The fight for anaesthesia safety in dentistry

Anisha Hall Hoppe, Dental Tribune International

Tue. 26 March 2024

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Last April, Dental Tribune International first spoke with Drs Rita Agarwal and James Tom, paediatric anaesthesiologist and dentist anaesthesiologist, respectively, about the ongoing efforts towards improved safety in anaesthesia in dentistry. That conversation was continued in a second interview, and in this third part, they offer a critical look at attempts to improve safety for dental patients undergoing anaesthesia in the US, explain where insurance companies fit in and make suggestions for immediate changes towards protecting dental patients.

Paediatric anaesthesiologist and clinical professor at Stanford University, Dr Rita Agarwal. (Image: Rita Agarwal)

Drs Agarwal and Tom, what are some examples of “safety measures” that have been touted by regulating bodies or clinicians but really do very little—or perhaps even risk patient harm?
Dr Agarwal: The very concept of the anaesthesia care team as practised by dentists in the US is not safe for all types of sedation and anaesthesia. There are multiple standards in medicine that physicians, institutions and other healthcare providers are expected to follow. These include recommendations on preparing the patient, the type of equipment to have present, the number of personnel and the level of their training, and the process that needs to be in place if an emergency occurs. These also include recommendations on tracking and reporting of any complications and adverse events that occur during sedation or anaesthesia. None of these standards have to be followed by dentists, because the profession is not governed by any medical board or any of the many national accrediting bodies that oversee so many aspects of medicine. Dentistry is considered separate and different from medicine and therefore not subject to the same rules and regulations.

One of the “safety measures” touted by the American Association of Oral and Maxillofacial Surgeons is the addition of dental anaesthesia assistants. Certification merely requires possessing a high school diploma and completing six months of working with a dentist, 36 hours of online training and an exam. While such assistants can help with some aspects of care, they are clearly not as qualified to help when complications or adverse events occur.

Dentist anaesthesiologist and associate professor at the University of Southern California, Dr James Tom. (Image: James Tom)

Dr Tom: This may be controversial and is very much in line with what Rita has stated, but I would like to expand on this. A recent requirement for providing paediatric moderate sedation and general anaesthesia is to have at least two personnel in the operatory who are certified in paediatric advanced life support (PALS). On the surface and perhaps to many not really involved in sedation or anaesthesia, PALS seems like a great idea. The certification imparts basic skills in recognising, diagnosing, and treating paediatric shock and cardiac emergencies and providing some airway management, but it also emphasises working within a team for resuscitation. In reality, PALS cannot be practically implemented in most dental offices because having two dentists in the room is not cost-effective at all and having a dentist and a dental assistant or two is the most likely practice scenario.

What is overlooked is that dental assistants are not trained or licensed to recognise or diagnose paediatric cardiac dysrhythmias or even the causes of cardiogenic, obstructive, or distributive shock. They are also not licensed to administer resuscitative medication or to intervene using a manual defibrillator during a paediatric sedation or anaesthesia crisis. They can only assist with basic life support (CPR) that anyone can be trained to perform. PALS is just window dressing and does not provide a true safety measure.

So, these “certified assistants” are actually virtually useless in an emergency?
Dr Agarwal: Oral surgeons and others who practise the single-operator model support a model whereby an oral surgeon or dentist both performs the dental procedure and administers the anaesthesia while a dental assistant “monitors”. Many mistakenly assume that dental assistants are similar to nurses or nurse aides and have basic medical training. They do not. Dental assistants can have as little as a high school education and then on-the-job training. They have no medical background and no medical education. Furthermore, as I mentioned earlier, programmes for dental anaesthesia assistants involve some online modules and a national certifying exam. Compare this to a physician anaesthesiologist who has attended high school, college, medical school and at least four years of specialised training in anaesthesiology or to a dentist anaesthesiologist who has completed high school, college, dental school and at least three years of specialised training in anaesthesiology.

When complications occur—in medicine, we always assume that complications will occur at some point—you need experienced people to help manage multiple aspects of the patient’s care. You may need someone to start CPR and to perform additional airway manoeuvres, such as bag mask ventilation or even intubation. You will most likely need additional medication to help support the patient’s blood pressure, heart rate or heart rhythm. A person with no medical background, no matter how wonderful they are, will not have the ability to perform or even help with many of these tasks.

What role do insurance companies play in ensuring patients are kept safe?
Dr Agarwal: Many insurance companies will not pay for a separate anaesthesia provider for routine dental care. They will however pay a sedation fee to the oral surgeon or dentist who is performing the dental care. This sedation fee is often higher than the reimbursement for the procedure itself. This incentivises dentists and oral surgeons to both perform the dental care and provide the sedation or anaesthesia.

Dr Tom: I think the biggest role that malpractice carriers have in this issue is in providing meaningful outcome data. There is no systematic process for tracking whether one type of practice results in fewer complications than another like we have in hospital or national healthcare service settings. The obvious source of data would be malpractice insurance carriers that have this important data. Closed claims could be examined for trends, and from there, we could use the data to substantiate claims of safety or lack thereof.

What are some changes that could be immediately enacted by stakeholders at various levels, such as clinicians, state board regulators, federal regulators and insurance companies?
Dr Agarwal: Insurance companies could start covering anaesthesia services, much the same way they do for any other surgery or procedure that requires anaesthesia. Unfortunately, dental and medical insurance is provided by different companies and neither wants to pay. Regulation can and should be increased to mandate evidence-based safe practices in all locations where anaesthesia and sedation services are being provided. There is no difference between anaesthesia or sedation being provided for an MRI, a tooth extraction, placement of ear tubes or repair of a laceration. The same rules and regulations should apply to everyone.

Dr Tom: I think an immediate action that could be taken is to have the large malpractice insurance carriers for all sedation and anaesthesia providers in dentistry release closed-claims data related to sedation or anaesthesia. It would be such an important release of information that could be stratified into meaningful data to be used to support new policies or challenge existing policy.