In wake of East Bay child’s death, dental group releases new guidance on anesthesia

The death last month of 4-year-old Lý Trí Dũng at an Oakland dental office has once again raised the question: Does California need stricter rules over the use of anesthesia in the dentist’s office?

Under the current rules, dentists who are trained in the use of anesthesia can — and often do — rely on assistants without that training to monitor vital signs. That differs from the rules for physicians, who can use deep sedation only if a patient is monitored by a separate clinician certified in the use of anesthesia.

But the most recent death has renewed scrutiny of California dental surgery regulations.

In newly released guidelines, the American Academy of Pediatric Dentistry, in conjunction with the American Academy of Pediatrics, recommends that two people credentialed to administer anesthesia be present in the room any time a child is deeply sedated. It’s a divergence from the positions of industry groups like the California Dental Association, which has argued that requiring two people qualified to administer anesthesia would make it harder for kids to get needed dental care.

Current California law allows credentialed dentists and oral surgeons to anesthetize children under 13 if they have two assistants present, and one of them is certified to provide pediatric life support in an emergency.

“Every state has their own rules, which really complicates things,” said Kevin Donly, president of the pediatric dentistry group. “We’re recommending you have that extra person who’s a true expert in anesthesia, and also life support in children, really concentrating on the kid’s vital signs to make sure everything’s going smoothly.” Donly said many people can be qualified to give anesthesia — it doesn’t have to be a doctor.

Little is publicly known about the circumstances of Dũng’s death, although the family has claimed on a GoFundMe page that he died after being sedated at the dentist. A Dental Board of California investigation is still pending and the coroner has yet to determine how he died. People reached at both offices of Youthful Tooth, including the Oakland location where Ly went into cardiac arrest, declined to comment.

Nevertheless, the tragedy has renewed a fierce debate around dentists inducing unconsciousness without help from a second certified anesthesia provider, whether that person is a nurse, a dentist, or a medical doctor. At least two seemingly healthy children in California have died under dental anesthesia in recent years, as have children in other states, according to media reports of the incidents. Unlike medical anesthesia, little is known about the outcomes of children sedated in dental offices.

“If we tried to do what they do in our practice as physicians, we’d get ripped a new one – get sued, lose our license to practice. It would be unimaginable,” said Rita Agarwal, former chair of anesthesiology and pain management for the American Academy of Pediatrics and a professor of anesthesiology at Stanford. She is part of a movement pushing to mandate two clinicians credentialed to provide anesthesia be present during the procedure.

Parents need to ask a lot of questions before agreeing to anesthesia, explained Karen Silert, a past president of the California Society of Anesthesiologists and professor of anesthesiology at UCLA.

“Anesthesia for children is risky business,” Silert said. “They have tiny mouths and a tiny airway behind it. It doesn’t take much to obstruct the airway, and their lungs are tiny so they don’t have a lot of oxygen reserves.”

Making the issue more complicated, there’s a huge disparity between what we know about medical and dental anesthesia outcomes.

Dozens of hospitals have collected thousands of detailed records about adverse events. “No healthy child without a pre-existing condition has died from anesthesia since [medical doctors] started collecting data,” Agarwal said.

But dentists don’t have that kind of data collection, and lessons learned in hospital surgical centers don’t necessarily apply in dentists’ offices.

Following the death of 6-year-old Caleb Sears of Albany during a dental procedure in 2015, the state Legislature ordered the Dental Board of California to produce a report on safety practices for anesthesia in child dentistry, under a bill known as Caleb’s Law. The report, released in December 2016, found there was too little data to make any determinations regarding best practices.

“The use of anesthesia and sedation, especially in pediatric patients, always carries some risk,” the California Dental Association said in a statement. “CDA’s highest priority is access to safe and effective dental care.”

In 2018, a second “Caleb’s Law” requiring two certified providers to be present during anesthesia was passed over in favor of a competing bill, which instituted the two-assistants rule.

Squirmy young children are especially challenging to work with, and aren’t good candidates for local anesthetic and a mild sedative like Valium, Silert said. “Think about kids in church. You can tell a seven-year-old to sit still for five minutes and you’ve got a fighting chance, but with a 2-year-old, no way.”

Ultimately, Agarwal and other experts say, those without anesthesia might not spot red flags like slowed breathing while the dentist is distracted by working on teeth.

“It’s like texting and driving. You can be the best texter or the best driver, but when you’re doing both, it can be a disaster,” she said.

Source: mercurynews
In wake of East Bay child’s death, dental group releases new guidance on anesthesia