NC Dental Board approves anesthesia changes, stops short of requiring separate anesthesia provider

The North Carolina Dental Board has approved changes to General Anesthesia and Sedation Rules meant to improve patient safety.
Published: Sep. 12, 2022 at 11:33 AM EDT
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RALEIGH, N.C. (WECT) - The North Carolina Dental Board has approved changes to General Anesthesia and Sedation Rules meant to improve patient safety. The changes come in the wake of outcry over the death of a prominent Wilmington cardiologist, who passed away after being over-sedated during a routine dental procedure in 2020.

Despite a loud push for the dental board to require a separate anesthesiologist or certified registered nurse anesthetist (CRNA) be present when a patient is sedated for dental procedures, the board declined to adopt that change. That safeguard is already required for most medical procedures requiring patient sedation, but dental providers who are licensed to perform anesthesia are permitted to simultaneously administer anesthesia and operate on a patient.

“The Dental Board considered moving toward the medical model but revised this proposal based on many comments received during the comment period,” the Dental Board said in a statement sent to WECT on Monday.

There were several arguments against the medical model. Dentists said the cost of implementing such a requirements would make dental care cost prohibitive for many patients. While this was not a central focus of the dental board when considering the rule revisions, they did express concern that there are simply not enough anesthesiologists and CRNAs available to oversee then tens of thousands of dental procedures performed under sedation each year in North Carolina.

The Dental Board also heard pushback from the deans of two North Carolina dental schools. If the change had been implemented, North Carolina would be the only state in the country following the “medical model” for sedation rather than the dental model, and it was uncertain if the new model would be acceptable to dental regulators.

“...UNC and ECU residents would not be eligible to provide deep sedation, moderate sedation or pediatric moderate sedation as required by CODA [Council on Dental Accreditation] for accreditation, which could be a fatal blow to our programs... It would seriously cripple our ability to train residents in multiple specialties and ultimately negatively affect access to care for the citizens of North Carolina,” the deans said in a joint comment to the Dental Board.

Critics of the change questioned whether the medical model was notably superior to the dental model, citing several studies analyzing anesthesia related deaths in medical settings. According to a 2009 National Institutes of Health study, which reviewed deaths in hospitals and other medical settings between 1999 and 2005, complications from anesthesia caused or contributed to 2,211 deaths during that time period, even when a designated anesthesia provider was present.

The dental board would also like to see more training offered to dental assistants specifically focused on airway management and patient management, so that if a patient were to suffer distress during anesthesia, it would be recognized more quickly and staff would have more training to help stabilize the patient.

While they stopped short of recommending a separate anesthesia provider, the Dental Board is recommending several significant changes aimed at improving patient safety.

They propose requiring capnography during anesthesia, a technology that monitors a patient’s breathing, level of sedation, and airway management to alert a dental provider in real time if a patient is in distress. The proposed rules would also impose maximum dosage limits for the use of certain sedation medications, and require reporting to the dental board any patient who suffered an adverse consequence during a dental procedure that led to them being admitted to the hospital within 24 hours. Currently, dental providers are only required to report deaths that occur within 24 hours, but in some cases, like the one involving Wilmington cardiologist Henry Patel, the patients are kept on life support for days before dying from anesthesia related complications.

“The board realizes that proposing rules that do not require the ‘medical model’ will come as a disappointment to many. We do not wish this decision to be viewed as a callous disregard of those who have died due to anesthesia mishaps in dental offices. We know that each person who passed away was valued, loved, and important to their family, friends, and the communities in which they lived, worked, and worshiped. This is especially true of Dr. Henry Patel about whom the Board received hundreds of comments highlighting his outstanding character and the breadth of his love and caring as a husband, father, friend, and physician. We extend our deepest sympathy to his and to each family,” the board statement read.

Dr. Patel’s widow, Shital Patel, has expressed disappointment in the board’s recommendation not to require a designated anesthesia provider be present during dental anesthesia in North Carolina. She said the proposed changes are moving in the right direction, and she is thankful for that, but they don’t even address some of her concerns about better regulating deep sedation.

The Dental Board noted that each of the recent deaths in dental offices occurred not because of weak or unenforced rules, but “primarily because the individual practitioners made extremely poor choices and were negligent in the practice of dentistry and emergency preparedness.” The board noted that in each instance where a death occurred, the licensee was disciplined. In the case of Dr. Mark Austin, the provider who performed the dental implant that resulted in Dr. Patel’s death, his dental and sedation licenses have been permanently revoked. The North Carolina Attorney General is weighing whether criminal sanctions in that case are appropriate after evidence surfaced about prescription drug abuse in Dr. Austin’s office.

The dental board also encouraged any patient who is concerned about going under anesthesia in a dental setting discuss those concerns with their dentist, and see if they could have a designated anesthesia provider on hand for their procedure. Preliminary research by the dental board indicates that nearly 25% of dentists already use a separate anesthesia professional when patients are sedated, and most will do so if the patient asks for one and is willing to cover the additional cost.

The revised rule proposals will be considered during a public comment hearing on November 16. Depending on the outcome of that hearing, the proposed revisions could be adopted as early as December.