Episode #321 Safer Dental Anesthesia, PART 2

We left you with a cliff hanger last week, but don’t worry. We have the rest of my conversation with Dr. Rita Agarwal today. Here are some of the key takeaways for keeping patients safe during dental anesthesia from today’s show.

1. Prior to scheduling an appointment for a dental procedure with anesthesia, there are some important questions families can ask including what medications are being used, who is responsible for the anesthesia, and can you ventilate my child if they stop breathing?
2. The team needs to be prepared for when the patient’s level of sedation goes deeper than planned and then be able to rescue the patient, which leads to the next one…
3. Airway rescue with bag-mask ventilation is a necessary skill.
4. Patients requiring deep sedation and general anesthesia should have a dedicated, separate anesthesia provider.
5. This is a systems problem and considerations include training, regulation, different state requirements, lack of data, and inconsistent emergency preparedness.
6. Standardization can help to improve safety.
7. In-situ simulation can help teams be prepared for emergencies in the dental office.
8. Sedation may not always be needed.
9. And finally, anesthesia professionals need to be advocates not just providers.

This is the Anesthesia Patient Safety Podcast and I’m your host, Alli Bechtel. We are going to talk about all of these and more, so stay right there.

Before we dive further into the episode today, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi, – we wouldn’t be able to do all that we do without you!”

Here’s where we left off last week.

“What can patients or parents and family members do when one of their loved ones requires a dental procedure to help keep them safe during the procedure? Are there certain questions they need to ask to figure out who’s going to be there? Are there credentials to be on the lookout for? And are there any warning signs that, you know, this might not be a safe place to have deep sedation or general anesthesia?

Yeah. So starting with the last one, I don’t know how you figure out the warning signs because a lot of times these are great dentists or great oral surgeons, and they’ll have great Yelp reviews. And, you know, so the usual things that we’ll often look at to try and figure out if someone is high quality or not is difficult. I know for me, when my children had to have their wisdom teeth out, my young adult children had to have their wisdom teeth out. I intentionally looked for an oral surgeon and I made sure that my dentist referred me to an oral surgeon that worked with an anesthesiologist. I was, I 100% wanted to be sure that that was the case because it’s also difficult if you’re like the one person insisting that they you bring in another person who never works in that office. So look for if the dentist is proposing or the oral surgeon is proposing, and sorry, and I say that the both things because a lot of oral surgeons, some are not actually dentists. They go up through medical school and then go into oral surgery through that route. But many are, most probably are, to start off with as dentists. And there’s definitely dentists, particularly in pediatrics, that will do some level of sedation. So the the key questions are to ask what are the medications being used? What level of sedation is being provided? And how do they know that? How do they judge that? Just ask the questions that will help determine it. The American Academy of Pediatrics actually has a site called healthychildren.org. It’s just healthychildren.org. And you can put in, you know, dental anesthesia, and there’s actually a write-up on things to look for and things to ask about. If they’re talking about deep sedation or general anesthesia, personally, you know, I think it’s it’s really incredibly important to make sure there’s at least another person who’s medically trained to provide that service available. And again, it could be another oral surgeon. It doesn’t necessarily have to be a physician. It could be another physician, maybe not an anesthesiologist, such as, you know, I would trust an emergency room. 100% I would trust an emergency room physician to do sedation for my for my child or for my loved one. I would trust an ICU physician as well, because I know they can manage the airway. And I think that’s the key thing. And I’m sorry, I meant to back one of the questions you had asked earlier, which I forgot to answer. The one, the one of the really key and important things is, you know, the ASA stresses over and over again in their sedation guidelines that you, as a practitioner who’s providing the sedation, need to be Able to rescue that patient from the next deeper level of sedation. And that is something I think is 100% missed in the in the dental world. I don’t know that they’re taught that. I don’t know that they know how to do that. I think they just assume this isn’t going to happen to me. It’s not going to be a problem. If you have an you know an oral surgeon who, by all, by all accounts, the one who took care of Caleb was highly, highly regarded, who is planning to do deep sedation/slash general anesthesia and doesn’t know how to bag mask? I mean, that’s a real problem. So things that families can ask is, do you have a way to ventilate my child if they stop breathing, or my loved one if they stop breathing? Simple as that. Can you provide them with oxygen if they stop breathing? Do you have narcan available if you’re planning on giving opioids? Um, nobody gave Caleb narcan, and that should be a basic thing that’s available in every card. There’s also flumazanil, which reverses benzodiazepines. That wasn’t administered. Do you have a way to rescue my loved one if for whatever reason they have a, you know, an a different reaction to the medications than you expect, and they stop breathing, or they have, you know, other complications, or their breathing gets difficult. So those are some things that I think loved ones can ask. And is there a separate person? And who is that separate person? And can I talk to them ahead of time? Because again, I mean, for me with my kids, a hundred and they were young, healthy adults. They were, they were, you know, 22-year-old boys. They are, I’m sorry, not they’re 22 now. They were they were 19 20-year-old young men. They were healthy as horses. There was no reason for me to expect there to be an issue, but I absolutely was going to be talking to the anesthesiologist ahead of time. So again, I chose an office where I specifically knew they worked with an anesthesiology group. And those are, you know, and for the child that needed deep sedation. The other thing to ask is, do they really need the sedation? Because honestly, we, you know, we think, oh, oh, yeah, it’s so much easier to be to get a little knockout medicine or a little something so I don’t have to feel this. But it’s really not that bad. I want to have one more story to tell. So my husband had a tooth that was knocked loose when we were on vacation in Norway. I think actually it was an old filling that had been in there and was having a lot of discomfort and pain with that tooth. My brother lived in Norway. We were visiting my brother. So my brother found a local dentist. He had, he actually worked out of his house. He kind of urgently took my husband in. He said that he fixed his tooth without even local anesthesia. And he said it was a little uncomfortable, but it wasn’t unbearable. So the point is, do they even need the sedation? And I think that’s a really important question to ask because I think we’ve gotten used to sometimes getting medications that we may or may not really need. And just not to make this about money and sense, but there is a charge with that, right? And for a lot of dentists and oral surgeons, the charge for anesthesia and the collection for anesthesia is actually greater than for whatever their procedure is. So they’re going to push sedation on people who may or may not need it. And so that’s, I think, another really important question to ask.

Oh, that’s great. Some really good resources. I will include a link to healthychildren.org in the show notes as well. And some really important questions to ask. Now, what is the responsibility for anesthesia professionals when it comes to keeping patients safe during dental procedures? Are there resources available to help guide safe practice? And is there research being done in this area currently?

I don’t think there’s really quote unquote research being done because I’m not really sure how we would do that. Although I mean, I think we all feel like this would be a really important area to look at, to look at, you know, outcomes with patients who receive anesthesia via one of the independent or you know, group, sort of mobile anesthesia groups. There’s there’s a lot of groups. There’s some that have really become national. There’s SMILE MD, I think it’s called. There’s there’s mobile anesthesia as a separate group. There’s there’s a whole bunch of groups. There’s a big group out of, I think it’s called dental sedation anesthesia out of Florida. There’s a big group that started in Ohio. They have multiple locations around the country. There’s a big group in Oregon. So there’s a lot of groups that provide this care. There’s also a lot of independent practitioners that provide this care really well. The person who provided the care for my first son was an independent practitioner in California. He had his own anesthesia machine. He was so proud of it. He would show it off. And he brought all of his own equipment. He worked with oral surgeons that were also certified in ACLS. So he so for him, they were sort of his backup in case there was an issue. For the second son, it was actually a dentist anesthesia group that did that did his anesthesia. And they were they were all around. So in terms of research, I mean, wouldn’t it be great? It would be really, really good. But that that implies that we have data to start with. So I think what what I’m doing and what I hope more people will do, and that is to continue to advocate for safer anesthesia care and for and to advocate a lot at the st at their individual state levels for safer dental anesthesia care and to bring these stories to light. And there’s there’s so many stories out there of unnecessary. I mean, one death is too many deaths, right? As far as we know, there have been six deaths this year so far in this country, in this country in the US. Several of them were in children, a couple of them were in adults, several of them did involve a separate anesthesia provider, several of them, a couple, a couple of them we don’t know, and a couple of them definitely did

not involve a separate anesthesia provider. There is too much we don’t know. And so I think that anesthesiologists should be on the front lines, really like shaking, shaking the walls of their individual states and saying, what are we doing to make this as safe as possible? This can be done safely. You don’t hear about, you rarely, you never, well, I shouldn’t say never, but you rarely hear about healthy people going in to have minor, minor procedures done in any other setting where they just die or they have major complications. There is a study done by oral surgeons themselves using a database from the uh primary insurance company that that that provides insurance for the majority of oral surgeons in this country. This was from about five or ten years ago. And they estimated that there was one death or serious neurologic complication that occurred about every four to six weeks. One death. And these are as presumably, if they’re selected correctly, presumably otherwise healthy patients. And again, as you heard me say earlier, I think that that is a source of a big part of the problem, is that many times the patient selection is not great. But they’re having minor, minor procedures done. Nobody should die from a minor procedure. Nobody should die from a sedation or anesthesia for a minor procedure. That just shouldn’t be happening. And we as anesthesiologists, as anesthesia professionals, know how to do this safely and do this well. And we should be, we should, all of us should be out there really advocating, probably at our state levels, to try and make this better and safer.

Absolutely. And it seems like dentists should also want to make this safer to partnering with the experts in sedation. But I’m sure that’s that’s maybe a dream going forward.

Yeah, I mean, I will I will say since Caleb’s law, since the first Caleb’s law, because what I didn’t tell you is the second part of Caleb’s law didn’t actually pass because there was too much pushback from the dental lobby and from the oral surgery lobbies, uh, both nationally and locally in California. We were able to have a pretty significant impact on the legislation that was being sponsored by oral surgeons to really strengthen the requirements for children undergoing deep sedation and anesthesia, that I think has helped, but there’s still deaths occurring in California despite all of that. To be fair, many dentists and oral surgeons really do want what’s safest for their for their patients. The problem, I think, comes that many of them are also taught that their training is adequate, their training is superior because they do a lot of office-based anesthesia as well as, you know, hospital-based, whereas most of us in anesthesiology in our residencies do very little office-based. We do all, I mean, I didn’t get any office-based anesthesia training when I was a resident, but that was, you know, 30 years ago. So I don’t know if it’s different now. I do think they get outpatient, like surgery center-based um experiences, but I don’t think most residents are getting office-based anesthesia training in anesthesiology. So oral surgeons in particular will argue that their training is not only as good, but probably better than what we get. So I think there’s a little bit of that hubris, I think, that comes from thinking that that you know as much as someone who’s trained a lot longer than you and been practicing this for a lot longer and has really tried to bring the scientific method to safety in a way that so far dental care has not. So I to be utterly, I mean, like I said, I chose oral surgeons who who prior to me, they’ve always worked with anesthesiologists. So they clearly want what’s best for their kids, um, for their patients. I’m sorry, they took care of pediatrics as well as adult patients. And I know that there’s a lot, there’s a lot of oral surgeons and dentists out there who really want what’s best for their for their patients. Um, but I think there’s also, you know, a fair number who, again, are taught

and told that what they do is just as good, if not better, than what we do. And, you know, it’s really hard to argue with the monetary incentive that comes with that. In fact, shortly after or during the time that we were having a lot of the discussion around Caleb’s law, and it was very, it was national at that time. It was, you know, the the issue around dental safety was featured on a number of different, like the Today Show and some other national shows. There was an article in one of the oral surgery journals that basically said if they were no longer able to charge for the anesthetic portion of dental implants, it would no longer be lucrative for them to do dental implants. So I think we have to keep that in the back of our mind. It’s really hard. We’re all humans. I am not being judgmental at all about this because I know I will be the same way. If I’ve been told that what I’m doing is as good and I haven’t had a problem so far, assuming that the majority of people are not having problems. This isn’t like, you know, it’s nationally one death in about 300,000 or one in every four to six weeks. I, as an oral surgeon, personally may have never had a problem. And it would be a huge, huge financial burden if I stopped doing this. Why would I stop doing it? And again, I’m not, you know, I think there needs to be more education. And I don’t think that it’s entirely impossible to make this safer within the dental or within oral surgeons’ offices. I just think it’s gonna require a lot of changes that so far I think a lot of people are not willing to look at.

And I know we have touched on some of this already, but what do you hope to see going forward when it comes to safe dental anesthesia? What do you think it’s gonna take to make sure that no one is harmed by anesthesia for dental procedures in the future?

So, what I would like to see is a really robust database that that will do, you know, something like MPOG that was set up in Michigan where institutions, practices voluntarily submit all of their information on every sedation they do. There are there are some really good examples of this. The Pediatric Sedation Research Consortium is one that takes, it’s multidisciplinary. It’s anybody who does sedation in children and volunteers to be part of the group. So you have to be, you know, you have to sign up. But once you’re part of that group, you submit every, you submit, you know, a report on every single sedation done within your institution, your office, your, you know, your practice, wherever that happens to be. It includes some dental offices, but it’s primarily hospital and clinic based, I would say. And it, you know, it’s it’s actually not that many anesthesiologists, it’s mostly ED, critical care, you know, others. And I would love to see some kind of robust database like that. We actually presented a very simple, stripped-down version of the tool that was used to gather data through the pediatric sedation research consortium that dentists could use. It would be an app that was available on their phone, it could be on their computer, on an iPad. It took less than three minutes to complete, and it would be for every single sedation that was done and then submitted to the database holders, which at the time it was the University of Dartmouth who had volunteered to kind of be the holder of all the data. And that would allow, I think, us to see where the systemic issues are. So one would be a really robust database to help determine systemic issues. Two is I would really like personally that all deep sedation and

general anesthesia is cared for by a separate provider. And that again could be a physician, it could be another oral surgeon, it could be another dentist with a license, it could be a cRNA who’s allowed within their states, you know, whatever, to do that. I think moderate and mild, I would also like the terminology to be the same as the ASA’s terminology, and for the protocols and guidelines and policies to follow the ASA’s, meaning that there needs to be heavy emphasis on recognizing and rescuing the next deeper level of sedation. So that’s what I would really like to see because the bottom line is if you can bag mask, especially in children, that’s almost always, that’s like 99% of the cause of problems in almost all patients. And there’s exceptions, of course, and I’m not saying that there isn’t, but if you just know how to bag mass effectively, you can keep a patient alive until emergency services can arrive to help, you know, do further level of care. So that’s what I would really like to see as much more robust rules and regulations. I’d like to see consistency across different states so that the same requirements for emergency medications and emergency supplies and emergency training is similar across the board. I think anywhere that provides any kind of sedation should be doing some sort of simulation training with mannequins and with, you know, again, how do you recognize, how do you treat, and how do you ventilate a patient who’s in trouble? And that should be done on a regular basis, whether that’s yearly or, you know, biannually, whatever, you know, whatever. It depends a lot, obviously, on what kind of sedation they’re doing and that kind of stuff, but it should be done at a regular basis.

And what’s next for your research or projects?

So we just published the paper on why do deaths and catastrophic injuries still occur in the dent in the dental office. And we’re gonna we’re working on this the similar group of us, uh, and we brought together, so it’s myself, a member of the ASA’s QI quality improvement committee. It’s a dentist anesthesiologist and someone who works in one of the big who provides a lot of mobile dental anesthesia care in practice. One of my colleagues and who’s a pediatric anesthesiologist who, because of Caleb’s law, basically now also does private, independent dental anesthesia care. I and I I’m not 100% sure. I think he has an office that he rents, that he does a lot of care, but he also travels to individual offices, but he’s an independent provider. So we have a group of people, and we’re working on writing another paper for anesthesia analgesia, which fingers crossed it’ll get accepted, kind of on the topic to try and continue to raise awareness. It’s difficult to know from an advocacy lens where to go next because of the fact that it is state by state. And so we really need champions within individual states to help take this to the next level. So that’s really going to be our next, I think, next goal is to try through the efforts like this with the with this podcast and with that paper to bring in additional support.

Oh, well, that’s great. We will have to stay tuned for that article in the future. And we hope that any listeners to the show who are interested in this area can maybe start to work as being a champion in their state or learning more about this issue. Is there anything else that you want to share that we have not talked about already today? We’ve talked about a lot.

Um, I think the one final thing I want to say is that as much as it seems like I’m blaming this solo sort of oral surgeon, dentist, anesthesia practitioner who’s doing the procedure as well as providing the anesthesia, I know that it’s deeper than that. And that’s why I feel so passionately about we really need to bring in people from all over and from all walks of life to really tackle this issue because it’s clearly not just that issue. And we know that there’s office-based anesthesia occurring around the country for other things, and this doesn’t seem to be happening in the same in the same way. It it may be, and we’re just not hearing it because a lot of what we hear about is through the media, and so there’s no it literally is. I mean, people could be dying left and right. I I don’t think they are. I’m just gonna say, but we’re not hearing about it unless the media gets a hold of it. So I really Really, you know, kind of implore listeners to listen out for these events. If patients are coming in, if they get patients transferred to their hospitals that have been

uh exposed to or had a problem with the dental office, you know, with the dental sedation, to maybe let us know. And to, you know, anyone who has ideas on how to move forward with this and how to try and make this safer, please again let me know.

Thanks for joining us for this 2-part series on keeping patients safe during dental anesthesia. Keep in mind that preventing catastrophic evens during dental anesthesia likely requires the same safety structure that anesthesiology has spent decades developing with appropriate patient selection, standardized monitoring, trained personnel deditcated to detecting clinical deterioration, effective rescue capability, and robust reporting and systems-based learning.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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