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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. Published online October 28, 2019. doi:https://doi.org/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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    1 Comment 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