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Pediatric anesthesiologist Irim Salik discusses her article, “The hidden danger in pediatric dental offices.” Irim reveals a terrifying oversight in ambulatory pediatric dental care: children are suffering neurologic injuries or dying during routine sedation, and there is no national database to track these adverse events. She explains how the convenience of office-based procedures (versus hospitals) introduces massive risks, including the “single provider model” where the dentist also directs anesthesia. Irim breaks down how inadequate monitoring (like lacking EtCO2 monitors), oversedation, and the inability to manage a respiratory emergency can lead to catastrophe. Learn what every parent needs to know about pediatric dental anesthesia and the fight for stricter national safety standards.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Irim Salik. She is a pediatric anesthesiologist. Today’s KevinMD article is “The hidden danger in pediatric dental offices.” Irim, welcome to the show.

Irim Salik: Thank you so much. I appreciate being here. It is a pleasure and an honor. Thank you.

Kevin Pho: Let’s start by briefly sharing your story. Then we will jump straight into your KevinMD article.

Irim Salik: Sure. Absolutely. I am a pediatric anesthesiologist. I work at Weill Cornell Medical Center in New York City. A mentor of mine mentioned to me that we should look into sedation for outpatient dental procedures in children. While we do know that anesthesia is exceptionally safe in children, it is actually safer for a child to have general anesthesia than for them to get in a car and drive to get gas or groceries with their parents. What we find is that if you look at the literature and media reports, there are rare cases of death or permanent neurologic injury that can occur during outpatient sedation for dental cases. This is not exclusive to dentistry, but I wanted to focus on dentistry because it involves children.

Kevin Pho: You talk more about that, of course, in your KevinMD article. Before you talk straight into that article, just give us a sense of how often pediatric dental procedures are accompanied by a pediatric anesthesiologist like yourself?

Irim Salik: That is a great question. I talk about procedures that occur in an outpatient dental setting. To be honest with you, it is very rare for a pediatric anesthesiologist to be present in an outpatient dental setting. In the hospital, it happens all the time. In an outpatient setting, there is a shortage of anesthesiologists and a shortage of resources. It is very rare that it happens.

The people who give anesthesia in the dentist’s office in an outpatient setting are either the pediatric dentists themselves (they either give laughing gas or nitrous oxide, which is considered very safe, or medication by mouth), nurse anesthetists, dental anesthesiologists, or sometimes physician anesthesiologists, although that is rare. Then there are oral and maxillofacial surgeons who give their own anesthesia, and they often start an IV. There are different practitioners, but to have a pediatric anesthesiologist in an outpatient dental setting is relatively rare.

Kevin Pho: Tell us about some of the hidden dangers that we need to know about that the literature says.

Irim Salik: I would like to stress that anesthesia is exceptionally safe, and these events are very, very rare. However, the point of this process was that I think it is important for physicians like myself to highlight and speak out about the fact that there should be a commitment to improving quality and safety in the outpatient setting.

Some of the problems that occur are airway compromise, respiratory depression or hypoventilation, and respiratory or cardiovascular arrest. There are instances where a patient is inadequately monitored. The personnel taking care of the patient do not have adequate rescue capabilities for the airway. There can be a delayed recognition if monitoring equipment is not adequate, and emergency response can be inadequate as well. This eventually leads to catastrophe where a child can develop a permanent neurologic injury or death.

Kevin Pho: That, of course, is the biggest fear that any parent has whenever they bring their child in for some type of outpatient dental procedure that requires anesthesia. Like you said, it is exceptionally safe. But sometimes you hear about these tragic cases in the news. In general, how often do these catastrophic events happen?

Irim Salik: That is actually the crux of the problem. We do not know. We only hear about them in news reports and in some closed claim analyses, but we actually do not know how often they occur. My message would be that it is important for us to be evidence-based and data-driven. In medicine, we report anesthesia-related outcomes to different registries. We have a national registry where we collect anesthesia-related data, and we benchmark our outcomes. These include the NACOR registry and the MPOG registry, where anesthesiologists participating in hospitals share their data.

It helps anesthesiologists meet quality reporting requirements. It also enables outcomes research that improves the quality and safety of care. However, for the dental industry, there is no comprehensive national database that captures outpatient dental procedural volume. We have no idea how many anesthetics are occurring, and we have no idea how many adverse events happen nationally. We just do not know.

We hear about them in news reports. I have actually tried to do a deep dive to get some information about exactly what happened, and it is very, very challenging. If these cases go through a malpractice suit, they are sealed through an NDA. It is very challenging to get this information. That is the crux of the problem, and that is what I think we have to change about the way we practice.

I believe that dentists who practice in an outpatient setting should report their anesthetic cases to a national registry so that we are able to collect this data, analyze it, and collate it to try to identify systemic risks that occur and patterns that we see. The reason why anesthesia has become so safe is that when we have an error, a near miss, or a fatality, we conduct a root cause analysis. We conduct a root cause analysis, which is essentially a systematic, structured process that allows us to identify the underlying reasons why an adverse event occurred. We are not trying to assign blame, but we are trying to prevent this event from occurring again. We have no such corollary in the dental industry.

Kevin Pho: What are some of the common procedures that may potentially expose a pediatric patient to risk from some of these anesthesia complications? Is it something as common as a wisdom tooth extraction?

Irim Salik: Yes. Some common procedures that I am hearing about include wisdom tooth extraction. It could be a child who is having a dental cleaning, a cavity filled that requires anesthesia, or multiple cavities filled. The most common reason why a child has to go to the dentist is that they are either not brushing their teeth enough or their parents are putting them to sleep with a bottle of milk or juice. If you are not cleaning the teeth, they develop massive decay.

In a hospital setting, what we do for these cases is we secure the airway with an endotracheal tube. In the dental office setting, that may or may not happen depending on who is providing the anesthesia. Without a secure airway, there is a very fine line between mild, moderate, and deep sedation. When that line is crossed, that is the time when catastrophe can strike. If there is not an adequate recognition and response, that is the time when airway compromise can lead to a cardiac arrest.

Again, as I said, this is very rare, but it is something that I think parents should be given adequate informed consent about. They should be told about the risks and benefits involved. Office-based anesthesia is something that is here to stay forever. The costs and resources are so prohibitive that there is no way that we can care for all the children who need to be seen by the dentist in a hospital or an ambulatory surgery center. We know that anesthesia is going to be safer in these settings because the backup systems in place are so robust. In an office-based setting, we don’t have those same backup systems in place, and that is what leads to trouble.

Kevin Pho: Now, in these catastrophic cases that you have read and studied, are there any common themes among those cases that led to that tragic result?

Irim Salik: Common things among the tragic cases are that the practitioner does not respond in a timely fashion. Monitoring equipment is not available. Capnography or end-tidal CO2 monitoring is the gold standard for deep sedation, general anesthetic, or even mild or moderate sedation. It is not available in every dentist’s office. Emergency airway equipment and the ability to do high-quality cardiopulmonary resuscitation, or CPR, are absolutely essential. It is important that someone in that room must be able to do adequate CPR. I am not sure that there is someone in the room who can do it. By the time someone calls 911 and an ambulance arrives, the child or the patient may already be in extremis or past the stage of being helped.

There are times when at a dentist’s office, you are in a rush and you give a little bit of sedation. It is taking too long or the child is not responding in an adequate fashion, so you give a little more. Then you give a little more. By the time you know it, the child now has an obstructed airway. You have to have someone who can manage the airway. We have moved away from the single provider model where the surgeon who is performing the procedure is also providing the sedation. That is very, very rare. It doesn’t occur because we realize the inherent risks that are present with that. However, even with an independent anesthesia provider, we find that adverse events occur. This leads us to believe that this is a systems-based problem. But again, without the data and without the evidence, we just do not know. This is why I think it is so important for dentists to be part of a national registry and report their data so that we can try and discern exactly what the risks and patterns are when a catastrophic event occurs.

Kevin Pho: So for parents who are listening to you now, and if they are bringing their child in for, say, a wisdom tooth extraction either to their dentist or oral surgeon, is there a checklist of questions they should be asking that office to ensure that the anesthesia is safe?

Irim Salik: Yes. Absolutely. I think it is important to know who will be providing the anesthesia for the case. I think I have to give a lot of credit to the dental anesthesiologists. This is a fairly new specialty since the late 1970s or early 1980s when the residency for dental anesthesiologists actually started. These are dentists that then do a three-year residency in anesthesiology. They are exceptionally skilled and they have done a lot to make the practice of office-based sedation much safer for children.

But you should know who is providing anesthesia. You should know if there is backup airway equipment and emergency medications available. Is someone available who can do cardiopulmonary resuscitation in an emergency? What is the plan in an emergency? I think it is important for parents to be aware also of what type of anesthesia is about to be given. Are we doing mild, moderate, or deep sedation or even a general anesthetic?

Also, for parents who have children, I think it is very different when your child is healthy versus if your child has underlying medical problems. If your child has a lot of comorbid diseases or conditions, I think it is prudent for parents to ask the question: “Should this case be done in a hospital setting?” If there is a problem, there is a recovery room nurse or potentially an ICU bed available if an event occurs where my child needs a higher level of care, especially if your child has comorbid diseases or conditions.

Kevin Pho: One of the things that you mentioned was basic monitoring equipment like end-tidal carbon dioxide monitors, so simply asking if the office has one of those. Would that be on the checklist in terms of absolute necessities?

Irim Salik: Absolutely. Oh yes. I think that is very important. I think if your child is receiving anesthesia, there should be end-tidal CO2 monitoring. That is an excellent point. Thank you.

Kevin Pho: We are talking to Irim Salik. She is a pediatric anesthesiologist. Today’s KevinMD article is “The hidden danger in pediatric dental offices.” All right, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Irim Salik: I would like to reiterate to parents that anesthesia is exceptionally safe. I would like to reiterate that you should be an informed consumer. If your child needs to receive anesthesia in a dental office, you should ask the important questions of who is providing the anesthesia, what type of monitoring equipment is available, and what type of emergency preparedness the office staff is capable of conducting. Is there end-tidal CO2 monitoring? That is an important question.

I think it is important for the dental industry to know that reporting their data to a registry would go a long way in improving quality and safety for children who receive outpatient dental care. I know it would require a culture change, a dramatic change in the culture of the way the industry practices. But it would be an extremely positive step towards quality improvement and patient safety.

Kevin Pho: Irim, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Irim Salik: Thank you so much. It was a pleasure. Thank you.