By Anne Blythe
A widow’s push to change the sedation rules for North Carolina dentists has struck a nerve in the dental profession.
The North Carolina State Board of Dental Examiners has been considering a proposed rule change that among other things would require dentists and oral surgeons to have a certified registered nurse anesthetist (CRNA) or an anesthesiologist in the room any time a patient is put under deep sedation.
Bobby White, chief executive officer of the board, said recently that such a prospect not only had inspired rigorous debate, it also prompted a robust response during the comment period that is part of the process for any proposed rule change.
“We got thousands of pages of documents,” White said. “That’s the most by far we’ve ever received.”
The comment period closed in early March, but White said he did not expect the board to revisit the issue at the meeting slated for May 18 and 19 at Sunset Beach.
Not only do the eight board members have to slog through all the comments and related documents for and against the change, but an advisory panel also needs to review them and offer guidance on what and how to move forward. It could be at least another month or two before the next steps occur.
The root of the proposal
The proposed rule change came after the death of Hemant “Henry” Patel in New Hanover County in 2020.
Patel, a cardiologist with ties to the New Hanover Regional Medical Center, had gone to Austin Oral and Maxillofacial Surgery for a tooth implant procedure that led quickly to his death.
Mark Austin, head of the oral surgery practice, administered anesthesia to Patel, who was 53 at the time, before and during a procedure that Shital Patel, the wife of the cardiologist, was told would last about 20 minutes.
Toward the end of the procedure, Patel’s oxygen saturation levels and heart rate dropped to dangerously low levels and he remained in that life-threatening stage for at least 20 minutes, according to a dental board order in which Austin agreed to permanently surrender his North Carolina dental license.
The order also cited Austin’s ongoing use of controlled substances that were present in his office, including the powerful opioid fentanyl. The document also cited him for improperly providing the drugs to employees.
Before calling 911 for help, Austin attempted to open Patel’s airway, but could not successfully insert an endotracheal tube, according to the order. Austin did not attempt CPR or take any other actions to try to restore a healthier heart rate, investigators found. Paramedics were able to open Patel’s airway and restore enough of a pulse to transport him to New Hanover Regional Health Center.
Patel died four days later from a brain injury related to lack of oxygen.
Shital Patel teamed up with others including Sen. Michael Lee, a Wilmington-based Republican, to advocate for changes to the sedation rules so it would be less likely any other family has to undergo what hers did.
Such experiences are rare. Since 2014, six sedation-related deaths have occurred in North Carolina dental offices, according to White.
Where’s the science?
That’s what oral surgeons underscored as they explained to the board why they thought requiring the presence of an anesthesiologist or certified registered nurse anesthetist (CRNA) to be present for procedures involving deep sedation went too far for such a small number of fatal incidents.
Dentists routinely sedate patients who struggle with dental anxiety by using drugs to minimally depress the central nervous system. That way a person can breathe and respond to verbal instructions without feeling jittery about teeth cleanings and other procedures.
Moderate sedation is when a patient remains awake and can follow the dentist’s instructions without having their airway supported. When a person is put into deep sedation they are on the verge of consciousness and can be awakened, but airway assistance is necessary.
Oral surgeons in North Carolina contend that if the rule change goes forward, it could be cost-prohibitive to hire an anesthesiologist or CRNA and result in higher prices and hardships for patients.
The North Carolina Dental Society, a professional and lobbying organization for oral health care providers, issued a statement earlier this year opposing the requirement for an anesthesiologist or CRNA to be on-site in dental offices for the administration of deep sedation.
“There is no scientific evidence to support that the proposed rule change would enhance patient safety or decrease adverse events occurring in the administering of sedation for dental care,” Alec Parker, the society’s executive director, said in a statement emailed to NC Health News.
“If the rule is passed, there would be increased costs of a separate dental anesthesia provider and the supply of medical and dental anesthesiologists and CRNA’s is not sufficient to meet the need in North Carolina, particularly in rural areas,” his statement continued. “In addition, North Carolina would be the only state in the country to require a separate anesthesia provider, if the rule is approved.”