be aware that whatever sedation is offered in a dental office, they want to find out if the dentist is following sedation guidelines published by a professional society such as the American Academy of Pediatric Dentistry. They want to make sure the dentist has a properly issued permit by the state, if the state in fact requires that dentists have permits to do sedation, and the overwhelming majority of states do have such regulations. Another inquiry they want to pursue is if the offices are equipped with appropriate monitors, whether the dentist has appropriate emergency materials and equipment that they can use while they are waiting for help from emergency management systems, and the extent of their training in emergency procedures.
Q: In cases where bad things happen, what kind of things go wrong?
A: A lot of times it depends upon the patient. For children, we worry mainly about airway issues and respiratory depression. And for adults, besides the airway issues, we have to worry about cardiac problems as well which don’t usually happen in kids unless the respiratory issues are not addressed quickly. Proper patient assessment, including obtaining a good detailed medical history, doing a physical examination of the airway, and medical referrals, as needed, are important keys to limit sedation liabilities.
Q: Does anybody know how often these deaths occur?
A: There have been three or four published papers on sedation deaths involving children over the past three or four decades and it’s hard to say if these publications involved the same patients. Based upon review of these articles, it is my opinion that many of the reported deaths in one article were likely the same deaths reported in another article. When you consider, going back to the 80s, maybe somewhere between 30 to 45 children may have died in dental offices. That said, they are all tragic, of course. But what we don’t know is how many sedation procedures have been performed during that same time period. So we don’t have a way of saying what the percentage of sedation deaths truly are in dental offices.
