Pediatric Dental Anesthesia: The Need for National Standards and Reporting
Leonard W. Naftalin, DDS, DADBA Immediate Past President American Society of Dentist Anesthesiologists (ASDA) and Kyle J. Kramer, DDS, MS, DADBA (ASDA President-Elect)
Original article
Salik I, Chan KM, Pesola I, Abramowicz AE. Death in the Dentist's Chair: The Urgent Need for Universal Pediatric Dental Sedation Standards. Anesth Analg. 2025 May 23. doi: 10.1213/ANE.0000000000007578. Epub ahead of print. PMID: 40408278.
Office-based anesthesia (OBA) has sometimes been described as the “Wild West” of anesthesia. Today’s PAAD (Death in the Dentist’s Chair: The Urgent Need for Universal Pediatric Dental Sedation Standards)1 recognizes that office-based pediatric dental anesthesia, in particular, lacks the oversight and standardized reporting found in accredited hospitals and ambulatory surgery centers (ASCs).1 Unfortunately, as this article makes clear, it is not feasible for every dental anesthetic to be performed in such regulated facilities—doing so would only exacerbate the already stretched anesthesiology resources, human and otherwise.
The issues raised in the article may seem straightforward, but they are in fact deeply rooted and complex. If these problems were easy to solve, they would have been resolved by now. Much of the so-called "low-hanging fruit" in healthcare reform has already been picked. For instance, contrary to the article’s assertion, there are national standards for dentist administered pediatric sedation and general anesthesia. Monitoring oxygenation and ventilation with pulse oximetry and capnography have become standard practices for quite some time, significantly improving the safety of sedation and anesthesia across all settings. However, in dentistry, nasal cannula capnography, used during sedation and non-intubated general anesthesia, can be challenging and unreliable due to procedural interference with CO2 readings with the surgical procedures being oral. As a result, along with capnography, the standard of care in dental settings often relies on the lost art of auditory monitoring of ventilation using a precordial stethoscope,2 which is still commonly taught in dental anesthesiology residencies.
The authors rightly identify the absence of a uniform standard for oversight and complication reporting. Currently, most states require practitioners report adverse outcomes to their respective dental boards. The American Society of Dentist Anesthesiologists (ASDA) has long advocated for state dental boards to provide this de-identified information for risk analysis. However, this issue is not limited to dental offices. Even ASCs and hospitals in the United States lack a unified required national outcomes database. This inconsistency is indicative of a broader deficiency in the U.S. healthcare system. To our knowledge, only countries with socialized medicine have universally mandated outcomes reporting. In the U.S., the lack of an accurate count of how many dental anesthetics are performed annually precludes reliable data on complication rates as well.
During my presidency of the ASDA, I (LN) actively encouraged our members to participate in voluntary outcomes reporting through the National Anesthesia Clinical Outcomes Registry (NACOR), maintained by the Anesthesia Quality Institute (AQI). Unfortunately, in the absence of mandatory participation—whether through incentives or regulation—many providers see little reason to contribute data. As opposed to hospital anesthesia providers where case data is imported automatically from the EHR, dentist anesthesia providers more commonly must manually enter all case data into the system which is perceived as an administrative burden. The article cites the SCOR database, previously managed by the Society for Ambulatory Anesthesia (SAMBA), but that initiative was ultimately discontinued, in part due to the high cost of sustaining such a system.
The regulatory framework for dentistry also differs significantly from that of medicine. In medicine, most facilities are accredited by third-party organizations such as The Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC), and while individual practitioners are licensed by state medical boards, they are also credentialed by the accredited facility. In contrast, dental practitioners are both licensed to practice and granted permits to administer sedation or general anesthesia by state dental boards. This creates additional complexity given the diverse range of general anesthesia providers in dental offices, which includes physician and dentist anesthesiologists, certified registered nurse anesthetists (CRNAs), and oral and maxillofacial surgeons. There are also many general dentists, pediatric dentists, periodontists and other dental specialties trained and permitted to provide moderate sedation only, either enterally or parenterally. Some states require a special permit to administer enteral minimal sedation as well as nitrous oxide alone. State dental boards are responsible for overseeing all these provider types. However, non-dentist providers—physician anesthesiologists and CRNAs—often resist oversight by dental boards, arguing that such boards lack jurisdiction over them. Unfortunately, history reveals that medical and nursing boards rarely investigate, let alone regulate or discipline these anesthesia providers for dental office-based morbidity or mortality. Such a system seemingly creates loopholes where little to no oversight exists, which is clearly problematic.
Compounding this issue is the fact that all of this regulation occurs at the state level. Laws are written by or must be approved by state legislatures and then interpreted and enforced by dental boards, resulting in a patchwork of regulations that vary widely from state to state—sometimes even conflicting with one another. In response to this inconsistency, the ASDA, in collaboration with the American Association of Oral and Maxillofacial Surgeons and the American Academy of Periodontology, has developed a model rules and regulations document.3 This resource is intended to help states create more uniform, consistent standards for sedation and general anesthesia in dental offices. Although the single operator-anesthetist mode of practice was still allowed due to political and resource realities, this model rules document does clarify who may provide deep sedation/general anesthesia to pediatric patients in a dental office. A pediatric endorsement of general anesthesia permits is required, which includes a minimum biyearly case requirement to ensure ongoing competency, limiting pediatric sedation/general anesthesia only to those who regularly manage children, which includes all anesthesia providers, dentist and non-dentist alike.
One important topic the article does not address is the lack of consensus on who qualifies as a pediatric patient? The American Academy of Pediatrics defines a pediatric patient as anyone under the age of 21.4 The American Academy of Pediatric Dentistry has favored a more physiological approach using “prepubertal” rather than a strict age-based definition for pediatric dental sedation.5,6 While respecting that the term “pediatric” is more than a description of physiologic parameters, the use of a defined age for the purposes of dental sedation and general anesthesia is important so that dental boards can create and enforce appropriate regulations, in a process that is similar to how graduate training programs requiring documented clinical experiences, or, as another example, a hospital medical staff member is credentialled for anesthesia privileges. Along with California, several state dental boards do require special permits for providers treating pediatric patients, with the definition of "pediatric" ranging from under age 8 to 13 years of age, and varying by state and permit level.
Serious morbidity or mortality should be astonishingly rare in dental offices. Undiagnosed medical conditions, poor or untruthful communication from parents/caregivers, unexpected airway anatomy and a host of other considerations means that, just as in the hospital, unexpected events can and will occur. Salik et al. have correctly highlighted the lack of uniformity in both regulation and reporting for pediatric dental OBA which should help us to improve safety. Achieving true standardization and improving safeguards, however, will require consensus on definitions, regulatory frameworks, and data reporting mechanisms. The safety of our pediatric patients depends on the dental profession’s willingness, and our professional colleagues buy-in, to meet this challenge with urgency and cooperation.
Send your thoughts and comments to Myron who will post in a Friday reader response.
PS from Myron: I was fortunate to meet Drs. Naftalin and Kramer when I was an invited speaker at an ASDA meeting. Both are now members of the PAAD’s executive council. At the meeting and mentioned in the article is the use of precordial stethoscopes which are still very commonly used by dentist anesthesiologists. And these are not your father’s (mother’s) precoridals. They are now digital, electronic, blue tooth enabled stethoscopes and are fantastic to assess the quality of heart sounds, rate, and rhythm, as well as breath sounds. Are any of you using them? Will take a closer look at these products in the near future.
References:
1. Salik I, Chan KM, Pesola I, Abramowicz AE: Death in the Dentist's Chair: The Urgent Need for Universal Pediatric Dental Sedation Standards. Anesth Analg 2025
2. American Dental Association: Guidelines for the use of sedation and general anesthesia by dentists. Adopted by the ADA House of Delegates, 2016
3. The American Society of Dentists Anesthesiologist, the American Association of Oral & Maxillofacial Surgeons, & American Academy of Periodontology: Model State Sedation/ General Anesthesia Rules. 2023
4. Hardin AP, Hackell JM: Age Limit of Pediatrics. Pediatrics 2017; 140
5. American DentalAssociation Council on Dental Education and Licensure: Guidelines for teaching pediatric pain control and sedation to Dentists and Dental Students., 2021
6. Coté CJ, Wilson S: Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143