February 2, 2017
by Dr. Peter Nkansah
Recently the Royal College of Dental Surgeons of Ontario chose to update the Standard of Practice for the Use of Sedation and Anaesthesia in Dental Practice. While this was a semi-scheduled review (the document is revised roughly every five years), the context for this latest revision is different from the others in recent memory. Caleb’s Law in California and a recent serious incident that harmed a four-year-old after receiving sedation/anaesthesia in Alberta have brought special focus onto two issues: dental anaesthetics for children, and the operator-anaesthetist (OA) mode of practice.
Caleb’s Law was triggered by the untimely death of six-year-old Caleb Sears in 2015 as well as other deaths under apparently similar situations. In Alberta, the Alberta Dental Association & College, although currently formally reviewing their rules around sedation dentistry, chose to ban deep sedations and general anaesthetics for OA dentists before the review was complete. Clearly, no one wants harm to come to any of our patients, and our hopes/well-wishes/condolences should go out to any families affected in this way, but do either of these changes really confer any extra level of protection to the people of Alberta or California?
Anaesthesia for dental patients is a challenging, yet appreciated and necessary service. Critics of sedation/anaesthesia for children and of the OAs often cite safety as the root of their concern, but what information is there to support this view? There is a battle between information and beliefs. Information tends to be objective. In contrast, beliefs are formed from the interpretation of information. As described eloquently by Yuval Noah Harari in his terrific book Sapiens, the existence of nations and companies are examples of “imagined reality”. If the right person(s) takes a position with enough force and charisma to convince others to believe, then information eventually begins to matter less. Canada exists because we collectively believe it does. There are borders, there is currency and there are unique traditions. But how wide is the Canada-USA border exactly? A millimetre? A metre? If you empty the country of all of the people, does Canada still exist? If all the people and practices were preserved but moved to a new, empty, unnamed location, would that new spot now become Canada? The answers would depend on our collective beliefs rather than information.
Shift your focus now to sedation/anaesthesia for dentistry. The non-zero mortality rate unfortunately claims some children, but does that make sedation/anaesthesia on children unsafe? Medical anaesthesiologists don’t do their own surgeries, and their hands are sometimes full in a case, so how could the OA dentist be safe? The determination of “safe”, in this instance, is mostly a belief. Since a zero rate is not possible, we would have to settle on an “acceptable” rate. Compromise is hard. Examination of anaesthetic-related deaths led to the creation of the “Harvard Standards” of anaesthesia in 1986. 1 These standards prescribe things like regular vital signs monitoring and the use of pulse oximetry during cases. These standards also set up measurable parameters that could be tested objectively in order to improve patient safety. The Harvard Standards are still in effect today because they work in reducing the incidence of adverse events.
What if Caleb’s death occurred before any dentistry was initiated? What if the Albertan girl’s injuries occurred after the dentistry was completed? In both scenarios, the operator-anaesthetist issue is moot, which is significant.
Are the risk statistics any different for OAs when compared to two-practitioner situations? You probably have an opinion on this but there is no research specific to this question. This is because to my knowledge, there is no objective information specific to this question; although there is at least one study underway attempting to provide some research data to this point. Without information, we are left with impressions and beliefs, which can be very strong and influential. However, this kind of “knowledge” should be viewed with a skeptic’s eye. For example, there is no science behind our local anaesthetic cartridges containing 1.8 mL; that happened because of the size of rifle bullet cartridges at a time of war. There’s no science behind the recommended maximum of 0.04 mg of epinephrine for cardiovascularly compromised patients either. They are both good numbers, but they weren’t arrived at via a path of evidence. These numbers of convenience became numbers of significance in dentistry through luck and longevity.
I will readily admit that some things can’t be rigorously studied (e.g. the safe minimum age for sedation). We also can’t actively question everything; otherwise we’d get nothing done. Where robust information is missing, we should employ critical thinking. When information is available, we should examine it without bias, and then use it as a tool, not as a weapon. Numbers alone never tell the whole story anyway.
At the end of the day, nobody wants patients to get hurt or to die while under our care. Nobody wants to support unsafe practices. The status quo carries a lot of weight but there is no such thing as permanence in our universe (not even our universe is permanent). Someday, the operator-anaesthetist mode of practicing sedation dentistry will become extinct. I don’t know when that will happen or why, but given enough time everything changes. (Enjoy your moon now, because it’s slowly slipping away from us.)
The end of the OA doesn’t have to be a bad thing. Having said that, I think it would be a bad thing if the cause of extinction was anything other than:
1. Information that the practice is dangerous; or
2. The emergence of a better, as-yet-unknown alternative. With fairness as our guide, let’s try to make tomorrow safer and better than today. OH
1 Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH and Seeman RG. Standards for Patient Monitoring During Anesthesia at Harvard Medical School. Journal of the American Medical Association, 256(8): 1017-1020, Aug. 22-29, 1986. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/8824/ by a University of Toronto Libraries User on 01/11/2017
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.