In recent years, there has been a large increase in the use of office-based sedation and anesthesia for surgical procedures, including pediatric dental care. Need for this care has been fueled by the increasing prevalence of dental caries in children and the cost savings associated with office-based care (frequently <20% of typical hospital charges). Generally, these costs are not covered by medical insurance, although they are frequently covered by Medicaid. Outcomes from office-based anesthetic practice, however, are vastly underreported in the medical literature, and quality review has relied upon self-reporting by the practitioner. Because of these factors, it is difficult to obtain reliable outcome data. It is also not possible to obtain these data from state medical boards, since adverse events that occur in the dental office must be reported to state dental boards rather than medical boards.
Recently, a group of researchers took a different approach to review the scope of catastrophic events, which are often reported by local news media. A search of the LexisNexis legal database was done for news media coverage of deaths from sedation or anesthesia in pediatric dental patients between 1980 and 2011. A separate search was done of a private foundation website set up specifically for this purpose. All cases were validated through other sources. Forty-four instances of death were identified (Table 1), and data were recorded regarding patient demographics, type of sedation administered (local, moderate sedation, general anesthesia), location (hospital, ambulatory surgery center, dental office), and person providing the sedation (dentist, oral surgeon, anesthesiologist). Anesthesiologists included both dental and medical anesthesiologists, and dentists included both pediatric and general dentists.
Several trends were noted. Most deaths involved either children aged 2 to 5 years (21 of 44; 47.7%)—an age where caries are prevalent and the ability to cooperate is limited—or teenagers (13 of 44; 29.6%). The majority of deaths occurred in an office-based setting (31 of 44; 70.5%). In most instances (25 of 44; 56.8%), the provider was doing both the dental care and the supervision of the sedation. General anesthesia was used in 10 cases; an anesthesiologist was the provider in 7 cases. Four deaths occurred with the use of local anesthesia. These may have been related to overdose or intravascular injection since seizures were mentioned in at least 1 of these instances.
Three of 44 patients had sedation risks that were not recognized preoperatively. One child aged 13 months (managed in a surgery center by an anesthesiologist) had an undiagnosed congenital heart defect uncovered at autopsy. A second child with Treacher Collins syndrome and a previous tracheotomy died during sedation in the office-based setting, as did a child with known pulmonary stenosis.
External, in-depth analysis of the circumstances surrounding the deaths was reported in 11 cases, and an adverse judgment rendered in 9 of these. Common deviations from the standard of care included inadequacies in monitoring, resuscitation efforts, and preoperative assessment as well as medication errors (including both local anesthetics and sedative agents).
