Dental News - The fight for improved safety of anaesthesia in dentistry

Anisha Hall Hoppe, Dental Tribune International

Mon. 3. April 2023

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Anaesthesia policy in dentistry is an increasingly controversial topic. Sedation and anaesthesia failures can lead to patient injury, and deaths have made headlines, particularly in the US, where regulation on how anaesthesia is administered in dentistry varies widely. There is very little oversight required, and even less data is recorded on the frequency of anaesthesia mishaps. In the first part of a series on anaesthesia use in dentistry, Dental Tribune International spoke with two of the leading voices on the topic, Dr Rita Agarwal and Dr James Tom, who joined forces in the wake of a medical tragedy in order to bring attention to the discrepancies that are costing patients their lives in the midst of routine procedures.

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

Dr Agarwal, Dr Tom, could you outline the issues with the single operator model that is used in many parts of the US and explain why it still persists?
Dr Agarwal: The single operator or surgeon/anaesthetist or operator/anaesthetist model—it has several names—occurs when the dentist or oral surgeon is performing the dental procedure or procedures and also providing the anaesthesia or sedation. This is a model that does not occur in medicine. Occasionally a physician will perform a procedure and supervise or be responsible for the sedation, but they have at the very least a trained nurse to assist them. While a dentist or oral surgeon may have a dental assistant to help monitor the patient, a dental assistant has very minimal medical training.

In anaesthesiology, we focus on the ability to rescue. If a patient were to have a problem with his or her breathing, blood pressure, heart rate or cardiac system, it is necessary to have people in the room who can help resuscitate him or her. One person, no matter how good or well trained, cannot do it alone. It’s really about having the appropriate training, attention and priorities. Medicine and anaesthesiology in particular figured this out years ago and went from a culture of blame and shame (i.e. it is the individual’s fault) to looking at systemic factors and trying to improve care for everyone.

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

This is different than the model in the dental profession, whereby all complications are attributed to the individual practitioner. Many of the so-called dental anaesthesia assistant certifications do not actually train an individual to help care for a patient under sedation or anaesthesia. At most, dental anaesthesia assistants are trained to watch the monitors, and not to assist in rescuing a patient if there is a complication. Specifically, the training the dental assistants receive is highly variable, inconsistent and based upon the experience and current practices of the practitioner who is delivering the training.

Dr Tom: In most private dental settings, the average health insurance will only cover a procedure if the oral surgeon actually performs the anaesthesia and the surgery at the same time. This has historically been beneficial for dental insurance companies here in the US, where they have a very strong lobby. It has been a traditional way to practise, dating from the time when people started taking out teeth and using ether for anaesthesia.

You came together after a tragic accident in which a child died during a routine dental procedure because of improper sedation. Could you tell us what efforts you have been making to prevent these scenarios, and what obstacles you have faced?
Dr Agarwal: It makes no sense that medical practitioners operate under one model and sets of guidelines and are highly regulated by several government and state agencies, but dentists doing the same thing are exempt from this. My hope is that we can create guidelines or recommendations that apply to anybody who performs sedation in any situation or location. Legally, nobody has to follow them, but the more guidelines that are out there, the harder it is to justify a different practice model, particularly if you have a bad outcome. The lawyers will hold up these guidelines in court and say: “How do you justify not following X, Y or Z guidelines?”

However, to create these guidelines we need data, and there is, at present, no record of how many adverse outcomes there have been. Because unless an event results in something egregious like death or emergency room admittance, it doesn’t have to be reported to anyone. There may be many “near misses”, which can be educational and lead to practice improvements. The patient may not die but he or she may just not be quite right afterwards, and that never gets reported. Anaesthesiologists and quality improvement scientists recognise the value of reporting near misses as well as complications, developing data collection systems and training personal to critically evaluate these reports and help guide improvements in outcome.

Dr Tom: What Dr Agarwal refers to is this data vacuum that seems to be intentional. About ten years ago, a malpractice insurance carrier for dentists presented some startling data at a paediatric dentistry conference. Basically, the statistics indicated that either a death or a severe brain injury occurred at least once every six weeks during dental procedures conducted with sedation and anaesthesia. There definitely seems to be a culture to protect the release of such data.

"In most private dental settings, the average health insurance will only cover a procedure if the oral surgeon actually performs the anaesthesia and the surgery at the same time"

So, how do medicine and dentistry differ when it comes to enacting change?
Dr Agarwal: You can’t sneeze without getting reported in medicine. There are so many layers and organisations involved, and anybody can report anything. But even though there are many different reporting mechanisms, there are still ways things will slip by. However, there are highly coordinated efforts towards change in the field of anaesthesiology and medicine. The American Society of Anesthesiology (ASA) American Patient Safety Foundation (APSF) are committed to improving safety and have developed resources and committed funding to collecting, examining and analysing quality improvement data. There are voluntary programmes for self-monitoring that have very high participation, in addition to mandatory requirements. In reporting all problems that occur, including adverse events or side effects such as a new allergy to a drug, a group can learn a great deal about its practice and how to improve it. In the medical field, there are multiple layers and organisations and people who really care about this.

Dr Tom: Dentistry as a whole doesn’t have that type of reporting to enable practitioners to predict or examine outcomes. When a procedure has adverse results, the dental practitioner is most likely to decide not to try it again. And what is more of a danger, dentists may decide to keep the failure to themselves so as not to jeopardise the growth of their practice. However, it has been the severely adverse outcomes that have really planted the flag on this whole landscape of sedation and anaesthesia and dentistry. We have, at least, made everybody aware that there are practice models out there that can be examined, improved and left to patient choice.

Unfortunately, we only hear about sedation and anaesthesia mishaps when the media gets hold of it. And, unfortunately, they become sensationalised to the detriment of all those who are involved. This is where special interest groups can get involved to ensure that over-regulation doesn’t step in, or sometimes to promote self-serving policies.

In essence, dentistry is always very reactionary when it comes to adverse outcomes. When it comes to harmful events or clinical failures, market forces drive the reaction. For example, when dental products do not work very well, it may need a string of clinical failures by private practitioners to make the manufacturer see that consumers in the dental profession are not buying these products anymore. Dentistry, at times, lacks a robust and active peer-review process for products, services and practices.

Editorial note:

Part two of the series will explore how Drs Agarwal and Tom have worked with regulators in trying to enact change and will describe the circumstances that pushed them to work towards helping clinicians realise the dangers of the single operator model.

Dr Rita Agarwal is a paediatric anaesthesiologist and a clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford Medicine. She is a past chair of the American Academy of Pediatrics Section on Anesthesiology and a past president of the Society for Pediatric Pain Management.

Dr James Tom is a dentist anaesthesiologist and associate professor and co-chair of the Department of Diagnostic Sciences, Anesthesia and Emergency Medicine at the Herman Ostrow School of Dentistry of the University of Southern California. He is a past president of the American Society of Dentist Anesthesiologists.