Anesthesia and sedation in dental patients has come under scrutiny in recent years, fueled in part by high-profile tragedies, such as the deaths of six-year-old Caleb in 2015, cardiologist Dr. Henry Patel in 2020, and the five media-reported deaths in 2025. These incidents serve as a stark reminder that the current landscape of dental sedation practices is fraught with inconsistencies and a lack of oversight, which can have devastating consequences for patients. They highlight the urgent need for reform.
One of the primary issues is the variability in state regulations governing dental sedation practices. Currently, there is no independent state or federal oversight, and regulations differ significantly from state to state. For instance, only 36 states require the use of pulse oximetry during deep sedation or general anesthesia, 44 states have continuing education requirements for sedation providers, and 42 states lack preoperative fasting guidelines. Only California and Florida require any sort of airway evaluation before sedation. Emergency preparedness varies, with only 23 states specifying required emergency and airway equipment in dental offices. This inconsistency can lead to inadequate monitoring and emergency response, putting patients at risk.
To address these concerns, it is essential for organizations such as the American Dental Association (ADA), the American Association of Oral and Maxillofacial Surgeons (AAOMS), and CODA to collaborate with the American Society of Anesthesiologists (ASA), the American Academy of Pediatrics (AAP) and American Society for Patient Safety (APSF) on improving education and training for dental practitioners. This includes improving:
- The understanding and appreciation of the continuum of depth of sedation.
- The use of the same language, definitions and requirements as the ASA, including the ability to rescue from the next level of sedation.
- Advocacy for use of the same standards of care for patient selection that exist in office-based and ambulatory surgery settings regardless of who is providing the anesthesia care.
A common practice in dentistry and oral surgery is the single-provider/operator-anesthetist model (also known as the oral surgery anesthesia care team model), whereby the dentist or oral surgeon performs the procedure and simultaneously administers anesthesia. In this model, the dentist or oral surgeon will usually have dental assistants helping them with the procedure and anesthetic. Dental assistants have no medical training; many will have only a high school education and on-the-job training. AAOMS recommends two dental assistants be present when the dentist or oral surgeon is administering deep sedation or general anesthesia. They recommend but do not require that one of the dental assistants have Dental Anesthesia Assistant National Certification Examination (DAANCE) training and certification. This is a program that offers 36 hours of web-based learning, followed by a national certification exam. There is no advanced life support training such as PALS or ACLS, and in most places even DAANCE certified assistants cannot draw up medications or otherwise help with airway management or resuscitation.
Educational requirements for health care workers in this setting vary significantly:
- Dental assistant: Basic requirement is high school; advanced requirement is on-the-job training.
- Dental anesthesia assistant: Basic requirements are high school and six months of practice; advanced requirements are 36 hours of online education and a national examination.
- Dental hygienist: Basic requirement is 2-4 years of college; advanced requirements are an associate or bachelor’s degree and a national certifying exam.
- Registered nurse: Basic requirement is at least 2-4 years of college; advanced requirements are an associate or bachelor’s degree and national certifying exams.
Not all the recent deaths have involved the oral surgery anesthesia care team (operator-anesthetist, single operator) model. Currently, most information on morbidity and mortality is derived from media reports, leaving a significant gap in our understanding of the epidemiology of these events. Most states do not track morbidity and mortality data and no state collects near miss data. The need for robust data collection on adverse events and near misses cannot be overstated. The Dental Anesthesia Incident Reporting System (DAIRS) is a step in the right direction, providing an anonymous, self-reporting platform for dental anesthesia providers to report incidents. However, the implementation of a comprehensive database for dental anesthesia and sedation is necessary to drive improvements in patient safety. This would provide invaluable insights into root cause analysis and help drive improvements in patient safety.
The involvement of a separate highly trained and qualified anesthesia provider such as an anesthesiologist, dentist anesthesiologist, oral maxillofacial surgeon, other physicians or dentist trained in the provision of deep sedation and general anesthesia is another critical aspect of enhancing safety in dental practices. These professionals bring specialized training and expertise that can mitigate risks associated with anesthesia. Unfortunately, the dental lobby has often argued against this approach, citing concerns about increased costs and access to care. It is essential to challenge these narratives and advocate for the safety of patients above all else.
Insurance companies also play a significant role in this equation. Improved reimbursement for anesthesia services can incentivize dental practices to prioritize safety and invest in qualified anesthesia providers. Additionally, federal or state oversight of dental office-based settings is necessary to ensure that all practices adhere to established safety standards.
In conclusion, the tragic deaths of patients undergoing dental sedation underscore the urgent need for reform in this area. By fostering collaboration among dental and medical organizations, advocating for standardized practices, and prioritizing patient safety, we can bridge the gap in dental sedation practices. It is time to ensure that every patient receives the highest standard of care, regardless of the setting in which they receive treatment. As health care providers, we must remain vigilant and committed to improving patient safety, ultimately preventing further tragedies in the future.
Rita Agarwal is a double board-certified pediatric anesthesiologist at Stanford University and Lucile Packard Children’s Hospital. Her work focuses on pediatric pain management, neuroanesthesia, medical education, advocacy, mentorship, and sponsorship. She serves as chair of the California Society of Anesthesiologists’ Women in Anesthesiology Committee, is active with the ASA and CSA communications committees, and is one of two hosts of the CSA podcast Vital Times.
Dr. Agarwal is an active member of the Society for Pediatric Anesthesia and the Society for Pediatric Pain Medicine, where she contributes to educational and editorial initiatives. A representative sample of her publications includes work on pediatric sedation safety in Pediatrics, anesthesia for pediatric chest trauma in Seminars in Cardiothoracic and Vascular Anesthesia, airway management in laryngotracheal injuries in children in Paediatric Anaesthesia, opioid use in children during the perioperative period, perioperative management of pediatric patients using medicinal marijuana, dental anesthesia safety, outpatient opioid prescribing guidelines for children and adolescents, and safe and effective pain management in children in American Family Physician. She has also written on workforce trends in pediatric anesthesiology, adverse event disclosure, and perioperative considerations for adolescents and young adults with substance use disorders.
She has completed training in evidence-based coaching and is passionate about advocacy for safer care for children undergoing dental anesthesia and appropriate pain management for pediatric patients, while also supporting physicians through mentorship and coaching. She shares updates through her Stanford profile, on X as @ritaagarwal6, on Instagram as @ragarwal62, and on Bluesky as @momdoc3.bsky.social.
Sangeeta Kumaraswami is an anesthesiologist.
