Are You Ready to Perform Sedation Dentistry?
Marc Leffler, DDS, Esq.
A general dentist in practice for over 30 years (“Dr. E”) decided to take advantage of a change in her state’s laws regarding dentists being permitted to provide sedation in conjunction with dental procedures, by attending a weekend course on dental sedation management. Dr. E maintained BLS certification, as did one of her three dental assistants. Brochures in her office waiting room made it known that patients could now be provided with sedative medications, and a similar update was added to the practice’s website.
A longstanding 73-year-old male patient (“Mr. Q”) who was 5’10” tall and weighed 255 pounds, with hypertension (treated with a beta-blocker) and Type II diabetes (treated with an oral hypoglycemic and “diet”), appreciated having all of his dentistry performed in one office setting by Dr. E, whom he had known for many years. Over time, she had provided him with treatment in nearly all phases of dentistry (fixed prosthodontics, periodontics, endodontics, and a mandibular advancement device for obstructive sleep apnea [OSA]), and he was now in need of transitioning toward a maxillary implant-supported prosthesis because the fixed bridge abutment teeth had become increasingly periodontally involved. Working together, they agreed on a plan which involved the extraction of the remaining upper teeth and the placement of an immediate maxillary denture, with implants to be placed at a later date.
With Dr. E now offering sedation dentistry, Mr. Q requested sedation for the extraction phase, and Dr. E agreed. An appointment was scheduled for a month later, by which time the laboratory-fabricated denture would be ready. In preparation, the patient was told to refrain from taking anything by mouth after midnight and up to his 11:30 a.m. appointment. Dr. E saw no need to obtain a medical consultation because she knew the patient quite well and believed that his health status had been unchanged for over a decade. Mr. Q complied with every aspect of the pre-treatment instructions he had been given.
The patient presented to the office on the morning of treatment, accompanied by his adult daughter. Dr. E seated her patient in a “supplemental” treatment room and gave him a 10 mg tablet of diazepam and a hydrocodone-acetaminophen tablet, with the goals of sedation and pain abatement by the time treatment would start about 30 minutes later. She told him to lay back in the chair and relax, while she turned out the room lights and went to treat another patient. Approximately 15 minutes later, she looked in on Mr. Q, to find him sleeping and snoring loudly. But, from the adjacent room, she soon heard the snoring abruptly stop, replaced by gurgling and what she would recall to be an “odd gasping sound”.
Dr. E went to check on her patient and found him not responsive to her speaking or hand pressure. Because this room was generally not used for treatment, but rather just examinations and post-operative checks, it was not equipped with oxygen, so she asked her assistant to bring in the centrally-hooked in N2O/O2 set-up from another room. By the time the assistant was able to disassemble that equipment and attach an O2 canister, an estimated 6-7 minutes had elapsed. Dr. E finally applied 100% O2 through a nasal mask, as she did not have a full face mask in the office, so she had no means to force the flow into Mr. Q’s lungs. There was no pulse oximeter available. While she had been trained in CPR techniques, the statute had not required (and she did not complete) ACLS training, so there was neither a laryngoscope nor an endotracheal tube in the office. At this point, Dr. E instructed a staff member to call 911. By the time paramedics arrived and transported him to a hospital, Mr. Q was pronounced dead.
Despite his age, an autopsy was performed due to the circumstances. Among the findings of the coroner were that the patient had died of asphyxiation due to an obstructed airway, and hypoxemia. His pre-existing OSA (which was well-known to Dr. E, but apparently not adequately considered) played a significant role in this series of events coming to fruition.
Shortly after Mr. Q’s estate was in place, relatives hired an attorney who obtained Dr. E’s office records, which were evaluated by a dentist anesthesiologist. Based upon the review of that practitioner, the attorney wrote a letter to Dr. E, in which he demanded a monetary settlement following a list of claimed acts/omissions of negligence which were claimed to have caused the patient’s death: failure to obtain medical clearance; failure to directly monitor the patient after the delivery of sedative and narcotic medications; failure to consider and account for the patient’s underlying conditions, specified as age, obesity, diabetes, OSA, and hypertension; failure to have training and knowledge regarding the use of resuscitative equipment; failure to have the necessary emergency equipment available and ready to use; failure to train office staff as to how to respond to medical emergencies; and failure to timely contact emergency responders.
The letter concluded with the threat that, if the matter was not settled within a stated time period, the family would seek criminal prosecution of the dentist based upon “gross negligence”. As an aside, this threat led to a disciplinary inquiry against the attorney. Because expert support for the dentist’s actions could not be obtained, Dr. E’s professional liability carrier reached a pre-suit settlement with the estate, for an amount which took into account the patient’s age and pre-existing medical conditions. Dr. E was not criminally prosecuted, but she was sanctioned by her State’s Dental Board.
The author is reminded of his father’s words many years ago, after passing a road test and becoming a licensed driver: “Just because the state gave you a license to drive doesn’t mean you know how to drive.” Similarly here, Dr. E had fulfilled the basic requirements of her state’s regulations for the use of sedation in conjunction with dentistry, but that was demonstrated in this case study to be far less than what was needed to safeguard her patient under these circumstances. Dentists are wise to recognize and constantly uphold the concept that they must “do no harm”, and, as a corollary, realize that the lawful ability to perform treatment does not equate to a technical or academic level of expertise to safely and properly perform that treatment. Practicing within one’s abilities means not only managing procedures, but the ability to manage complications and the judgment to know when not to engage in the first place, despite whatever pressures may be placed by external sources—whether patients or employers.
While it is fairly infrequent for the norms of dentistry to differ between states, the areas of enteral and parenteral sedation, as well as general anesthesia, are clear exceptions. Dentists who practice on the borders of neighboring states may be fully permitted to sedate their patients in one of their offices, while strictly forbidden from doing so in another. Therefore, dentists should become aware of what local laws do and do not allow, and should periodically familiarize themselves with changes that come about, in order to protect themselves and their patients. Organized dentistry groups often establish guidelines, but they do not establish local laws and they do not have the ability to govern dental practice. So reliance on such guidelines, alone, may lead dentists astray.
The issue of obtaining medical consultation or clearance in advance of dental procedures has been a concern for years, and its need continues to grow as the population ages and more medical treatment solutions extend lifespans. Dentists are not expected to be as expert regarding medical issues as their physician colleagues, but dentists should know when to seek the input of treating physicians. It should not “bother” physicians to assist in the dental health of their patients, but even if they appear to be inconvenienced by a question from a dental colleague, that cannot serve as an excuse for failing to obtain a needed consultation. Finally on this subject, good risk management dictates documentation whenever such a consultation takes place, ideally by a writing (letter, email) from the physician, but at least by way of a contemporaneous chart entry by the requesting dentist in which the physician is identified and the guidance is detailed.
When sedation is used by dentists, complete familiarity with all medications employed is an absolute. So, too, are the concepts of titration and dose, so as to allow the patient to be adequately sedated, but not overly so, the latter situation greatly increasing risk. In some patients, especially if older, sedatives and/or narcotics have been known to lessen a patient’s drive to breathe, so caution must dictate. And the need to take, follow, and record vital signs cannot be ignored.
This case study involves a patient with numerous medical problems, some of which are generally addressed here. While all deviations from medical norms deserve due consideration, common conditions which are often seen as sources of malpractice suits include patients taking anticoagulants (bleeding concerns); patients with certain structural cardiac anomalies (potential need for antibiotic coverage); diabetes (increased infection risk, and management of empty stomach while maintaining adequate circulating glucose levels in sedation/general anesthesia settings); OSA and obesity (airway concerns, especially with sedation/general anesthesia); osteoporosis (impacts of bisphosphonates); and uncontrolled hypertension (stroke concerns). Careful medical history reviews and updates are critical to the sound medical stability of dental patients, whether sedated or not. As the old dental school adage goes, the teeth are connected to the body.
The final point here is to recognize that all team members of a dental staff have uniquely important roles in the safe practice of dentistry. Maximizing their regular and ongoing training will provide a sense of comfort among their dentist employers and an extra layer of protection for patients. It is often not until a problematic issue arises in an office that the value of the staff is truly appreciated.
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