Is it Safe for Children to Receive Sedation/Anesthesia from an Oral Surgeon or Dentist using a Single Provider/Operator Model?

Recently on this site there has been much discussion on updated guidelines put out by various groups that argue that children having deep sedation and anesthesia are not safely being served by dentists and oral surgeons using a single provider/operator model. Instead these guidelines call for a multi-provider model where the person doing the dental work or oral surgery and the person administering and monitoring the sedation/anesthesia are two separate individuals. See the posts AAOMS Pushes Back on Anesthesia Guidelines for Pediatric Patients and Updated Sedation Guidelines in Dentistry for Children for additional details. Some of the individuals leading the charge against the current anesthesia delivery model for children have published a new opinion piece titled “The Single-Clinician–Operator/Anesthetist Model for Dental Deep Sedation/Anesthesia: A Major Safety Issue for Children” published online in JAMA Pediatrics on Oct. 28, 2019 (written by C. J. Cote, R. E. Brown, and A. Kaplan, pp. E1-E2). This opinion piece contains strong language that one prominent oral and maxillofacial surgeon argues in a comment on Oct. 29, 2019 is

“…driven by self-interest camouflaged by the emotional language of safety.”

So in the interest of attempting to be more fair and balanced, let’s look more closely at the authors of this piece in JAMA Pediatrics before diving into the content of the piece. One author is Charles J. Coté, a now retired professor formerly affiliated with Massachusetts General Hospital and Harvard Medical School. He has been involved in crafting the sedation guidelines for the American Academy of Pediatrics since 1985. Dr. Cote’s work in 2000, has long been cited on this site on the dental deaths page because it showed that a proportionately large number of adverse sedation events in pediatrics occur with dental treatment versus other medical specialties. So the question becomes, well what does he have to gain by this piece? Perhaps in the past he had a particularly bad encounter with a dentist or oral surgeon and instead of enjoying retirement just wants to make their lives more difficult. Or perhaps, he was profoundly troubled by his work in 2000, and the continued deaths he has heard about of children under anesthesia at dental and oral surgery offices and just wants to help see an end to this. Another author is Anna Kaplan who is the aunt of a 6 year old children who died while having a tooth removed at an oral surgeon’s office in 2015. She is a coauthor on a bill in California known as Caleb’s Law and has previously testified about this bill, see the article The Single Operator Model of Sedation Leads to Caleb’s Law. While she is a doctor and is currently a pediatric resident in California, one could certainly argue that she being emotionally driven in her work due to losing her nephew.

Now, let’s look at some of the content of the article. The article mentions how Caleb’s law attempted to require a separate provider of anesthesia for dental procedures and oral surgery under deep sedation or general anesthesia but was met with harsh opposition and not passed. It is argued that allowing the dentist or oral surgeon to bill for both dental procedures and anesthesia is against the standards of the medical community. The article mentions how in 2016 AAP guidelines set force a certain standard that someone administering sedation must have along with requiring an independent observer who is up to date with Pediatric Advanced Life Support. The oral surgery and dental community in 2016 developed what is known as Dental Anesthesia Assistant National Certification Examination (DAANCE) as a result of these 2016 AAP guidelines. DANCE requires that to be certified as someone who can be an independent observer, they must complete 36 hours of internet study and pass an exam. The piece is highly critical of the individuals who pass this exam and feel they can not replace a skilled medically trained observer stating:

“It is frankly astonishing that such a person, with no practical clinical experience, can be certified to be the skilled observer…It is unrealistic to expect that such an individual could provide any meaningful help in a genuine life-threatening emergency.”

The perceived lack of ability of a DAANCE certified person to assist in the event of an emergency by a pediatric patient is argued as to what prompted the updated guidelines in the joint statement by the AAP and the the American Academy of Pediatric Dentistry. These new guidelines explicitly for the second person to be an anesthesia trained clinician (anesthesiologist, certified registered nurse anesthetist, a second oral surgeon, or dentist anesthesiologist). Since this is in general not being utilized by dentists and oral surgeons administering anesthesia or deep sedation to children the opinion piece states:

“It is essential that parents, pediatricians, and family practitioners are informed of this significant safety issue. In 2019, healthy children continue to be injured or die specifically because of the actions of the oral surgery community and legislators…”

The prominent oral surgeon mentioned earlier who responded in a comment to this piece in JAMA Pediatrics, mentions that the piece does not provide any supporting data to a show decreased risk of death when adding a second anesthesia trained clinician to the care team. Furthermore, such an addition has costs involved which could lead to decreased access to care. Such points are also made by the American Association of Oral and Maxillofacial Surgeons, see the post AAOMS Pushes Back on Anesthesia Guidelines for Pediatric Patients. The oral surgeon in his comments also asserts “Most deaths occurring in a dental office are associated with anesthesia delivered by an itinerant medical or dental anesthesiologist functioning as a separate provider.” Two cases are mentioned but no other data to back up this claim is provided.

There appears to be a lot of opinion fueled by emotion on both sides going back and forth regarding the safety of a single provider/operator model for delivery of anesthesia to children undergoing dental procedures. It has long been argued on this site many years ago even before digging more into dental deaths and from the recent back and forth of opinions on the single provider/operator model, that for a teenage patient having wisdom teeth extracted, they should consider having it done at a hospital where a separate anesthesiologist is available. However, this has just been based on personal opinion shaped by personal experience that might not be the safest way to go. The data from future studies may or may not actually bear this out. However, when faced with the option of either having 1) a DAANCE-certified observer who completed 36 hours and passed an exam or 2) an anesthesia trained clinician (anesthesiologist, certified registered nurse anesthetist, a second oral surgeon, or dentist anesthesiologist), as the second patient observer when a child is under deep sedation/general anesthesia while having a dental procedure performed by a dentist or oral surgeon, what responsible parent would really chose option 1 over option 2 if money were no issue. Since money is an issue for some, forcing upon every child option 2 may in fact reduce access to care for some, so the question becomes does this improve patient safety? Without clear data, opinions will continue to dominate.