February is National Children’s Dental Health Month, and Dentistry Today is celebrating the event with a series of blogs focused on various aspects of pediatric care. #NCDHM
Many professional organizations are going to great lengths in establishing protections for pediatric dental sedation via guidelines, position papers, and relevant academic journal reports. The strength in their combined professional recommendations serves to advance clinical practice and enhance standards of care. Safety for children’s dental sedation would seem to be of paramount concern.
Unfortunately, the reality too often speaks to a wanton disregard for standards and guidelines. Additionally, state regulatory boards too frequently seem asleep at the wheel. Some may talk a good line about the importance of safety with children’s dental sedation, especially that of our disadvantaged Medicaid demographic. However, too much is empty lip service.
This article will examine specific cases from a variety of states. In total, it only views a relative handful of situations with negative outcomes. But one is urged to remember that each case seriously impacts the life of a child and the lives of that child’s family, friends, and community.
On March 10, 2017, a 4-year old boy died at the Must Love Kids Pediatric Dentistry clinic in Vancouver, Washington, as result of multiple drug intoxication from anesthesia according to the Clark County Medical Examiner’s Office. Dr. Chester C. Hu, the treating anesthesiologist, was retained by the clinic and delivered services as an independent contractor medical company on-site. While in the clinic’s recovery room, the child stopped breathing. He was then transported to the hospital, where he was pronounced dead.
The pediatric dentist owners of the clinic were charged with “unprofessional conduct” by the Dental Quality Assurance Commission (state dental board), alleging there was no written contract with the anesthesiology group. The owners refuted those allegations and responded with a formal letter, placing the onus of responsibility for the patient’s negative outcome within their facility upon the independent contractor.
“The independent contractor anesthesiologist agrees they were responsible for all aspects of the anesthesiology services, including the monitoring and recovery of our patient,” the owners wrote.
“Respondent’s care of Patient A failed to meet the standard of care by failing to make use of proper monitoring equipment, such as a pulse oximeter to measure oxygen saturation and by failing to have an appropriately credentialed and trained individual assigned to monitor Patient A continuously until he showed signs of emerging from sedation. Respondent’s failure to meet standard of care put Patient A at grievous risk of harm and contributed to Patient A’s death,” the Washington State Medical Quality Assurance Commission (medical board) wrote in its findings.
The agreed upon state’s order included a $5,000 fine to Hu and mandatory compliance with the guidelines of the American Academy of Pediatric Dentistry and American Academy of Pediatrics. These are guidelines any prudent anesthesiologist should follow without need of a state order. The fine seems to almost trivialize the child’s death.
Certainly, culpability must belong to the anesthesiologist. But the facility should also be licensed and inspected, with proper personnel and protocols for patient monitoring and for assisting with essential patient airway stabilization and reversal drugs. That usually becomes the responsibility of dental clinic owners. After all, they own (or rent) the facility.
It’s reasonable to question what Washington is requiring for credentialing and especially for facility inspection involved with children’s dental sedation. Hu’s medical license wasn’t revoked, and his most severe sanction only seemed to be a modest monetary fine. No alleged violations were charged for shortcomings with the sedation facility.
Arizona has seen some significant problems, with two recent children’s deaths that occurred subsequent to dental care at the same Kool Smiles Dental clinic in Yuma, as well as a dentist anesthesiologist who had been operating under dubious credentials.
One of the deaths was a 2-year-old boy subsequent to in-office dental sedation services provided by a contracted licensed anesthesiologist at the Yuma clinic in December of 2017. Police witness reports state that the monitoring nurse turned off or muted the alarm signal on the boy’s pulse oximeter at least twice. The nurse allegedly told police that the pulse oximeter was not functioning properly and that its volume required muting. The child died four days later after sustaining severe brain damage.
In February of 2016, a 4-year-old girl visited Kool Smiles’ Yuma clinic to be treated for an abscess. The clinician extracted the tooth, and the girl subsequently showed signs of a fever. When the family returned the next day, they allegedly were told that the girl would be fine and that they should go home, though Kool Smiles said the practice advised the family to take her to their physician for further evaluation. There was no further contact between Kool Smiles and the family, and the girl died of an infection a few days later.
In 2018, investigative reporter Dave Biscobing discovered that Dr. Pankaj Goyal, a licensed dentist anesthesiologist under the Arizona State Board of Dental Examiners (ASBDE), had a faked two-year anesthesiology degree. Related documents and letters required for licensure had forged signatures. There also were shifting and conflicting claims about where Goyal received his training.
The investigation further revealed that written warnings about Goyal’s bogus credentials had been submitted to the ASBDE for numbers of prior years. Board officials including ASBDE executive director Elaine Hugunin declined to provide information about the results of those previous warnings or answer questions about how Goyal was vetted. Concerned for the public’s safety, Biscobing openly voiced serious questions during the ASBDE’s meeting on June 1, 2018. His questions to the state dental board remain unanswered.
Biscobing’s public records request demonstrated that the ASBDE was more concerned with keeping data about Goyal a secret than in serving the public interest. Eventually, Arizona governor Doug Ducey got involved and asked the dental board to suspend Goyal’s license. But on August 3, 2018, the ASBDE unanimously voted on for Goyal to keep his dental license despite a recent arrest for multiple felony violations, inclusive of forgery and fraudulent schemes.
Seemingly under pressure, Hugunin abruptly retired as the dental board’s executive director, and the governor placed the dental board’s services under control of the Arizona Department of Health Services. On November 1, 2018, Goyal and the board agreed to suspend his full dental license and delay the board’s investigation, pending his trial.
The state’s governor had to be embarrassed before the inept and/or corrupt state dental board took necessary action after many years of inaction. The public welfare took a backseat to clandestine government regulator dysfunction.
In December of 2013, Dr. Lily Geyer of Kailua, Hawaii, was performing a baby root canal on a 3-year-old girl when the child stopped breathing and went into cardiac arrest. The girl died a month later. The Honolulu chief medical examiner said the girl “likely died as a result of the sedatives and local anesthesia given at the time of the dental procedure.” Geyer was charged with two counts of manslaughter and with second degree assault.
Geyer’s attorneys made a strong case that the girl’s death was related to her mother’s failure to disclose an upper respiratory infection on the health history. Geyer testified that if she had known of the girl’s condition, she would not have treated her with sedation. State experts, however, testified that they saw no evidence of such infection. Geyer was acquitted of all charges in November of 2018.
Sedation services were delivered in-office and monitored by the general dentist, who also simultaneously delivered dental treatment. Monitoring and sedation delivery were also provided by an uncertified dental assistant. Advanced life support means were not immediately available at the dental facility.
There was so much wrong with this scenario. How can a general dentist in a busy children’s Medicaid practice both provide dental services and properly monitor sedated patients? Where is the appropriate training and certification for staff? Where is the appropriate certification for the facility for proper training, specialized equipment, and reversal protocols for patients under sedation and for those in recovery areas? Calling 911 is often too little and too late.
Texas is definitely worth noting, just from its sheer number of dental sedation mortality cases. Brooks Egerton presented a seven-part series for the Dallas Morning News that highlighted the disturbing situation in Texas as well as nationally. Much centers around disadvantaged dental Medicaid patients. We see state dental boards that seem callous, inept, and corrupt failing to regulate and weed out bad actors. In fact, many dental boards actively cover up for habitual violators.
We witness a repeated pattern of failure to follow established standard-of-care sedation guidelines by dentists, with little to no adverse consequences for offenders. Habitual doctor violators may pass from state to state, with minimal to no background checks. Many dentists’ delivery of sedation services remains unimpeded, despite a lack of training, credentialing, or licensure. A history of adverse outcomes is seemingly no impediment for these disturbing doctors.
Last year, a Harris County Texas grand jury indicted Bethaniel Jefferson, DDS, for alleged criminal violations in the sedation care of a 4-year old girl who sustained severe brain damage. Records indicate that the child was sedated with five medications over seven hours. The practice focused on a high volume of child Medicaid patients
All services were provided in-office. The same general dentist delivered dental treatment as well as sedation care. Records also establish a pulse maximum of 195 beats per minute and a blood pressure high of 168/77. Blood oxygen saturation fell to a low of 49%. Jefferson had two prior consent agreements for alleged violations before the Texas State Board of Dental Examiners. One specifically involved alleged sedation record keeping violations.
Safety in children’s dental sedation is at a crossroad in Mississippi. The Mississippi State Board of Dental Examiners (MSBDE) must enact safeguards as recommended at its meeting on December 7, 2018, or a child will die, according to board certified physician anesthesiologist Heddy Dale Matthias, MD.
Matthias made it very clear that it isn’t a question of if a child would die if safety measures aren’t taken, but when. The Mississippi Association of Pediatric Dentistry, the Mississippi Chapter of the American Academy of Pediatrics, and the Mississippi Association of Nurse Anesthetists all supported her views on sedation safety protocols during the MSBDE meeting.
During the meeting, Matthias presented a 19-point summary on the minimal preparations that any sedation facility must establish and maintain, including dangerous shortcomings and undefined measures by the MSBDE:
- An operating dentist with a general anesthesia permit, which requires, according to the board, an undefined amount of training in general anesthesia.
- A licensed anesthesia provider who can demonstrate education, training, and certification in anesthesia. (The board has no specific qualifications for this.)
- Stringent policies and procedures regarding the conduct of surgery and general anesthesia. (The board has no policies and procedures about this practice.)
- Periodic inspections of the facility. (I submit the board is not qualified to perform these inspections.)
- Periodic inspections of all equipment and the safe use and storage of medications.
- A written “transfer agreement” to a hospital as a safeguard against the rare yet inevitable and unpredictable complications of anesthesia.
- A fully equipped recovery room with qualified personnel. (Many dental offices providing sedation do so without recovery rooms or qualified nurses.)
- National certification by an office-based surgery certification program. The American Association for Accreditation of Ambulatory Surgery Facilities and the the Accreditation Association for Ambulatory Health Care provide bi-yearly Joint Commission and Medicare inspections using national safety standards.
- A qualified registered nurse to assist the anesthesiologist in the operatory, especially in case of an emergency. To date, we have reports of receptionists and/or dental assistants performing this job.
- Stationary equipment that belongs to the operatory and is not brought in, uninspected, for surgeries.
- Advanced Cardiovascular Life Support and Pediatric Advanced Life Support certification for all dentists, anesthesiologists, and nurses.
- Emergency protocols. (The board has no rules on this.)
- Preoperative evaluation, in person or by phone, by the anesthesiologist prior to the day of surgery. Any child with an ASA category (this is a category promulgated by the American Society of Anesthesia that grades the severity of systemic disease) greater than II should not be treated in an office. (The board has no regulations on this.)
- Appropriate mandatory and age-appropriate equipment includes airway management tools, a blood pressure monitor, capnography, oxygen saturation, suction, a defibrillator, an electrocardiogram, intravenous equipment, an anesthesia machine with vaporizers, and an Ambu bag. (The Board has no specific regulations on this.)
- Necessary medications include sedatives, anesthetics, epinephrine, atropine, succinylcholine, lidocaine, bicarbonate, and dantrolene (for treatment of malignant hyperthermia) if anesthetic gases or succinylcholine are used. These medications should be inspected, stored, and dated according to national standards, and they should remain in the office, not transported into the office. (The board has no specific regulations on this.)
- Dental assistants, dental hygienists, and office staff are to perform within their qualifications and are not to be used as nurses, recovery personnel, or general anesthesia assistants. (The board, at the December meeting, seemed to believe that these personnel could perform some medical tasks.)
- The exact equipment, qualified personnel, procedures, and policies that are available in an ambulatory surgical center or hospital must be identical in an office operatory.
- The dental regulations might be read to prevent MD anesthesiologists and Certified Registered Nurse Anesthetists from performing anesthesia in dental offices, as the board has opined, “We have no jurisdiction over these other practitioners.”
- Informed consent, including the offering of referral to a dentist who can perform this procedure in an ASC (ambulatory surgical center) or hospital. (Note: bold lettering was by Matthias.)
Matthias also has specific concerns about interstate corporate dental chains, which operate in Mississippi with itinerate dental anesthesiologists on contract retainer. They primarily focus on the disadvantaged children’s dental Medicaid population.
She and other authorities find serious deficiencies with setup and inspection of the dental clinics as sedation facilities. Troubling aspects extend to appropriate certification and training of support staff, as well as emergency and recovery protocols.
To read Matthias’ full letter to the Mississippi Governor Phil Bryant, download the attachment featured at the top of the article.
Unfortunately, this is only a two-part report. One could easily write a book on this disturbing topic, considering the countless other cases of abuse, neglect, and incompetence across the country. We’re facing a serious national crisis when it comes to the dental sedation of our children. It’s not a minor regional issue. It’s not some insignificant few. Problems are quite extensive and must be addressed.
First, we must recognize and applaud the safety framework for children’s dental sedation treatment provided by a wide variety of concerned professional healthcare organizations. These groups often collaborate with entities outside their specific fields for the greater good of public safety. Organizational leadership in healthcare, as well as academics in medicine and dentistry, all have joined together to serve these noble ends. We definitely have established many reasonable safety standards.
Just like how the non-use of automobile safety belts and restraints can negatively impact public highway safety, so do unenforced guidelines and standards for children’s dental sedation. If statutes are unenforced, laws become meaningless. Our children can and do die.
The lives of children should mean more than an abstract numerical accounting, which isn’t even recorded for dental sedation morbidity and mortality. But proactive change costs money. Just as the public and automobile industry allocated funding for seat belts and restraining devices, so too must this happen for children’s dental sedation services.
State regulatory boards must license, verify, inspect, and provide background checks on providers, protocols, and their facilities. If states’ dental boards can’t or won’t provide this essential public service, other agencies must be found that will. Sanctions for violators must be firm, fair, and swift, and they must be made very public. We’re discussing a potential life-threatening serious imminent threat to the public welfare. This goes far beyond the risks of placing fillings with defective margins.
Regulators must be held accountable too. Enabling violators with serial wrist-slap regulation only serves to embolden abuse. State dental boards no longer must be permitted to act as clandestine isolated protected fiefdoms that seem only accountable onto themselves. Regulators involved in serial coverups of violators must be exposed and removed from public service, as recently observed in Arizona by the governor’s positive actions.
The larger question remains. How far will our society go to protect the health and safety of our children?
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at firstname.lastname@example.org or smilesofsantafe.com.