Morbidity and mortality from pharmacosedation and general anesthesia in the dental office

Abstract

Morbidity and mortality (M&M) statistics have been used to determine the safety of pharmacosedation and general anesthesia for dental procedures. Although relevant, these data often do not describe what actually caused the problems. Descriptive data are needed to understand etiologic factors and to accurately set malpractice insurance rates, establish legislative regulations, and determine means of prevention. The purpose of this study was to characterize the factors involved in causing M&M in a national data base of dental patients who received either pharmacosedation or general anesthesia. Letters were sent to all state dental boards requesting detailed information on cases associated with M&M during the last 15 years. Follow-up letters and telephone contacts were made with noncompliant boards. Forty-three cases were reported from nine states, with mortality comprising 81.4% of the cases. The mean patient age was 18 years, with a range from 2 to 42 years. Seventy-five percent of the cases were classified as American Society of Anesthesiologists (ASA) class I, 21% as ASA II, and 4% as ASA III. The mean number of pharmacological agents used was three, with a range from one to seven. In 32% of the cases heart rate was monitored, in 23% respiration was monitored, in 23% blood pressure was monitored, in 8% tissue oxygen saturation was monitored, and in 4% heart rhythm was monitored. Fifty-nine percent of the practitioners performed basic life support as a part of resuscitative efforts, 21% performed some measure of advanced cardiac life support, and in 45% of the cases narcotic reversal was attempted. Forty-five percent of the practitioners were oral and maxillofacial surgeons, 37% were general practitioners, 15% were pediatric dentists, and 4% were periodontists. The data generally characterized the M&M as occurring in young, healthy patients in whom multiple pharmacological agents were used with limited monitoring and resuscitative efforts. No significant differences were found between specialists and general practitioners or between general anesthesia and pharmacosedation with respect to the number of M&M cases, patient age, gender, ASA classification, the type of patient monitoring, resuscitative efforts by the practitioner, or state board verdicts. General anesthesia cases involved a greater number of pharmacological agents ( P < .05), more often included barbiturates ( P < .05), and were more likely to have some form of patient monitoring compared with pharmacosedation cases. General practitioners used significantly more routes per case ( P < .05), whereas specialists were more likely to have monitored cases, monitored more physiological parameters, and provided more thorough resuscitative efforts than generalists. Board penalties tended to be lenient, with 60% of the dentists receiving either probation or license suspension. Specialists were more likely to have their license suspended ( P < .05), whereas general practitioners were significantly more likely to have their license revoked ( P < .05).