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Viewpoint
October 28, 2019

The Single-Clinician–Operator/Anesthetist Model for Dental Deep Sedation/Anesthesia: A Major Safety Issue for Children

Author Affiliations
  • 1Formerly Department of Anesthesia, Critical Care, and Pain Management, Massachusetts General Hospital, Harvard Medical School, Boston
  • 2Formerly Division of Pediatric Anesthesia, The Massachusetts General Hospital for Children, Boston
  • 3The Kentucky Children’s Hospital, University of Kentucky, Lexington
  • 4Section on Anesthesiology and Pain Medicine, The American Academy of Pediatrics, Itasca, Illinois
  • 5UCSF Benioff Children’s Hospital Oakland, Oakland, California
JAMA Pediatr. 2019;173(12):1127-1128. doi:10.1001/jamapediatrics.2019.3823

In the June issue of Pediatrics,1 the American Academy of Pediatrics (AAP) published a joint statement with the American Academy of Pediatric Dentistry updating the 2016 AAP sedation guideline.2 This statement contains strong wording concerning the need for an independent, skilled professional to manage children during deep sedation in the dental setting. It is essential for pediatricians and family practitioners to understand why this document was revised. The guideline reiterates the need for an appropriate history and physical examination, including a focused airway examination. For high-risk patients (eg, syndromic children or serious health issues), consultation with an anesthesiologist or other specialist is suggested. It provides a list of age-appropriate and size-appropriate equipment; resuscitation drugs and other sedation basics, including opioid and benzodiazepine antagonists; and decision algorithms for the management of airway obstruction, laryngospasm, and apnea. Oxygen saturation, expired carbon dioxide, heart rate, and other parameters are documented on a time-based record. Both the independent observer and the dental clinician must be up to date with Pediatric Advanced Life Support (PALS) or Advanced Pediatric Life Support certification.

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    2 Comments for this article
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    Thomas Dodson, DMD, MPH, FACS | University of Washington School of Dentistry
    I acknowledge that this Viewpoint is an opinion, not a data-driven, piece.

    The authors focus on the theoretical risk of the single clinician operator/anesthetist model, increased probability of death. They fail to measure or report a decreased risk for death associated with their proposal of adding another provider to the clinical team. They fail to address the real and tangible increase in costs and decrease in access to care if their proposed model is implemented.

    The authors elected to ignore a common risk factor for anesthetic-related deaths in the dentist office: Most deaths occurring in a
    dental office are associated with anesthesia delivered by an itinerant medical or dental anesthesiologist functioning as a separate provider. In Washington state, the two most recent anesthetic-related deaths in the dental office were associated with an itinerant medical or dental anesthesiologist functioning as a separate provider.

    Given the authors’ reluctance to contaminate their viewpoint with data, their editorial appears driven by self-interest camouflaged by the emotional language of safety. it is unfortunate that the authors failed to solicit input and data from the clinicians with primary, recognized expertise in the delivery of care using the single clinician operator/anesthetist model, oral and maxillofacial surgeons.
    CONFLICT OF INTEREST: Associate editor - Journal of Oral and Maxillofacial Surgery; Oral and maxillofacial surgeon with expertise in the delivery of care using the single clinician operator/anesthesia model; Fellow, American Association of Oral and Maxillofacial Surgeons; President, Washington Society of Oral and Maxillofacial Surgeons
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    In response to Dr. Dodson
    Anna Kaplan, MD | UCSF Benioff Children's Hospital Oakland
    The AAP has reviewed the evidence concerning safe sedation practice many times since 1985 resulting on consensus guidelines for sedation safety meant to apply to the care of all children. The AAP review process includes multidisciplinary medical and dental practitioners. The most recent guideline in particular addressed dental sedation. The American Society of Anesthesiologists, the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation all strongly support this guideline update. Further, two large prospective sedation/anesthesia databases, demonstrate zero deaths in over five million children categorized as ASA physical status 1 or 2 for which the AAP guidelines were followed. These data suggest far greater safe anesthetic outcomes when compared with the Oral and Maxillofacial Surgery National Insurance Company closed claims data base from 2000-2013 involving 39,392,008 office based anesthetics which reported 113 deaths or neurologic injury, or one such event every 6.4 weeks; this death rate is nearly 4X greater than that reported for patients receiving general anesthesia in the hospital setting regardless of risk category or elective/emergent status from 1999- 2005 (death rate ~1/1,100,000 and near zero in children 5-14 years of age).

    We recognize that such outcomes have also occurred during sedation/anesthesia for dental care administered by pediatric dentists, dentist anesthesiologists, and medical anesthesiologists, however when these events are examined, nearly all involve egregious deviations from the recognized standards of care. The medical and most dental communities recognize the inherent dangers of the single operator model. No surgeon, gastroenterologist, radiologist, emergency medicine physician, or critical care physician would risk sedating a child without the support of a second well trained and experienced clinician. The important difference is the presence of trained eyes, attentive to the safety of the child, and capable of saying “stop now" while being sufficiently well trained to assist with any emergency. Ethically, the responsibility owed to patients and parents is full disclosure of the provider model with autonomy to choose. If the data reported by Bennett et al reflect reality, how many parents are truly informed and capable of providing informed consent for the management of their children in dental offices using the single provider model?

    Our goal in publishing this viewpoint is simple: To assure that every child has deep sedation/anesthesia using management standards that have withstood the rigors of scientific inquiry and shown to be the safest care that can be provided every single time. The discussion should not be about dollars, jobs, or territory. This discussion is simply about the lives of children undergoing elective, non-emergent dental procedures. The oral surgery community is the outlier in this discussion. Their method for providing procedural sedation in the dental office setting reflects thinking that the medical community has shown to be dangerous. It is the responsibility of oral surgeons and the AAOMS to demonstrate why the single-operator model is safe.

    We challenge the AAOMS to join us in examining dental outcomes with all provider models and providers to perform root cause analysis to determine what went wrong, why, and how to prevent recurrence.

    Signed,

    Dr. Coté, Dr. Brown and Dr. Kaplan
    CONFLICT OF INTEREST: I have testified on this issue
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