Is pediatric dental anesthesia safe?
Right on the homepage of the ADSA is a big box: “getting sedated at the dentist: there’s nothing to worry about”. Recent news, however, seems to contradict that statement. In Texas alone, there are at least 85 reported deaths of patients who died following dental procedures between 2010 and 2015. Two pediatric dental anesthesia deaths in California (6 year old boy Caleb Sears and 3 year old girl Marvalena Rady have been in the news recently. In these cases, anesthesia was reportedly administered by dentists with anesthesia training. But what constitutes ‘anesthesia training’? Does that imply the clinician is a dentist anesthesiologist? What is a dentist anesthesiologist, and how does that differ from a physician anesthesiologist, oral surgeon, or dentist with an anesthesia license?
What’s in a name? No wonder people are confused.
In the FAQ section of the ADSA website, they state “Anesthesia is administered by a licensed anesthesiologist, who was trained in a formal anesthesia residency program.” This is confusing to patients, as well as to the journalists covering these deaths. Many readers believe that a ‘licensed anesthesiologist’ is a physician who is a board certified anesthesiologist, not understanding that this is a dental professional designation. To take the ADBA exam to practice dental anesthesia, dentists must have completed a 2-3 year dental anesthesia residency after completion of dental school. For physicians, “anesthesiology residency” refers 4 years of training after completion of medical school, and perhaps up to 2 more years fellowship training to specialize in pediatric anesthesiology.
Most people assume the title “anesthesiologist” refers to a physician specialist, just as when flight attendants asks if there is a “doctor” on board, they specifically mean a medical doctor rather than a person who holds a doctoral level academic degree. I am not disparaging the dental programs. I’m just saying the terminology is confusing, and patients have a right to know the difference. [Update: one dentist anesthesiologist wrote to me and shared this perspective, saying that at least monthly, he has conversations about confusion related to anesthesia clinicians. In his words, how can we “expect the public to understand the difference of what a CRNA, an anesthesia assistant, a physician anesthesiologist, and a dentist anesthesiologist is if even the professionals in our field don’t know what a dentist anesthesiologist is?” I cannot agree more.]
What about safety standards?
Anesthesiology News recently reported on this issue. According to Joel Weaver, DDs, PhD, spokesman for the American Dental Association (ADA) “the educational and training requirements to administer sedation and anesthesia are regulated by individual state dental boards”. Kenneth Reed, DMD, is the president of the American Dental Society of Anesthesiology (ADSA), agrees: “there are no nationwide standards; there are only guidelines”.
Caleb Sears’ father Tim Sears talked about the confusion many parents have about the difference between care by a medical doctor specializing in anesthesiology vs other clinicians giving anesthesia: “The risks vary and parents should know that. I only wish we had known that”.
But dentists can perform sedation and anesthesia themselves, without the need for a physician or dental anesthesiologist, as long as the dentist has met the requirements of his or her own state dental board. Dr. Herlich, DMD, MD – a medical doctor and also a dentist who acts as the liason between the American Society of Anesthesiology (ASA) and the ADSA – says that dental boards and dental offices do not have to follow ASA standards of care.
Moreover, after publishing this post, I received many informative emails from dental anesthesiologists who told me (and this paragraph is clearly an update to the original post) that the politics and economic interests are a major barrier. I didn’t know that the ADA has refused to recognize the specialty group of dentist anesthesiologists, despite three decades of advocacy efforts by the ASDA. Apparently, this is linked in part to insurance issues and to the economic interests of groups such as those teaching “weekend anesthesiology training offered to dentists at motels” according to Dr. Michael W. Davis, DDS. As he notes, if the ADA recognized the specialty of dentist anesthesiologists, ” dental anesthesiologists would be better positioned to help establish clinical standards of care for anesthesiology. We might have a group which actually monitored patient morbidity and mortality associated with dental sedation (not currently done, except informally by the media). We might have a dental specialty group, which could best educate the dental profession and public, on dental sedation matters.” It certainly makes sense to me that if the specialty has not been recognized, the issue of informed consent is further muddied. One dental anesthesiologist told me it is actually illegal in his state for him to call himself a Dentist Anesthesiologist to his patients, because of the lack of recognition by the ADA and his state laws of the expertise he has earned by completing his postgraduate training and passing the examinations of both the American Dental Board of Anesthesiology and the National Dental Board of Anesthesiology. This seems to be an absurd situation in which the clinicians within the specialty of dentistry who possess the highest level of training in anesthesia are not recognized as having significantly more expertise than the “motel” programs Dr. Davis describes. Another letter I received stated that the ADA refuses to adopt ASA standards because of political pressure from dentists and oral surgeons who wish to retain their current ability to provide their own anesthesia services. Yet another told me that dentist anesthesiologists have been advocating for ADA to adopt ASA standards, especially capnography – a real time monitor of breathing – but have repeatedly been denied. He also said that ‘Dental Advanced Life Support was created so that dentists could circumvent ACLS and PALS requirements. Of course, these are emails from clinicians who have chosen to correspond with me; as such, they represent just a sample of personal experiences and perspectives.
Respect for patients’ autonomy and decision-making
This may sound like an objection to the “dentist anesthesiologist” as a profession, but it is not. Simply, it is our duty as healthcare professionals to be transparent. Patients deserve to understand the differences among confusingly similar titles and designations. And moreover, patients should know whether their anesthesia will be given by a dentist anesthesiologist or an assistant with little formal training at all. Patients have a right to this disclosure, as part of our professional respect for their autonomy to make their own medical decisions.
A pediatric anesthesiologist first becomes a medical doctor, then trains for four years to specialize in anesthesiology, and then spends an additional one to two years further sub-specializing in pediatric anesthesiology, because children are physiologically very different from adults. In fact, I’ve personally had parents of young patients ask me if I am a pediatric anesthesiologist, and because I am not, they have declined my care. I was not insulted that they wanted someone even more specialized. I happily transferred their case to one of my pediatric anesthesiology colleagues.
Dr. Weaver of the American Dental Association agrees: “sedating children is very different from sedating adults. Many state dental boards require the dentist…to qualify for a special anesthesia permit.” But as we have already learned, there are no national standards for what that permit requires, and some states do not require it at all. And, the standards are determined by the ADA, not by the ABA or by medical boards or even the two national boards for dental anesthesiology.
As long as the terminology is confusingly similar but the standards of safety are not standardized, and also do not reflect the standards of the American Society of Anesthesiologists, I think this is a problem.
To be clear, I value and respect all of the professionals and educational programs in this post. My purpose is simply to raise awareness of the issue of confusion for patients, who have the right to understand the training and roles of the people caring for them as well as the risks of anesthesia. That is the basis of the “informed consent” process, which is at the heart of shared medical decision making. A common theme emerging from these recent deaths is that parents felt they were not fully informed. But without question, patients deserve to be fully informed. If you go to the emergency room, you may see a nurse practitioner (NP) or physician assistant (PA) instead of a physician. If you have surgery, an NP or PA may be performing portions of the procedure. There is nothing wrong with the variety of clinicians in healthcare. Certainly, all clinical professionals have experienced or will experience adverse patient outcomes over their careers, and this does not necessarily imply that errors was made.
Patients simply have a right to know. And, they have a right to demand safety standards for anesthesiology that reflect the standards of anesthesiologists, equally applied in all states.