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Safe Anesthesia in California Dental OfficesJuly 29th, 2016
You've probably read about the recent tragic deaths of two healthy children – Marvelena Rady, age 3, and Caleb Sears, age 6 – in California dental offices.
State Senator Jerry Hill has asked the Dental Board of California (DBC) to review California's present laws and regulations concerning pediatric dental anesthesia, and address the question of whether they assure patient safety. Assemblymember Tony Thurmond has sponsored "Caleb's Law", also asking for review of California's Dental Practice Act, and requiring improved informed consent for parents.
On July 28, I had the opportunity to attend a stakeholder's meeting at the Department of Consumer Affairs in Sacramento, to hear a presentation of the DBC's report, and as President-Elect to be part of the delegation offering comments on behalf of the California Society of Anesthesiologists (CSA).
By long-standing California state law, dentists and oral surgeons are able to provide anesthesia services in their offices. They may apply for one of four different types of permits for anesthesia:
- General anesthesia
- Adult oral conscious sedation
- Pediatric oral conscious sedation
- Parenteral conscious sedation.
The CSA holds the strong opinion, which we made clear, that the route of administration is not the point, especially for small children. Sedation is a continuum, and there is no way of reliably predicting when moderate sedation may turn into deep sedation, and deep sedation into a state of unresponsiveness which is equivalent to general anesthesia. Oral "stacking" of medications has led to deaths in children, sometimes even before the dental procedure has begun or well after it has finished. There is no justification, we maintained, for different standards in fasting guidelines, emergency equipment, or monitoring for procedures done under sedation as opposed to under general anesthesia.
One of the problems with current California regulations is their use of outdated terminology. The ASA, the American Academy of Pediatrics (AAP), and the American Academy of Pediatric Dentistry (AAPD) all agree on standard definitions of the terms minimal, moderate, and deep sedation. California dental laws and regulations use the words "conscious sedation" and "moderate sedation" interchangeably.
By California definition, moderate sedation should use "drugs and techniques that have a margin of safety wide enough to render unintended loss of consciousness unlikely", but California does not restrict sedation permit holders from using propofol, ketamine, methohexital, fentanyl, nitrous oxide, or midazolam. There are no age restrictions or physical class guidelines regarding eligibility of children for office dental procedures.
As everyone in this department knows, a surgeon cannot perform any procedure, except under straight local anesthesia, without a separate qualified professional to give anesthesia or sedative medications and monitor the patient. Similarly, an anesthesiologist performing an interventional pain procedure cannot give sedation at the same time.
Yet in the offices of dentists and oral surgeons, it is perfectly acceptable in California law for the same person to perform the dental procedure and direct sedation to be given by a second person who also assists with the procedure. That person is likely to be a "dental sedation assistant", who has completed one year of experience as a dental assistant and who has completed 40 hours of didactic education, 28 hours of laboratory instruction, and 20 supervised cases involving sedation or general anesthesia.
No state at this time requires the presence of a physician anesthesiologist, a nurse anesthetist, a registered nurse, or any other medical professional during sedation or anesthesia for dental treatment, even for small children. At present, 29 states require the presence of a third person to serve as a "dedicated anesthesia monitor" in addition to the dentist and dental assistant; California does not.
As you would hope, CSA takes strong exception to the concept that sedation and anesthesia should be given to a young child — or for that matter to any patient — without a qualified person whose only job is to watch the patient and to administer sedation or anesthesia. We were very pleased to see our opinion shared — and expressed in the strongest terms — by Paula Whitehead, MD, who attended on behalf of the AAP, and by Michael Mashni, DDS, a past president of the American Society of Dental Anesthesiologists.
The July 28 meeting was solely for the purpose of gathering opinion from interested parties. The DBC will be preparing a second report with possible recommendations for changes to California laws and regulations concerning pediatric dental anesthesia, with keen interest on the part of the state legislature and the Department of Consumer Affairs.
We will be watching these developments closely, and I will report back with further information as it becomes available. I would like to extend sincere thanks to Dr. Swati Patel and to everyone who made it possible for me to attend the Sacramento meeting on a day when I know staffing was very tight. All of our efforts are on behalf of children and parents who have every right to safe, consistent anesthesia care during dental procedures.
Karen Sibert, MD
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