Early childhood cavities (ECC) is the single most common chronic childhood dental disease. In the treatment of ECC, children are often sedated under general anesthesia. An estimated 100 000 to 250 000 pediatric dental sedations are performed annually in the United States. Many of these procedures are not necessary and are performed by “suspect” children’s dental clinics under the auspices of treating the caries aggressively to stay ahead of the game. As we see below, most times, it is not worth the risk of general anesthesia complications to perform restorative work on a child’s baby teeth.
In 2016, the American Academy of Pediatric Dentistry (AAPD)1 announced, “Because restorative care to manage ECC often requires the use of sedation and general anesthesia with its associated high costs and possible health risks, and because there is a high recurrence of lesions following the procedures, there now is more emphasis on prevention and arrestment of the disease processes.” The AAPD’s policy statement goes on to enumerate methods of chronic disease management, active surveillance, and interim therapeutic restorations and states, “Non-surgical interventions should be implemented when possible to postpone or reduce the need for [previously accepted] surgical treatment approaches.”
A common rationale for aggressive surgical treatment with sedation or general anesthesia has been the vastly overstated association between tooth decay in primary teeth and subsequent decay in permanent teeth. In fact, this connection is modest, with the relative risk ratios ranging from 1.4 to 2.6.2,3 One reason the association it not strong is that the shedding of decayed primary teeth eliminates sites for bacterial colonization in the mouth and thus reduces risk of caries in the permanent dentition. The loss of primary teeth with replacement by permanent teeth is a normal developmental process that requires no professional intervention.
The following case, as relayed by the AAP shows why it is simply just too risky to place a child under general anesthesia to work on baby teeth cavities. In other words the risk is simply too great to justify the reward (i.e., filling a cavity in a baby tooth that is going to be lost by the child in a short amount of time anyway):
A 4-year-old boy presented to a dentist’s office for treatment of rampant ECC. The dentist is a pediatric dentist and his clinic specializes in treating young children with severe caries. The dentist has a license to provide moderate sedation, and his staff is certified in pediatric advanced life support.
The mother reports that the child complains of pain while eating and occasionally wakes up in the night because of tooth pain. Previous visits to the family’s regular dentist are difficult because the child has behavioral issues and is uncooperative with oral examinations. The family’s dentist is able to determine that the child has decay affecting his front teeth but is unable to provide treatment because of the child’s behavior. The family’s dentist does not feel comfortable sedating children and therefore refers the child to a pediatric dentist. Because of the child’s clinical symptoms, there is concern for extensive disease affecting the child’s molars. The family dentist explains that a pediatric dentist is trained to treat a child’s cavities with the aid of anesthesia.
The pediatric dentist recommends moderate sedation in the office to perform a thorough examination and treat decay. A separate provider, the dental assistant, provides sedation and monitors the child during the procedure. The child is given an oral dose of the sedative midazolam and inhaled nitrous oxide. He requires an extra dose of the midazolam sedative because of his inability to tolerate the procedure.
After the procedure, the dentist leaves the child in the recovery area to speak with the mother about the procedure. The recovery area is staffed by a dental assistant, who clinically monitors children recovering from sedation. When the mother and dentist arrive in recovery, the child is noted to be cyanotic. There is no pulse oximeter, and respiratory efforts are absent. The staff initiates cardiopulmonary resuscitation and calls 911. Paramedics initiate cardiopulmonary resuscitation, but the child is pronounced dead on arrival at the hospital.
In the field of dental malpractice, one can never make a blanket statement that something is malpractice without first understanding the entire situation and fully reviewing all of the available information including but not limited to all of the medical and dental records, all radiographs and any and all facts that can otherwise be gleaned about the situation from eyewitnesses, relatives, the dentist and all staff involved in the care and treatment at issue. However, there have been way too many cases of child deaths from anesthesia related complications after being put to sleep to have baby teeth worked on. The literature in the field, including the article cited above is slowly catching up with this horrendous trend of over-treatment of children resulting in death. This is a great start, but more must be done to shine a light on the pediatric dentist offices who specialize in filling cavities in children’s baby teeth.
For almost 25 years, Attorney Robert J. Fleming has been handling wrongful death cases, dental malpractice and medical malpractice lawsuits for individuals and families who have been injured or died as a result of the negligence of others in and around the Atlanta, Georgia area. He is a partner in the law firm of Katz Wright Fleming Dodson & Mildenhall, LLC and regularly handles cases in Atlanta as well as Alpharetta, Brookhaven, College Park, Duluth, Decatur, Doraville, Johns Creek, Jonesboro, Lawrenceville, Norcross, Peachtree City, Riverdale, Roswell, Sandy Springs, Stone Mountain, Smyrna, Peachtree City, and other cities in Georgia. If you or your child has been seriously injured or died as a result of dental care and would like quality legal representation or if you would just like to consult about a potential case, contact Robert J. Fleming directly on (404) 525-5150 or contact us online.