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Patient Safety Tip of the Week
Need for
Universal Pediatric Dental Sedation Standards
The number one issue in dental patient
safety has always been pediatric dental sedation. There are, of course,
circumstances where necessary dental care must be rendered to children who must
be sedated. But our columns listed below detail the many cases of deaths resulting
from pediatric dental sedation or anesthesia.
Our September 2019
What's New in the Patient Safety World “New Guidelines for Pediatric Dental Sedation” discussed the 2019 update of the joint AAP
(American Academy of Pediatrics) and the AAPD (American Academy of Pediatric
Dentistry) “Guideline for Monitoring and Management of Pediatric Patients
Before, During, and After Sedation for Diagnostic and Therapeutic Procedures” (Cote
2019). This is a comprehensive guideline that
notes how pediatric procedural sedation differs from that in adults and focuses
on multiple facets of procedural sedation in pediatric patients:
·
no administration of sedating medication without
the safety net of medical/dental supervision
·
careful pre-sedation evaluation for underlying
medical or surgical conditions that would place the child at increased risk
from sedating medications
·
appropriate fasting for elective procedures and
a balance between the depth of sedation and risk for those who are unable to
fast because of the urgent nature of the procedure
·
a focused airway examination for large (kissing)
tonsils or anatomic airway abnormalities that might increase the potential for
airway obstruction
·
a clear understanding of the medication’s
pharmacokinetic and pharmacodynamic effects and drug interactions
·
appropriate training and skills in airway
management to allow rescue of the patient, age- and size-appropriate equipment
for airway management and venous access
·
appropriate medications and reversal agents
·
sufficient numbers of
appropriately trained staff to both carry out the procedure and monitor the patient
·
appropriate physiologic
monitoring during and after the procedure
·
a properly equipped and staffed recovery area
·
recovery to the pre-sedation level of
consciousness before discharge from medical/dental supervision
·
appropriate discharge instructions
That guideline was endorsed by the American
Academy of Pediatrics, the American Academy of Pediatric Dentistry (AAPD), the
American Society of Anesthesiologists (ASA), the Society for Pediatric
Anesthesia, the American Society of Dentist Anesthesiologists, and the Society
for Pediatric Sedation.
In that September 2019 What's New in the
Patient Safety World “New
Guidelines for Pediatric Dental Sedation”
we stressed that perhaps the most important item in the guideline is a
requirement that such procedures be done in the presence of two qualified
individuals. That means that the dentist or oral surgeon performing the dental
or oral surgery procedure cannot be the individual administering and monitoring
the sedation. This ensures that individuals are attending to one primary task
and not involved in two different tasks simultaneously.
The guideline also clarifies that deep
sedation or general anesthesia must be administered by a qualified anesthesia
provider (a physician anesthesiologist, certified registered nurse anesthetist,
dentist anesthesiologist or second oral surgeon). Because children commonly
pass from an intended sedation level to an unintended deeper level of sedation,
practitioners of sedation must have the skills to rescue the patient from a
deeper level than that intended for the procedure. The ability to rescue means that
practitioners must be able to recognize the various levels of sedation and have
the skills and age- and size-appropriate equipment necessary to provide
appropriate cardiopulmonary support if needed.
The guideline includes discussion on
monitoring and documentation before, during, and after the procedure. There is
good discussion on capnography for continuous expired carbon dioxide
measurement. The guideline also emphasizes caution, as we have in multiple
columns, regarding the use of devices such as “papooses” that might restrict
chest movement or obstruct airways. We were also pleased to see the guideline
emphasizes the need in nonhospital facilities for a protocol for the immediate
activation of the EMS system for life threatening complications. We’ve
previously advised that drills and simulations should include even front office
staff so they can facilitate such emergency responses.
We thought those guidelines would go a long
way to ensure the safety of pediatric patients undergoing sedation and/or
anesthesia for dental procedures. But what is lacking in many states is a
mechanism for ensuring that these guidelines are being
followed. Our December 2023 What's New in the Patient Safety World
column “State
Struggles with Pediatric Dental Anesthesia”
highlighted some of the struggles some states are having in implementing such
guidelines.
Now a new opinion piece
in the journal Anesthesia & Analgesia says there is an urgent need for
universal pediatric dental sedation standards. Salik et al. (Salik 2025) note that the American Academy of
Pediatric Dentistry (AAPD) and the American Dental Association (ADA) identify specific
populations of children who require deep sedation or general anesthesia for
dental interventions, including children with special needs, situational
anxiety, uncooperative behavior, cognitive disabilities, or medical conditions
that mandate general anesthesia. But they go on to identify constraints of the
hospital operating room environment and difficulty for pediatric dentists obtaining
block time as factors bolstering the need for pediatric dental office-based
anesthesia. They also note there is a growing need for office-based anesthesia for
pediatric dental procedures based on reduced cost, increased access to
outpatient services, less wait time, and more efficient scheduling. Yet, the
morbidity and mortality associated with office-based anesthesia for pediatric
dental care are likely underreported, noting that a national database of
complications associated with pediatric office-based dental care does not
currently exist.
They call for dental societies,
policymakers, and regulatory boards to demand higher standards for pediatric
dental OBA care, including universal reporting standards for adverse events
that can inform policy change through the creation of a national registry.
Such standards would include comprehensive
preoperative assessment of a patient’s medical history and potential risk
factors for anesthetic adverse events and standards for provider training,
continuous recertification, meticulous oversight, emergency preparedness, and
adherence to safety protocols in settings where sedation is provided.
As we have advocated in the past, they call
for having a certified anesthesia provider with the sole responsibility of
patient monitoring, along with advanced resuscitation and airway equipment. for
dental procedures requiring deep sedation or general anesthesia. Informed
consent should be obtained so that parents are aware of the risks associated
with anesthesia, as well as the alternatives, including higher-level care in a
hospital setting.
Importantly, simulation exercises and
systematic emergency response drills to maintain preparedness for
sedation-related complications should be undertaken in pediatric dental
offices. We’ve previously advised that drills and simulations should include front
office staff so they can facilitate such emergency responses. Salik et al.
stress the importance of effective execution and training in high-quality
cardiopulmonary resuscitation (CPR) by dental practitioners.
And they call for all anesthesia-related
morbidity and mortality to be tracked to provide aggregate data for practice
improvement and ensure compliance with sedation practice guidelines.
They go on to cite the danger of allowing
the dentist or oral surgeon to direct sedation while simultaneously performing
the procedure and point out that the dental assistant assigned to monitor the
patient in such single-provider practices often has no formal medical training,
cannot establish intravenous access, rescue an airway, or administer
medications.
They note that, in the United States, there
is no nationally mandated standard for monitoring of dental patients during
sedated procedures. While capnography has been found to play a significant role
in reducing perioperative respiratory adverse events, its utilization is not
monitored or enforced during dental office-based anesthesia procedures. Some
states have begun to mandate the use of EtCO2 monitors for dental
sedation, and this should eventually become the minimal standard of care for
pediatric office-based anesthesia cases on a national level.
They describe many obstacles to change,
including powerful lobbies, resistance to increased oversight. preservation of
professional autonomy, increased operational costs of requiring an additional
anesthesia provider, limited accessibility to dentist anesthesiologists in
underserved areas, and reimbursement disparity between government-subsidized
care and private practice fees.
This opinion piece
by Salik et al. is a powerful reminder that, despite the 2019 publication of guidelines for pediatric
dental sedation, there remain significant gaps in patient safety during
office-based pediatric dental sedation and anesthesia even as the demand for
such office-based procedures is increasing.
Some of our previous columns on dental
patient safety issues:
March
15, 2016 “Dental
Patient Safety”
August
2016 “Guideline
Update for Pediatric Sedation”
March
28, 2017 “More
Issues with Dental Sedation/Anesthesia”
August
8, 2017 “Sedation
for Pediatric MRI Rising”
November
28, 2017 “More
on Dental Sedation/Anesthesia Safety”
July 2019 “Dental
Prescribing Called Into Question”
September 2019 “New
Guidelines for Pediatric Dental Sedation”
May 5, 2020 “COVID-19 and the Dental
Office”
January 25, 2022 “More on Dental Patient
Safety Issues”
December 2023 “State
Struggles with Pediatric Dental Anesthesia”
January 2025 “Dental
Prophylaxis in Patients with Prosthetic Joints”
References:
Coté CJ, Wilson S, American Academy of
Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring
and Management of Pediatric Patients Before, During, and After Sedation for
Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143(6): e20191000 June
2019
Salik, Irim MD; Chan, Kar-Mei MD; Pesola,
Isabel MD; Abramowicz, Apolonia E. MD. Death in the Dentist’s Chair: The Urgent
Need for Universal Pediatric Dental Sedation Standards. Anesthesia &
Analgesia ():10.1213/ANE.0000000000007578, May 23, 2025
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