By Roger G. Sanger, DDS, MS
In the wake of recent news coverage of the deaths and injuries of pediatric dental patients, Dr. Roger Sanger, DOCS Education's Pediatric Sedation Dentistry Course Director, offers some startling facts that have gone unreported or underreported.
Key among these: Pediatric sedation dentistry, done right, is perfectly safe. In fact, in this essay, Dr. Sanger argues that rather than shy away from treating children, more dentists should be trained on the proper way to address the epidemic of early childhood caries.
The NBC News program, Sunday Night with Megyn Kelly, recently broadcast a report about healthy children and teens who visited the dentist and died or suffered serious brain damage as a result of sedation gone bad. A string of similar stories has likewise surfaced with increasing frequency in other news outlets.
Each child's tale is heartbreaking; an unspeakably tragic and devastating loss first and foremost for the loved ones and friends of the children, but also for the attending dentists and their team members, who likewise are scarred for life by the horrific experience.
Just imagine having a healthy young patient die while under your care?
Every compassionate person who views these news reports, and especially oral health care professionals whose chosen purpose in life is to improve the health of their patients, has got to wonder: Why would any dentist with a soul ever use sedation on a child, if there is a real possibility that the child will be seriously injured or die?
In this article, I will attempt to address that question and in doing so, encourage more dentists, not fewer, to train to treat children and adolescents using sedation – provided it is the proper type and administered correctly.
Brace yourself for some startling truths; ones that NBC News and the other mainstream news organization have yet to report.
Pediatric sedation dentistry, done right, is perfectly safe. Honest to goodness.
I personally have treated more than 15,000 children and adolescents under all forms of in-office sedation protocols – relying on oral sedative drugs thousands of times – and never once had a problem. Not once. After the introduction of formulated orally-given midazolam syrup in the 1990s, I've never even needed to use its readily available sedation reversal agent, which if necessary, can be a life saver.
I don't have access to the medical records and dental board investigations for any of the cases reported sensationally in the media. Sorry to say that often times these records are "sealed" by the regulatory agencies and courts. So, I am unable to comment if the dental teams that administered sedation to the affected children were properly trained and followed all standard-of-care safety protocols. Only the regulatory agencies and courts can determine negligence.
However, as I practiced and as I have taught for decades, when it comes to treating kids, especially preschoolers, standard-of-care alone is simply not enough. Pediatric dentists, and general dentists who treat kids and adolescents, have to go above and beyond the standard of care to ensure the safety of the young people for whom they are responsible.
When dentists follow the carefully vetted pediatric oral sedation protocol that we teach at DOCS Education, each and every one of their patients should leave their office after treatment, healthier and with a better quality of life than when they arrived – free of the pain and suffering from a mouthful of dental caries. Realize that dental caries remain the single most untreated disease in the US if not the world. It has been documented that children die because of untreated dental infection that when left untreated, reached the brain.
Let me repeat that. Following safe, effective, and proven oral sedation protocols, when combined with proper training in airway crisis recognition and management, will result in each and every pediatric patient leaving your office healthier than when they arrived.
An Oral Sedation Proponent
Which is why today and for more than a decade, I have been a proponent of treating kids with safe, oral sedation, to reduce their anxiety, accomplish care most of the time in a single session, have the kids remember nothing about their dental visit, and leave parents, the dentists, and team members far less-stressed.
I will outline my recommended protocol, the DOCS Education approach to treating kids safely with oral sedation, below.
But first, I want to remind any current dentist who treats children, any current dentist who ever considered treating children, any dental school students who might treat kids in the future, and the hundreds of dedicated dental regulators nationwide, why we do what we do.
When I went into pediatric dentistry almost five decades ago, many of my dental school classmates laughed at me, literally. They assured me that pediatric cavities were an endangered species, certain to become extinct with the soon-to-be available "vaccine" to prevent them.
"You know, Sanger, you are a stupid idiot," they chided me. They forecast that my future would be a mundane one solely dedicated to seeing kids to clean their healthy teeth.
Many of my classmates turned out to be great dentists, but awful prognosticators.
Dental caries in kids in 2017 are at epidemic levels, and we're seeing an explosion of cases in preschool-age children, where such problems used to be comparatively rare.
According to the American Academy of Pediatric Dentistry (AAPD), tooth decay is far and away the most common chronic childhood disease in America.
Now consider from surveys by the AAPD that one in every five kids today is unmanageable as a dental patient. These are the children who just go "nuts" if a dentist or hygienist gets anywhere near them, especially young children. And, remember, more young children today are consumed with dental caries. Sugar enriched diets and poor oral hygiene can be cited in this epidemic.
The Riskiest Alternative
If we don't treat kids today with oral sedation, how will these kids be treated?
The riskiest alternative – the one that seems to be the root cause of the preponderance of the pediatric deaths that we read about – is the use of general anesthesia (deep sedation) in the dentist's office.
With the child completely asleep and with depressed reflexes, the dentist can perform extensive treatments without resistance and without causing the child much in the way of anxiety.
Most dentists who rely on deep sedation, even those who utilize a trained anesthesiologist whose sole job is to administer the anesthesia and monitor the child, don't intubate the patient in their practices.
The danger is that under general anesthesia, if the child's airway closes and the child is not intubated, the chances of that child dying or suffering serious brain injury rise significantly. Trying to intubate a child once his or her airway has collapsed is an "iffy" proposition at best.
The safest alternative, if using general anesthesia, is to treat the child in a hospital setting, intubating the child, and using a team approach that includes the dentist, a trained anesthesiologist, and numerous hospital staff personnel trained in crisis recognition and management.
Needless to say, asking parents to pay for a hospital team of experts to treat cavities is seldom popular, and even if the child is covered by government aid programs or health insurance, the availability of hospital care is sorely insufficient to match the demand that would be created if all young children needing dental care required hospital treatment.
There are, of course, those dentists who still treat children strictly with nitrous oxide, which remains the universal standard of care for older children and adults. Nitrous oxide is certainly far safer than deeper levels sedation, but it has some serious flaws. Among them are these: Kids are far more anxious and therefore far less patient when it comes to dental treatments. The amount of work that a dentist can complete in any one visit is limited and in some younger children even impossible with only nitrous oxide. Many older kids treated with nitrous oxide alone will sit through one dental visit, perhaps two. But often, after that, they'll outright refuse to see the dentist. Worse, the kids will grow up dreading dental visits, making them reluctant or no-show patients for life.
Some people, who don't understand that poor pediatric dental hygiene often leads to serious oral health issues in adults, might argue that since these baby teeth will eventually fall out anyway, there is no need to treat them in the first place.
Even if we ignore the implications that such an approach would have for the kids when they grow up, parents won't long be able to ignore the pain and health consequences that untreated kids experience. Yes, "baby teeth" do fall out! But, in many cases dental caries especially in younger kids can progress rapidly and cause pain and suffering long before the tooth "falls out."
Better to endure some pain now and in the future, some might argue, than kill the kids or leave them brain damaged. Which would be correct, if those were the only two choices: pain or risk of death and injury.
But they are not the only two.
The DOCS Education pediatric oral sedation protocol works and ought to be embraced as the new standard of care for pediatric dentistry.
DOCS Education asks dentists who see the benefits of treating children with oral sedation to attend a three-day, 25-hour course [http://docseducation.com/catalog/pediatric-sedation-dentistry], which is held throughout the year. In each course, we delve into the proven science of our protocol; explain in detail how to implement the protocol; and "drill" time and again on all the safety procedures and equipment necessary to keep children safe.
The DOCS Education Protocol
Herein, I can only provide a brief overview of our protocol.
It begins with proper education. Our instructors, of which I am only one, are hands-on dental and medical veterans who understand the science, pharmacology, psychology, emergency prevention, recognition and management, and the regulatory landscape of safe pediatric oral sedation.
When the course is over, patient and parent selection is the next step, and it's of paramount importance. Some kids, for a variety of medical or psychological reasons, should never be sedated for dental care outside of a hospital setting. Period.
More than any other lesson we teach, knowing whom not to treat as a patient will save lives and prevent injury. Far too often, the dentist knows the child should be treated by an interdisciplinary team at a hospital but "gives in" to parental pressure due to money concerns, hospital fears, etc. and attempts to treat the child with in-office sedation – a disaster waiting to happen.
Once the patient is properly screened for suitability, parental education is essential. Parents have to make a very hard choice, one which some of them can't accept. When parents are informed, and still unwilling to embrace the DOCS Education protocol, they should not be accepted to your practice, either. Remember, the "R" word. "Referral" is always an option. Many children's hospitals and large regional medical centers have pediatric dental and anesthesiology teams very capable of caring for children with physical, medical, and/or psychological challenges whose dental care can be safely performed at their facilities.
The choice is to administer a safe oral sedative to their child that will allow the dentist to work efficiently and will leave their child with no memory whatsoever of the procedure. But, and for some parents this is the deal breaker, their young child will very likely cry during the procedure. It is very welcome that young children cry during sedation – not from pain but from being in an unfamiliar setting. It is not only natural for them to cry but also an indication that their airway is open and breathing normal. But for some parents and some dentists/staff, crying is an indication that the sedation has not been enough and is a failure. Quite the contrary, crying indicates the proper level of "conscious" sedation was chosen and the child was not "oversedated' to a higher unsafe level where "unconsciousness" could occur. Moreover, to prevent their child from wiggling, which, because of the nature of oral/dental surgery could cause injury, the child will be immobilized much like they would be in a hospital surgical setting. And, as is the case in hospitals, parents won't be allowed in the room with their child once the treatment has begun – which is necessary so that the dentist can give his or her full attention to the child, without having to comfort the anxious parent.
Countdown to Disaster
The alternative, one which some dentists do at the insistence of squeamish parents, is to sedate their children so heavily that they won't cry – but as a consequence, there is a risk that the child's airway will constrict or close, resulting in loss of oxygen to all organs--but especially the heart and brain—causing organ damage or failure, resulting death.
Some dentists, too, can't stomach a crying child. Their emotions overcome their logic, so they unnecessarily sedate their pediatric patient to eliminate the crying – which invites the possibility of an airway crisis.
I love children. I became a pediatric dentist because of my affection for kids. But over the years, a crying child has become music to my ears. Because when a sedated child in my surgery operatory is crying, I know that his or her airway is open and operating correctly. It's when children can't cry – or for that matter breathe on their own – that the countdown to disaster has begun.
When I watched the Sunday Night with Megyn Kelly segment on pediatric dental deaths, it chilled me to my bones. The anguish of the families and the loss of precious life is incomprehensible.
It was a public service to alert parents, professionals, and lawmakers to the potential dangers of pediatric sedation gone wrong.
What needs to be said and remembered, however, is the enormous blessing of safe pediatric sedation done right: healthy kids who will grow into adulthood with far fewer oral health issues and no fear or anxiety when it comes to seeing a dentist.
But, remember we have a great sedative drug in midazolam. According to surveys by AAPD of its members, midazolam is the most popular sedative drug used in pediatric offices today. It is often combined with nitrous oxide and sometimes an antihistamine for a safe "NO MEMORY" minimal oral conscious sedation in-office protocol. Plus, this protocol is a "NO OPIOID" protocol. With the opioid epidemic now getting tremendous media attention, it should be of great relief to parents that the DOCS protocol advocates that no opioid be used in pediatric conscious sedation.
Finally, remember that safety always starts with prevention. In pediatric sedation, that means not only choosing the right child, the right parent, the right drug protocol, the right equipment, etc., we must be trained and prepared for the unexpected. A unique part of the DOCS training is an entire day in the three-day course devoted to crisis management. It is called Advanced Pediatric Airway Management (APAM) where seven reality-based scenarios that will be "played out" on human simulators where a crisis has occurred on a sedated pediatric patient involving airway problems. Add to this "interactive education" are "hands on" stations where intraoral airway tube intervention, surgical airway intervention, intranasal rescue drug access, and intraosseous rescue drug access are performed on animal cadaver material.
Perhaps one day, the elusive vaccine – the one that is supposed to prevent childhood cavities – will become a reality. We all hope.
Until then, however, pediatric sedation dentistry, as taught by DOCS Education, is as close as children get to having a reason to not fear visiting their dentist, ever again.
About the Author:
Roger Sanger, DDS, MS, is DOCS Education's Pediatric Sedation Dentistry Course Director. A lifelong educator, Dr. Sanger first served as a faculty member at USC Children's Hospital and then the University of Colorado Medical Center where he attained the rank of Full Professor and Chair of the Department of Pediatric Dentistry and Orthodontics. In private practice after that for more than 29 years, he founded a multi-doctor, multi-office children's dental group serving six counties on the central coast of California. The group was a leader in establishing two children's dental surgicenters that treat more than 8,000 cases of pediatric oral sedation a year.
Dr. Sanger has authored two clinical textbooks and numerous scientific articles, as well as a textbook on pediatric dental practice management. In addition to teaching for DOCS Education, he is also Course Director for the Game Changers in Pediatric Dentistry course for the Institute for Pediatric Dentistry. Dr. Sanger is currently Executive Director for MCNA Dental of Idaho, the administrator for the Idaho dental Medicaid program. He is a graduate of the University of Southern California (USC) School of Dentistry and completed a residency and fellowship in pediatric dentistry and received a Masters in Health Care from USC Medical Center and Hospitals. He is a Life member of ADA and AAPD.
Registration is now open for three upcoming pediatric sedation dentistry courses offered by DOCS Education and directed by Dr. Sanger with a team of other dental and medical faculty. Seating is limited.
The three-day sessions will be held August 18-20 in Memphis; November 10-12 in Seattle; and February 23-25, 2018, in San Francisco. For more information or to register, click here. You can also phone a DOCS Education course specialist at 855-227-6505.