AAOMS Pushes Back on Anesthesia Guidelines for Pediatric Patients

Earlier this year in 2019, the American Society of Anesthesiologists (ASA), the Society for Pediatric Anesthesia (SPA), the American Society of Dentist Anesthesiologists (ASDA), the Society for Pediatric Sedation (SPS), the American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) put out updated guidelines regarding the use of deep sedation and general anesthesia for children at a dental facility. The ASA, SPA, ASDA, and SPS put out a separate distinct set of guidelines from the AAPD/AAP. These guidelines are available from https://www.asahq.org/advocacy-and-asapac/advocacy-topics/office-based-anesthesia-and-dental-anesthesia/joint-statement-pediatric-dental-sedation and the June 2019 edition of Pediatrics in an article titled “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures” written by Coté and Wilson, which was previously discussed in the blog post Updated Sedation Guidelines in Dentistry for Children. The guidelines are slightly different but the bottom line is both call for the abolishment of oral surgeons and dentists using a single provider/operator model and instead to use a multi-provider team-based safe practice model, where the surgeon or dentist and the person responsible for the sedation are two different individuals. The guidelines advocate for

“…the provision of a second well-trained professional capable of monitoring the patient, managing the airway, establishing venous access for the administration of rescue medications, and resuscitation…”

Naturally, the American Association of Oral and Maxillofacial Surgeons (AAOMS) is not pleased with these guidelines being released and pushes back on them in an article titled “AAOMS Response to Recent Challenges to OMS Office-Based Anesthesia for Pediatric Patients” appearing in the Journal of Oral and Maxillofcial Surgery (in press, 2019) written by A. T. Indresano et al. In the article it is argued that AAOMS has a long history of being dedicated to safe, cost effective, and accessible anesthesia with a particular focus on a culture of anesthesia patient.

The authors argue that if a general dentist delivers dentistry while a separate medical anesthesiologist, dental anesthesiologist or CRNA (anesthetist) provides anesthesia this is not safe as claimed by the ASA, SPA, ASDA, and SPS statement because general dentists and dental assistants likely do not have the capability to establish venous access, administer drugs and provide airway assistance. Essentially they argue over some of the language used in the ASA, SPA, ASDA, and SPS statement due to differences in anesthesia training received by different dental providers. The authors explain the anesthesia training oral and maxillofacial surgeons receive and also point out the new anesthesia emergency management simulation training that will promote safety, discussed in the post Oral and Maxillofacial Surgeons Using Simulation to Improve Preparedness for Adverse Events with Sedation and Anesthesia. The authors point out a perceived shortcoming of the two guidelines in that neither defines the age of a pediatric patient. They argue that numerous organizations and papers indicate children 8 years and older allow for resuscitative techniques similar to small adults, while children 7 and under require different resuscitative techniques and thus a pediatric age of 7 and under is logical. The authors also point out that unlike some prior claims that no data registry exists in dentistry that can allow for identifying safety events, AAOMS has developed the OMS Quality Outcomes Registry (OMSQOR), which has been discussed in the post Outcomes Data Registry for Dentistry.

In the article in by Indresano et al. the authors also address how a small number of adverse events occur in dentistry that are intensely focused by the media leading to emotions and not science playing a role in shaping anesthesia guidelines. They mention how a review in California (related to a review prior to the implementation of Caleb’s Law previously discussed in the post The Single Operator Model of Sedation Leads to Caleb’s Law) showed nine anesthesia deaths from 2010 to 2015 in patients 21 years old and under and that there were no deaths reported by those who used OMS National Insurance Company (OMSNIC) in California (about 50% of all oral surgeons in California) from 2005 to 2015. Further, in Texas a review from 2011 to 2016 found five deaths and one brain damage case with none of these involving oral and maxillofacial surgeons. The authors also mention how retrospective and prospective studies, individual case studies, surveys and closed claims reports have shown low morbidity and mortality for oral and maxillofacial surgeon anesthesia delivery (many of such reports can be found on the mortality rates in dentistry page although only one is mentioned). The authors in the article by Indresano et al. also point out how the ASA, SPA, ASDA, and SPS statement relies mostly on citations that are position papers, opinion pieces, and media news articles with only two of the references to be considered some analysis of primary data. One of these articles showed that the greatest number of mortalities were associated with general dentists and pediatric dentists. The authors further argue that each medical or surgical specialty should be left to craft its own guidelines for practice of procedural sedation. The authors state:

“AAOMS contends that any new overly restrictive guidelines based on hyperbole, opinion, fueled by emotion, and without scientific and statistically valid support will do significant harm by 1) reducing access to care, 2) by increasing costs, 3) by limiting care availability to at-risk populations and 4) by likely increasing the demand on already-overburdened hospital emergency room resources. Any changes should only be proposed when there is supporting scientific evidence and all of these intended or unintended consequences are considered.”

As discussed previously in the post Profit Motives in Oral and Maxillofacial Surgery Utilizing Sedation oral and maxillofacial surgeons have strong financial incentives to be able to bill for both the surgery and sedation. Some would certainly not agree with the rebuttal in the article in by Indresano et al. The authors point out some very recent changes that AAOMS has made by rolling out new anesthesia emergency management simulation training and the OMS Quality Outcomes Registry. The reality is, is that the new simulation training center has not yet opened and no data has yet been analyzed that has been entered into the OMSQOR. Furthermore the statement in the article that “AAOMS and its members have been dedicated to providing safe, cost-effective, and accessible anesthesia services for adult and pediatric patients in the outpatient setting for more than 60 years with an unparalleled safety record” is not backed up with any supporting facts or data. As stated on the wisdom teeth controversy page, critics in the early 1970s labeled wisdom teeth extraction as the “Blue Plate Special” because the procedure was covered by Blue Shield of Pennsylvania and driven by profit and insurance coverage. Further as stated on the sexual assault under anesthesia for wisdom teeth removal page there are numerous cases dating back decades of oral surgeons abusing patients while under anesthesia. While the authors tout numerous studies showing low morbidity and mortality rates for oral and maxillofacial surgeon anesthesia delivery, they did not attempt to compare their results with that of anesthesiologists, except for one study which focused on a small amount of media case reports. As discussed in the article, The Single Operator Model of Sedation Leads to Caleb’s Law other data has shown less favorable results for oral and maxillofacial surgeons than what is argued in the article by Indresano et al. that “the data presented show similar results whether an oral and maxillofacial surgeon or an anesthesiologist was the anesthesia provider.” Therefore, one could argue that while the AAOMS authors argue that reliance on opinion and media case reports has driven the updated guidelines advocating for a multi-provider team-based safe practice model, the rebuttal by the AAOMS authors also relies on opinion and media case reports.

For those considering having deep sedation or general anesthesia for a dental related need it would seem an oral and maxillofacial surgeon should be chosen over a general dentist or pediatric dentist in general based on the training for anesthesia that is received. However, it would seem pediatric patients sedated in dental offices are best served under a multi-provider model, where the surgeon or dentist and the person responsible for the sedation are two different individuals. The arguments that it will reduce access to care, increase costs, and increase the burden on hospital emergency departments seem like a real possibility, but this just further gives fuel to the notion that the U.S. needs universal health care that also includes dental care. At the end of the day patient safety should win over profits.