A healthy, 4-year-old girl was brought to the pediatric dental office for treatment of several cavities. The parents were told their child would be given medication to help her “sleep” through the procedure. Easier and quicker than going to a hospital, office-based dental sedation was presented as a safe, routine option for children.

After the sleeping medication was administered, the child grew quiet and became still. The dental work began. At some point, her breathing slowed. A monitor showed her oxygen level dropping. An alarm sounded, then was promptly silenced.

The dental team adjusted her position, prompting her oxygenation to increase, and the procedure continued. While the dentist was focused on treating her cavities, the child’s lips turned blue. An ambulance was called. By the time the paramedics arrived 10 minutes later, the child’s heart had stopped. Professionals performed CPR on the floor of the dental office and rushed her to the hospital. She never recovered and was left brain dead. Later, the cause of death was declared lack of oxygen during dental sedation.

Like the above scenario, preventable deaths of children in office-based settings occur repeatedly and quietly, case by case, state by state. How often does this happen? We honestly do not know. There are no reliable national incidence rates for dental anesthesia-related mortality due to lack of standardized reporting requirements. A study has reported that most deaths in office settings occur in 2- to 5-year-old children with a dentist as the anesthesia provider. The instances that we are aware of come from malpractice claims, media reports, and grieving families that are desperate for change through advocacy. This implies the true scope of this problem is likely underreported. Also of note is the issue of health care disparity, as the children who are disproportionately affected are from vulnerable, resource-poor communities.

What makes these losses of life particularly tragic is that they are avoidable. They occur because important safeguards may be absent in an office-based setting.

In modern hospital systems, anesthesia-related death is extraordinarily rare. This is the result of a half-century of advancements in monitoring, standardized training, checklists, a team-based approach, and a sophisticated safety culture cited as a model for other high-risk fields. Anesthesiologists’ commitment to vigilance and redundancy has been heavily influenced by the fields of aviation and human factors engineering.

As a board-certified pediatric anesthesiologist with 15 years of clinical experience, I can attest anesthesiologists’ anticipation of rare but catastrophic events as expectations, rather than exceptions, has engrained a mindset for the routine preparation of backup plans A, B, and C before complications even arise. We rely on evidence-based quality improvement strategies and utilize high-fidelity simulation techniques to ensure patient protection. For the aforementioned reasons, anesthesia is frequently considered the safest part of surgery.

And yet, children still die under sedation.

The factors surrounding anesthesia-related deaths reveal an uncomfortable truth: Anesthesia safety is not uniform and depends heavily on who is providing care, where anesthesia is administered, and what systems are in place when things go awry. When anesthesia-related deaths do occur today, they tend to occur in dental offices, cosmetic surgery suites, endoscopy centers, or medical spas during routine procedures requiring “sedation.” In the majority of these instances, support teams are smaller and redundancy is stripped away. The assumption is that nothing serious will happen, and customarily, nothing does.

In many office-based settings, particularly during dental sedation, the person performing the procedure is also responsible for sedation, known as the single-provider model. Monitoring equipment is limited. Emergency equipment may be available, but is often unused, rarely included in emergency simulation scenarios, and seldom stress-tested. Especially in children, anesthesia is unforgiving of delayed recognition.

Office-based pediatric dental care is more affordable and easier to obtain than care in a hospital setting. Considering our health care system’s finite resources, cost, health care access, and convenience matters, which is why office-based anesthesia remains mandatory for comprehensive pediatric dental care.

While health care policy reform for dental anesthesia oversight is long overdue, there are strong political forces that continue to protect the status quo. In the meantime, there are important questions that parents should address prior to office-based sedation, including:

• Is there a dedicated provider whose only job is monitoring my child? Is this person an anesthesiologist or separate anesthesia professional?
• How will my child’s breathing be monitored? With a pulse oximeter only, or continuous carbon dioxide monitoring/capnography (a monitor that allows providers to know within seconds if breathing patterns have changed) as well?
• What equipment is available if my child stops breathing? (oxygen, bag-mask ventilation, pediatric-sized airway devices, advanced airway tools)?
• What children do you NOT sedate in this office?
• Who monitors my child after the procedure and for how long?

Until oversight aligns with risk, it remains essential that parents obtain meaningful informed consent before sedation, a responsibility with profound consequences.

Irim Salik is a pediatric anesthesiologist.