The Single-Provider-Operator-Anesthetist Model for Dental Deep Sedation/Anesthesia: A Major Safety Issue for Children

Charles J. Cote, MD, FAAP; Raeford Brown Jr, MD, FAAP; Anna Kaplan, MD

Dental AnesthesiaIn 2019 the American Academy of Pediatrics (AAP) published a joint statement with the American Academy of Pediatric Dentistry (AAPD) updating the AAP sedation guideline.1,2 This revision was prompted by the preventable death of Caleb, a healthy 6-year-old sedated for removal of a supernumary tooth. Multiple sedating medications caused apnea and airway obstruction, the oral surgeon was unable to clear the airway, and there was no other skilled help in the office. Caleb was asystolic when the EMTs arrived and he died.3 Caleb’s aunt, Anna Kaplan, now a pediatric resident, worked to introduce legislation (Caleb’s law)4 in California that required an anesthesia-trained provider for deep sedation/anesthesia. This was opposed by the oral surgery lobby,5 and the California Legislature codified the single-provider-operator-anesthetist model for oral surgeons whereby the operating dentist/oral surgeon simultaneously provides deep sedation/anesthesia and performs the dental procedure (two tasks concurrently). The single-provider-operator-anesthetist model codified in this law contradicts all known anesthesia standards.6

The 2016 AAP guideline clearly stated the skills required for administering deep sedation: The person administering/directing the sedation must be “able to provide advanced pediatric life support and capable of rescuing a child with apnea, laryngospasm, explicit or airway obstruction. Required skills include the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trump, laryngeal mask airway) and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation.”2 It explicitly states that there must be an independent observer whose only responsibility is to observe the patient and is capable of assisting with or managing emergencies. The AAP model is a multiple-provider-sedation-care team whereby multiple individuals are immediately present to initiate rescue.

In response, the oral surgery community developed a Dental Anesthesia Assistant National Certification Examination (DAANCE) with no pre-examination educational requirements. It consists of 36 hours of internet study covering the following:

“The self-study materials and the final exam cover five major areas:

  1. Basic sciences
  2. Evaluation and preparation of patients with systemic diseases
  3. Anesthetic drugs and techniques
  4. Anesthesia equipment and monitoring
  5. Office anesthesia emergencies.7

Individuals who pass the examination are expected to “possess the expertise to provide supportive anesthesia care safely and effectively. The Dental Anesthesia Assistant (DAA) is knowledgeable in the perioperative and emergent care management of patients undergoing office-based outpatient anesthesia. The DAA is able to effectively communicate pertinent information to patients and their escorts as well as members of the health care team.”7

It is astonishing to assume that a person with no practical or clinical experience would be certified to be the independent observer with all of the skill-sets described above learned in just 36 hours of internet reading. Such an individual would likely be incapable of providing any meaningful help with a genuine life-threatening emergency as they lack hands-on medical training, are not skilled in starting an IV, and not licensed to draw up and administer life-saving medications.

Consider the patient who developed airway obstruction, with the operating dentist the only person present with any medical knowledge. He/she must recognize the problem, manage the airway to provide oxygen, and then cease airway support to administer rescue medications; the only backup is 911. The DAANCE provider may be able to inform the dentist that something is wrong, but they cannot do much to help. It is truly dangerous to substitute a DAANCE observer for a skilled anesthesia professional.

Following introduction of the DAANCE oral surgery practice model, the AAP and AAPD crafted new wording. The 2019 sedation guideline now states explicitly that deep sedation/anesthesia must be provided by an anesthesia-trained provider and the operating dentist must be currently PALS-certified to assist the anesthesia provider with an adverse event. This provides a ready-to-respond sedation team on site. The single-provider-operator-anesthetist oral surgery model must be replaced with the multiple-provider-sedation-care team AAP/AAPD model.

It is essential that patient safety advocates be informed of this significant safety issue; healthy patients continue to suffer adverse outcomes specifically because of this single-provider-operator-anesthetist oral surgery practice model. We have a professional and personal responsibility to educate parents and patients to ask their oral surgeon very specific questions: “How will I/my child be monitored and by whom? Is there an independent observer whose only responsibility is to watch me/my child, certified in and up-to-date in resuscitation and trained in the delivery of anesthestics? Is the equipment for resuscitation immediately available?” If the answer to these questions is ambiguous or “no,” then patient safety may be compromised. It is critical for health care professionals, patients, and parents to speak to their associated legislatures to oppose proposals that support the single-provider-operator-anesthesia model for oral surgeons since California’s approval of this law has encouraged oral surgeons across the U.S. to propose similar legislation.


Charles J. Cote, MD, FAAP, is professor emeritus at Harvard Medical School, Division of Pediatric Anesthesia, and at the Massachusetts General Hospital for Children in the Department of Anesthesia, Critical Care and Pain Management, Boston, MA.

Raeford E Brown, Jr., MD, FAAP, is professor of anesthesiology and pediatrics at the University of Kentucky/The Kentucky Children’s Hospital and chair of the Section on Anesthesiology, Lexington, PA, and Pain Medicine, The American Academy of Pediatrics.

Anna Kaplan, MD, is a resident in pediatrics at the University of California San Francisco Benioff Children’s Hospital, Oakland, CA. She is co-author of Caleb’s Law.

The authors have no conflicts of interest.


  1. Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients before, during, and after sedation. Pediatrics. 2019;143:6 e1–31.
  2. Coté CJ, Wilson S, American Academy of P, American Academy of Pediatric D. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. Pediatrics. 2016;138(1).
  3. Caleb’s Parents Cs. 2018. Parental permission to discuss child’s death.
  4. Caleb’s Law. Accessed December 21, 2020.
  5. Moran D. How $3 million in political donations stands in the way of justice for this boy’s death. Accessed December 21, 2020.
  6. Gelb AW, Morriss WW, Johnson W, Merry AF, International standards for a safe practice of anesthesia W. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) international standards for a safe practice of anesthesia. Can J Anaesth. 2018;65:698–708.
  7. Surgeons AAoOaM. Dental anesthesia assistant national certification examination (DAANCE). Accessed December 21, 2020.