Sedation is being used in more and more dental offices across the country as a safe and effective means of allowing millions of patients with dental phobia to undergo much needed dental work. There has also been an increase in its use with children, who often have a difficult time tolerating dental treatment also. In an effort to help children cooperate better or to ease their anxiety, liquid sedatives or laughing gas are often administered. Unfortunately, in rare cases, children can fall into a much deeper level of sedation than intended, and the consequences can be severe.
In recent years, a few reports of deaths of sedated children at dental offices have made headlines. Obviously, parents, lawmakers and dental professionals have taken notice and continue to work on eliminating this devastating outcome. According to a recent article in the New York Times, researchers at the University of Washington found 44 cases over three decades in which dental patients died after sedation or general anesthesia. Most were 2 to 5 years old.
In order for the use of sedation in dentistry to be safe, certain protocols must be followed and many factors must be carefully weighed. In 2016, the American Academy of Pediatric Dentistry joined forces with the American Academy of Pediatrics to write specific guidelines. Here are some things to think about when considering the use of sedation in dentistry:
Sedation can fall on a sliding scale from minimal to moderate to deep to general anesthesia. “It is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation,” the guidelines state. Parents and patients should be sure to ask the dentist what level is being aimed for and what emergency measures are available if sedation is taken too deep.
“The risk is small but there’s always a risk when you sedate a child, primarily of airway obstruction, where the child – for whatever reason – becomes oversedated,” said Dr. Joseph P. Cravero, a senior associate in perioperative anesthesia at Boston Children’s Hospital. Cravero also spoke on how a dental office differs from a hospital setting. “If you are working in a hospital, you press a button, an alarm goes off and everyone comes to help with that kid,” he added. But in an office, “you end up having to call 911 for help.”
Some children are especially vulnerable during sedation because of factors that include age and anatomy, like enlarged tonsils for example. A 2009 study suggested that children younger than 6 may have a greater risk of adverse events after analyzing data of 50,000 sedation/anesthesia procedures at 37 locations. The authors concluded that the safety of sedation depends on a practitioner’s ability to manage less serious events.
“Kids under 6 have a smaller airway that can easily be blocked,” Dr. Horst said. “The size difference is so enormous” between a 4-year-old and a 12-year-old. Very young children “don’t have as much of an oxygen reserve in their blood as older children or adults so their body can’t compensate for short lapses in oxygen,” he said.
Overweight and obese children require special consideration too, said Dr. Deborah Studen-Pavlovich, the director of the pediatric residency program at the University of Pittsburgh School of Dental Medicine. A sedative “doesn’t get metabolized as quickly as the drug is stored in fat cells so they have a longer recovery time,” she said.
It is understood why, but a 2009 study found that children with developmental disabilities have three times the risk of having a decrease in blood oxygen levels when sedated, which could lead to life-threatening complications.
Know the Alternatives
“Sedation is above and beyond routine dentistry,” said Dr. Paul Casamassimo, the chief policy officer for the American Academy of Pediatric Dentistry’s research center. While it may be necessary to complete a root canal on a 3-year-old with severely decayed molars, it isn’t always required to treat less advanced cavities. Dr. Jeremy Horst, a pediatric dentist at the University of California, San Francisco, said “It’s not appropriate for sedation to be a first-line treatment,” for all cavities. Less risky and less invasive options should always be discussed.
The quality of a dentist’s sedation training is definitely important. Administering moderate sedation, or “conscious” sedation, like laughing gas, requires a lot of vigilance in monitoring. For moderate sedation, dentists should have rescue drugs on and a monitor oxygen levels and heart rate. Additionally, the American Society of Anesthesiologists recommends “a qualified individual” other than the dentist monitor the patient, because it “reduces risk of adverse events,” said Dr. Jeffrey S. Plagenhoef, the society’s president.
Both deep sedation and general IV anesthesia should only be administered by qualified providers.
The bottom line is that parents and patients alike should be told the risks, benefits and alternatives to sedation dentistry. If your dentist doesn’t freely discuss this with you before treatment, it’s most definitely time for a second opinion.