The fight for anaesthesia safety in dentistry

Anisha Hall Hoppe, Dental Tribune International

Tue. 19. March 2024

save

Carrying on the conversation from the first part on the ongoing fight for improved safety in anaesthesia in dentistry, Dental Tribune International again spoke with Drs Rita Agarwal and James Tom, paediatric anaesthesiologist and dentist anaesthesiologist, respectively. In this interview, they talk about their work with regulators and developments at policy and guideline level. They also offer a critical look at attempts to improve safety for dental patients undergoing anaesthesia in the US.

Drs Agarwal and Tom, you have explained to us already the dangers of the single-operator model common across the US. What are some of the key experiences you have had in working with regulators to enact change?
Dr Agarwal: I first got involved with legislators in the California State Assembly through the American Academy of Pediatrics and the California Society of Anesthesiologists. I was the chair of the American Academy of Pediatrics Section on Anesthesiology and Pain Medicine at the time and happened to live in the area where the recent death of a young boy had occurred at his oral surgeons’ office under anaesthesia. His aunt (Dr Annie Kaplan) had written and had passed a law called Caleb’s Law that, among other things, asked for the Dental Board of California to investigate paediatric deaths during anaesthesia for dental procedures.

The board did the review and made several recommendations. Caleb’s Law Part 2 was an attempt to codify and pass into law these recommendations. This is when I met Dr Tom and lobbyists and other members of a coalition that were in support of this new law. Unfortunately, there was a lot of resistance from a variety of organisations, including the powerful dental and oral surgery lobbyists. They also drafted a law at the same time, and as a result, there was a lot of confusion among lawmakers as to who was right. This led to trying to explain our positions and what seemed very obvious corrections to current law to people who had no background in medicine. The lawmakers often felt caught between experts, and since our position was perceived as being more costly to patients, insurance companies, state governments and dentists, it was rejected.

Dr Tom: We’ve continued to work with multiple state professional dental associations, other national professional organisations and educational accreditation organisations to craft practical and rational measures to improve sedation and anaesthesia safety. There are always very strong proponents, and of course, there are some who vigorously oppose these efforts in order to maintain the status quo. Change is difficult on any level, but in many cases, it takes honest introspection and sometimes fresh perspectives from motivated individuals to gain traction in these areas.

For instance, on an educational level, the dental anaesthesiology profession supported our periodontist colleagues in implementing parenteral moderate sedation training in residency programmes. There were push-back and issues with implementation across all of the programmes nationwide, but overall, the level of training and ultimately patient care improved in this particular dental specialty. This was on the level of the Commission on Dental Accreditation, which governs and sets educational standards for every US specialty training programme. Other dental disciplines have been resistant to increasing or expanding training opportunities because of limitations of time or faculty or because of expense.

Paediatric anaesthesiologist and clinical professor at Stanford University, Dr Rita Agarwal. (Image: Rita Agarwal)

On a policy and guideline level, we have been active in taking a critical look at current guidelines. Both Rita and I have been involved in the revisions to the national paediatric sedation and anaesthesia guidelines for our respective professional organisations, and we have had numerous areas in which our medical and dental spheres overlapped. Perhaps one of the most significant areas of change occurred with our involvement in the recent sedation and anaesthesia guidelines developed jointly by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry. These are probably the only specific guidelines that call for a separate trained anaesthesia provider when administering deep sedation or general anaesthesia to a paediatric patient. We have had strong support from our colleagues in medicine, and at this moment, dentistry is at a crossroads in implementing these paediatric guidelines published in 2019.

What obstacles have you faced in explaining the current risks and potential for loss of life to someone who is in a regulatory position but who has no medical background?
Dr Agarwal: This was very challenging, particularly since the oral surgery and dental lobbies were also talking to the same people and saying the opposite of what we were. I remember one particular time when a senator told a pre-eminent paediatrician and paediatric anaesthesiologist, who had authored many articles and guidelines on safe sedation practices, why he (the physician) was misinterpreting the guidelines that he (the physician) had written! The legislators did not really know whom to believe, because they were hearing different things from very respected professionals.

Dr Tom: By far, educating the lawmakers and their staff in drafting legislation has to be one of the biggest obstacles facing us. It would seem that legislating additional measures to increase patient safety would be a straightforward exercise, but this is complicated by powerful lobbies interested in keeping a profitable model intact, by state agencies being unable to enforce and practically control practice models and even by matters concerning the workforce and access to care. It’s not as easy as implementing an automobile seat belt law or speed limit because it involves so many moving parts (training, workforce, access to care, compensation, etc.).

Another complicating aspect concerns the ability of dentistry as a profession to self-regulate. Unlike medicine, dentistry still enjoys a certain degree of regulatory autonomy and for this reason attracts those to the profession that are entrepreneurial. The threat of additional practice regulation and of perceived increases in cost is a strong talking point for regulators and legislators in the political arena.

Dentist anaesthesiologist and associate professor at the University of Southern California, Dr James Tom. (Image: James Tom)

Since we last spoke, have there been any major developments regarding patient safety?
Dr Agarwal: Both the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation have created guidelines or updated their guidelines regarding anaesthesia provided outside the operating room. While these are improvements on guidelines that existed before, neither goes quite far enough and they are not enforceable.

Dr Tom: The Dental Board of California has recently updated its requirements for renewing and obtaining sedation and general anaesthesia permits for dentistry. If anaesthesia and sedation providers intend on providing sedation to paediatric patients, they must submit documentation that demonstrates that they have been in the active practice of paediatric sedation or anaesthesia on the basis of actual redacted patient records. There is a minimum requirement to submit proof of at least 20 cases of paediatric deep sedation or general anaesthesia for permit renewal or for initial permit application. This is now termed a “paediatric endorsement” and is required for dentists and physicians alike. It’s a good measure to ensure that any anaesthesia or sedation provider, whether an oral surgeon, physician or dentist anaesthesiologist, has been actively providing successful care to paediatric patients for at least two years on a continual basis in a dental office setting. We know that the practice setting is much different than a hospital or surgical centre setting, so this may provide an extra layer of assurance that those who have not had meaningful training or experience in treating children are not subjecting the occasional paediatric patient to a practice with which they are unfamiliar.