Anesthesia Patient Safety Podcast

#285 Safer Smiles

• Anesthesia Patient Safety Foundation • Episode 285

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A routine dental visit should never turn into a medical emergency. We sit down with Dr. Rita Agarwal, pediatric anesthesiologist and patient safety advocate, to unpack why dental anesthesia operates on a separate track from hospital-based care—and how that gap can put patients at risk. From the heartbreaking story of six-year-old Caleb Sears to the hard truths about monitoring requirements, staffing models, and training, this conversation brings clarity to a topic most families and many clinicians assume is standardized.

We dive into what “sedation” really means in dentistry, why route-based labels can hide true depth of anesthesia, and how inconsistent state rules leave dangerous blind spots. Dr. Agarwal explains the pillars of safer dental sedation: careful patient selection, a separate and qualified anesthesia provider for deep sedation or general anesthesia, and the ability to rescue from the next deeper level, including effective bag-mask ventilation and the timely use of reversal agents. We also explore the role of capnography, reliable oxygen supply, and scenario-based drills that make rapid response second nature.

Safety grows when systems learn. That’s why we spotlight the urgent need for robust data: routine reporting of outcomes and near misses from dental offices using a simple, standardized tool. Pair that with harmonized terminology aligned to ASA levels, simulation training, and clear emergency protocols, and dentistry can match the reliability gains anesthesia has achieved in hospitals. For parents and patients, we offer direct, practical questions to ask before consenting to sedation—who monitors, what training they have, what equipment is on hand, and whether sedation is truly necessary.

If this conversation gave you new tools or changed your perspective, help us spread the word. Subscribe, share with a colleague or a parent who needs it, and leave a review so more people can find evidence-based guidance on dental anesthesia safety.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/285-safer-smiles/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_01:

So she just assumed that the same standards that apply to sedation and anesthesia in medicine also applied in dentistry. It never occurred to her, as it didn't occur to me and many others, that there was a whole nother parallel system that had grown up alongside of medical anesthesia and sedation.

SPEAKER_00:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel, and I'm your host. Thank you for joining us for another show. We have a very exciting interview show today on a topic that we haven't covered on the podcast before. Let's break out the toothpaste and floss because our guest today is passionate about keeping patients safe during dental office-based anesthesia care. Before we dive further into the episode today, we'd like to recognize Frazinius Kabi, a major corporate supporter of APSF. Frazinius Kabi has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Frazinius Kabi. We wouldn't be able to do all that we do without you. Our guest today is Dr. Rita Agarwal, a pediatric anesthesiologist at Stanford and Lucille Packard Children's Hospital. Dr. Agarwal was the Pediatric Anesthesia Program Director at the University of Colorado for 18 years and has served as the editor for the Society for Pediatric Anesthesia Newsletter, Communication Chair, and Member of the Board of Directors. She is the past chair for the American Academy of Pediatrics section on anesthesiology and pain management, and the vice president for the Society of Pediatric Pain Management. Dr. Agarwal is passionate about patient safety during dental procedures and an expert in this area. We are so excited to have her on the show today. And now my conversation with Dr. Rita Agarwal. To get us started today, can you introduce yourself and tell us a bit about your anesthesia training, career, and your current role? And how did you become interested in pediatric anesthesia as a focus for your practice?

SPEAKER_01:

Thank you. Good morning, and thank you for letting me be on the show. I went to medical school at Baylor College of Medicine in Houston. That's where I started. I kind of grew up all over the world, but ended up in Houston with my family. I didn't really know anything about anesthesia or pediatric anesthesia when I started medical school. I was 100% sure that I was going to be a neurologist. That's what I went to medical school for, thinking, oh, the study of the brain, it's so interesting. That's what I'm going to do. And then I did my neurology rotations. And I actually, I mean, I really enjoyed them in that I loved the people I worked with. I really liked the patients. But at that time, this was back in the late 80s, there was very little we could do for a lot of these medical problems. And so I kind of was like, oh, I don't really want to do this. I'm not really sure what I want to do. I think maybe I'll do surgery. So, like many people who end up in anesthesiology, I started in surgery. And um, I had like one elective month left in my medical school year. And a lot of my colleagues and friends suggested doing anesthesia as an elective. So I did a month elective. I had had very minimal exposure to anesthesia prior to that. I really didn't know much about it. And oh my gosh, I fell in love with it. And at this point, I had already matched into surgery, so I was already committed to doing that. And throughout my first year of internship, I'm like, you know, I really like this surgery thing, but I really, really liked that anesthesia so much more. And it these hours are really insane. And I know that I want to have a family and I'm married to a surgeon and who's gonna stay home. And I, gosh, I really, really enjoyed anesthesia. And so um, through a variety of different events that occurred during that year, I became more and more convinced I wanted to do anesthesia. And my thought at that time was because I liked the acute care kinds of aspects of surgery and anesthesia, I could do critical care. So I went into anesthesia. I switched um after my internship year, went into anesthesia, basically thinking I would do critical care. And actually had started applying for and interviewing for and having been accepted for a couple of different fellowships when I did my peas anesthesia rotation um in my in residency. And that was it. I think within a week, I was like, oh my, it was an epiphany. It's like a light went off for me. And it was like, this, this is what I am supposed to be doing with my life. This is this is what I want. And so, you know, I had to, because I had to sort of do an about face. I had to really sit and think about it. At that time, um, believe it or not, at Baylor College of Medicine and Texas Children's, there actually was not a fellowship available in PEEDS anesthesia. So I knew I was gonna have to leave Houston. And my husband was working in Houston at the time. But um, yeah, so that's kind of what led me to pediatric anesthesia.

SPEAKER_00:

That is so interesting. And it's so cool that you found the right path for yourself, even after exploring all these other areas too. Since this is the Anesthesia Patient Safety podcast, we like to start the conversation off about patient safety. So, what got you interested in patient safety in your practice?

SPEAKER_01:

I mean, I think all anesthesiologists at heart are interested in patient safety, right? I mean, that's so much of what we do. We can see how easy it is to harm patients if we're not vigilant or we're not patient paying attention. I think though there were a couple of events early in my career interestingly involving wrong drugs. There was an event when I was still a resident where one of, and it was this wasn't my case, but I was actually rotating in the ICU at the time and ended up taking care of this patient for a really long time. It was an um a pregnant mom who had was having twins and had to have a crash C-section. And unfortunately, at the time, the esmalol vial and the automatate vial, both beginning with E, were both glass vials and looked very, very similar. And the resident inadvertently drew up the esmalol vial instead of automated and injected that into the patient uh for induction. She naturally, it was, I mean, a huge overdose of a very strong beta blocker instead of an anesthetic agent. She had a cardiac arrest. She was out for a long time. They were able to get the twin the babies out successfully. She ended up actually, and when she first was transferred to the ICU for us to care for, I took care of her. It was at the beginning of my rotation. I ended up taking care of her for, you know, close to a month. And um, certainly at the beginning, we really didn't think she would survive. By the end of the time, she was showing signs of improvement. And I actually got to see her about a year later. And even though she still had, you know, some deficits, but that was, I think for me, the first thing as a resident that made me realize how important patient safety is and how important all the work that we do, or all the work that the Patient Safety Foundation does, is particularly around different medications in similar, in similar containers and how profound, profoundly that can affect a patient's life and outcome. So I would say that was the first thing that really got me interested in the importance of really looking out for patient safety.

SPEAKER_00:

Medication safety is a topic that we talk about on this podcast quite a bit, and the APSF has done a lot of work on medication safety. And it's interesting because we still see wrong drug or wrong route errors today. So there's still more work to be done in this space. I know that you have spent a lot of your career focusing on patient safety, especially when it comes to patient safety during dental procedures. So can we just get started on that topic by talking about the history of dental anesthesia and how did you first become aware of the threats to patient safety during dental procedures?

SPEAKER_01:

Yeah, great. So, as probably most of the listeners know, it was actually dentists who invented anesthesia, right? So um, anesthesia predates physicians administering it. It was dentists who invented nitrous oxide and ether. Um, and it was dentists who used it originally. And so there's sort of been these two parallel routes that have existed and developed side by side, which I think a lot of people probably haven't recognized, especially in the medical profession. We've never really paid attention to what happens on the other end. When I started my fellowship in pediatric anesthesia, it was in Colorado at the then the Denver Children's Hospital. There's a very, and there still is, a really fantastic dental school there and a really, really strong pediatric dental department. And the dental school was right next to the hospital, and the dental clinic was right next to the hospital. And so we actually took care of a lot of patients for dental anesthesia, all under general anesthesia. They had a clinic, they did some, they did some sedation. The clinic was actually right next to our outpatient surgery center, which was right next to, or they were all attached to the main hospital. So um it was done in a very controlled, very careful, very thoughtful manner. So it was never something I really thought about as being problematic until I actually moved out to California, which was about 11 years ago now. At that time, I was the chair of the American Academy of Pediatrics section on anesthesiology and pain medicine, as well as having gotten very involved with the California Society of Anesthesiology. There was a young child, Caleb Sears, who's was six years old at the time. He went in to had an extra tooth in his mouth that needed to be removed. So he went to his oral surgeon's office. The oral surgeon said he would need general anesthesia for it. He reassured the family that there would be somebody there, quote unquote, monitoring Caleb the entire time. Caleb's aunt was a surgery resident who, so she just assumed that the same standards that apply to sedation and anesthesia in medicine also applied in dentistry. It never occurred to her, as it didn't occur to me and many others, that there was a whole nother parallel system that had grown up alongside of medical anesthesia and sedation. So Caleb went in, he received midazolin, nitrous oxide, ketamine, fentanyl, propofol, and he naturally stopped breathing. Unfortunately, at that point, the oral surgeon didn't seem to know what to do. There was no bag mask ventilation, there was no effort to ventilate him. He did try to intubate Caleb, breaking several of his teeth in the process and not being successful with his intubation attempt. They at some point called 911, and there's a lot of question about how long it was before that occurred. When the paramedics arrived about 10 minutes later, no one was doing CPR, no one was administering oxygen, no one was trying to ventilate him. Pretty much nothing was happening. And so I got involved and I became aware of this through Annie, who is Caleb's aunt, and through the American Academy of Pediatrics and the CSA. Because what Annie and her family did, what Caleb's family did, was go to the legislature and say, how is this possible? How can there be, you know, how can this happen? Caleb went on to pass away. Um, they were able to resuscitate him, but at that point he had been down for so long that he ended up passing a few days later. So their entire family, you know, was as you can imagine, devastated. And he started looking into like what's available. What are what is what is what are the numbers of complications that occur in dental offices in patients undergoing anesthesia? Nobody knows. What's the number of deaths? Nobody knows. The California Board of Dentistry ultimately was able to pull up, I forget the exact number, but some number of reports. And the data is very sparse. It's very thin. And so she went to the legislature and had a law passed called Caleb's Law that basically required, and I'm sorry, this is a long, a long haul to answer your question, but it really underpins how I got involved and why I'm still so passionate about this. Um, so this initial law basically asked the dental board to do a study on pediatric anesthesia or sedation deaths and complications and anesthesia in children undergoing dental care. It asked them to create a separate consent form so families understood that in fact the person monitoring the child is not a medical professional. They are a dental assistant. And a dental assistant is wonderful, right? We all go to the dentist regularly. I go to I go every six months. I love my dentist, I love my dental assistants, I love my dental hygienist. But they are required to have no more than a high school level education, um, plus some on-the-job training. And some may go on to have some additional online medical training through what's called the JANT program, which is the dental anesthesia assistant national certifying exam, where they get like 36 hours of online training and then they have to pass an online exam. That's it. So that was one of the things was the consent. And then there were a few other parts of that, one of which is included, and this is one of the calls that I have, is uh to create a robust data system to actually track complications and deaths in dental offices. So that happened. The California Board of Dentistry actually did this study, and they came up with several recommendations. So I was involved because Annie, then working with her local congressman, tried to create a law to pass through the California Assembly to improve dental safety by actually following the recommendations of the dental board. And these recommendations included better data collection, better pre-op to have separate people available if they're going to do deep sedation or general anesthesia. And there was there was a few other things in there. They wanted content experts. The AAP reached out to me as the then current chair of the section on anesthesiology, and also someone who lived in California and actually lived in the same Bay Area that that Annie and her Annie Kaplan and her family lived. And then the CSA also was brought in for the same reason. So that was my initial introduction to this. And I will tell you, it took me a while with people trying to explain to me why this was a problem. I'm like, well, I don't understand if they have the dentists or the oral surgeons do anesthesia training as part of their oral surgery training. So I don't understand why they can't do this. Plus, I had worked with dentist anesthesiologists in Colorado who had all done three-year residencies in anesthesia in dental. One had done it in formal anesthesiology when that was still available. Several had done it, actually, I'd worked with several dentists who had were anesthesiologists back in the day when dentists could actually do anesthesiology programs. More recently, though, I had worked with dentist anesthesiologists who had gone through special training programs for dentists, but it was a three-year program with pretty intense training around how to safely anesthetize children in sort of the office-based setting, and taught them a variety of techniques, and they spent a lot of time in the hospital as well as in the clinic. So that was my initial introduction to all of this. I just, I remember it took me, like they kept trying to say, you know, there's someone monitoring, but they have no more than a high school education. And I'm like, oh no, they're exaggerating. There's no, there's no way. I mean, nurses have more than that, right? No, but the thing is, dental assistants are not nurses. They don't have even the bare minimum medical training. They have at most, at most, maybe this 36-hour online course. And at most, all they can really do is sit and watch the monitors. They can't actually help with resuscitation. They can't draw up drugs, they can't help manage an airway, they can't, they can't administer drugs per their, you know, per their rules and regulations. They could, if they're basic life support certified, they could at least do CPR. Um, but it didn't sound like, at least in Caleb's case, that anybody was doing any of that.

SPEAKER_00:

Wow, what an introduction into the scope of this problem. And I think you're right, this is something that not a lot of people think about because we just think about going to the dentist as something that is thought of as being routine and safe. And it's not always the case. Now, when we're thinking about the scope of the problem for patient safety for dental procedures, could we just step back a little bit and talk about? So, what are the different options for anesthesia for dental procedures? Because I think this will lead us into how patients can be harmed later on in our discussion.

SPEAKER_01:

Sure. So we actually published a recent paper that gives a little bit more of a backdrop called Why Do Deaths and Catastrophic Injuries Still Occur in Dental Anesthesia. So there are a lot of different options, starting with straight local, which most of us have probably received for either fillings or some tooth removals or something like root canals, that kind of stuff. Straight local works really, really well. There's a lot of people, however, who have a lot of anxiety around getting local anesthesia. Either it's still, even though they'll put like a topical on your gum first before they inject, it still can be a little bit uncomfortable. And there are a lot. Of people who have have real dental phobia or needle phobia for a variety of different reasons, for whom straight local is really very scary. And this is for both children and for adults. And just to be clear, this is not just a pediatric problem. Some of the deaths and some of the people that we've worked with have had adult loved ones who have passed away because of dental sedation. Then it goes all the way from mild anxiolysis to basically general anesthesia in the dental office. Because I think that's a very different kettle of fish than what occurs in the office setting. So we start right there with one of the issues that that occurs in dental anesthesia. First of all, sedation and anesthesia for dentistry is guided and regulated differently for every single state. Every state sets their own requirements, their own guidelines, their own policies and procedures around who, what, where, what's required, emergency drugs, you know, all of that kind of stuff. Not only that, but they actually define anesthesia and sedation differently than we do in our medical profession of anesthesiology. They use terms like oral conscious sedation or parental moderate sedation or oral moderate sedation. And so there's in a lot of dentistry, the route of administration actually is how they define the level of care, I guess, that they're providing. Because as you can imagine, not all dentists' office are going to be equipped to start IVs, right? Something as basic as starting an IV is not going to be present in all of these kinds of situations. And so if you can just do medications by mouth, then you don't have to worry about an IV. It also then will go on, you know, you'll follow a different path in terms of what you need to have available in your office. And of course, that's going to impact cost. If you need to have IV equipment, if you need, you know, you then you have to be checking it, you have to be checking your fluids, you have to make sure things are up to date. You may have to dispose of them. So it increases the cost if you're going to have IV stuff available. So many dental offices will just offer basically what they'll call oral mild or minimal or conscious sedation. Again, the terms vary depending on the state and what you're doing. So that can include some kind of a benzodiazepine. It may also include some oral opioid. It may include, you know, hydroxazine or, you know, some other kind of sedative medication just to try and sort of quote unquote take the edge off. Then again, depending on the state, depending on the office, depending on the particular dentist and what kind of training they have and what kind of training they need for that state's requirements for various sedation levels, they may offer more. They may offer IV sedation, they may offer what they're going to call moderate or deep sedation. Um, what we would call moderate or deep sedation. They have, like I said, different terminology for it. Most of their rules do not require a separate anesthesia provider, even if they're doing, and a lot of what is really general anesthesia with a natural airway, they're calling sedation. Basically, the patients aren't moving, they're not responding to painful stimulus, but they're still calling it sedation. So those are some of the various things that are offered. And dentists can use, again, depending on their training, depending on their state requirements, they can use all the medications that we use. They generally don't use, I don't think, I don't actually know about muscle relaxants, but they have propofol, they have fentanyl, just like in Caleb's case. They have ketamine, they have medazolan, um, they have other types of opioids, you know, Demerol, morphine. Um, what else is there? I think those are the main things. They have, you know, they have most of the types of anesthetics that we would think of being associated with general anesthesia. They have those available. Some places may have gas if they have an anesthesia machine and they have a scavenging system. Some traveling anesthesiologists will have their own little portable anesthesia machine that they can bring with them. And to continue with kind of what's available, so there's also a difference in who's providing the anesthesia. Um, in many dental situations, it's the dentist or the oral surgeon. Dentists have to have additional training. And again, state state determined what that additional training is to provide deeper levels of sedation and anesthesia. Whereas oral surgeons, because of the fact that they've done five months of anesthesia as part of their oral surgery residency, are almost always automatically given a license to do general anesthesia or, you know, anything up to general anesthesia. So it may be the dentist by themselves, it may be the oral surgeon by themselves, they may have a colleague, either, you know, again, a dentist who's licensed or an oral surgeon to help, or they may have a CRNA in states where they're independently licensed, or in states where they're allowed to be supervised by the dentist or oral surgeon, or it may be a separate anesthesiologist who comes in to, you know, to provide the anesthesia in their office. Uh when my children had their wisdom teeth out, I made sure I paid. And it's, of course, it's out of pocket. It's not covered by any of the insurance. Whereas if I had let the oral surgeon do the anesthesia, there would have been some, some of it would have been covered by the insurance. I paid out of pocket to have a separate anesthesiologist who worked with that office come in and do the anesthesia for my kids. And they were adults, they were young adults, they were like 19 or 18, 19, 20-ish in that range. So they were not children at that point. But I still was not gonna, you know, not gonna take the risk.

SPEAKER_00:

Well, and speaking of rest, one of the APSF patient safety priorities is clinical deterioration with the focus on preventing, detecting, and determining pathogenesis and mitigating clinical deterioration in the perioperative period. This is something that anesthesiologists really focus on for our patients when it comes to providing safe anesthesia care. And this is also something that seems vital when keeping patients safe during dental procedures. So it sounds like there may be options to have an anesthesiologist present during the procedures. But what do you see as the most important considerations when it comes to preventing this clinical deterioration during dental procedures?

SPEAKER_01:

So I think there's two things. And increasingly, as I've spent more time in this world and in this field, I think one of the most important things is patient selection. Because I don't think, and I I'm not a dentist or an oral surgeon, I don't know what they were taught, but I do work with um dentists. So many of the deaths, particularly in adults that we hear about, and even some in children, it's clear that that patient was not an appropriate candidate for an outpatient setting. And most surgeon centers or ambulatory surgery, you know, surgical centers, they wouldn't be considered a candidate because they have too many comorbidities, such as obstructive sleep apnea or such as underlying cardiac disease, or you know, some other thing that would make them a poor candidate to be cared for in a purely outpatient setting. So I think the first thing is a really increased emphasis on patient selection, that not every patient, even for quote-unquote minimal sedation or conscious sedation or whatever they want to call it, that they may not tolerate a little bit of midazolam. And this is something anesthesiologists have learned the hard way, right? We've spent years in years the APSF being, you know, at the forefront of some of this research, really advocating for and recognizing that not all patients are the same. And you can't take, you know, they may all be maybe a 50-year-old and a 50-year-old and a 50-year-old. But if the one 50-year-old is running marathons and the other 50-year-old is on um, you know, has really severe sleep apnea and is on a uh BAP machine at night, and the other 50-year-old maybe has had bad cancer, and they may be healthy, or they may have been in remission now, but they've been exposed to all these oncology medications, they are not the same person and they can all react and respond differently. So I think starting out by really recognizing and having respect for the significance of comorbidities and how they may impact a patient's response and reaction to sedation. So I think it starts there. Then the second thing is really having people like how can you have someone recognize, like you said, the first thing is recognizing and diagnosing causes of deterioration. But how can anyone recognize that as a problem if they don't have any medical background? So I think that's a huge part of it. I really truly believe that anyone getting deep sedation or general anesthesia is best cared for by an independent practitioner who is trained. Personally, of course, I think it should be a physician anesthesiologist, obviously, but I recognize that there's also not enough. There's not enough of us to go around. And so, you know, that creates a problem that is difficult to solve sometimes without bringing in other people. So I think a CRNA is better than an oral surgeon doing this by themselves. I think another oral surgeon is actually fine. If you have a separate oral surgeon whose job it is to monitor the patient, they are hopefully trained well enough to recognize when deterioration is occurring, when there's a clinical problem occurring before it becomes, you know, too late, before they have a cardiac arrest or before they become profoundly hypotensive or have a, you know, have a heart attack or whatever the issue is going to be. So I personally think for deep sedation and general anesthesia, there should be someone else there. There are a lot of physicians, for example, emergency room physicians. And I'm not advocating for this, but again, I'm recognizing I'm being pragmatic in that there is not enough people to do this. And I do know that within my state, there are intensive care physicians who provide sedation for dental patients because I I guess there's more of them than there are of us. And maybe they have more time. I don't know. I'm not quite sure why, but but I know that that is a practice in in parts. And I still, again, I believe that that is a heck of a lot safer than a single. Doesn't matter who it is. I mean, we don't have surge surgeons, don't provide their own anesthesia. They don't, you know, they may do sedation for patients, but they don't provide their own, they don't provide their own deep sedation or general anesthesia for the most part. So those are the two things that I think would really make this safe. And then the third thing, and I, and this again is something that anesthesiologists have really led the way, is having good data collection tools. So we know what's happening. We can identify when there are problems occurring, what is the cause of the problem. In dentistry, it's still very much a finger-pointing blame and shame. Oh, it was this dentist or this oral surgeon who did this. It was this um, you know, it was this patient who had this one singular issue that led to this problem. The, you know, that was 30, 40 years ago in anesthesia. We've moved well beyond that and much more into root cause analysis and looking for systemic issues and how to cope with systemic issues. And I the dental world has really not done that in the same way. And I do think that's the third part of it is to have probably a separate group who will look at so that I know they've created a dental patient safety foundation that's supposedly based somewhat on um our patient safety foundation. I don't know because we're not privy to any of that. So I don't actually get to see any of that information, but there clearly needs to be a very robust way to track when problems do occur, including near misses. And I think in in probably more importantly, near misses, right? Because that's where you can identify the opportunities to improve care.

SPEAKER_00:

Absolutely. And I just wanted to ask too, are there monitoring requirements? And have those changed over the years? It sounds like they're probably going to be different state by state or office by office, but it seems like that could be a really big step for improving safety, would be to make some monitoring standards like we have in anesthesiology.

SPEAKER_01:

There are no monitoring requirements. I mean, well, let me rephrase that. It is very much state by state. There are a number of states that don't even require pulse oximetry for deep sedation or general anesthesia. So, yes, that obviously would make that would be a start, right? And and not just, I mean, there's a story. Sorry, if you don't mind my telling the story, of a little boy, uh, this was in Arizona, who went to the dentist, had multiple, you know, levels of work that he needed to have done, had a successful anesthetic, had a successful dental procedure, was then taken to the recovery room or their recovery area and left with a dental staff. And we don't know what the qualifications of this dental staff were. We're suspecting it was just, you know, somebody in the front office was hooked up to a pulse oximeter and an oxygen tank. The pulse oximeter kept alarming, the dental staff kept silencing the alarm, and then at some point just took it off and said, Oh, these things never work on children. The child went on to have a respiratory rest and later passed away. And it turned out the oxygen tank was completely empty. So here was this child who was not getting oxygen, whose pulse oximetry was continuing to alarm, but was completely ignored. So it's more than just a requirement for monitoring. It also requires that you have people available who understand what the significance of the monitor is. And if there's a problem, know how to both troubleshoot the monitor because we all know there are definitely times when the monitors are giving us false alarms and are just super annoying. But there's also probably many, well, the definitely many, many, many more times when that is not the case and there's an actual problem. So back to your, you know, the the pillars of what the APSF is trying to achieve this year is to know how to do the differential diagnosis to figure out what the pathogenesis is of the problem. You can't do that if you don't have medical personnel available or looking. I know that for a lot of the anesthesiology groups or private practitioners that do mobile anesthesia, particularly in dentist's office, they often, so they come in with all of their equipment. They often will bring in at least an EMT trained person or a nurse with them so that there's always at least one other person available that can assist when there's issues.

SPEAKER_00:

Oh, that's good. And probably a very big step towards improving patient safety. So, what can patients or parents and family members do when one of their loved ones requires a dental procedure to help keep them safe during the procedure? Are there certain questions they need to ask to figure out who's going to be there? Are there credentials to be on the lookout for? And are there any warning signs that, you know, this might not be a safe place to have deep sedation or general anesthesia?

SPEAKER_01:

Yeah. So starting with the last one, I don't know how you figure out the warning signs because a lot of times these are great dentists or great oral surgeons, and they'll have great Yelp reviews. And, you know, so the usual things that we'll often look at to try and figure out if someone is high quality or not is difficult. I know for me, when my children had to have their wisdom teeth out, my young adult children had to have their wisdom teeth out. I intentionally looked for an oral surgeon and I made sure that my dentist referred me to an oral surgeon that worked with an anesthesiologist. I was, I 100% wanted to be sure that that was the case because it's also difficult if you're like the one person insisting that they you bring in another person who never works in that office. So look for if the dentist is proposing or the oral surgeon is proposing, and sorry, and I say that the both things because a lot of oral surgeons, some are not actually dentists. They go up through medical school and then go into oral surgery through that route. But many are, most probably are, to start off with as dentists. And there's definitely dentists, particularly in pediatrics, that will do some level of sedation. So the the key questions are to ask what are the medications being used? What level of sedation is being provided? And how do they know that? How do they judge that? Just ask the questions that will help determine it. The American Academy of Pediatrics actually has a site called healthychildren.org. It's just healthychildren.org. And you can put in, you know, dental anesthesia, and there's actually a write-up on things to look for and things to ask about. If they're talking about deep sedation or general anesthesia, personally, you know, I think it's it's really incredibly important to make sure there's at least another person who's medically trained to provide that service available. And again, it could be another oral surgeon. It doesn't necessarily have to be a physician. It could be another physician, maybe not an anesthesiologist, such as, you know, I would trust an emergency room. 100% I would trust an emergency room physician to do sedation for my for my child or for my loved one. I would trust an ICU physician as well, because I know they can manage the airway. And I think that's the key thing. And I'm sorry, I meant to back one of the questions you had asked earlier, which I forgot to answer. The one, the one of the really key and important things is, you know, the ASA stresses over and over again in their sedation guidelines that you, as a practitioner who's providing the sedation, need to be Able to rescue that patient from the next deeper level of sedation. And that is something I think is 100% missed in the in the dental world. I don't know that they're taught that. I don't know that they know how to do that. I think they just assume this isn't going to happen to me. It's not going to be a problem. If you have an you know an oral surgeon who, by all, by all accounts, the one who took care of Caleb was highly, highly regarded, who is planning to do deep sedation/slash general anesthesia and doesn't know how to bag mask? I mean, that's a real problem. So things that families can ask is, do you have a way to ventilate my child if they stop breathing, or my loved one if they stop breathing? Simple as that. Can you provide them with oxygen if they stop breathing? Do you have narcan available if you're planning on giving opioids? Um, nobody gave Caleb narcan, and that should be a basic thing that's available in every card. There's also flumazanil, which reverses benzodiazepines. That wasn't administered. Do you have a way to rescue my loved one if for whatever reason they have a, you know, an a different reaction to the medications than you expect, and they stop breathing, or they have, you know, other complications, or their breathing gets difficult. So those are some things that I think loved ones can ask. And is there a separate person? And who is that separate person? And can I talk to them ahead of time? Because again, I mean, for me with my kids, a hundred and they were young, healthy adults. They were, they were, you know, 22-year-old boys. They are, I'm sorry, not they're 22 now. They were they were 19 20-year-old young men. They were healthy as horses. There was no reason for me to expect there to be an issue, but I absolutely was going to be talking to the anesthesiologist ahead of time. So again, I chose an office where I specifically knew they worked with an anesthesiology group. And those are, you know, and for the child that needed deep sedation. The other thing to ask is, do they really need the sedation? Because honestly, we, you know, we think, oh, oh, yeah, it's so much easier to be to get a little knockout medicine or a little something so I don't have to feel this. But it's really not that bad. I want to have one more story to tell. So my husband had a tooth that was knocked loose when we were on vacation in Norway. I think actually it was an old filling that had been in there and was having a lot of discomfort and pain with that tooth. My brother lived in Norway. We were visiting my brother. So my brother found a local dentist. He had, he actually worked out of his house. He kind of urgently took my husband in. He said that he fixed his tooth without even local anesthesia. And he said it was a little uncomfortable, but it wasn't unbearable. So the point is, do they even need the sedation? And I think that's a really important question to ask because I think we've gotten used to sometimes getting medications that we may or may not really need. And just not to make this about money and sense, but there is a charge with that, right? And for a lot of dentists and oral surgeons, the charge for anesthesia and the collection for anesthesia is actually greater than for whatever their procedure is. So they're going to push sedation on people who may or may not need it. And so that's, I think, another really important question to ask.

SPEAKER_00:

Oh, that's great. Some really good resources. I will include a link to healthychildren.org in the show notes as well. And some really important questions to ask. Now, what is the responsibility for anesthesia professionals when it comes to keeping patients safe during dental procedures? Are there resources available to help guide safe practice? And is there research being done in this area currently?

SPEAKER_01:

I don't think there's really quote unquote research being done because I'm not really sure how we would do that. Although I mean, I think we all feel like this would be a really important area to look at, to look at, you know, outcomes with patients who receive anesthesia via one of the independent or you know, group, sort of mobile anesthesia groups. There's there's a lot of groups. There's some that have really become national. There's SMILE MD, I think it's called. There's there's mobile anesthesia as a separate group. There's there's a whole bunch of groups. There's a big group out of, I think it's called dental sedation anesthesia out of Florida. There's a big group that started in Ohio. They have multiple locations around the country. There's a big group in Oregon. So there's a lot of groups that provide this care. There's also a lot of independent practitioners that provide this care really well. The person who provided the care for my first son was an independent practitioner in California. He had his own anesthesia machine. He was so proud of it. He would show it off. And he brought all of his own equipment. He worked with oral surgeons that were also certified in ACLS. So he so for him, they were sort of his backup in case there was an issue. For the second son, it was actually a dentist anesthesia group that did that did his anesthesia. And they were they were all around. So in terms of research, I mean, wouldn't it be great? It would be really, really good. But that that implies that we have data to start with. So I think what what I'm doing and what I hope more people will do, and that is to continue to advocate for safer anesthesia care and for and to advocate a lot at the st at their individual state levels for safer dental anesthesia care and to bring these stories to light. And there's there's so many stories out there of unnecessary. I mean, one death is too many deaths, right? As far as we know, there have been six deaths this year so far in this country, in this country in the US. Several of them were in children, a couple of them were in adults, several of them did involve a separate anesthesia provider, several of them, a couple, a couple of them we don't know, and a couple of them definitely did not involve a separate anesthesia provider. There is too much we don't know. And so I think that anesthesiologists should be on the front lines, really like shaking, shaking the walls of their individual states and saying, what are we doing to make this as safe as possible? This can be done safely. You don't hear about, you rarely, you never, well, I shouldn't say never, but you rarely hear about healthy people going in to have minor, minor procedures done in any other setting where they just die or they have major complications. There is a study done by oral surgeons themselves using a database from the uh primary insurance company that that that provides insurance for the majority of oral surgeons in this country. This was from about five or ten years ago. And they estimated that there was one death or serious neurologic complication that occurred about every four to six weeks. One death. And these are as presumably, if they're selected correctly, presumably otherwise healthy patients. And again, as you heard me say earlier, I think that that is a source of a big part of the problem, is that many times the patient selection is not great. But they're having minor, minor procedures done. Nobody should die from a minor procedure. Nobody should die from a sedation or anesthesia for a minor procedure. That just shouldn't be happening. And we as anesthesiologists, as anesthesia professionals, know how to do this safely and do this well. And we should be, we should, all of us should be out there really advocating, probably at our state levels, to try and make this better and safer.

SPEAKER_00:

Absolutely. And it seems like dentists should also want to make this safer to partnering with the experts in sedation. But I'm sure that's that's maybe a dream going forward.

SPEAKER_01:

Yeah, I mean, I will I will say since Caleb's law, since the first Caleb's law, because what I didn't tell you is the second part of Caleb's law didn't actually pass because there was too much pushback from the dental lobby and from the oral surgery lobbies, uh, both nationally and locally in California. We were able to have a pretty significant impact on the legislation that was being sponsored by oral surgeons to really strengthen the requirements for children undergoing deep sedation and anesthesia, that I think has helped, but there's still deaths occurring in California despite all of that. To be fair, many dentists and oral surgeons really do want what's safest for their for their patients. The problem, I think, comes that many of them are also taught that their training is adequate, their training is superior because they do a lot of office-based anesthesia as well as, you know, hospital-based, whereas most of us in anesthesiology in our residencies do very little office-based. We do all, I mean, I didn't get any office-based anesthesia training when I was a resident, but that was, you know, 30 years ago. So I don't know if it's different now. I do think they get outpatient, like surgery center-based um experiences, but I don't think most residents are getting office-based anesthesia training in anesthesiology. So oral surgeons in particular will argue that their training is not only as good, but probably better than what we get. So I think there's a little bit of that hubris, I think, that comes from thinking that that you know as much as someone who's trained a lot longer than you and been practicing this for a lot longer and has really tried to bring the scientific method to safety in a way that so far dental care has not. So I to be utterly, I mean, like I said, I chose oral surgeons who who prior to me, they've always worked with anesthesiologists. So they clearly want what's best for their kids, um, for their patients. I'm sorry, they took care of pediatrics as well as adult patients. And I know that there's a lot, there's a lot of oral surgeons and dentists out there who really want what's best for their for their patients. Um, but I think there's also, you know, a fair number who, again, are taught and told that what they do is just as good, if not better, than what we do. And, you know, it's really hard to argue with the monetary incentive that comes with that. In fact, shortly after or during the time that we were having a lot of the discussion around Caleb's law, and it was very, it was national at that time. It was, you know, the the issue around dental safety was featured on a number of different, like the Today Show and some other national shows. There was an article in one of the oral surgery journals that basically said if they were no longer able to charge for the anesthetic portion of dental implants, it would no longer be lucrative for them to do dental implants. So I think we have to keep that in the back of our mind. It's really hard. We're all humans. I am not being judgmental at all about this because I know I will be the same way. If I've been told that what I'm doing is as good and I haven't had a problem so far, assuming that the majority of people are not having problems. This isn't like, you know, it's nationally one death in about 300,000 or one in every four to six weeks. I, as an oral surgeon, personally may have never had a problem. And it would be a huge, huge financial burden if I stopped doing this. Why would I stop doing it? And again, I'm not, you know, I think there needs to be more education. And I don't think that it's entirely impossible to make this safer within the dental or within oral surgeons' offices. I just think it's gonna require a lot of changes that so far I think a lot of people are not willing to look at.

SPEAKER_00:

And I know we have touched on some of this already, but what do you hope to see going forward when it comes to safe dental anesthesia? What do you think it's gonna take to make sure that no one is harmed by anesthesia for dental procedures in the future?

SPEAKER_01:

So, what I would like to see is a really robust database that that will do, you know, something like MPOG that was set up in Michigan where institutions, practices voluntarily submit all of their information on every sedation they do. There are there are some really good examples of this. The Pediatric Sedation Research Consortium is one that takes, it's multidisciplinary. It's anybody who does sedation in children and volunteers to be part of the group. So you have to be, you know, you have to sign up. But once you're part of that group, you submit every, you submit, you know, a report on every single sedation done within your institution, your office, your, you know, your practice, wherever that happens to be. It includes some dental offices, but it's primarily hospital and clinic based, I would say. And it, you know, it's it's actually not that many anesthesiologists, it's mostly ED, critical care, you know, others. And I would love to see some kind of robust database like that. We actually presented a very simple, stripped-down version of the tool that was used to gather data through the pediatric sedation research consortium that dentists could use. It would be an app that was available on their phone, it could be on their computer, on an iPad. It took less than three minutes to complete, and it would be for every single sedation that was done and then submitted to the database holders, which at the time it was the University of Dartmouth who had volunteered to kind of be the holder of all the data. And that would allow, I think, us to see where the systemic issues are. So one would be a really robust database to help determine systemic issues. Two is I would really like personally that all deep sedation and general anesthesia is cared for by a separate provider. And that again could be a physician, it could be another oral surgeon, it could be another dentist with a license, it could be a cRNA who's allowed within their states, you know, whatever, to do that. I think moderate and mild, I would also like the terminology to be the same as the ASA's terminology, and for the protocols and guidelines and policies to follow the ASA's, meaning that there needs to be heavy emphasis on recognizing and rescuing the next deeper level of sedation. So that's what I would really like to see because the bottom line is if you can bag mask, especially in children, that's almost always, that's like 99% of the cause of problems in almost all patients. And there's exceptions, of course, and I'm not saying that there isn't, but if you just know how to bag mass effectively, you can keep a patient alive until emergency services can arrive to help, you know, do further level of care. So that's what I would really like to see as much more robust rules and regulations. I'd like to see consistency across different states so that the same requirements for emergency medications and emergency supplies and emergency training is similar across the board. I think anywhere that provides any kind of sedation should be doing some sort of simulation training with mannequins and with, you know, again, how do you recognize, how do you treat, and how do you ventilate a patient who's in trouble? And that should be done on a regular basis, whether that's yearly or, you know, biannually, whatever, you know, whatever. It depends a lot, obviously, on what kind of sedation they're doing and that kind of stuff, but it should be done at a regular basis.

SPEAKER_00:

And what's next for your research or projects?

SPEAKER_01:

So we just published the paper on why do deaths and catastrophic injuries still occur in the dent in the dental office. And we're gonna we're working on this the similar group of us, uh, and we brought together, so it's myself, a member of the ASA's QI quality improvement committee. It's a dentist anesthesiologist and someone who works in one of the big who provides a lot of mobile dental anesthesia care in practice. One of my colleagues and who's a pediatric anesthesiologist who, because of Caleb's law, basically now also does private, independent dental anesthesia care. I and I I'm not 100% sure. I think he has an office that he rents, that he does a lot of care, but he also travels to individual offices, but he's an independent provider. So we have a group of people, and we're working on writing another paper for anesthesia analgesia, which fingers crossed it'll get accepted, kind of on the topic to try and continue to raise awareness. It's difficult to know from an advocacy lens where to go next because of the fact that it is state by state. And so we really need champions within individual states to help take this to the next level. So that's really going to be our next, I think, next goal is to try through the efforts like this with the with this podcast and with that paper to bring in additional support.

SPEAKER_00:

Oh, well, that's great. We will have to stay tuned for that article in the future. And we hope that any listeners to the show who are interested in this area can maybe start to work as being a champion in their state or learning more about this issue. Is there anything else that you want to share that we have not talked about already today? We've talked about a lot.

SPEAKER_01:

Um, I think the one final thing I want to say is that as much as it seems like I'm blaming this solo sort of oral surgeon, dentist, anesthesia practitioner who's doing the procedure as well as providing the anesthesia, I know that it's deeper than that. And that's why I feel so passionately about we really need to bring in people from all over and from all walks of life to really tackle this issue because it's clearly not just that issue. And we know that there's office-based anesthesia occurring around the country for other things, and this doesn't seem to be happening in the same in the same way. It it may be, and we're just not hearing it because a lot of what we hear about is through the media, and so there's no it literally is. I mean, people could be dying left and right. I I don't think they are. I'm just gonna say, but we're not hearing about it unless the media gets a hold of it. So I really Really, you know, kind of implore listeners to listen out for these events. If patients are coming in, if they get patients transferred to their hospitals that have been uh exposed to or had a problem with the dental office, you know, with the dental sedation, to maybe let us know. And to, you know, anyone who has ideas on how to move forward with this and how to try and make this safer, please again let me know.

SPEAKER_00:

I can include some of your contact information in our show notes too, so people know how to get a hold of you. Yeah, beautiful. Yes, I would love that. All right. Well, thank you so much for joining us on the show today. Thank you so much for having me. Thank you so much to Dr. Agerwall for joining us on the show today and for your work on adult and pediatric patient safety during dental procedures. We are looking forward to a future where no patients are harmed during sedation for dental procedures, and we can continue to advocate for patient safety and collaborate to help improve and maintain patient safety going forward. If you have any questions or comments from today's show, please email us at podcast at apf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apf.org for detailed information and check out the show notes for links to all the topics we discussed today. Before you go, we hope that you will take a moment to like, review, and share the Anesthesia Patient Safety podcast with just one colleague, trainee, or team member. Our listeners are increasing every year, and we are already looking forward to bringing you the best in perioperative and anesthesia patient safety in 2026 and beyond. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.