Reader response
Myron Yaster MD
From Charles J Coté MD, Professor of Anaesthesia (Emeritus), Harvard Medical School
I appreciate the efforts of Salik et al urging the need for universal pediatric dental sedation standards.1 I would point out that death in the dental chair is an issue that has existed dating back at least to the early 1980’s when several pediatric deaths in California dental offices awakened the leadership of the AAP to ask guidance from the Section on Anesthesiology and out of this the first sedation guideline by any organization was developed in conjunction with our pediatric dental colleagues.2 Over the years these guidelines have had multiple updates and revisions in response to evolving practice and to uniform definitions between organizations. The 2016 update3 was developed in response to the pediatric dental community asking for guidance regarding the use of capnography and the 2019 guideline4 was developed in response to the Oral Surgery single provider model (See below). Unfortunately, there are multiple issues here, none of which is easy to address but I will attempt to add clarifications.
1) Each state develops their own dental practice regulations but virtually none will even entertain input from physicians since we are not dental trained! So, anything that worries us like the dangers of sedation, monitoring, training, skills required, etc. is left for the most part to the individual dental board without physician (anesthesiology) input.
2) The definition of a “pediatric patient” has been a bit confusing; I recommend using the AAP definition along with those of the WHO and NIH, which is <18 years of age.5-7
3) Calib’s Law in California passed after and because of his death in the dental chair, required reporting of all cases of hospital admission (adult or pediatric) from dental offices.8 The intent was to gather prospective data that would allow simple analysis: What went wrong? Why did it go wrong? How to prevent it in the future? Unfortunately, retrieving these data has been blocked by using HIPAA as an excuse. So that valiant effort at trying to crack the nut to provide science based recommendations is blocked.
4) Nearly 80% of Oral Surgeons are insured by the same insurance company (but they also all own stock in the company I am told and the limits are low ($1,000,000/$3,000,000) which discourages most malpractice attorneys from going after them because there is too small a pot of gold. Also, in most states, a physician cannot testify against a dental practitioner so again it is a very protected and self-serving issue. I once gave a lecture at Medical Malpractice meeting about this issue and after my presentation, one lawyer came up to me describing the death of a 17-year-old female Olympic athlete undergoing wisdom teeth removal; she told me she took the case because she was so upset, but she also lost a lot of money.
5) At the ASA in 2022 I was on a panel addressing these issues and asked the then president of the OMS society in the Q & A session if he would provide the California data so we could analyze it together. He assured me in public “yes” but the real answer as described above was NO!
6) I also proposed that since 80% of oral surgeons are insured by the same company they are in a perfect position to perform closed claims analysis and even offered to link them up with ASA so they could use ASA methodology but once again no reply.
7) In response to the AAP guideline requiring an independent observer for deep sedation who was also skilled to help with rescue, the oral surgeons developed their own version: The Dental Anesthesia Assistant National Certification Examination (DAANCE).9 With 30 hours of internet self-study (and no educational requirements), these individuals are expected to learn: “Basic sciences; Evaluation and preparation of patients with systemic diseases; Anesthetic drugs and techniques; Anesthesia equipment and monitoring; and Office anesthesia emergencies.” Clearly such an individual is totally unqualified and inexperienced to provide any meaningful help during a life-threatening event. Imagine a code with only one “skilled” provider – who manages the airway while the dental practitioner needs to stop to give rescue medications since a DAANCE person is not licensed to do this? In response to the DAANCE program, the AAP crafted a sedation guideline update in 2019 with a specific addition regarding the deep sedation of pediatric dental patients.4 The update states that the deep sedation/anesthesia provider must be a physician anesthesiologist, a CRNA, a dentist anesthesiologist or a second oral surgeon AND that the operating dentist must be PALS up to date certified so that at least two people with skills could rescue the child. So, AAP requires a skilled anesthesia provider and OMS requires a technician while they provide both sedation/anesthesia and simultaneously perform the procedure (and bill for both). This is the single provider model whereby the dentist provides both the anesthesia, and does the procedure simultaneously, that must be eliminated but we seem powerless to address the problem.
So, despite the good intentions of Salik et al in pointing out the need for dental sedation standards, there are huge roadblocks that are driven by a desire to prevent any physician input into the OMS realm of practice and, in reality, to preserve a second lucrative source of income. Money and politics are winning over patient safety. The OMS insurance company has the data but they have no interest in objectively examining it with a closed claims approach. I have been fighting this battle for 40+ years but unfortunately, I seem to be losing the battle (and the war). Sedation standards are great but only if they are followed. We have a very well-crafted AAP guideline that provides a safe sedation roadmap but the oral surgeons choose to not follow the path of safety and ignore it.
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 (In eng). DOI: 10.1213/ane.0000000000007578.
2. Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients. Pediatrics 1985;76(8):317–321. DOI: 10.1542/peds.77.5.754.
3. Coté CJ, Wilson S.. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016;138(1). DOI: 10.1542/peds.2016-1212.
4. 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(6). DOI: 10.1542/peds.2019-1000.
5. Hardin AP, Hackell JM, et al. Age Limit of Pediatrics Committee on Practice Ambulatory Medicine. Pediatrics 2017;140(3) (https://doi.org/10.1542/peds.2017-2151).
6. National Institute of Health Glossary of Definitions: Child. (United States National Institutes of Health (2019) Guidelines for the review of inclusion on the basis of sex/gender, race, ethnicity, and age in clinical research. https://grants.nih.gov/grants/peer/guide lines_ gener al/ Review_ Human_ subje cts_ Inclu sion. pdf.).
7. The Convention on the Rights of the Child: The children’s version Uniteed Nations International Childrens Emergency Fund (UNICEF). (https://www.unicef.org/child-rights-convention/convention-text-childrens-version).2017
8.(http://www.calebslaw.org/).
9. Surgeons AAOMS. DAANCE. (https://aaoms.org/practice/anesthesia/anesthesia-assistants/education/daance/).