Anesthesia in Alberta dental offices questioned after girl suffers brain damage

Alberta is one of just two provinces where dentists with specialized training both administer general anesthetic and perform a dental procedure on a patient, according to a CBC inquiry. The majority of provinces require at least two "operators" to do such work in an accredited dental office.

'A professional anesthesiologist has only one responsibility ... you look after that patient'

The standards for the administration of general anesthetic by dental professional varies by province in Canada. (CBC)

Alberta is one of just two provinces where dentists with specialized training both administer general anesthetic and perform a dental procedure on a patient, according to a CBC inquiry.

The majority of provinces require at least two "operators" be present in accredited dental offices to do such work — one person to deliver the sedative drugs and another to perform the procedure.

Last month, a four-year-old Edmonton girl was rushed to hospital after receiving general anesthetic at a downtown dental office. According to her family, the child stopped breathing for an unknown length of time and suffered permanent brain damage.

The details of what happened are now under investigation by the Alberta Dental Association and College, which has released no information about the incident itself. But the organization has said the dentist in question has had his privileges to administer general anesthesia and deep sedation suspended.

General anesthetic drugs are regularly used in non-hospital environments — from dental offices to rural medical facilities — by trained professionals who are not anesthesiologists.

But several anesthesiologists who spoke to the CBC noted they are trained to take on one particular task when a patient is "put under:" to keep that patient safe and to monitor and control breathing.

CBC contacted 10 provincial dental organizations to inquire about regulations for the administration of general anaesthetic by their members. All but New Brunswick responded.

Ontario is the only other province where dentists can take on both tasks, delivering anesthesia and performing a dental procedure (another professional, such as a trained nurse, must also be present).

But the Royal College of Dental Surgeons of Ontario is now revising its general anaesthesia standards, due to concerns.

Provinces set the rules

The CBC found variations among provinces when it comes to regulations for the administration of general anesthetic by dentists and oral surgeons. For example:

  • The Manitoba Dental Association currently does not permit any of its members to administer general anesthetic to children under 12.
  • The Dental Council of Prince Edward Island mandates that any case requiring general anesthesic be referred to a hospital.
  • In Newfoundland and Labrador, one operator is permitted to administer general anesthetic and perform a dental procedure but there is no record of dentists or oral surgeons putting that rule into practice. Registrar Larry O'Brien told the CBC: "I went through my records, and the only ones doing general anesthesia are doing it in hospital with an anesthetist ... no one is doing general anesthesia in the office."

The Royal College of Dental Surgeons of Ontario formed a working group three months ago to review its standards. The group is looking at issues such as recommended sedation dosages and guidelines on the time needed between appointments.

"We're also looking to see, when we come to deep or general anesthesia, whether there should be a separate operator or not," said registrar Irwin Fefergrad.

"Right now, there's no evidence that suggests there's a problem with it. But I'm not waiting for a problem."
Irwin Fefergrad is the registrar for the College of Dental Surgeons of Ontario, the group that regulates the province's dentists. (Provided)

Facilities that offer general anesthesia services are inspected annually for everything from record-keeping to equipment and drug supplies, Fefergrad said, adding he believes they have the best standards in dentistry in the country.

But standards must be reviewed about every five years. The college is doing this review early.

"You can't stay stagnant on a standard," Fefergrad said. "You've always got to look at the research and literature and update it. At the end of the day, we may well say we got it right. I don't think so. There will be changes. I just don't know what they're going to look like."

Fefergrad noted the college he leads is separate from the professional organization that represents dentists.

"My job is patient-first and acting in the public interest," he said. "Dentists understand that ... part of my job is to say, you have a body that looks out for your interests, that's called the association. I'm not that."

Little girl in long-term recovery

After being rushed from a downtown dental office to hospital last month, four-year-old Amber Athwal was recently moved out of the Stollery Children's Hospital and into the Glenrose.

Her parents have quit their jobs to care for her, and a Go Fund Me campaign has raised thousands of dollars. The family is considering using some of the money for alternative therapies. Her family says she has improved "very, very little."

Amber Athwal all dressed up for kindergarten orientation day and a trip to the dentist on Sept. 2. (Athwal family)

According to her family, Amber and her father arrived at Dr. William Mather's dental office on Sept. 7, after the office called to say there had been a last-minute cancellation.

According to the family, Mather was told Amber had eaten breakfast that morning. Family members say they are unclear about who was with the little girl either during the procedure or in recovery.

CBC News interviewed several anesthesiologists — physicians who have completed a minimum five-year residency in anesthesiology after their first medical degree. They say guidelines suggest no food be consumed in the hours leading up to the administration of general anesthetic. Clear liquids are sometimes permitted.

The risk is that regurgitated food could be aspirated into the lungs.

Dr. Saifee Rashiq is the interim chair in the department of anesthesiology and pain medicine at the University of Alberta. He noted that anesthesia is safely administered in many non-hospital environments. But he offered these questions to ask if a patient is going to be anesthetized outside of an Alberta Health Services hospital facility:

  • Who's going to be giving my anesthetic?
  • What kind of training have they done?
  • How many cases have they done?
  • What would happen if there's an emergency?
  • What are the backup procedures?

"Mission 1 for the anesthesiologist is to make sure the airway and the breathing continue without interruption," said Dr. Saifee Rashiq, interim chair in the department of anesthesiology at the University of Alberta. "At the moment we put someone to sleep, they lose the ability to cough things out of their lungs."

Rashiq could not comment on the specifics of Amber's case, or the standards set out by the Alberta Dental College and Association.

In an Alberta Health Services hospital, he said, anesthesiologists have one job: to concentrate on the patient in front of them.

"A professional anesthesiologist has only one responsibility, there are no exceptions: you look after that particular patient, and you're not supposed to be doing anything else."

If patients receive anesthesiology outside of a hospital, he suggested they ask several questions, including who will administer the anesthetic, what training they have, and what would happen in an emergency?

"A good facility will welcome these questions and have very ready answers for them."

The Alberta Dental Association and College did not respond to requests for an interview for this story. It has not indicated whether the results of the full investigation into the incident will be released.

Calls for transparency

Liberal leader David Swann has criticized the transparency of the dental college and said he wants more public information from the organization when it comes to any disciplinary action taken against dentists.

The medical and dental professions have been "given the privilege" of self-regulation, Swann said.

"It's always up to the discretion of the government of the day and the minister of the day to assess whether they continue to be functioning fully and in the public interest," he said. "That will be an assessment for Minister (Sarah Hoffman)."