CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD

 

Dental Anesthesia and Sedation: Where Are We Now?

by
  • Agarwal, Rita, MD, FAAP, FASA
| Feb 04, 2019

Agarwal-RitaIn 2015, healthy, happy 6 ½ year Caleb Sears suffered a cardiac arrest in his oral surgeon’s office after receiving midazolam, ketamine, propofol, fentanyl, and nitrous oxide, and became apneic. He later passed away. His devastated family could not understand how this tragedy had happened and set about trying to change California law that governs the administration and monitoring of anesthesia and sedation provided by dentists/oral surgeons. Their initial attempt, spear-headed by Caleb’s aunt Anna Kaplan, MD, resulted in the passage of AB 2235 authored by former Assembly Member Tony Thurmond (D-Richmond) that required the Dental Board of California (DBC) to review and report on the laws and regulations governing dental anesthesia at that time. This was known as Caleb’s Law Part 1 and there is more information at Parents Who lost son struggle to strengthen rules.

The next step was to codify all the recommendations made by the DBC, which included the provision of a separate dedicated and independent anesthesia provider for children < 7 years of age undergoing deep sedation or general anesthesia.  AB 224 (Thurmond, Caleb’s Law Part 2) was proposed in the California Assembly in Jan 2017 and included a complete representation of all the patient safety recommendations from the DBC. It was sponsored by the American Academy of Pediatrics-California Chapter (AAP-CA), the California Society of Anesthesiologists (CSA) and the California Society of Dentist Anesthesiology (CSDA). At the same time, SB 501 authored by Senator Steve Glazer (D-Orinda) was also introduced and was sponsored by the California Association of Oral and Maxillofacial Surgeons (CALOMS) and strongly supported by the California Dental Association (CDA). The full details of the struggle to pass meaningful legislation is chronicled in a series of excellent reports by CSA lobbyists Bryce Docherty and Vanessa Cajina in the Under the Dome series. 

In summary, AB 224 (Thurmond) failed to reach Governor Brown’s desk, largely due to fierce opposition from CALOMS and the CDA. The CDA was able to convince the Legislature that having additional personnel in the dental office dedicated to ensuring proper monitoring of the dental anesthesia would make access more difficult for children seeking these dental procedures and significantly increase costs. Only after much debate and significant amendments to strengthen several provisions, SB 501 (Glazer) was eventually signed into law by Governor Brown in October 2018.

The major provisions of SB 501 can be found here

 

Some of the most significant parts of the new law pertaining to deep sedation and general anesthesia have been copied in Addendum 1. The major area of disagreement for dentist anesthesiologists and the CSA is the statute which continues to allow for the single operator-anesthetist model of practice, whereby the operating dentist/oral surgeon can supervise and provide anesthesia at the same time. This law attempts to make that practice safer by mandating that at least one other person, in addition to the “anesthesia permit holder” in the room is certified in Pediatric Advanced Life Support or “ the board may approve a training standard in lieu of Pediatric Advanced Life Support (PALS) certification if the training standard is an equivalent or higher level of training for pediatric dental anesthesia-related emergencies than PALS.” Since this law continues to allow the use of dental sedation assistants, whose curriculum and training is determined and overseen by a small handful of California oral surgeons, and who do not receive enough general medical education to understand or pass PALS, we remain skeptical as to the quality and manner of dental-anesthesia related emergency training that these assistants will receive.

 

There were some clear wins in SB 501 (Glazer), however, the most important of which were:

  • Mandated reporting of adverse events to the DBC, and maintenance of these records for at least 15 years
  • Adoption of standard ASA and CMS terminology for levels of sedation and anesthesia.
  • An analysis of cost of providing care with a separate anesthesia provider, versus care with a single provider.
  • The Law adds a requirement for a pediatric endorsement:

    “A dentist may apply for a pediatric endorsement for the general anesthesia permit by providing proof of successful completion of all of the following:

    (1) A Commission on Dental Accreditation (CODA)-accredited or equivalent residency training program that provides competency in the administration of deep sedation and general anesthesia on pediatric patients. 

    (2) At least 20 cases of deep sedation or general anesthesia to patients under seven years of age in the 24-month time period directly preceding….

  • A requirement for 24 continuing education hours in sedation and anesthesia over 24 months.

All of which seem to be positive developments, but not quite enough to ensure that every child undergoing sedation or anesthesia whether in a dental office, clinic, outpatient unit or operating room, receives the same standard of care as a child receiving sedation or anesthesia in a medical setting.

Yikes, that doesn’t seem enough? Are there any other wins?

  •  As previously noted, there has been high visibility media coverage of these issues, featuring our very own Karen Sibert, MD, FASA, that has brought this issue to the public’s attention. This attention has been sustained and can be found in video, print and social media.

  • CSA contacted and deployed joint AAP-AAPD guideline authors Charles Cote, MD, and Steven Wilson, DMD, to assist in our lobbying efforts on why a separate dedicated and independent anesthesia provider is needed in a dental office to  safely provide deep sedation or general anesthesia.

  • Charles Coté, MD, gave generously of his time and expertise by flying to Sacramento several times to testify and meet with key legislators at the State Capitol.

  • As a result, Dr. Coté contacted his co-author Steven Wilson, DMD, and with approval from the AAP set about writing an addendum that explicitly recommends having a separate dedicated and adequately trained anesthesia provider (such as physician anesthesiologists, dentist anesthesiologists, CRNAs, Certified Anesthesiology Assistants (CAAs, sedation trained physician or dentists etc.) administering and monitoring the anesthesia or sedation for a child in dental practices. The addendum has been approved by all interested AAP Sections, Councils and Committees (which includes the Section on Oral Health, Section and Committee on Pediatric Emergency Medicine, Committee on Drugs, and many others) and is awaiting final approval form the AAP Board of Directors.

  • Once the Addendum is published, CSA will consider supporting legislation to further improve upon SB 501 (Glazer).

  • The outrage related to unnecessary dental sedation deaths has led to many articles in the anesthesiology, pediatric, and pediatric dentistry literature as well as mainstream media questioning these practices.

  • Concerns Regarding the Single Operator Model of Sedation in Young Children. Agarwal R, Kaplan A, Brown R, Coté CJ. Pediatrics. 2018 Apr;141(4).

  • Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy? Lee H et al. Pediatrics. (2017)

  • Office-Based Anesthesia: Safety and Outcomes in Pediatric Dental Patients. Spera AL et al. Anesth Prog. (Fall)

  • Should Kids Be Sedated for Dental Work, New York Times 2017 Aug 24. Should kids be sedated?

  • Governor Signs Finley's Law in Hawaii Hawaii News Now 2017 July 10 

  • Increased interest nationally from physician anesthesia advocates in other states (Pennsylvania, Wisconsin, Texas). Advocacy workshops focusing on Dental Anesthesia and Caleb’s Law around the country. 

  • New information for parents.   

  • Both the AAP and the CSA continue to make safer dental anesthesia a priority. The ASA and the Society for Pediatrics Anesthesia are joining the fray to help with national initiatives. There is a growing coalition of interested organizations who will continue this fight.

  • There have been social media campaigns to improve knowledge about the differences between dental sedation practices and medical sedation practices.

  • A coalition representing Pediatric Dentistry, Pediatrics, Anesthesiology, Dentist Anesthesiologist and Dr. Anna Kaplan, presented the tool used by the Pediatric Sedation Research Consortium to the Dental Board of California. This tool is a simple, easy to use, inexpensive, and objective way to gather data. Hopefully the DBC will seriously consider the use of this tool, which will allow them to easily store data for the required 15 year minimum.

What Else Can We Do?

  • There is still a lot that is unknown and some of the deaths in children are not easily explained. Gathering high quality data regarding all sedation events could really make a difference in determining best practices.

  • We must encourage the DBC to adopt the data tool used by the Pediatric Sedation Research Consortium or work with them if they choose develop their own tool.

  • Consider support for additional legislation once the AAP/AAPD sedation guideline addendum is published.
    Continue to be vigilant and look for opportunities to improve patient care in all settings.

  • Consider literature on dental sedation and anesthesia for families on our website and discuss similar efforts with the ASA and other interested organizations  


 



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