Teen dies after 'routine' wisdom tooth surgery

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By Linda Carroll MSNBC.com April 6, 2012

When 17-year-old Jenny Olenick went in to have her wisdom teeth removed, her parents weren’t worried. After all, wisdom tooth extraction is so common these days that it’s almost become a rite of passage for teens.

“She was supposed to be out of there in an hour and a half,” Jenny’s mom, Cathy Garger, told TODAY. “Just something we all do, going to the dentist. She was supposed resume normal functioning within about four days or so.”

But the routine procedure quickly took a tragic turn. Just 15 minutes after Garger and her husband dropped Jenny off at the clinic they received an urgent call from the oral surgeon’s office.

“We heard the ambulance sirens going in the background,” Garger remembers. “And as my husband and I were riding up the elevator we said, ‘That’s for Jenny.’ We just knew it.”

Though Garger and her husband were worried, they still had no idea of how badly things had gone wrong during the “routine” procedure on March 28, 2011. When they got to the hospital, doctors told them the outlook was bleak. Their daughter died 10 days later.

The autopsy report revealed that the apparently healthy teen had died of “hypoxia while under anesthesia for a tooth extraction.” In other words, she’d been deprived of oxygen for so long that her brain was severely damaged. Sometimes when patients are under anesthesia their heart rate can slow, and then the body gets less and less oxygen if doctors can’t get their heart back up to speed. Jenny’s death was ruled to be an accident.

Jenny’s was the second reported hypoxia-related dental procedure death last year. Earlier in the year, 13-year-old Marissa Kingery died after an oral surgery went wrong. Her death was also ruled an accident.

Story continues...

http://todayhealth.today.msnbc.msn.c...h-surgery?lite

Originally Posted by Danbo1957

Story continues...

http://todayhealth.today.msnbc.msn.c...h-surgery?lite

Anything can go wrong anytime. This is an anecdotal case, 1 out of 2 this year. For example, an OD might prescribe atropine drops for a baby. If the parent administers too many of them in too short of a time period to the baby's eye, the baby can die. And these are just simple eye drops and not general anaesthesia complications. Every patient is different.

What type of sedation is typically used for oral surgery? Intermittent versed, fentanyl?

It is sad that a teen die just for a tooth extraction.

Originally Posted by PMPMD

What type of sedation is typically used for oral surgery? Intermittent versed, fentanyl?

Are you asking about the drugs used or the types of sedation...

Most oral surgery is done under local anesthetics without sedation. I took out 4 wisdom teeth a few days ago on local.

Going under general anesthesia for 4 wisdom teeth is pretty excessive, but then, some people are just wusses. It's sad the girl died, but medical complications happen every day. Sad that it was just for her tooth extractions, but then, people die on operating tables getting plastic surgery and all kinds of elective treatments too.

Originally Posted by djeffreyt

Are you asking about the drugs used or the types of sedation...

Both. As an anesthesiologist, I've worked with oral surgery residents in the OR, but I have no idea what they're using in the office when they're out in practice. Versed, propofol, etc.

The few dentists I know who do general use propo and versed. They usually are hospital based and do it with and anestheologist present. Conscious sedation I'm not totally sure. Oral in office sedation is usually just halcyon and nitrous.

In Australia and New Zealand it has been agreed by the various professional bodies that sedation for dental procedures or other investigations (e.g. colonoscopy) is limited to "light sedation" (e.g. a bit of fentanyl and some midazolam) and anything else must be carried out by an Anaesthetist.

As an example propofol (and other like drugs e.g. etomidate or ketamine) are restricted and available only to those medical practitioners who have the need for them within their vocational scope of practice; namely emergency medicine, intensive care medicine, anaesthesia and maybe palliative care or rural hospital medicine

Originally Posted by PMPMD

Both. As an anesthesiologist, I've worked with oral surgery residents in the OR, but I have no idea what they're using in the office when they're out in practice. Versed, propofol, etc.

Oral Surgeons typically will draw up a deep sedation mix using a midaz, propofol, ketamine, fentanyl cocktail. Contrary to what the dental student said, many many oral surgeons put their patients under at least conscious sedation for 3rd molar extraction. They usually keep them pretty light from my experience (since they have local on-board), and will begin to push if the patient begins to stir

If they're doing something more complex than extraction/implant (osteotomy, plastics, etc) all the ones i've worked with will either bring in a separate gas passer for general or take the patient to the OR

Pediatric Dentists will typically do either oral sedation with benzos, or N20 at 50% or IV benzo with fentanyl(s)

There are some general dentists who have sedation permits who will also do IV benzos and fentanyl(s)

Originally Posted by Sublimazing

Oral Surgeons typically will draw up a deep sedation mix using a midaz, propofol, ketamine, fentanyl cocktail. Contrary to what the dental student said, many many oral surgeons put their patients under at least conscious sedation for 3rd molar extraction. They usually keep them pretty light from my experience (since they have local on-board), and will begin to push if the patient begins to stir

If they're doing something more complex than extraction/implant (osteotomy, plastics, etc) all the ones i've worked with will either bring in a separate gas passer for general or take the patient to the OR

Pediatric Dentists will typically do either oral sedation with benzos, or N20 at 50% or IV benzo with fentanyl(s)

There are some general dentists who have sedation permits who will also do IV benzos and fentanyl(s)

Thanks that's what I was interested in.

I find it fascinating, and very disturbing, that in US a dentist is allowed to administer things like propofol, ketamine etc which here, in the out patient setting i.e. not in the hospital operating theatre, only a Consultant Anaesthetist can give and he has to have all the monitoring equipment and bits and pieces which come with the responsibility of doing so by virtue of the professional standards of ANZCA and the agreed standards between the various Colleges (e.g. Dentistry, Anaesthetics, Emergency Medicine, Intensive Care Medicine)

An "oral surgeon" here is a max/fac i.e. a Physician, but they are not allowed to administer those drugs because it is not within their vocational scope of practice.

As anesthesiologist also....I'll chime in what I think happened.

Standard cocktail (pick your drugs, versed, fent, some propofol....)

Patient gets uncontrollable. Either get them deeper or lighten them up.....young patient starts getting more secretions....classic larygospasm

Than it becomes an issue how quickly this spasm gets relieved. Did anesthesiologist take timely appropriate steps (positive pressure, sux?). Did they timely secure the airway.

Even after securing the airway, you could still be dealing with flash pulmonary edema and that could continue to interfere with oxygenation.

Those are questions that need to be answered.

Office-based procedures are are huge growth area in anesthesia billing. While an anesthesia machine isn't necessary to be available for a MAC procedure, appropriate equipment should be available. Debif?

I am not a fan of this "safe sedation" company. Company was sold to a bunch of private equity investors a few years ago. Private equity investors....we all know what happens when they get involved.

Oral surgeons do a rotation through anesthesiology, some OMS's I've shadowed told me knew more about anesthesiology during their rotation than some of the residents in the department. I also agree its nearly standard practice to put the patient under during third molar extractions - especially if the insurance pays for it. "David after the dentist" ring any bells?

Originally Posted by MaxillofacialMN

Oral surgeons do a rotation through anesthesiology, some OMS's I've shadowed told me knew more about anesthesiology during their rotation than some of the residents in the department. I also agree its nearly standard practice to put the patient under during third molar extractions - especially if the insurance pays for it. "David after the dentist" ring any bells?

No reason to insult the anesthesiologists. They train us. Hopefully we do know more than at least some of their residents. We only have 4-6 months to learn one of the most important skills and services we offer. We only have 200 residents a year training with anesthesiologists in a select few academic centers, we can only hope we leave good impressions.

Sedation for 3rds in an OMS office is ALMOST standard practice due to referrals. They are in your office for the sedation and comprehensive and fast extraction 'experience'. LOTS of 3rds are taken out under local by GPs.

Due to the age, doubt david was in for his 3rds. Likely got himself some SSCs.

I wasn't trying to insult the anesthesiologists, just saying what I've heard from some OMSs.

Originally Posted by MaxillofacialMN

Oral surgeons do a rotation through anesthesiology, some OMS's I've shadowed told me knew more about anesthesiology during their rotation than some of the residents in the department. I also agree its nearly standard practice to put the patient under during third molar extractions - especially if the insurance pays for it. "David after the dentist" ring any bells?

Neither a max/fac or a dentist is an anaesthetist; one run through anaesthesia be it in medical school or on their house officer year is not equivalent to five years of anaesthesia training to become an anaesthetist.

To even get your hands on propofol, ketamine, thiopentone*, etomidate etc here you have to be a vocationally trained anaesthetist (i.e. a Consultant)

In the UK the provision of general anaesthesia for dentistry must take place in hospital after 31 December 2001 according to the UK Department for Health.

Not sure how in the land of the Litigious it is possible for dentists or max/fac's to go round knocking people out .... hmm

* If I see anybody dishing out thiopentone to people I'm going to come over there and slap you, nasty horrendous yellow powdered muck of Satan that stuff is.

Originally Posted by MaxillofacialMN

Oral surgeons do a rotation through anesthesiology, some OMS's I've shadowed told me knew more about anesthesiology during their rotation than some of the residents in the department. I also agree its nearly standard practice to put the patient under during third molar extractions - especially if the insurance pays for it. "David after the dentist" ring any bells?

IV sedation cases can be very challenging, because of the fine line between inadequate sedation (too light, moving, laryngospasm) and too deep (apnea, airway obstruction, hypotension). Deep sedation absolutely requires a dedicated, trained professional who is not the proceduralist.

Greetings,

This tragic case involves a OMFS (DDS/MD) and the anesthesiologist (MD). I do not think he puts the patient down on his own as well as doing surgery at the same time. Let's not start blaming on the surgeon until we hear all the facts. DP

I was certainly not making any specific implications about this particular case. I was merely making general comments about anesthesia training and sedation in general.

Originally Posted by PMPMD

I was certainly not making any specific implications about this particular case. I was merely making general comments about anesthesia training and sedation in general.

I agree with you. Six month does not equal 4+ year in training like you have had and I don't think any OMFS would make such claim of being equal. DP

Originally Posted by Dr. Dai Phan

I agree with you. Six month does not equal 4+ year in training like you have had and I don't think any OMFS would make such claim of being equal. DP

I realized the individual making the claim was a "Pre-Podiatry" student and not a member of the dental profession.

Originally Posted by PMPMD

I realized the individual making the claim was a "Pre-Podiatry" student and not a member of the dental profession.

I wasn't saying anesthesiologists are worse at anesthesiology than oral surgeons, but merely that I have shadowed OMSs that said that while they were doing their residency, they knew more about anesthesiology than some of the residents who were in the department.

Some previous posters were suggesting that OMSs don't know how to administer sedatives, and I was merely relaying an anecdotal story to the contrary.

It seems like the way the media is spinning it, the parents are putting blame on the oral surgeon. However, as mentioned he was working with an MD anesthesiologist during the procedure. I'm not sure why this conversation is even going into the "dentists shouldn't be giving prop." The OMS (dual degree) was doing the procedure and not the one pushing the drugs.

One thing I'll point out is that the tired argument is that omfs only get 4ish month in anesthesia...but they spend 3 years (at least) doing tons of the type of sedations they will run in private practice under attendings' guidance

I don't think you could ever compare them to an anesthesiologist, but to say they operate under only 4 months of training is misleading

Oh, but they should all use a dental anesthesiologist

Originally Posted by Sublimazing

Oral Surgeons typically will draw up a deep sedation mix using a midaz, propofol, ketamine, fentanyl cocktail. Contrary to what the dental student said, many many oral surgeons put their patients under at least conscious sedation for 3rd molar extraction. They usually keep them pretty light from my experience (since they have local on-board), and will begin to push if the patient begins to stir

If they're doing something more complex than extraction/implant (osteotomy, plastics, etc) all the ones i've worked with will either bring in a separate gas passer for general or take the patient to the OR

Pediatric Dentists will typically do either oral sedation with benzos, or N20 at 50% or IV benzo with fentanyl(s)

There are some general dentists who have sedation permits who will also do IV benzos and fentanyl(s)

Oh, I never said most 3rd molar extractions were done with local only, I said most oral surgery. By that I meant extractions in general, as well as all the other things we could toss in with that lump term called oral surgery. Yeah, most full boney 3rd molar exts are done with some level of sedation beyond local but if you wanna include all the extractions done and more, most is just local anesth

Patients get refered to Oral surgeon to be sedated. The question is where their oxigen saturation monitor was and who was watching it.

Originally Posted by djeffreyt

Oh, I never said most 3rd molar extractions were done with local only, I said most oral surgery. By that I meant extractions in general, as well as all the other things we could toss in with that lump term called oral surgery. Yeah, most full boney 3rd molar exts are done with some level of sedation beyond local but if you wanna include all the extractions done and more, most is just local anesth

Yes and I referred to you as a "dental student' which when i just read it back sounded condescending...which was unintentional. I knew what you meant, but was clarifying for our MD friend. My apologies.

Originally Posted by oralcare123

Patients get refered to Oral surgeon to be sedated. The question is where their oxigen saturation monitor was and who was watching it.

100% agree. I think regardless of where one stands on the Oral Surgeon as an anesthesia provider/surgeon argument, we all would agree that anyone giving any form of cons sedation on up should have the pulse ox, temp monitor, ekg, TES, and ET CO2 monitoring going and be fully versed in their reading of those devices

The comparison of OMFS or even dental anesthesiologists to medical anesthesiology is silly. They are completely different. OMFS spends 5 months on anesthesia, typically working as a PGY-2 level anesthesia resident. The training is designed to give residents the skill set to manage the type of patients and procedures that will be encountered in private practice. Primarily healthy patients, many of them young. The training involves the management of ASA 3 and 4's as well as managing bigger cases than would ever be managed in private practice. As mentioned by a previous poster, OMFS then spend the remainder of their training continually providing anesthesia to their patients in the clinical setting. Safe and effective anesthesia is a core component of OMFS training and is something that most programs take great pride in providing excellent training in.

Medical anesthesia involves an intern year and then 3 years of anesthesia training that covers the gauntlet of anesthesia, including pain management, regional anesthesia, critical care, OB, cardiothoracic, neurosurg, transplant, vascular etc. Many of these cases are very, very different than anything the dental specialists will ever encounter either in or outside of a training environment. The comparison with dental providers is apples to oranges. Handling those more involved cases allows the anesthesiologist to be more prepared to manage complications as they arise, but things happen. As in this case, where an MD trained anesthetist lost a healthy young patient.

There is a hell of a lot more to anesthesia than putting a healthy, ASA 1 or 2 person to sleep for thirds, which is why their programs are longer and cover so much more. You simply don't need 3+ years pure of anesthesia training to do in office sedation on the typical OMFS patient. Smart OMFS learn both what they can and can't do and intelligently choose what cases to provide anesthesia for and what cases to have help with or what cases simply need to be done in a hospital OR...but even when you get help, things can go south. Tragic as it is when it occurs, there is risk to every surgical or anesthetic event, medical or dental.

I don't understand why so much deep sedation is done for extractions of 3rds... Isn't nitrous + local sufficient especially for ASA I and II's? Is deep sedation done because that's what the public wants or is there some other reason? Just curious...

Just what people want and insurance will pay for it. I had my thirds out with nitrous and local and it wasn't a big deal at all. Some people don't like the thought of the surgery happening to them while their awake.

*they're

Originally Posted by PMPMD

IV sedation cases can be very challenging, because of the fine line between inadequate sedation (too light, moving, laryngospasm) and too deep (apnea, airway obstruction, hypotension). Deep sedation absolutely requires a dedicated, trained professional who is not the proceduralist.

One look at the OMS literature and the safety record of OMS as dual proceduralist/anesthesia provider provides some strong evidence against this opinion. We are not gastroenterologists, our training is different and we have a very different patient pool. The largest review showed around a 1 in 850,000 mortality rate for outpatient OMS.

MD anesthesiologists are the ones who developed the 4-6 month training course for oral surgeons during residency. MD anesthesiologists are the ones who train us.

Originally Posted by PMPMD

My specific problem is not with OMFS administering ANY sedation while they are proceduralists, but specifically deep sedation with propofol without having a second individual trained in general anesthesia present. The study you cited doesn't really refute this particular concern, as propofol was only used in a small % of cases - 0, 0, 3, and 8 % in the 4 years sampled, respectively (Table 2).

This is not my personal opinion, it's also on the package insert:

Nowhere in your previous post did you state that you were specifically speaking regarding the use of propofol. The word "propofol" does not even appear in the thread until the post you just made.

As far as the warning, OMS are unintended crossfire in the battle between anesthesia and GI. As I said above, our training, our procedures, everything about what we are doing is different than the GI docs. We receive a training at the PGY-2 anesthesia level. We have emergency and surgical airway training. We are operating in the head and neck 100% of the time. It's comparing apples to oranges.

As far as evidence: Propofol appears to have the lowest risk for adverse events. There is no statistically significant difference in the number of adverse outcomes between the administration of propofol for ambulatory surgery by OMS as an anesthetist/surgeon and anesthesiologist/nurse anesthetist.

Originally Posted by armorshell

Nowhere in your previous post did you state that you were specifically speaking regarding the use of propofol. The word "propofol" does not even appear in the thread until the post you just made.

As far as the warning, OMS are unintended crossfire in the battle between anesthesia and GI. As I said above, our training, our procedures, everything about what we are doing is different than the GI docs. We receive a training at the PGY-2 anesthesia level. We have emergency and surgical airway training. We are operating in the head and neck 100% of the time. It's comparing apples to oranges.

As far as evidence: Propofol appears to have the lowest risk for adverse events. There is no statistically significant difference in the number of adverse outcomes between the administration of propofol for ambulatory surgery by OMS as an anesthetist/surgeon and anesthesiologist/nurse anesthetist.

Actually another post #9 referred to propofol - when I asked about specific drugs used. .

I still have concerns related to any proceduralist also administering their own deep sedation, particularly with propofol. I think the data you cite may mitigate those concerns - I don't have access to your last citation so I can't really see the methods used, etc. If oral surgeons feel they can select patients who are low risk for this type of sedation, that is their call. I have my own opinions on how to do anesthesia, and you have yours. We will have to agree to disagree.

Originally Posted by Regmata

The comparison of OMFS or even dental anesthesiologists to medical anesthesiology is silly. They are completely different. OMFS spends 5 months on anesthesia, typically working as a PGY-2 level anesthesia resident. The training is designed to give residents the skill set to manage the type of patients and procedures that will be encountered in private practice. Primarily healthy patients, many of them young. The training involves the management of ASA 3 and 4's as well as managing bigger cases than would ever be managed in private practice. As mentioned by a previous poster, OMFS then spend the remainder of their training continually providing anesthesia to their patients in the clinical setting. Safe and effective anesthesia is a core component of OMFS training and is something that most programs take great pride in providing excellent training in.

Medical anesthesia involves an intern year and then 3 years of anesthesia training that covers the gauntlet of anesthesia, including pain management, regional anesthesia, critical care, OB, cardiothoracic, neurosurg, transplant, vascular etc. Many of these cases are very, very different than anything the dental specialists will ever encounter either in or outside of a training environment. The comparison with dental providers is apples to oranges. Handling those more involved cases allows the anesthesiologist to be more prepared to manage complications as they arise, but things happen. As in this case, where an MD trained anesthetist lost a healthy young patient.

There is a hell of a lot more to anesthesia than putting a healthy, ASA 1 or 2 person to sleep for thirds, which is why their programs are longer and cover so much more. You simply don't need 3+ years pure of anesthesia training to do in office sedation on the typical OMFS patient. Smart OMFS learn both what they can and can't do and intelligently choose what cases to provide anesthesia for and what cases to have help with or what cases simply need to be done in a hospital OR...but even when you get help, things can go south. Tragic as it is when it occurs, there is risk to every surgical or anesthetic event, medical or dental.

I did a kidney transplant case today...pt almost lived but my program does almost all that stuff...no OB...but we're treated like the CA1s and CA2s...plus a med track GPR year with 8 months of IM/peds/anes/ED and 4 months OR/consult dental..I mean I wouldn't say training is apples and oranges...maybe apples and smaller...work infested...apples. But when I get out I'll stick to ASA 1 and 2 and mostly dental/OS procedures with some plastics stuff

And I brought up propofol...I work with a number of omfs now and in the past and all of them used propofol in pp. I'm not an OS resident though... Maybe I got a skewered geographic sampling.

Originally Posted by Sublimazing

And I brought up propofol...I work with a number of omfs now and in the past and all of them used propofol in pp. I'm not an OS resident though... Maybe I got a skewered geographic sampling.

Nope, everyone in PP uses propofol, as does anyone in academic settings who can get it.

Originally Posted by Regmata

The comparison of OMFS or even dental anesthesiologists to medical anesthesiology is silly. They are completely different. OMFS spends 5 months on anesthesia, typically working as a PGY-2 level anesthesia resident. The training is designed to give residents the skill set to manage the type of patients and procedures that will be encountered in private practice. Primarily healthy patients, many of them young. The training involves the management of ASA 3 and 4's as well as managing bigger cases than would ever be managed in private practice. As mentioned by a previous poster, OMFS then spend the remainder of their training continually providing anesthesia to their patients in the clinical setting. Safe and effective anesthesia is a core component of OMFS training and is something that most programs take great pride in providing excellent training in.

Medical anesthesia involves an intern year and then 3 years of anesthesia training that covers the gauntlet of anesthesia, including pain management, regional anesthesia, critical care, OB, cardiothoracic, neurosurg, transplant, vascular etc. Many of these cases are very, very different than anything the dental specialists will ever encounter either in or outside of a training environment. The comparison with dental providers is apples to oranges. Handling those more involved cases allows the anesthesiologist to be more prepared to manage complications as they arise, but things happen. As in this case, where an MD trained anesthetist lost a healthy young patient.

There is a hell of a lot more to anesthesia than putting a healthy, ASA 1 or 2 person to sleep for thirds, which is why their programs are longer and cover so much more. You simply don't need 3+ years pure of anesthesia training to do in office sedation on the typical OMFS patient. Smart OMFS learn both what they can and can't do and intelligently choose what cases to provide anesthesia for and what cases to have help with or what cases simply need to be done in a hospital OR...but even when you get help, things can go south. Tragic as it is when it occurs, there is risk to every surgical or anesthetic event, medical or dental.

Not only do we spend 5 months on dedicated anesthesia training, but spend the rest of our training putting people to sleep in the clinics almost on a daily basis, then go out and do it for 20-30 years.

I suppose I should have worded my statement differently, so as not to include training. As an OMFS resident I've done trauma's, a crane, emergent vascular, had the opportunity for transplant etc...and dental.anesthesia residents tend to get even more exposure. The level of complexity of cases managed in training is far greater than what we will see in PP.

Even the cases we do in our clinic have a tendency to be very complex as our program is a dumping ground for problem/complex patients that the local PP guys don't want to deal with.

Anesthesia training for OMFS is solid and spans the entire residency, save med school years and a few of the off service rotations. Not only do we train heavily in anesthesia, but we train as both the proceduralist and anesthesia provider. We learn the way we will practice, this is an important advantage to our training