We all have questions, but sometimes it’s difficult to find reliable answers. With sedation and general anesthesia recently featured so prominently in national news, Shift magazine goes behind the scenes in an interview with a past president of the American Society of Dentist Anesthesiologists to discover answers to some important questions dealing with dental anesthesia and related issues involving patient safety in pediatric dentistry.
IN A RECENT UPDATE:
STATISTICS FROM A 2014 ASA CONVENTION*
• In data from more than 3.2 million cases of anesthesia use between 2010 and 2013, the rate of complications decreased from 11.8 percent to 4.8 percent. The most common minor complication was nausea and vomiting (nearly 36 percent) and the most common major complication was medication error (nearly 12 percent).
• The death rate remained at three deaths per 10,000 surgeries/ procedures involving anesthesia.
• Among the other findings: complication rates were not higher among patients who had evening or holiday procedures; patients older than 50 had the highest rates of serious complications; and healthier patients having elective daytime surgery had the highest rates of minor complications.
*In a recent update, Dr. Jeana Havidich, an associate professor of anesthesiology at Dartmouth-Hitchcock Medical Center in New Hampshire, presented the above preliminary data at an American Society of Anesthesiologist convention in October 2014. (theanesthesiaconsultant.com)
1. With recent nation-wide news stories reporting sedation-related tragedies in dental offices, are the risks for in-office anesthesia going up? Or is it still safe?
ANSWERS BY Michael Mashni, DDS
MM: We are all concerned when we read reports of poor outcomes occurring in dental offices. Of course, even a single poor outcome is one too many. One problem we face, however, is that the facts are rarely available for the experts to review. Furthermore, we don’t have access to a centrally maintained database which allows us to track all outcomes. Much of what we know regarding the circumstances surrounding reported poor outcomes is based on what we hear from the media or from attorneys pleading the case for their clients.
The safety of anesthesia will always be questioned after any poor outcome, and hopefully we can all take the opportunity to review how we practice and explore how we can improve the safety of the patients we treat. We must continually ask ourselves probing questions. How can we learn from these cases to determine what went wrong? And how can we prevent the same problems from occurring again?
Many factors can affect the safety of anesthesia. Safety is related to the training of the individual anesthesia provider, his/her experience (particularly with pediatric patients), and coexisting or current medical conditions such as a concurrent upper-respiratory-tract infection. Additional risk factors include such things as food in the stomach, length of the procedure, and even the common sense of the provider. If an anesthesia provider determines that a patient would be put at increased risk while undergoing anesthesia, then treatment may need to be referred to a hospital or surgery center, depending on the specific circumstances. In many cases, however, children can still be safely treated in the dental office by practitioners who are properly trained and prepared.
2. What are the differences between using a medical anesthesiologist vs. a dental anesthesiologist? Are they trained differently?
MM: Physicians and dentists each travel a different pathway prior to their anesthesia training. Physician anesthesiologists are well trained in all aspects of anesthesia. Historically, dentists have trained side by side with physician colleagues in the same program. When this practice was no longer an option, training programs for dentists developed with rotations in the anesthesia departments of hospitals and medical centers, but also concentrating on treating patients for dental reasons, and more specifically, in the dental office setting.
Prior to the accreditation of dental anesthesia training programs, the training varied by location and school. Now, however, set standards exist which all dental anesthesiology training programs must follow. Currently, the length of such training is three years. These programs maintain high minimum standards for treatment of pediatric patients and train dentists in providing outpatient anesthesia in a dental office. Both physician anesthesiologists and dentist anesthesiologists are qualified to treat patients in the office setting. We may conclude that all anesthesia providers— whether trained via a medical or dental track—must be properly qualified to work in a dental office setting that will ensure the safety of patients.
3. With increasing scrutiny becoming the norm, should I as a pediatric dentist be requesting a medical clearance on all my sedation cases, or is it ok to just let the anesthesiologist do the H&P?
MM: That is a good question. A medical history and a focused physical evaluation (H&P) must be performed on each patient prior to administering anesthesia. One purpose of the medical history is to review the medical systems and determine if more questions need to be answered or more tests performed. Routine lab tests or chest x-rays used to be standard prior to surgery, but this practice has long been abandoned as these procedures rarely altered treatment, unless they revealed an existing contraindication. Medical clearance by itself may not be helpful and may only give a false sense of security.
After reviewing a medical history and/or evaluating the patient, if you determine that a consult is necessary, then you should absolutely obtain one prior to treatment. Just as routine laboratory tests or chest x-rays are not necessary, a medical consult is not necessary for every patient. A medical consult should be directed towards addressing specific conditions and not be a general request for “clearance.” A note from a physician which only indicates “ok to treat” is worthless. A child with a failing heart may be “ok to treat” for the purpose of repairing the cardiac defect. This does not mean the patient would be ready for dental treatment in an office-based setting.
4. Do any statistics demonstrate whether it is safer to have my patient intubated vs. using an open-airway technique?
MM: Both techniques have been used safely and successfully for many years. I am not aware of any studies comparing the two modes of practice. Medicine has tended to intubate patients and more recently adopted a practice of using supraglottic airways such as a laryngeal mask airway. Dentistry, on the other hand, has a strong history of utilizing an open-airway technique.
The main benefit of intubation is achieving a protected airway. The downside of using an intubation technique is the potential soreness or trauma it may cause. These results, however, are infrequent, particularly when performed by skilled providers.
When using an open-airway technique, the anesthesiologist must manage the airway. My observation is that patients wake up more smoothly following an open-airway procedure. My friends who choose to intubate their patients would disagree. So, the debate continues….
5. What are some important factors to consider when choosing an anesthesia provider to assist my practice?
MM: Safety is your number one consideration; but it is also number two, three, and four! Start with the provider’s training. Make sure the anesthesiologist completed an anesthesia residency either in medicine or dentistry. Look at the amount of training and experience the provider has had with pediatric patients. Kids are not small adults and shouldn’t be treated as such.
Board certification in anesthesia by the American Dental Board of Anesthesiology (dentists) or the American Board of Anesthesiology (physicians) is verification of training at the highest level. For dentists, active membership in the American Society of Dentist Anesthesiologists indicates the highest level of ongoing training in anesthesia for dentistry. Make sure the provider has experience or training in providing sedation in the dental office setting. Ask for references from other dentists or physician colleagues.
6. With the rising cost of medical insurance deductibles, do you foresee more people opting to request in-office sedation for dental procedures in the future?
MM: There is no question that in-office anesthesia is more cost effective than performing procedures in a surgery center or a hospital. Since I began my training in anesthesia in the early 1990’s, I have observed pressure to move anesthesia outside the hospital to ambulatory settings. However, cost savings should not be the only consideration. As discussed above, safety is our priority, and if a patient’s needs require the use of a surgery center or hospital operating room, then finances shouldn’t dictate that treatment be performed in a dental office.
This being said, anesthesia provided in ambulatory centers and even in dental offices has a long track record of safety. Advances in medicine will only improve this record. New devices such as Bluetooth precordial stethoscopes, video laryngoscopes, vein finders, and supraglottic airways have been developed. These instruments have become widely available since my training and all give me tools that help me treat patients more safely in ambulatory settings. I cannot foresee a decrease in utilization of in-office anesthesia.
7. If I currently use oral sedation in my office, are there reasons I should consider inviting an anesthesiologist to partner with me in providing in-office sedation?
MM: My opinion is that minimal sedation—more specifically, sedation administered by the oral route—is the most underutilized tool in dentistry. A divide exists between medicine and dentistry regarding providing sedation and anesthesia for potentially painful or uncomfortable procedures. I once had a chalazion (blocked duct in my eyelid) for which my ophthalmologist recommended treatment in the hospital operating room despite most ophthalmologists performing such treatment under local anesthesia in the office. I’m told this procedure involves only a simple excision, yet my medical insurance authorized the anesthesia in the hospital without question.
I never had the procedure performed but compare this simple chalazion procedure to a dental procedure requiring you to do several pulpotomies, seat a number of SSCs, and maybe even perform an extraction. Why is it that in dentistry we expect patients to just grin and bear it? Pediatric dentists or others with training in minimal sedation, should continue providing sedation services as long as the treatment falls within the scope of both the dentist’s training and the AAP/AAPD guidelines (AAP/AAPD Guidelines for Monitoring and Management of Pediatric Patients Before, During and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016).
If done within the guidelines for minimal and moderate sedation, failures can be expected. If you experience a 100 percent success rate using minimal sedation, then you are either ultra conservative and lucky with your patient selection or you are overdosing a small percentage of your patients. An anesthesiologist is available for the patients that require deeper levels of sedation.
8. Where do you see in-office sedation moving in the future, and how can dental professionals help ensure this option will be available for future generations of pediatric dentists?
MM: In-office sedation is growing due to the strong safety record and the current demand. By choosing appropriate patients that can be treated in the office by minimal sedation and utilizing a qualified anesthesiologist, dentists will be providing a much-needed and safe alternative to a surgery center or hospital. As a profession, we need to continue to improve outcomes and continuously look at our processes and procedures to see how we can improve, even if we think we are doing a good job as it is now. Poor outcomes will always prompt a review and sometimes new regulations and laws. Tracking outcomes data will either establish our practices as safe or show us how to improve. Poor outcomes will always prompt a review and sometimes may result in new regulations being adopted and/or new laws being passed. This is the best defense we have against reflex moves that would place limits on anesthesia in the dental office.