CDA Essentials 2018 • Volume 5 • Issue 6

S upporting Y our P ractice 32 | 2018 | Issue 6 A comprehensive preoperative assessment is a vital part of forming an appropriate anesthetic plan. an opportunity to learn about how harm previously occurred, which could prevent future injury from happening to other patients if a clinician was to encounter a similar case,” adds Dr. El-Mowafy. “As a profession, it’s our responsibility to monitor our outcomes and that way we can take action to reduce the number of patient harm events to as close to zero as possible.” We asked Dr. El-Mowafy to tell us more about the study. What did your research find? The results of our study show that the prevalence of death is 0.8 per 1 million patient encounters, and the serious morbidity rate is 0.25 per 1 million cases. In comparison, previous data shows that the likelihood of dying from a motor vehicle crash is 1 in 113, and the odds of dying from being struck by lightning are 1 in 174,000. Patients should know that the risk of anything catastrophic happening is really very low, and healthy patients who have deep sedation or general anesthesia in the dental office seem to be at no more risk than they would be in a hospital. Howmany deaths or injuries does that translate to? We found there were three reported deaths and one case of severe morbidity in Ontario during the 20-year time period of our study. Two of these incidents involved pediatric patients. Also, we estimated that about 3.7 million deep sedations and general anesthetics were administered in Ontario for dental treatment in an office-based setting in that same time frame. Is deep sedation and general anesthesia less risky today than it has been in the past? If so, what improvements have made these procedures safer? The results of our study would imply that it is, although the differences in mortality are minimal from previous studies. A 1997 study 1 by Nkansah et al., found that the mortality rate was 1 death per 1 million cases, whereas our study found 0.8 deaths per 1 million cases—so we’re talking about a really small difference. However, one thing we know that has changed since that time is that safer medications are being used. Secondly, there has been an advancement in education. At U of T, the length of the anesthesia program has increased from 24 to 36 months. In general, the training style in anesthesia programs has also changed to focus on simulation-based training. This gives trainees an opportunity to actively practice managing an emergency on high-fidelity mannequins and settings while being observed and critiqued by their superiors. This type of training is very fruitful. Lastly, there has been an advancement in monitors. At the time of the 1997 study, there hadn’t been a total adoption of capnography and pulse oximetry, which are both used regularly now. I mention this last because monitors are useless without an experienced, well- trained anesthesiologist present! Can you tell us more about the circumstances of the three deaths and one case of severe morbidity that your study found? Our plan as a research team is to publish the details of these cases in a separate manuscript. Review of these cases involved careful consultation with reports from hospitals, the coroner and the clinicians involved. Because these cases are sensitive matters for both the families and the clinicians involved, I encourage you to review the manuscript. It’s important to make sure that the details are reported exactly as they were relayed to us. Can you share any general learning outcomes from these cases? Primarily, these cases reaffirm the importance of case selection. Our role in the office environment is to see relatively healthy patients. Specifically, the American Society of Anesthesiologists (ASA) classifies patients according to their physical status; a classification of ASA I is a normal, healthy patient; ASA II is a patient with mild systemic disease, such as asthma that is well-controlled; and ASA III is a patient with severe systemic disease, such long-standing diabetes. Our role, as dentists in private practice, is to see patients in