Dental sedation and anesthesia: Adverse events and recommended protocol
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.
Taking action to mitigate adverse events
Each day a large number of patients are put under some form of sedation. Patient care and safety must always be the primary objective. In addition to being properly trained in approved residency programs, it is requisite that the doctor and staff have current Basic Life Support (BLS) certification and even Pediatric Advanced Life Support (PALS) certification. Emergency drills should be practiced on a quarterly basis. Offices must maintain emergency medical kits, portable oxygen carts, and AED machines. To be compliant with many state laws, monitoring equipment will need to include capnography, and the doctor will need to have a precordial stethoscope. Additionally, appropriate protocol mandates that there is always a third, dedicated staff member who provides patient monitoring.
Patient safety must be the first priority in all situations. Added vigilance is required when sedation is prescribed. Regardless of current mandates, we have the obligation and opportunity as health-care providers to take all appropriate precautions when treating patients with sedation and general anesthesia.
1. Houpt M. Project USAP 2000: Use of sedative agents by pediatric dentists—15-year follow-up survey. Pediatr Dent. 2002;24:289-294.
2. Saxen MA, Wilson S, Paravecchio R. Anesthesia for pediatric dentistry. Dent Clin North Am. 1999;43:231-245, vi.
3. Cravero JP, Blike GT, Beach M, et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: Report from the Pediatric Sedation Research Consortium. Pediatrics 2006;118:1087-1096.
4. Chicka MC, Dembo JB, Mathu-Muju KR, et al. Adverse events during pediatric dental anesthesia and sedation: A review of malpractice insurance claims. Pediatric Dentistry. 2012;34:231-238.
5. Luce EB, McNeill RG, Yu DH, et al. Report to the Texas Sunset Advisory Commission: Blue Ribbon Panel on Dental Sedation/Anesthesia Safety of the Texas State Board of Dental Examiners. GetResponse website. https://multimedia.getresponse.com/801/24395801/documents/491840601.pdf?_ga=1.125661066.1242463108.1483979633. Published Jan 4, 2017. Accessed August 3, 2017.
6. Pediatric Anesthesia Study, Dental Board of California. Dec. 2016:56.
John R. Ayre Jr., DDS, is a board-certified pediatric dentist practicing at Woods Dental Group and Orthodontics, a practice supported by Pacific Dental Services in Conroe, Texas. He graduated from Loma Linda University School of Dentistry and completed his pediatric residency at Lutheran Medical Center in Brooklyn, New York. He has been practicing dentistry since 1999.