Joint Statement from the American Society of Anesthesiologists, the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation Regarding the Use of Deep Sedation/General Anesthesia for Pediatric Dental Procedures Using the Single-Provider/Operator Model
The late 20th and early 21st centuries have seen a continuous reduction in mortality and morbidity from intraoperative and periprocedural accidents involving sedation and general anesthesia for children. In the last 31 years, the American Society of Anesthesiologists (ASA) and the American Academy of Pediatrics (AAP) have separately created guidelines for the management of children and adults based on a rigorous examination of the scientific literature.1-4 There are minor differences in the statements from these two groups, but the provision of a second well-trained professional capable of monitoring the patient, managing the airway, establishing venous access for the administration of rescue medications, and resuscitation is an essential feature common to both. This approach is termed the multi-provider team-based safe practice model, as the surgeon or proceduralist and the professional responsible for the monitoring and sedation of the patient are two distinct individuals with separate patient-specific tasks.5
The oral surgery community has practiced a different approach to providing sedation/anesthesia for children. The single-provider/operator practice model, whereby the operating dentist is simultaneously performing the procedure and directing the anesthesia or deep sedation, that they have embraced, uses a dental assistant as the monitoring entity.6 This person has virtually no hands-on or formal medical training, cannot administer drugs, cannot establish venous access and cannot reliably provide definitive airway assistance. These activities, critical to the safe administration of sedation, are outside the scope of practice of a dental assistant.
The goal of procedural sedation is to provide anxiolysis, analgesia and amnesia. Safety requires proper pre-sedation evaluation, fasting, informed consent and a systematic approach that includes physiologic monitoring, age and size-appropriate equipment, knowledge of the pharmacology of all medications administered for sedation, antagonism and resuscitation, appropriate recovery observation, and strict discharge criteria. Sedation is a continuum, and each patient is unique. The response to a particular dose of medication or combination of medications may result in minimal sedation in one child but deep sedation/general anesthesia in another. A life-threatening emergency may occur at any time, regardless of health status. One must always be prepared for unexpected adverse events. For children, this most commonly means compromised breathing (apnea, airway obstruction, laryngospasm). The concept of swift recognition of crisis and rescue is essential, i.e., if one intends to provide moderate sedation, the provider must have the skills to rescue from deep sedation, and if the intent is to provide deep sedation, then one must have the skills to rescue from a state of general anesthesia. The needed flexibility in the management of the child is why, over the past 31 years, sedation guidelines have evolved to include specific skill sets for practitioners administering sedation. At a minimum, the sedation provider must be "able to provide advanced pediatric life support (PALS) and capable of rescuing a child with apnea, laryngospasm, and airway obstruction. Required skills include the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, laryngeal mask airway) and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation."1 A second observer, who is also skilled, and PALS certified, must also be present to assist with the anesthetic emergency while additional support is summoned; this is particularly critical in a dental office-based setting as the only backup is to call 911.7
The AAP recently updated their Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures.1 The original 1985 guideline was developed following concerns regarding children in California who died undergoing dental or oral surgery procedures.8 The guideline has now matured to include the latest in anesthesia monitors including capnography. Input from pediatric physician anesthesiologists, pediatric emergency medicine specialists, pediatric intensivists, the American Academy of Pediatric Dentistry (AAPD), dentist anesthesiologists and others, provided sound recommendations regarding the skills needed to provide a multi-provider team-based safe practice model for deep sedation and general anesthesia for children undergoing dental procedures. Most importantly, the guideline now specifies that a separate skilled anesthesia trained provider must administer sedation/anesthesia and be the independent observer; the operating oral surgeon or dentist must be PALS certified to provide skilled help should an emergency arise.
Unfortunately, the AAP guideline update was prompted by continued tragic outcomes in children undergoing dental or oral surgery procedures, ironically some in California.5,9-13 These deaths or injuries were directly related to a different treatment paradigm from that recommended by the AAP, the American Society of Dentist Anesthesiologists (ASDA), the AAPD, and ASA.9-12,14 The single-provider/operator practice model advocated by the American Association of Oral and Maxillofacial Surgeons (AAOMS) allows the oral surgeon to direct sedation/anesthesia while simultaneously performing the procedure. With the single-provider/operator practice model, crucial monitoring of the child's vital signs may be left primarily to a dental assistant who is not medically trained and is incapable of assisting with a life-threatening medical emergency (e.g., laryngospasm, apnea, seizure, anaphylactic reaction). All other sedation guidelines specifically require a skilled observer who is PALS certified, whose only responsibility is to observe the patient and is capable of assisting with emergencies. The oral surgery community has developed a nationwide program called DAANCE (Dental Anesthesia Assistant National Certification Examination) specifically designed to circumvent the recommendations of the AAP patient care multi-provider team-based safe practice model. This program of self-directed study has no accredited educational requirements and consists of 36 hours of online education and an online examination. The prerequisite of this AAOMS certification program only consists of a current cardiopulmonary resuscitation (CPR) or basic life support (BLS) card.6
With this minimal online review, the AAOMS claims that Dental Anesthesia Assistants (DAA) are said to "possess the expertise to provide supportive anesthesia care safely and effectively.6 The DAA is knowledgeable in the perioperative and emergent care management of patients undergoing office-based outpatient anesthesia." We are at a complete loss as to how such an individual with no real-life medical experience and no significant hands-on training could provide skilled help with a life-threatening event since DAANCE does not even qualify participants to draw up or independently administer medications. Even if trained to do so, drawing up and administering anesthetic or resuscitative medications runs counter to most state dental regulations where dental assistants cannot even administer intra-oral local anesthesia.6 With the single-provider/operator practice model, the only medically skilled individual may be a single oral surgeon. Imagine the child who develops laryngospasm during a procedure. The oral surgeon or dentist must simultaneously attempt to clear the airway, perform bag/mask ventilation, start an I.V., and draw up and administer lifesaving medications since the DAA is incapable of providing skilled help to rescue the child. The oral surgeon must stop providing oxygenation with bag-mask ventilation with the hope of rapidly establishing venous access and administration of rescue medications before a hypoxic injury.11,12,15-17
The model that the AAOMS continues to embrace does not ensure an appropriately qualified, dedicated monitor who is prepared to meaningfully help in the event of a patient emergency. ASA, the Society for Pediatric Anesthesia (SPA), the ASDA, and the Society for Pediatric Sedation (SPS) in the interest of safe oral surgery/dental care for all children, endorse the highest standards for procedural monitoring, administration of sedating drugs, and resuscitation by trained professionals independent of the operating surgeon/dentist, as clearly stated in the revised AAP guidelines. The use of a second oral surgeon to manage sedation, monitoring and rescue would be entirely consistent with this standard.18,19 The standards that continue to be espoused by the AAOMS are wholly inconsistent with the standards of practice for any clinician under any circumstance involving elective pediatric care, including those of the World Health Organization.19 We call on oral surgeons and other dental practitioners who provide deep sedation or general anesthesia using the single-provider/operator model to abandon this practice for the care of pediatric patients sedated in dental offices.
Raeford Brown, M.D., FAAP
Professor of Anesthesiology and Pediatrics
The University of Kentucky
Charles J. Coté, M.D., FAAP
Professor of Anesthesia (Emeritus)
Harvard Medical School
Linda J. Mason, M.D., FASA
Kirk Lalwani, M.D.
Cynthia Fukami, D.M.D., M.S.
Susanne Kost, M.D., FAAP, FACEP
- Coté CJ, Wilson S; for American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019;143(6).
- Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. 2018;128(3):437-479.
- Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: a Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 1996;84(2):459-471.
- American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002;96(4):1004-1017.
- Agarwal R, Kaplan A, Brown R, Coté CJ. Concerns regarding the single operator model of sedation in young children. Pediatrics. 2018;141(4).
- AAOMS. Dental Anesthesia Assistant National Certification Examination (DAANCE). https://www.aaoms.org/continuing-education/certification-program-daance.
- Coté CJ, Wilson S; for American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016;138(1).
- Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Committee on Drugs. Section on anesthesiology. Pediatrics. 1985;76(2):317-321.
- Otto M. Aftermath of child's death continues to highlight risks of pediatric dental anesthesia. Association of Health Care Journalists website. https://healthjournalism.org/blog/2019/01/aftermath-of-childs-death-continues-to-highlight-risks-of-pediatric-dental-anesthesia/2019.
- Caleb's Law. http://www.calebslaw.org/caleb-s-story-and-law/.
- Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013;23(8):741-746.
- Lee H, Milgrom P, Huebner CE, et al. Ethics rounds: death after pediatric dental anesthesia: an avoidable tragedy? Pediatrics. 2017;140(6).
- Wu G. 4-year-old boy dies after dental procedure in Oakland - state board investigating. San Francisco Chronicle. May 16, 2019.
- Walsh P. Teen's death after oral surgery prompts suspension of Edina dentist's license. February 23, 2016. Star Tribune. http://www.startribune.com/teen-s-death-after-oral-surgery-prompts-suspension-of-edina-dentist-s-license/369660871/. Last accessed July 12, 2019.
- Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. 2000;105(4 Pt 1):805-814.
- Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000;106(4):633-644.
- Chicka MC, Dembo JB, Mathu-Muju KR, Nash DA, Bush HM. Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent. 2012;34(3):231-238.
- American Academy of Pediatric Dentistry Council on Clinical Affairs. Use of anesthesia providers in the administraiton of office-based deep sedation/general anesthesia to the pediatric dental patient. https://www.aapd.org/media/Policies_Guidelines/BP_AnesthesiaPersonnel.pdf. Last revision 2018. Last accessed July 12, 2019.
- Gelb AW, Morriss WW, Johnson W, Merry AF; for International Standards for a Safe Practice of Anesthesia Workgroup. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Can J Anaesth. 2018;65(6):698-708.