A dangerous truth is hidden behind the winning smiles and cartoon-adorned walls at pediatric dental offices: Children are dying or suffering from debilitating neurologic injury during routine care, and few are paying attention. This glaring oversight in ambulatory pediatric dental care is concerning not only for the potential harm to vulnerable, unknowing families but also to the medical community at large. Now more than ever, pediatric dental care is being provided at private offices rather than in a hospital setting due to ease of scheduling, shorter wait times, and lower cost.
For children with severe anxiety, special needs, or medical conditions that make cooperation difficult, anesthesia can be the only way to safely perform essential dental care. Yet with convenience comes risk, as catastrophic consequences stem from inadequate staffing and monitoring, oversedation, and inability to manage adverse events in an office-based setting. In 2017, the American Academy of Pediatrics listed “preventing deaths in dental offices” as one of its top national priorities. Yet, nearly a decade later, there is still no national database tracking adverse events tied to pediatric dental anesthesia. Without data, how can we truly understand the scope of the problem—or fix it?
Perhaps the most infamous case of pediatric mortality associated with office-based dental anesthesia gone awry is that of Caleb Sears in 2015, a 6-year-old who died when his vocal cords suddenly closed during sedation, making it impossible for him to breathe on his own. His dentist was simultaneously administering anesthesia while directing his dental care. California state legislative bodies enacted policy change, mandating the state dental board to report anesthesia-related deaths or injuries, and ensuring that an independent anesthesia provider was present during deep sedation or general anesthesia. Regrettably, states vary considerably regarding reporting standards for adverse events, minimum credentials for training, continuing education to maintain skills, and life support credentials, creating a non-uniform system of benchmarks that leaves children vulnerable. A decade later, 2-year-old Er’Mias Mitchell died under similar circumstances in July 2025 while receiving anesthesia during removal of a cavity.
The exact scale of pediatric mortality associated with office-based anesthesia remains poorly quantified due to lack of mandated reporting. Dental providers are hesitant to disclose medical errors as they may harm their practice enrollment, or lead to litigious onslaught from patients. This culture of assigning blame instead of process improvement is one of the largest impediments to ensuring patient safety. It is almost impossible to combat a problem we are not fully aware of. A 2024 survey of pediatric dentists found that approximately fourteen percent reported major adverse events associated with sedation, leading to a minimum extrapolation of about 443 cases per year nationally.
Anesthesia administered by a credentialed provider who then remains an independent observer is stunningly safe, more so than driving your children around to run an errand. This is largely due to the fact that the anesthesia community has gone to great lengths to identify, analyze and prevent adverse outcomes through closed claims databases and meticulous quality improvement implementation. Unfortunately, the office-based anesthesia dental community has not followed suit, leading to a glaring deficiency in adverse event tracking unless a preventable tragedy is splashed across the pages of a national newspaper or discussed on a morning news hour.
What can go wrong during sedation? In both the hospital and ambulatory care setting, complications can arise (after all, to err is human). Primarily, patients who have complicated medical histories with underlying heart or lung disease or underlying colds should not have anesthesia administered at a dental office, but rather rescheduled to a hospital setting or have their dental intervention delayed, respectively. Although extraordinarily rare, medication dosing errors (local anesthetics, paralytics, or sedatives) can result in cardiac arrest. Slowly increasing sedative doses leading to a pause in breathing is the most common cause of cardiac arrest in pediatric patients. These medication related events are then made worse by lack of timely recognition, lack of resuscitation equipment and inadequately trained personnel.
The problems associated with ambulatory pediatric dental care are multi-faceted and challenging to overcome in our current health care system. The first issue is who should provide anesthetic care for children requiring anesthesia. Dental providers have found a way to circumvent recommendations from various sedation societies recommending that an experienced, appropriately credentialed anesthesia provider be exclusively tasked with medication administration, vital sign monitoring, and rescue if the need arises. In the single provider model touted by the American Association of Oral and Maxillofacial Surgeons, the oral surgeon can simultaneously perform the dental procedure and direct sedation. While OMFS providers undergo rigorous training following dental school, safety concerns are more probable during multi-tasking. The mandated dental anesthesia assistant tasked with patient monitoring for such procedures can have qualifications of a high school diploma or equivalent, with hands-on training provided once on the job, with no ability to rescue a patient if the need arises.
What is less clear are the standards of anesthetic care that should be upheld by the providers leading sedation for these children. There are no universal standards of sedation nationally nor are there minimal requirements for vital sign monitoring or clinical expertise of providers guiding anesthesia for ambulatory pediatric dental care. In an operating room setting, most children who undergo dental care receive general anesthesia with an endotracheal tube placed through their nose to allow easy access to the patient’s teeth and gums. In contrast, in an office-based setting, children are given oral medications by a provider without intravenous access or a secure airway. Due to time constraints, there are times when the dental provider will not wait for the medication to take effect thereby necessitating higher doses of sedation medication, which can then lead to catastrophic respiratory compromise if the child stops breathing. In some such cases, dental and/or anesthesia providers are unable to start an intravenous catheter, support the child’s breathing through airway maneuvers or provide life-saving cardiopulmonary resuscitation in cases where the heart stops beating if breathing is halted long enough. More concerning than the inability to rescue a child’s airway is the possibility of not recognizing if the child’s breathing has halted due to lack of vital sign monitoring. The very basic anesthetic monitors for a child undergoing sedation include pulse oximetry to monitor oxygenation, an electrocardiogram to monitor heart rate and rhythm, a blood pressure monitor and end tidal carbon dioxide monitoring (EtCO2), are often not available in outpatient settings.
Much work is left to be done mandating stricter national sedation guidelines and credentials for the professionals providing anesthesia for outpatient pediatric dental care. Our first goal should be national recognition of the scope of this problem while constructing definitive guardrails to prevent its occurrence. Every family deserves the peace of mind to know that a routine dental office visit requiring anesthesia will not end in tragedy.
Irim Salik is a pediatric anesthesiologist.
