Dental sedation and
anesthesia: Adverse events
and recommended protocol
John R. Ayre Jr., DDS
DENTAL SEDATION is commonly administered for the treatment of anxious
children. It is one of the hallmarks of training for pediatric dentists. It is estimated
that between 10% and 20% of children and special needs adults will require
pharmacosedation to safely and efficiently complete dental treatment. 1, 2 Children
and the elderly present the highest risk and lowest error tolerance in patient safety
during sedation procedures. Although rare, the most serious adverse outcomes of
sedation are brain damage and death. 3, 4 No one should die from visiting the dentist.
INCIDENCE OF ADVERSE EVENTS IN THE US
A number of severe adverse events have occurred in the
United States during the past five years. In response, state
legislatures have told their dental boards to investigate
dental anesthesia–related deaths and mishaps. These
panels are composed of dental anesthesiologists, oral surgeons, pediatric dentists, and general dentists. All are actively licensed and practicing dentists who frequently
perform in-office sedation. Many teach sedation/anesthesia
in dental schools.
The panels reviewed deidentified data compiled during
board investigations that were involved in patient mortali-ties and patient harm during or following dental treatment
in which sedation/anesthesia was administered. They
evaluated substance and application of emergency protocols related to the administration of the sedation/anesthesia. They also reviewed other state laws and rules and
In 2016, a Texas panel performed an intensive review
of 78 cases. 5 Nineteen were determined to have been mishandled, six were identified as major events (death or
permanent injury), and four of the six were children under
eight years of age. An additional 13 were categorized as
mishaps (adverse events without permanent injury).
Between 2011 and 2016, five deaths and one brain injury
occurred that were directly related to sedation/anesthesia.
It was revealed that oral and maxillofacial surgeons, pediatric dentists, and dental anesthesiologists perform approximately 411,000 sedation/anesthetics annually in Texas.
Adding all licensed Texas dentists, the total number of
sedation procedures is estimated to be between 500,000
and 1,000,000 annually.
Texas is not alone. A July 2016 pediatric anesthesia study
undertaken by the Dental Board of California found that
between 2010 and 2015, nine pediatric deaths were noted
from various combinations of local anesthetic, sedation,
and general anesthesia. 6 Fifty-six additional pediatric hospitalizations were also described, many of which are still
Key findings from these reviews include:
• They occurred in the presence of highly trained dentists,
• The incidents were varied and occurred in office settings,
outpatient surgical centers, and hospitals.
nurse anesthetists, and medical anesthesiologists.
• No one type of provider or sedation delivery model had
better outcomes, i.e., oral sedation was no safer than IV
or general anesthesia.
• The nature of the mishaps was varied but included drug
overdoses and the patients becoming more sedated
• There were cases of premature discharge.
• There was poor drug selection.
• There was poor management in the early stages of a
developing urgency that allowed the condition to deteriorate to an emergency.
• There were delayed calls to 911.