In Texas a dentist can get a permit to sedate patients without ever even practicing – under supervision – on a patient first.
Can’t believe it? Well, how about the fact that an anesthesia training course lasts just eight hours and can be fitted in on a weekend?
Recently we reported the unsettling case of Nevaeh Hall, the four-year-old who walked into a Houston dental office in January, and left it in an ambulance rushing to an emergency room after the sedation procedure went seriously awry and she was deprived of oxygen.
The dentist, Dr. Bethaniel Jefferson, was in good standing with the Texas State Board of Dental Examiners and had an up-to-date permit allowing her to sedate patients in her office when the four-year-old child was entrusted to her care for treatment. It had taken Jefferson only eight hours of continuing education courses to get her level two sedation permit, according to Jim Moriarty, the Houston lawyer who is representing Nevaeh's mother, Courissa Clark, in a lawsuit filed in state district court against Jefferson.
Following publication of the cover story, we decided to ask a few more questions about anesthesia and Texas dentists.
The qualification requirements to get a permit from the Texas State Board of Dental Examiners to sedate a patient can be met without even touching a real patient, says Dr. Roger Byrne, a Houston oral surgeon with more than 40 years' experience.
The training to keep a permit current is also lacking, Moriarty contends. “Her [Jefferson’s] training was laughable,” Moriarty told the Houston Press. “She had an eight-hour course over a weekend, and if you walked in alive and left the same way, you passed. Because of that she had a permit allowing her to sedate her patients. It shouldn't have happened.”
(We've asked the State Board of Dental Examiners to comment on this but haven't heard back. We'll update as soon as we do. We’ve previously made repeated requests for comment to Jefferson, without any response. We will update if we hear from her as well.)
There are four types of permits issued by the State Board of Dental Examiners for sedation and anesthesia, according to the state agency's website. (Level one allows one type of sedation drug; level two allows two or more; level three allows the dentist to use an IV; level four allows the use of sedation drugs and anesthesia drugs like Propofol.)
The level four permit is available only to dentists who have been trained to use anesthesia in school and to dental anesthesiologists, according to Byrne, who was hired by Moriarty as an expert witness for Nevaeh's case. However, the other permits can be obtained with continuing education classes and helping to administer sedation to a certain number of patients, Byrne says.
The trick is, the state qualification standards, as mandated by the American Dental Association, are not terribly stringent, Byrne says. For instance, it is required that a dentist should have 24 hours of classroom instruction to obtain a level two permit, but the state doesn't actually review the courses that are taught to ensure the dentist is actually learning everything he or she needs to know about safely sedating patients.
The dentist is also only required to participate in ten sedation cases. Of those ten cases, only three of the patients the dentist sedates have to be actual people, Byrne says. And the dentist can join up to five fellow trainees working as a group to learn how to properly sedate a patient.
“If you have a dentist who does ten cases where seven of them are virtual reality, and the dentist is working in a group of five and they only see three live patients throughout their training, it's entirely possible that a dentist could do everything required in the training, get the permit, start doing sedation and never have actually sedated a real patient until they start doing it on their own,” Byrne says.
There are some protections in place. Dentists with level two, three or four permits are not supposed to sedate children under 12 or sick adults unless they have been certified in basic life support, advanced cardiovascular life support and pediatric advanced life support. But again, Byrne says, it's about the details. A dentist takes a continuing education course and obtains a permit, but the permit doesn't say anything about what exactly he is permitted to do, Byrne says. “It's just been a cluster of mistakes all around the state, because the board doesn't have leadership,” Byrne says.
The root of the problem stems from the State Board of Dental Examiners itself, Moriarty says. The board, a state regulatory agency created in 1897 to license dentists in Texas, oversees the more than 8,000 dentists in the state, according to the 2015 U.S. Bureau of Labor Statistics report. The board is chronically underfunded, understaffed and struggling, according to a recent report on the board issued by the Sunset Advisory Commission, the state entity charged with reviewing state agencies to see that they are being run correctly.
The dental board has come under frequent fire from the Sunset Commission over the years. First it was summarily abolished during its Sunset review in 1993 because of a legislative skirmish the board had been dragged into. It was revived in 1995, but was then placed under another Sunset review in 2003 because there were concerns about “serious enforcement deficiencies” according to the Sunset Commission report issued in April 2016. The State Board of Dental Examiners has been undergoing a review this year as well, and once again it has been found wanting, especially when it comes to how the agency handles anesthesia permits.
In April, the Sunset Commission staff report found that there have been 112 complaints concerning anesthesia administered at dentist offices across the state between 2012 and 2015. Of those cases, 41 resulted in the death of a patient tied to some component of anesthesia, according to the report. (Keep in mind that the Florida state legislature instituted a moratorium on using anesthesia in medical offices after learning about 40 anesthesia-related deaths in Florida doctor offices.)
The State Board of Dental Examiners has a number of other concerns – the agency has a backlog of cases and is only now dealing with complaints filed in 2013, and the agency is still working from paper case files instead of electronic records, as was noted in the agency's September 2015 self report to the Sunset Commission – but the anesthesia permitting problem was still third on the Sunset Commission's list of issues to be addressed and remedied. The staff report spelled out the commission's findings and concerns:
“In recent years, the board has seen an increase in related complaints involving serious patient harm and sometimes death [due to anesthesia]. The board lacks the authority and resources to routinely inspect the offices of dentists providing some anesthesia services and does not require written emergency action plans for any dentist administering anesthesia to help ensure thoughtful planning and readiness for the unexpected."
The report also advocated allowing the board to conduct inspections of dental offices where anesthesia is performed.
In August, the Sunset Commission came out with its decisions on the issues raised in the staff report. The commission decided to deal with the anesthesia and sedation issues by doing the following:
- Authorizing the board to inspect dentist offices where anesthesia is being administered in addition to allowing the board to give permits and establish minimum education standards and training requirements.
- Directing the board to revise its rules to ensure dentists with anesthesia permits have written emergency management plans.
- Create a five- to ten-person “blue ribbon panel” to review data on anesthesia over the last five years and to examine emergency protocols in dental offices. The committee will also review how dentists are permitted, educated and trained to administer anesthesia to adults and children.
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The panel met at the end of August and is scheduled to report its findings to the state legislature on January 11.
At the August State Board of Dental Examiners meeting, the board proposed the new rule suggested by the Sunset Commission requiring written emergency plans. The board also announced that it is hiring an anesthesia permit specialist. On top of all that, despite the "blue ribbon panel" tasked with taking on this issue, the agency's regular anesthesia committee is also going over the anesthesia issues raised by the Sunset Commission and is scheduled to report to the board in November. It seems the Sunset Commission's instructions have sunk in with the board and agency officials.
But for now, the old system is still in place. Currently, dentists are not required to have a written emergency plan. There's no funding to hire inspectors to check out dental offices and make sure dentists are performing sedation according to the rules. The state legislature may decide to kick some funding to the board to allow more office inspections when state lawmakers convene in January, but right now, inspectors go to a dental office only when a complaint has been filed. This leaves patients vulnerable, Byrne says.
“Jefferson had already had two complaints dealing with sedation before the board," Byrne says. "She was on the phone praying with her pastor about this, and she was calling the pharmacist asking what to do about it, never realizing the girl was in hypoxia. They gave the girl water and Nevaeh threw it up. The girl got cold and they tried to warm her up. Jefferson went about her day while they left Nevaeh to rest; she treated other patients. Based on her actions, Jefferson still thought that girl was going to wake up and be normal. It doesn't sound like she had any idea. That's the most troubling part of all of this.”