Death due to Wisdom tooth extraction

[DrReo]

http://www.foxnews.com/story/0,2933,289171,00.html

Granted this article is from a few years ago. How often does it happen? Also, extracting 3rd must be a large liability, do any GPs you know perform this or is it always referred to the oral surgeon?

A study 10 years ago found that one in every 700,000 people die when given a general anesthetic in a dentist's chair. This makes death one of the last problems to fear when having wisdom teeth pulled.

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[Dentgirl09]

http://www.foxnews.com/story/0,2933,289171,00.html

Granted this article is from a few years ago. How often does it happen? Also, extracting 3rd must be a large liability, do any GPs you know perform this or is it always referred to the oral surgeon?

Scary to think about. This is why I'm going to pay attention in my classes. You can never know too much inforamation and when it may come in handY!

 

[DrReo]

http://forums.studentdoctor.net/showthread.php?t=167547

Another interesting case. (Didn't want to bring another old thread up. Evidently, this drives some crazy )

 

[aphistis]

1 in 700,000 is pretty good, especially when you consider that the overall death rate for general anesthesia is generally accepted to be 1 in 250,000. Lots of factors contribute to the difference (i.e. I'm not using this to claim that dentists are better at anesthesia than anesthesiologists), but it still says very good things for the safety record of anesthesia in the hands of properly trained dentists.

 

[tinman831]

Here's another article pertaining to the incident. It says that there may have been a "kink" in the o2 tube providing air to the patient. 😕 This happened over 1.5 years ago. Anyone find out what the outcome of the investigation was?

 

[War Eagle]

Also, extracting 3rd must be a large liability, do any GPs you know perform this or is it always referred to the oral surgeon?

I had my wisdom teeth pulled by a GP. But I wasn't put under general anasthesia, so that may not be relevant to your question. I remember counting something like 16 shots in my mouth. The worst was the one in my palate. Ouch!!!

 

[Rube]

No normal patient should be under general anesthesia for extractions. That seems to be the first thing that went wrong. Next, I'd like to see the amount of drugs administered.

 

[DrReo]

Here's another article pertaining to the incident. It says that there may have been a "kink" in the o2 tube providing air to the patient. 😕 This happened over 1.5 years ago. Anyone find out what the outcome of the investigation was?

Tinman, I saw that article. They also stated he has been practicing for 32 years.

 

[BioMaxDDS]

I had my wisdom teeth pulled by a GP. But I wasn't put under general anasthesia, so that may not be relevant to your question. I remember counting something like 16 shots in my mouth. The worst was the one in my palate. Ouch!!!

I remember my GP gave me 2 shots and just went to work

 

[aphistis]

No normal patient should be under general anesthesia for extractions. That seems to be the first thing that went wrong. Next, I'd like to see the amount of drugs administered.

By itself, dosages won't tell you everything. My personal record for sedation so far is 120mg propofol and 1500mcg alfentanil, just to settle the patient down enough to tolerate a retrobulbar nerve block. Without knowing more about the clinical context, the dosages used don't reveal as much as you think.

 

[robhmnt]

I shadowed a general dentist in a clinic owned by himself and a couple of other partners three years ago in California. The guy would NOT extract ANY teeth, even premolars, without putting the patient under GENERAL anesthesia to charge an extra $350 for the anesthesia. And he did it all by himself. It can get pretty nasty when people want to make more and more money in a very short amount of time. I would ask him why he puts all of them under general anesth, and he would say, "because it is more convenient".

 

[aphistis]

I shadowed a general dentist in a clinic owned by himself and a couple of other partners three years ago in California. The guy would NOT extract ANY teeth, even premolars, without putting the patient under GENERAL anesthesia to charge an extra $350 for the anesthesia. And he did it all by himself. It can get pretty nasty when people want to make more and more money in a very short amount of time. I would ask him why he puts all of them under general anesth, and he would say, "because it is more convenient".

You have to be careful with your definitions when you're talking about sedation and anesthesia. Giving a single dose of IV versed/fentanyl will provide excellent conditions for a brief oral surgery procedure, but typically doesn't bring you anywhere near "general anesthesia."

I'm not trying to nitpick this thread to death, but people should be very careful talking about subjects like this if they don't have the training to appreciate what they're actually saying.

 

[robhmnt]

You have to be careful with your definitions when you're talking about sedation and anesthesia. Giving a single dose of IV versed/fentanyl will provide excellent conditions for a brief oral surgery procedure, but typically doesn't bring you anywhere near "general anesthesia."

I'm not trying to nitpick this thread to death, but people should be very careful talking about subjects like this if they don't have the training to appreciate what they're actually saying.

'
Did I ever talk about sedation? I meant "general Anasthesia." In modern medical practice, general anaesthesia (AmE: anesthesia) is a state of total unconsciousness resulting from general anaesthetic drugs" - Wikipedia.
Does any dentist ever charge $350 for a sedation + about $300 for a tooth extraction? The dentist I am talking about would put every patient under a general anasthesia of 30-45 mins for any tooth extraction. That is they would be unconscious for the entire time.

 

[Rube]

Yes, I know of dentists who charge $350 for three .25 mg doses of Halcion and then charge $350 for a complete boney. Given what you have left out of your description and the unlikelyhood of a dentist administering GA, what you are talking about sounds like a sedation. A GA patient needs to have an airway established, because they can't maintain their own. Did you see the dentist intubating the patient for his premolar extractions? In the dental office? I doubt it.

 

[aphistis]

'
Did I ever talk about sedation? I meant "general Anasthesia." In modern medical practice, general anaesthesia (AmE: anesthesia) is a state of total unconsciousness resulting from general anaesthetic drugs" - Wikipedia.
Does any dentist ever charge $350 for a sedation + about $300 for a tooth extraction? The dentist I am talking about would put every patient under a general anasthesia of 30-45 mins for any tooth extraction. That is they would be unconscious for the entire time.

OK then, I'd like to hear more about these general anesthetics. What kind of monitoring was the dentist using? Was the dentist administering general anesthesia and performing the procedures? How did s/he induce GA? What was their airway management plan? How did they maintain general anesthesia during the case? Any prophylactic medications administered? What kind of postoperative supervision were these patients receiving? How about discharge criteria?

Trust me, dude, you don't want to keep going down this road.

 

[Aceofspades]

It is my understanding that the marked difference between sedation and general anesthesia is paralysis and total unconsciousness induced by GA. How can a GP monitor the anesthesia while performing the dental procedure at the same time? I think you would need at least 2 people, the anesthetist/anesthesiologist and the dentist, to safely perform those functions.

 

[robhmnt]

A GA patient needs to have an airway established, because they can't maintain their own.

Yes, an airway and ECG were established every single time. It was not a sedation!

OK then, I'd like to hear more about these general anesthetics. What kind of monitoring was the dentist using? Was the dentist administering general anesthesia and performing the procedures? How did s/he induce GA? What was their airway management plan? How did they maintain general anesthesia during the case? Any prophylactic medications administered? What kind of postoperative supervision were these patients receiving? How about discharge criteria?

Trust me, dude, you don't want to keep going down this road.

What road are you talking about?
I shadowed at this clinic for two months a year and a half before starting dental school, and didn't know about the details at the time, but could certainly see the set up ECG and airway for every tooth extraction. His assistant was always helping him out, but there was certainly no Anesthesiologist around. You think he would pay for an anesthesiologist to charge the patient for an extra $350 ? That would not be profitable at all. Btw, I could distinguish a premolar from molar at the time.

 

[DrReo]

Bill, what would be the advantage of an anesthesia residency when the dentist will be performing the procedures and cannot focus on anesthesia and typically need a CRNA...

 

[aphistis]

It is my understanding that the marked difference between sedation and general anesthesia is paralysis and total unconsciousness induced by GA. How can a GP monitor the anesthesia while performing the dental procedure at the same time? I think you would need at least 2 people, the anesthetist/anesthesiologist and the dentist, to safely perform those functions.

Definitions of sedation vs. general anesthesia: http://www.asahq.org/publicationsAndServices/standards/20.pdf

To answer your question, I would not offer general anesthesia to a patient on whom I will be performing dental procedures.

Bill, what would be the advantage of an anesthesia residency when the dentist will be performing the procedures and cannot focus on anesthesia and typically need a CRNA...

There are several advantages. For one, it provides superior training, and a great deal of experience, in various sedation techniques I will then be able to offer my own patients. Second, it gives me the ability to work with other dentists who, by bringing me to their office, can then offer expanded anesthesia/sedation services to their own patients, while still providing their patients' dental care themselves. Finally, it gives you the training and breadth of experience to handle an enormous diversity of clinical scenarios, both when things are going well and when they start going very badly.

 

[ToldYouSo]

Ok I had to get surgery done in my mouth, it broke midway and I still had a piece of tooth inside and so the oral surgeon put me under general anesthesia, but I don't remember getting a tube inside my mouth, would he have done this after I was unconscious?

 

[smileforme31]

http://www.foxnews.com/story/0,2933,289171,00.html

Granted this article is from a few years ago. How often does it happen? Also, extracting 3rd must be a large liability, do any GPs you know perform this or is it always referred to the oral surgeon?

A study 10 years ago found that one in every 700,000 people die when given a general anesthetic in a dentist’s chair. This makes death one of the last problems to fear when having wisdom teeth pulled.

maybe he had something to eat, drink.. etc before the procedure. i believe theres a strict restriction on water and food before ur procedure because something like this can happen. there was an episode on nip/tuck where the woman didn't tell the surgeon she had medications prior to the surgery and she died (but she did this on purpose..)😕 so maybe tat could have been the case?

 

[pietrodds]

Yes, an airway and ECG were established every single time. It was not a sedation!



What road are you talking about?
I shadowed at this clinic for two months a year and a half before starting dental school, and didn't know about the details at the time, but could certainly see the set up ECG and airway for every tooth extraction. His assistant was always helping him out, but there was certainly no Anesthesiologist around. You think he would pay for an anesthesiologist to charge the patient for an extra $350 ? That would not be profitable at all. Btw, I could distinguish a premolar from molar at the time.

Dude, just stop already... it's painful reading your post! There's no way he was intubating/doing GA and doing an ext in 30 minutes... by himself and charging 350 bucks. With that said, I'm sure there's guys out there working the sedation thing hard to make a quick buck especially amongst some of the gov't subsidized dental plans but don't confuse sedation with general anesthesia... you look like an ignorant fool and it invalidates any appropriate statements/arguments you might have.

 

[Guy Smiley]

Maybe what he saw was an OMFS doing an LMA. I know there are some programs out there that do a significant amount of LMA's and sedate with sevo. Otherwise, I agree. I can't conceive of anyone doing actual GA for an exo in their office by themselves.

 

[ItsGavinC]

It is my understanding that the marked difference between sedation and general anesthesia is paralysis and total unconsciousness induced by GA. How can a GP monitor the anesthesia while performing the dental procedure at the same time? I think you would need at least 2 people, the anesthetist/anesthesiologist and the dentist, to safely perform those functions.

We do IV sedation in our clinic several times a week for pedo patients, and we present it as GA to the parents. At the levels we are running, you cannot tell the difference between deep sedation and GA. For the intents and purposes of monitoring and patient safety there is no difference. The patients are not response to commands and cannot be aroused without discontinuing the meds (propofol pump). Occasionally they have laryngospasm, and they often desat. Kids desat crazy quick and often go from 99 to 85 in a matter of 5 seconds by monitor.

 

[ItsGavinC]

As an aside, the title of the thread is misleading. He didn't die due to wisdom tooth extraction. He died due to a respiratory complication as a result of anesthesia.

Deep sedation/GA (and I believe even moderate sedation) should be left to an anesthesiologist (dental or medical). A dentist has no business doing dental work AND running anesthesia on these cases. It's just asking for problems.

 

[aphistis]

We do IV sedation in our clinic several times a week for pedo patients, and we present it as GA to the parents. At the levels we are running, you cannot tell the difference between deep sedation and GA. For the intents and purposes of monitoring and patient safety there is no difference. The patients are not response to commands and cannot be aroused without discontinuing the meds (propofol pump). Occasionally they have laryngospasm, and they often desat. Kids desat crazy quick and often go from 99 to 85 in a matter of 5 seconds by monitor.

What do you do for laryngospasm? Positive pressure or do you have to reach for the succinylcholine? For what it's worth, if genuine laryngospasms are a common event during dental sedations, I don't think it's inappropriate to suggest revisiting the techniques being used. Like you said, in small kids with minimal FRC, a lost airway scenario can get very ugly very quickly.

 

[Rube]

Deep sedation/GA (and I believe even moderate sedation) should be left to an anesthesiologist (dental or medical). A dentist has no business doing dental work AND running anesthesia on these cases. It's just asking for problems.

I think there are some "safe" PO drug protocols for moderate sedation out there that are pretty hard to mess up on an ASA I or even some ASA II. I wouldn't even try with a kid though without much more training.

 

[Dent0Paste]

When everyone is saying "dentist" do they strictly mean a GP or can this be applied to an OMS as well? I work for an OMS and we do General Anesthesia (complete unconsciousness, airway control, o2 sat, ecg, etc.) and the OMS performs the anesthesia (valium, then propofol, and sometimes versed or ketamine) for 30 minute tooth extractions. Even 15 or 20 minute extractions occasionally depending on whether or not the patient wants it. We don't stick any tubes down throats just head tilt chin lift. Also, the patients are unresponsive to painful stimuli. It seems to me this is general anesthesia.

 

[aphistis]

When everyone is saying "dentist" do they strictly mean a GP or can this be applied to an OMS as well? I work for an OMS and we do General Anesthesia (complete unconsciousness, airway control, o2 sat, ecg, etc.) and the OMS performs the anesthesia (valium, then propofol, and sometimes versed or ketamine) for 30 minute tooth extractions. Even 15 or 20 minute extractions occasionally depending on whether or not the patient wants it. We don't stick any tubes down throats just head tilt chin lift. Also, the patients are unresponsive to painful stimuli. It seems to me this is general anesthesia.

That may very well be the case. Postdoctorate-level anesthesia training is, as far as I'm aware, required of residents at every OMFS program in the country. Very few general dentists, on the other hand, are adequately trained to be employing anything beyond light IV sedation. It's not a knock against them, it's simply the direction they've chosen to tailor their professional development. Each dentist has a unique constellation of strengths and limitations they bring to their patients, and advanced anesthesia training is just one more possible item on the list.

 

[drashleypaige]

Well when I got my wisdom teeth extracted back in May 2007, my GP wouldn't even go near them. I was referred to an oral surgeon and placed under general anesthesia. The only complication (if you want to call it that) was that my oral surgeon tried 3 times to start an IV on me and ended up causing major brusing on my forearms. Other than that, all I remember is counting backwards from 100 and then waking up with my mouth full of gauze and feeling super woozy.

 

[DrReo]

That may very well be the case. Postdoctorate-level anesthesia training is, as far as I'm aware, required of residents at every OMFS program in the country. Very few general dentists, on the other hand, are adequately trained to be employing anything beyond light IV sedation. It's not a knock against them, it's simply the direction they've chosen to tailor their professional development. Each dentist has a unique constellation of strengths and limitations they bring to their patients, and advanced anesthesia training is just one more possible item on the list.

Asphistis, I read somewhere that ~250 GPs have post grad training in anesthesia.

 

[ItsGavinC]

What do you do for laryngospasm? Positive pressure or do you have to reach for the succinylcholine? For what it's worth, if genuine laryngospasms are a common event during dental sedations, I don't think it's inappropriate to suggest revisiting the techniques being used. Like you said, in small kids with minimal FRC, a lost airway scenario can get very ugly very quickly.

Positive pressure usually gets them through it, but we've used succs to break it as well. Laryngospasms aren't common, sorry if I gave that impression. Respiratory issues are FAR more common. My mentioning of the spasm was simply to illustrate that there better be somebody in the room (who is dedicated to the anesthesia side of things!) to handle the anesthesia and complications. A dentist would be crazy to handle both sides of things.

 

[ItsGavinC]

I think there are some "safe" PO drug protocols for moderate sedation out there that are pretty hard to mess up on an ASA I or even some ASA II. I wouldn't even try with a kid though without much more training.

Absolutely. But, as a general rule, if you are administering moderate sedation you had better know how to handle a patient in deep sedation. Many pediatric dentists give oral demerol & hydroxyzine (or other combinations) on a routine basis.

 

[ItsGavinC]

When everyone is saying "dentist" do they strictly mean a GP or can this be applied to an OMS as well? I work for an OMS and we do General Anesthesia (complete unconsciousness, airway control, o2 sat, ecg, etc.) and the OMS performs the anesthesia (valium, then propofol, and sometimes versed or ketamine) for 30 minute tooth extractions. Even 15 or 20 minute extractions occasionally depending on whether or not the patient wants it. We don't stick any tubes down throats just head tilt chin lift. Also, the patients are unresponsive to painful stimuli. It seems to me this is general anesthesia.

Anyone using propofol and ketamine should know what they are doing. OMFS are trained in it--and you can see why. It's an excellent service to offer to the patient, especially for those brief procedures.

You are also correct that it is technically deep sedation/GA. You can't draw a line between the two so you can call it what you will. During these cases the OMFS will typically have another trained and capable individual in the room (a nurse?) to assist with monitoring, etc.

I'm referring specifically to general dentists that think they can run moderate/deep sedation on a patient with only them and their dental assistant. There is a reason that these people--be it a anesthesia fellowship, a dental anesthesia program, or a 4/6-year OMFS program--do extra training. Part of being a good anesthesia provider is experience. The time to have "crap your pants" moments is during your training.

 

[Rube]

Absolutely. But, as a general rule, if you are administering moderate sedation you had better know how to handle a patient in deep sedation. Many pediatric dentists give oral demerol & hydroxyzine (or other combinations) on a routine basis.

100% agree you must be prepared for where a case may go not for what you planned for. From what I have seen, a solid hx and physical exam is crucial for any well done sedation. The problem for us dental students is that you can get by taking an OK history in d school because most of the time it doesn't matter but when you are sedating it really does matter.

 

[toofshucker]

Positive pressure usually gets them through it, but we've used succs to break it as well. Laryngospasms aren't common, sorry if I gave that impression. Respiratory issues are FAR more common. My mentioning of the spasm was simply to illustrate that there better be somebody in the room (who is dedicated to the anesthesia side of things!) to handle the anesthesia and complications. A dentist would be crazy to handle both sides of things.

Amen to that. I have no beef with any dentist wanting to offer this service, but I cannot understand why they would want to take the risk of trying to play anesthesiologist and dentist at the same time. Hire an anesth and let him to his job and you do yours.