VOLUME 35, ISSUE 2

The practice of dental anesthesia is one of considerable history and with a fair record of safety. Doctors of dentistry are primarily responsible for moderate sedation, depending on different levels of certification. In Texas, this is regulated by the Texas State Board of Dental Examiners. While anesthesia practice remains a complex and often underestimated practice of medicine, there are prestigious schools offering dedicated training programs for dental anesthesia, underscoring the importance of safety and specialty dedicated care that pediatric and complex adult dental patients often require.

Occasional complications and disastrous outcomes from sedation in the dental office are most often reported in the mainstream news, which further emphasizes the necessary diligence and vigilance required for dental anesthesia and the shared airway. Unfortunately, unlike office or hospital-based anesthesiology with robust reporting and quality metrics, data for dental anesthesia safety and complications is less readily available. Additionally, most dental office sedation and anesthesia occurs for the care of children and parents are frequently uninformed of the potential dangers that exist with office based sedation and anesthesia, even in a healthy child.

Anesthesiologists frequently perform or supervise sedation with multiple specialties and the American Society of Anesthesiologists (ASA) practice guidelines for moderate sedation were developed in collaboration with the American Association of Oral and Maxillofacial Surgeons (AAOMFS), American Dental Association and American Society of Dentist Anesthesiologists. However, implementation of these guidelines may not be universal. The AAOMFS, while adhering to standards of office-based anesthesia, developed a program of certification for dental chair assistants (DAANCE), that would meet, in their opinion, the skills and knowledge of an anesthesia assistant in cases of general anesthesia or deep sedation supervised by the oral surgeon. Oral maxillofacial surgeons are trained and credentialed in general anesthesia for dental procedures based on dental board credentialing requirements. The ASA has expressed concerns regarding the safety of the single provider/operator model that many dentists employ. In this model, the dentist supervises an assistant who provides the anesthesia or sedation while the dentist is, at the same time, performing the dental procedure. This is in contrast to the model advocated for by the ASA where a separate person is supervising the sedation or anesthesia while another person performs the procedural portion of patient care. Despite conscientious supervision by oral surgeons, the single provider/operator model can be challenging because it requires one person to perform both tasks simultaneously. Problems with the ability to adequately supervise sedation while at the same time performing the procedural portion of dentistry have been described in the past with resultant delays in diagnosis of severe issues which have led to poor patient outcomes.

The Texas Society of Anesthesiologists (TSA) has similar safety concerns related to proposed legislation in the 2023 Texas legislative session (HB 1930) which would allow for certified registered nurse anesthetists (CRNA) to provide sedation/anesthesia in dental offices without physician supervision, thereby circumventing the current law that requires physician supervision of CRNAs in Texas. Having neither an anesthesiologist nor a dentist trained in deep sedation/general anesthesia immediately available puts patients at increased risk for bad outcomes.

A potential solution to necessary education and training is an initiative with an anesthesiology-led dental anesthesia program at McGovern Medical School and the University of Texas Health School of Dentistry. The dental school traditionally supported two general anesthesia programs (pediatric and periodontics) and recently added a 3rd. For the 2017-18 academic class of the General Practitioner Residency Program (a 1-2 year program offered to dental school graduates to further prepare and expand their skills for general community dentistry), an anesthesiologist proctored moderate sedation program was started. Five residents/year undergo structured, rigorous training including lectures, simulation and continuously supervised clinical care. While learning about safe administration of moderate sedation, they also have opportunities to assist in delivery of deep sedation and general anesthesia by a board-certified anesthesiologist in the care of complex patients. The advanced training provided in sedation and anesthesia allows these dentists to provide a higher level of care in an office setting and facilitates the care for patients who would otherwise have care delayed for financial or logistical reasons if hospital based care was required.

The program is now in its 6th year of service and dental residents consistently report a positive and significant impact of this supervised clinical experience that leads to an increased understanding of the complexity of anesthesiology and patient comorbidities as well as improved knowledge of applied physiology and pharmacology.

Given the safety concerns with the use of untrained dental assistants to administer and monitor sedation and anesthesia in dental offices, this general dental practitioner training may serve as a useful alternative model to improve patient safety and inspire prospective dentists to pursue additional training in dental anesthesiology.

Continued education and training in dental sedation emphasizes the importance of safe anesthesia care and innovative programs may help avoid front page news articles of tragic outcomes as a result of unsupervised sedation/anesthesia in dental offices.