In dental offices nationwide, children who need cavities filled or teeth pulled are sometimes sedated. Ideally, it makes them less anxious and more cooperative.

They may swallow a liquid sedative or inhale laughing gas and once it kicks in, they will be conscious but calmer, so the dentist can do extensive work.

But in rare cases, children fall into a much deeper level of sedation than intended. If they are not rescued quickly, they may stop breathing or even die. It is critical for the dental staff to keep track of the patient’s vital signs and quickly recognize an obstructed airway or a problem with the heart or breathing.

In recent years, a few reports of sedated children dying at dental offices have come to light, alarming lawmakers, parents and the dental profession. In 2013, University of Washington researchers found 44 cases over three decades in which dental patients died after sedation or general anesthesia. Most were 2 to 5 years old.

More recently, in 2016, Daisy Lynn Torres, 14 months old, underwent general anesthesia at an Austin, Texas dental office to fix two cavities, and died after her heart and breathing stopped. Her parents sued after dental experts found no evidence of cavities on her X-rays. In June, Daleyza Hernandez-Avila, 3, went to a surgical center in Stockton, California, to have her teeth fixed and never woke up.

In Hawaii, 3-year-old Finley Boyle fell into a coma after being sedated during a dental procedure and later died. Her dentist, former Kailua dentist Lilly Geyer, was indicted on charges including prohibited acts related to controlled substances in connection with the 2013 incident. Geyer is scheduled for trial in October.

For sedation to be safe, certain protocols are critical and many factors must be carefully weighed, according to the 2016 guidelines jointly written by the American Academy of Pediatric Dentistry and the American Academy of Pediatrics.

1. Understanding Sedation

Sedation is a continuum from minimal to moderate to deep to general anesthesia, and “it is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation,” the guidelines note. So parents should ask the dentist what level they’re aiming for and what emergency measures will be taken should, for example, moderate sedation become deep and a child can no longer breathe on his or her own.

“The risk is small but there’s always a risk when you sedate a child, primarily of airway obstruction, where the child — for whatever reason — becomes oversedated,” said Dr. Joseph P. Cravero, a senior associate in perioperative anesthesia at Boston Children’s Hospital.

A dentist’s office generally has fewer hands on deck than a hospital if trouble strikes. “If you are working in a hospital, you press a button, an alarm goes off and everyone comes to help with that kid,” Cravero said. But in an office, “you end up having to call 911 for help” and the dentist must begin resuscitation during the wait.

The Pediatric Sedation Research Consortium — which collects data mostly from hospitals, not dental offices — has found a low but persistent rate of life-threatening events associated with sedation, such as airway blockage, a drop in blood oxygen levels or a spasm of the vocal cords that makes breathing hard.

Unfortunately, it’s not known how many children are sedated in dental offices nor the actual frequency of problems. “What you have in dentistry are reports of disasters, and that’s all we have to go by,” said Cravero, a co-founder of the consortium.

2. Risk Factors

Some children are particularly vulnerable during sedation because of their youth, anatomy or other factors. Enlarged tonsils may increase the chance of airway obstruction, for example.

Children younger than 6 may have a greater risk of adverse events, a 2009 study suggested, based on nearly 50,000 sedation/anesthesia procedures at 37 locations, mostly hospitals. The authors concluded that the safety of sedation depends on a practitioner’s ability to manage less serious events. No deaths were recorded, but airway obstruction happened roughly 2,800 times.

“Kids under 6 have a smaller airway that can easily be blocked,” said Dr. Jeremy Horst, a pediatric dentist at the University of California, San Francisco. “The size difference is so enormous” between a 4-year-old and a 12-year-old. Very young children “don’t have as much of an oxygen reserve in their blood as older children or adults, so their body can’t compensate for short lapses in oxygen,” he said.

Overweight and obese children merit special consideration, too, said Dr. Deborah Studen-Pavlovich, director of the pediatric residency program at the University of Pittsburgh School of Dental Medicine. A sedative “doesn’t get metabolized as quickly as the drug is stored in fat cells so they have a longer recovery time,” she said.

It is unclear why, but a 2009 study found that sedated children with developmental disabilities have three times the risk of having a decrease in blood oxygen levels that can lead to life-threatening complications.

3. Know the Alternatives

“Sedation is above and beyond routine dentistry,” so the first thing parents should ask is whether it is necessary, said Dr. Paul Casamassimo, chief policy officer for the American Academy of Pediatric Dentistry’s research center.

Sedation may be needed, for example, if a 3-year-old requires root canals for badly decayed molars or has a throbbing abscess, said Casamassimo, who sedates children at Nationwide Children’s Hospital in Columbus. But less advanced cavities may be treated by brushing a liquid called silver diamine fluoride on decayed parts to stop the infection. (The substance may darken decayed areas, but baby teeth fall out.)

“It’s not appropriate for sedation to be a first-line treatment” for all cavities, Horst said. Less risky and less invasive options, such as placing a temporary filling to buy time until a child will sit for a proper one, should be discussed.

4. Experience Counts

The quality of dentists’ sedation training matters, because a dentist needs to be able to choose the right candidates and the appropriate drug and know how to rescue an oversedated child. Pediatric dentists train for an added two or three years to learn sedation.

By contrast, a general dentist may have taken a weekend course in moderate sedation. “Classroom training is not enough,” Studen-Pavlovich said.

Moderate sedation, also known as “conscious” sedation, requires more vigilance than minimal sedation, such as laughing gas, because children could slip from moderate to deep sedation, which means they cannot necessarily maintain their own airway. For moderate sedation, dentists should have rescue drugs on hand and monitor oxygen levels and heart rate. In addition, the American Society of Anesthesiologists recommends “a qualified individual” other than the dentist monitor the patient, because it “reduces risk of adverse events,” said Dr. Jeffrey S. Plagenhoef, the society’s president.

Both deep sedation or general anesthesia using an IV should be administered only by qualified anesthesia providers, according to the anesthesiologists’ society.

Pediatric dentists also learn how to manage kids by talking to them. “Anyone can work on a patient who is knocked out,” said Dr. Jeanette MacLean, a pediatric dentist in Glendale, Arizona, adding, “Behavior management is a dying art form.”

Money plays a role, too. Dr. Peter Hartmann, a general dentist in Santa Barbara, California, worries “that sedation and anesthesia are overused as profit-making tools.”

The bottom line is parents should be told the risks, benefits and alternatives, MacLean said. “If not, get a second opinion.”

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Star-Advertiser staff contributed to this report.

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