On July 9th, the show Sunday Night with Megyn Kelly aired a piece called “Children at Risk? Kids and Sedation at the Dentist’s Office” that may generate discussion among your colleagues and in your practices. The lead reporter in the piece was NBC News national correspondent Kate Snow. In that piece, the safety of sedation dentistry for children was questioned. More specifically, concerns were raised with respect to training, multi-tasking dentistry and anaesthesia, and the general challenges of paediatric anaesthesia. In the piece, the terrible cases of Neveah Hall (brain-damaged in Texas) and Caleb Sears (a death in California) were visited. First and foremost, as I have said before in these pages, anytime a patient is harmed in the process of delivering dental care, it’s awful. When that patient is a child, it’s worse. To that end, our first priority should be to empathize with the affected families. Second, as healthcare professionals, we must continue our quest for greater patient safety. There is always room for better.
Much of the piece focussed on the shortcomings particular to the Hall and Sears cases, as well as on some of the systematic weaknesses in the United States. In the U.S., as in Canada, each state (or province) has its own set of rules established by its own jurisdictional regulator, so making accurate blanket statements is not possible. While the overall tone of the piece was not kind to dentists, I was able to find some comfort in the realization that in many jurisdictions, the Canadian model of sedation for dentistry is well ahead of that of our neighbours to the south.
The term “operator-anaesthetist” has been reduced to a generic term referring to dentists who offer sedation in their practices. It’s a little bit like the way most of us refer to all facial tissue as “Kleenex”. Unfortunately, this can lead to some misconceptions. In the case of sedation dentistry, these misconceptions can lead to conclusions that miss the mark. While there may be some “operator-anaesthetists” in practice in Canada, in most jurisdictions, the term “procedural team anaesthesia” is a more accurate descriptor for the mandated method of delivering sedation/anaesthesia for dentistry. The distinction is important. In the operator-anaesthetist (OA) model of delivery, during the appointment, there may be only two people in the operatory: the dental practitioner, who is also the anaesthetist, and an assistant, who is sometimes a registered nurse. In the procedural team (PT) approach, there are at least three people in the operatory for the appointment. There is the dental practitioner, a sedation assistant, who again is usually a registered nurse and not working in the mouth, and a dental assistant. This is the common model in Canada. The third model, of course, is the one where the operating dentist is entirely separate from the anaesthetist, but that model was not an issue in the Sunday Night piece. Intuitively, one would think that having six trained hands in the operatory, as in the PT model, would add a layer of safety to the procedures. My intuition says this too but this has never been shown to be true, making my opinion no more than just my opinion (of which I have many).
There is a scarcity of data specific to the question of safety in anaesthesia for dentistry, much less each of its subsets (e.g. moderate conscious sedation, children, etc.). We know that overall it’s safe because, like plane crashes, serious mishaps in the dental office make the news. These stories are newsworthy because they are rare events. But how safe is “safe”? There are a few studies, notably by D’Eramo looking at oral surgeons (the OA model) in Massachusetts, and by me (albeit 20 years ago), but these older studies don’t provide much evidence to act on, even though the results in each investigation have been very good. Not having much information to work with makes us rely on guesswork in creating new rules and regulations. That’s rarely a good situation.
According to Ms. Snow’s piece, most states allow any dentists to use multiple-agent sedation techniques on children with “a few days of training”. This may be true in the U.S. but it is not true in Ontario or any other province that I am aware of. That’s good for Canadians.
Interestingly, the experts included in the piece were Dr. Wendy Sue Swanson, a paediatrician and the author of the Seattle Mama Doc™ blog, who was (unofficially) representing the American Academy of Pediatrics, and Dr. Karen Sibert, a medical anaesthesiologist and the author of the blog, A Penned Point, who is a member of the California Society of Anesthesiologists. Neither of them are satisfied with the OA model of sedation, their positions are historic and on the record.
In order to balance the piece, sort of, Dr. Roger Byrne, an oral surgeon introduced as the author of the sedation guidelines for dentistry in Texas, was shown the case of Neveah Hall. He was asked to comment on the four-hour delay between the apparent start of trouble and the activation of Emergency Medical Services. Not surprisingly, he said that this was a case that was not run properly. In California, Dr. George Maranon, a member of the California Association of Oral and Maxillofacial Surgeons, appeared on-camera in order to refute the claim that the OA model was attractive largely because of the financial upside to collecting fees for the delivery of both the dentistry and the anaesthetic. This was a hard issue to address palatably, since it is partially true, which is unpalatable. The answer Dr. Maranon gave, unfortunately, was “That couldn’t be further from the truth…”, which isn’t really true unless you are working on a salary. Ms. Snow’s reasonable follow-up question was why is it not better to have a separate anaesthesia-trained person in the room during procedures? To paraphrase the answer, Dr. Maranon said that there was no evidence to suggest that this change would enhance safety. Fair enough. Ms. Snow then took that position back to Dr. Swanson and asked why not wait for evidence? Dr. Swanson ignored the question and stated “As we’re getting better and smarter in medicine, let’s get to the cream of this and get rid of every death that we can. Why would we wait?” I suppose the response to Dr. Swanson’s non-response statement would be to agree to the goal of eliminating anaesthesia-related deaths, but that change without direction may not save anyone. For what its worth, no dentist-anaesthesiologists or paediatric dentists were included in the piece. For the record, the American Academy of Pediatric Dentistry supports the use of anaesthesia for the dental care of children, when indicated and when the service is delivered to the standard of care.
When it comes to dentistry, including sedation/anaesthesia for dentistry, unfortunately our physician colleagues generally don’t know what they are talking about. In fairness, the opposite is also true, but no one asks dentists for our opinions about Ear, Nose and Throat procedures to be undertaken by those specialist physicians; this even though we work in the same neighbourhood. This is even true when there appears to be an overlap of disciplines, as with anaesthesia. Anaesthesia appears to be the domain of medicine. Appearances can be deceiving, which puts dentistry at a disadvantage. With time, opportunity and effort, perception becomes reality, so pieces like Ms. Snow’s and its follow-up “9 Questions to Ask Your Dentist Before Your Kids Go Under Sedation” that ran the next day on The Today Show stack the odds against the practice of anaesthesia by dentists. But only because the medical voices are louder.
In general, rest assured that we are doing things well in Canada. The PT model is a good one and enhancements are coming, but all it takes is one badly-timed mishap to upset the proverbial apple cart. I’ll cite the recent events in Alberta as Exhibit #1. The next great battle over dental anaesthesia in North America will not be fought between some combination of oral surgeons and paediatric dentists and dentist-anaesthesiologists and conscious sedationists. No, the battle will be with our medical colleagues. They are just barely onside now, but their relationship with us is cordial, more like tolerance and resigned acceptance as opposed to real affection. That’s okay, as long as we are aware of this. In the meantime, pay attention to what they (non-dentists) are saying about us (dentists). Then change the things you should change, and educate “them” on why you shouldn’t change the other things.
In the meantime, enjoy the following links:
Sunday Night with Megyn Kelly: http://www.nbcnews.com/megyn-kelly/video/children-at-risk-kids-and-sedation-at-the-dentist-s-office-989892675520
The Today Show: http://www.today.com/health/children-being-sedated-dentistry-practice-now-under-new-scrutiny-t113039
P.S.: On July 10th, the California State Business Professions and Economic Committee chose not to approve Caleb’s Law.
About the Editor
Dr. Nkansah is a Dental Anaesthetist with a private practice in Toronto. He is a member of the editorial boad for Oral Health and is an Assistant Professor at the University of Toronto’s Faculty of Dentistry.