SmithAir747
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Child With Facial Defect Dies After Dental Work

Sat Sep 08, 2012 3:06 pm

Here is a tragic story that took place yesterday (and strikes at my own heart, because I have the same rare deformity that the unfortunate patient had):

A 10-year-old Texas boy with the rare genetic craniofacial anomaly syndrome Treacher Collins syndrome, whose airway was compromised by a small jaw and tiny throat, died shortly after being administered anesthesia for a routine dental procedure, when he stopped breathing due to airway collapse while unconscious. Normally, the jaw holds the tongue forward out of the airway when at rest, but in children with TCS and other craniofacial disorders, the small, underdeveloped jaw lies too far back from normal position, so the tongue blocks the narrowed airway. In children with TCS, they often need a tracheostomy soon after birth (and often throughout life in conjunction with the reconstructive surgeries).

Treacher Collins Syndrome Ups Risk of Dental Complications

The follow-up story says that the death was preventable, and gives some coverage of the celebration of the boy's life at a local funeral home:

Medical Professionals Say Child's Death at Dentist Was Preventable


This story illustrates the need for the dental profession (and anesthesiology in general) to be aware of children (and adults too) with craniofacial disfigurements that affect the internal structure of the upper airway. This can happen at any age.

Do dental schools not devote any significant teaching time to dental and anesthetic complications of people with narrowed airways? Medical schools surely do (I have been worked on by anesthesiologists at teaching hospitals, who use me for training fellow anesthesiologists), and I have seen a whole textbook devoted to anesthetic management of the difficult airway.

The above story NEARLY happened to me when I was 3, at a local private pediatric dentist's office in Fort Wayne, IN. I was put to sleep (most likely with nitrous oxide) for a dental procedure. During that procedure, I quit breathing (respiratory arrest) due to my own compromised airway when I was unconscious (my tiny jaw and tongue too large for my mouth and throat due to my TCS). The dentist had to call in EMS and fire personnel from a local station. They had to resuscitate me. My mom did not find out until afterwards (she was in the waiting room, away from the operatory itself). Mom tells me that the dentist was so shaken that he himself appeared that he almost needed the resuscitation himself!

From that time on (since I was age 3), all of my childhood dentistry was taken care of at Riley Hospital for Children in Indianapolis, a tertiary-level children's hospital with a craniofacial clinic and the dental clinic staffed with people knowledgeable in difficult airways and equipped with emergency equipment.

Anesthesia has always been a challenge for me due to my compromised airway. Whenever I have surgery (since I was young), I have had awake fiberoptic intubation performed. I also have severe obstructive sleep apnea and use CPAP. I also had a tracheostomy from birth for several years, and several more tracheostomies in conjunction with my jaw surgeries over the years.

SmithAir747
I will praise thee; for I am fearfully and wonderfully made... (Psalm 139:14)
 
ltbewr
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RE: Child With Facial Defect Dies After Dental Work

Sat Sep 08, 2012 3:23 pm

The dentist should have said no to handling this child seeing obvious issues that were probably beyond his skills. No doubt he will face a massive lawsuit, unless limited by Texas law or insurance company bans on suits. At the least he should face discipline up to and including permanent recovation of his license to practice dentistry.
 
AM744
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RE: Child With Facial Defect Dies After Dental Work

Mon Sep 10, 2012 4:23 pm

Quoting SmithAir747 (Thread starter):
I was put to sleep (most likely with nitrous oxide) for a dental procedure.

Are we talking general anesthesia? The article says he was in for a filling. Aren't dentists supposed to use xylocain (sp?) shots to numb the area? I know I've never been put to sleep for dental procedures, including root canal therapy. Very sad indeed.
 
SmithAir747
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RE: Child With Facial Defect Dies After Dental Work

Mon Sep 10, 2012 6:00 pm

Quoting AM744 (Reply 2):

Quoting SmithAir747 (Thread starter):
I was put to sleep (most likely with nitrous oxide) for a dental procedure.

Are we talking general anesthesia? The article says he was in for a filling. Aren't dentists supposed to use xylocain (sp?) shots to numb the area? I know I've never been put to sleep for dental procedures, including root canal therapy. Very sad indeed.

Nitrous oxide (as used in this patient, and most likely used in my own near-death case) is used to sedate patients and keep them calm (especially younger ones) for fillings and other procedures. It's just one of several options dentists choose from for anesthesia (these include IV sedation, nitrous oxide, and local anesthesia such as Xylocaine/Novocaine injections). The dentist chooses one of these options based on his judgment of the patient's tolerance and anxiety, age, and other factors.

Most (private) dentists do not have experience with narrow airway cases when it comes to choosing the method of anesthesia. This is the "preventable" aspect of this tragic case.

What patients (like me) who have Treacher Collins syndrome and other craniofacial deformities affecting the patency of the airway need is specialised dental care from dentists who know difficult airways and from anesthesiologists who also know about these complications. These specialists are mainly found at university/medical school teaching hospitals, such as children's hospitals, who have dental clinics. Private/suburban/general dentists just do not have the experience, emergency equipment (for resuscitation of such cases), or knowledge of rare craniofacial disorders and their associated respiratory complications.

SmithAir747
I will praise thee; for I am fearfully and wonderfully made... (Psalm 139:14)
 
JAGflyer
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RE: Child With Facial Defect Dies After Dental Work

Tue Sep 11, 2012 1:45 am

In cases like this I have to always play the devils advocate. Where were the parents in this "treatment plan". Did they inform the dentist that the patient has a narrowed airway due to his craniofacial deformity? Did they know that nitrous oxide can/does reduce the respiratory rate? I think there is some information missing here. Surely a parent cannot just let a dentist administer drugs to their child without at least agreeing or knowing the side effects. In hindsight, a pedodontist might have been a better choice, especially considering the condition of the boy's mouth due to the TCS.
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