Is Conscious Sedation Safe?

There was an article last month in the New York Post about an incident here in Arizona where a patient died from complications after dental implant surgery. From reading the article and the comments readers made, I could see there were some erroneous conclusions being drawn that I felt should be corrected.

The article mentioned that the patient was “an avid gym-goer,” giving the impression that he was in top health. However, deeper research reveals that this was a compromised patient and there were several risk factors that were instrumental in helping cause his death.

The Post article and a similar one on the website of ABC15, the Phoenix ABC affiliate, also didn’t get into specifics on the level of anesthesia or sedation administered. That is a principal safety issue and needs to be explored and explained in order for the public to form educated opinions about what should be done. Just saying “anesthesia” doesn’t tell us much. Local anesthesia is anesthesia, and general anesthesia is also, but they are vastly different.

Finally, knowing what the Arizona Dental Board did about this case will clarify what happened and what further remedial actions, if any, need to be undertaken.

First, let’s explore the level of anesthesia that was used. To help with that, I looked up the website of the oral surgeon. There they list a full spectrum of levels of anesthesia that they offer:

• Local anesthesia
• Nitrous oxide sedation
• IV sedation, which they call “twilight sedation”
• General anesthesia administered in the office
• Hospital-based general anesthesia

With information from other research I did on this case, I’m pretty sure that this patient was given general anesthesia administered in the office. That is the riskiest level of anesthesia on the list, much riskier than IV sedation or oral sedation. (This practice doesn’t offer oral sedation. All of their conscious sedation cases receive and IV.) Most dentists who offer sedation to their patients offer oral sedation, which is extremely safe. I would argue that sedation is considerably safer than trying to use just local anesthesia (novocain alone) on an anxious patient. Serious dental emergencies, such as a stroke or heart attack, would be more likely to occur if a patient isn’t calmed by either conscious sedation or nitrous oxide sedation.

Then, the key to the case were the risk factors. To get further information, I found an article in an online publication for dentists, Dr. Bicuspid. They said that their investigation revealed that there were several risk factors in the case, including that the patient had smoked cannabis before his appointment. They suggested other risk factors but cannabis is the only one they mentioned. Cannabis can raise the risk of throat spasms that can close off the airway during anesthesia. They faulted the dentist for not knowing that, but the dentist protested that the patient didn’t appear impaired as they prepared him.

The Board ruled that in this case there were several deviations from the standard of care, specifically that the oral surgeon didn’t consider the patient’s risk factors, including his use of cannabis. They required him to take 12 hours of continuing education, after which his anesthesia permit was restored.

Attached to the Dr. Bicuspid article were some comments by dentists, some of whom complained that the punishment was little more than a slap on the wrist for a serious offense. However, we don’t know important details here which would help determine whether that was fair or not. Did they come to the conclusion that the patient bore much of the responsibility here? Maybe he even ignored warnings given him prior to surgery not to take any medicines or drugs beforehand. We just don’t know. I got an email from a patient recently who asked if he should tell his oral surgeon that he was on methadone. He mentioned that he was afraid that the surgeon would turn him down as a patient. “I feel as if I don’t want to tell them but I’m afraid not to tell him because I don’t want to die during dental implant surgery you know,” he said. While the dentist clearly bears some responsibility here, common sense would suggest that taking something like methadone or cannabis should be disclosed before general anesthesia. I checked the medical history forms on the surgeon’s website, and, while cannabis use wasn’t mentioned directly, there were clear directions to disclose the use of any drugs.

In conclusion, to answer the question in the title, yes, dental conscious sedation is extremely safe. This scary incident reported in the mass media is under a very different category—dental general anesthesia