July 27, 2012

Must-Ask Questions Before Your Kid Undergoes Dental Anesthesia

Regular readers of this blog and our companion blog on patient safety are familiar with our concern about medical providers that are as interested in beefing up their receivables as they are in delivering high-quality care. Doctors with financial interests in medical testing equipment, for example, and pharmaceutical companies that promote their drugs for uses beyond that which the FDA has approved deserve our disdain.

Now, pediatric dentistry has come under the scrutiny of ABC News, and parents should be aware of the stories it’s telling.

Some inadequately trained dentists seeking to enhance profits, the network reports, sedate their young patients inappropriately for treatments as simple as teeth cleaning. More than a dozen children have died after being sedated by dentists, according to the Raven Maria Blanco Foundation, an organization founded by the parents of an 8-year-old who died after a routine dental appointment. The foundation’s mission is to alert parents to the potential dangers of the increasingly widespread use of oral sedatives on patients as young as 18 months.

Dental oversight is disjointed – there is no standard certification for the administration of oral sedatives, and state regulations vary. Some states require only a weekend course for dentists to be certified. There is no national registry of dental deaths, and many deaths may go unreported or not attributed to dental sedation.

Raven Blanco died after her dentist, Dr. Michael Hechtkopf, gave her "three times the average range" of sedatives, according to the Virginia Board of Dentistry. Five-year-old Diamond Brownridge died after being sedated before having cavities filled and teeth capped. Her dentist, Dr. Hicham Riba, administered an excessive dose of sedatives and demonstrated no understanding of conscious sedation, according to the Illinois Board of Dentistry.

Parents, of course, want to spare their children the discomfort of medical procedures if they can. Dental professionals say sedation for routine procedures can make it safer to work on young, anxious patients who make it difficult or dangerous to use high speed drills and other equipment. The well-meaning combination can spell danger.

Extensive training is required to learn how to administer sedation safely and be prepared to deal with emergencies. Dr. Norbert Kaminski told ABC "This is something that is being presented to the practitioners, the dental community, as a very easy thing to do, and nothing could be further from the truth." Kaminski is a dental anesthesiologist who has sought tougher standards for dentists who use sedation on patients.

In the last five years, the news network said, more than 18,000 dentists across the country have taken weekend courses in oral sedation in local hotel ballrooms that promise to add tens of thousands of dollars to the bottom line. That isn’t what Kaminski has in mind.

"Pain-free dentistry can mean tens of thousands of dollars of extra income in your pocket annually, and as much as half a million extra in your pocket at retirement," wrote Dr. Michael Silverman, a dentist and entrepreneur whose company offers the weekend seminars. American Academy of Pediatric Dentistry spokesperson Dr. Indru Punwani told ABC that a weekend course is "inadequate" for preparing dentists to deal with emergencies that can arise through the use of oral sedatives.

To protect your child against careless, ill-informed or greedy dentists, ask these questions provided by the American Dental Association (ADA) about sedation or anesthesia for children.

Before the procedure:

  • Who will provide the pre-operative evaluation of my child including past medical history such as allergies, current prescription medications and previous illnesses and hospitalizations?

  • How long should my child should be without food or drink before the procedure? Are there exceptions for certain medications?

  • Will any sedation medication be given to my child at home before the appointment and, if so, how the child be monitored?

  • What training and experience does the sedation/anesthesia professional have in providing the level of sedation or anesthesia that is planned for the procedure? Does this training and experience meet all of the standards of the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists?

  • Does the assisting staff have current training in emergency resuscitation procedures, such as Basic Life Support for Healthcare Providers and other advanced resuscitation courses as recommended by the ADA guidelines? How often is the training regularly renewed?

  • Does the state dental board require a special sedation/anesthesia permit or license to administer the sedation/anesthesia you plan to use?

  • In addition to the use of local anesthesia (numbing), what level of sedation or general anesthesia will be given to my child? Is it minimal sedation (relaxed and awake), moderate sedation (sleepy but awake), deep sedation (barely awake) or general anesthesia (unconscious)?

  • How will my child be monitored before, during and after the procedure until the child is released to go home? Are the appropriate emergency medications and equipment immediately available? Does the office have a written emergency response plan for managing medical emergencies?

After the procedure:

  • What are the instructions and emergency contact information if I have concerns or complications after returning home?

If the answers are incomplete or unacceptable, find another dentist.
Link here for information provided by the Raven Maria Blanco Foundation, and here for our recent story about good oral health for infants.

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September 15, 2011

Keep Your Pliers Off My Kid's Wisdom Teeth!

That could be the modern parent's mantra, faced with the too common advice from dentists that a teenager should have healthy wisdom teeth removed "before they cause trouble."

Trouble is that the best evidence is that most wisdom teeth, impacted or not, never cause trouble to a young adult. And if and when they do, there is plenty of time to remove them when they send pain signals or show other signs of a real problem, and no downside to waiting until that day. Taking out healthy wisdom teeth causes, at a minimum, days of pain and need for heavy duty medications like Tylenol with codeine, and at a maximum, complications like loss of smell or taste.

Not to mention the considerable cost of paying oral surgeons and dentists to extract wisdom teeth.

The American Public Health Association says prophylactic removal of wisdom teeth injures tens of thousands of patients a year at a cost of billions of dollars. That's billions with a B.

Here is the APHA statement reviewing the scientific evidence on removal of wisdom teeth.

The only health group that supports removal of wisdom teeth before any pain arises is, you guessed it, the association of surgeons that do all the work: the American Association of Oral and Maxillofacial Surgeons.

Read more in a recent New York Times article by a thoughtful parent who ultimately concluded, after doing her own research, that "watchful waiting" was the way to go for her teen daughter.

And here are two dentists writing letters to the Times saying they agree based on their own experience that it's better to hold off and not rush into removal of wisdom teeth before you really need to.

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July 5, 2011

Good Oral Health Starts in Infancy

Pop quiz: Which of the following promote tooth decay?

(A). sugar;
(B). genetics;
(C). low immunity;
(D). watching "American Idol."

The correct answer, of course, is "all of the above" ... with a qualifier for (D). (You have to be snacking on Raisinettes or another sticky fruit while watching the show.)

Although sugar remains the primary suspect in the creation of cavities, people can be genetically disposed toward tooth decay, and low immune function can contribute, as can dietary habits generally considered healthful--sticky fruits such as raisins, although preferable to sucking on a Popsicle, also leave teeth vulnerable to the ravages of sugar residue.

So what can a concerned parent do?

It's hard enough for parents to control so many factors conspiring to turn their kids' mouths into a gaping maw of dental disaster, but now there's something else to consider. According to the Los Angeles Times, several studies have shown that cavity-causing bacteria can be passed from primary caregivers to wee ones.

Children are most susceptible as infants and toddlers, when their immune systems are works-in-progress. But any age before children have the motor skills necessary to brush well by themselves requires parental invervention for maximum protection.

If you want to hold the line on sharing the bacterial love that can compromise your child's oral health not only as a youngster but after the arrival of permanent teeth and into adulthood, first take care of yourself. Expectant mothers should address any dental decay or gum problems before Junior arrives to reduce the likelihood of transmitting disease. And the use of an antibacterial mouthwash during the lower-immune period of infancy and toddlerdom might be wise.

In addition, the dentist should become a close, personal friend of your child probably earlier than you expect. Measures you should take include:

  • schedule the first visit to a pediatric dentist at the time the first tooth appears or by the first birthday;

  • limit the contents of bottles and sippy cups to water except at mealtime;

  • limit snacking to a short interval--bacteria like any kind of sugar, whether from fruit, milk, honey or the refined white sugar in candy;

  • assist your child with tooth-brushing until he or she is old enough to tie shoes or write cursive--generally 7 to 9 years old.

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