Pre-evaluation necessary for dental surgeries, say doctors

Chennai: In a recent incident, Mr Manikam Ramasamy, a 63-year-old man suffered cardiac collapse after being administered anaesthesia for root canal surgery at a private dental clinic in the city. 

After recovering from anaesthesia, Manikram complained of chest pain and after being given several medications and passed away while he was being rushed to a hospital. 

In another instance, Vasudha, a three-year-old girl underwent a root canal treatment by a pediatric dentist as she complained of pain in teeth. However, her heartbeat was lost during the procedure and could not be recovered even through cardiopulmonary resuscitation (CPR) was used immediately. Vasudha was declared dead at the hospital.

There have been cases of fatalities during dental treatments that do not seem to reflect the reasons for the death. However, dentists stress on precautionary factors and need of awareness among people on the provision of basic facilities, sedation procedure, pre-anaesthetic evaluation and protocols to be followed by a dental clinic such that medical complications and fatalities can be prevented.

Stressing on the need for pre-anaesthetic evaluation, oral and maxillofacial surgeon Dr George Paul said that sedation should be given only in case of painful procedures.

“Several dental clinics in the city claim to provide ‘painless’ dental treatments under sedation which is not advisable if the patient is sensitive. Even more dangerously, pediatric dentists with little or no competence in providing life support are rampantly anaesthetizing children by themselves under the unacceptable notion that it is safe and can be given by anybody with a two-week course,” said Dr George Paul.

Lack of awareness on the part of patients also accounts for sudden deaths during medical procedures, said Dr S. Navaneethan, dental anaesthesist, Apollo White Dental.

“People should be aware of emergency equipment and emergency medical kit available at the clinic that should include oxygen cylinders, CPR, airways, suction and other monitoring and screening equipments,” he said.

While medical negligence committees and medical council investigate such cases after the loss is already caused, authoritative bodies such as Dental Council should set up a protocol for management of patient emergencies, which can help to prevent such fatalities.

 “There is no mandatory protocol by Dental Council of India on infrastructure and basic facilities to be available at a dental clinic before performing any dental procedure and there are no set guidelines for training on life support,” said Dr Yashwanth Venkataraman, Medical Director, Parasu Dental Centre.

When contacted, a senior official from Dental Council of Tamil Nadu said that the various regulations laid down by the Dental Council of India under the Clinical Establishments Act are yet to be adopted in the state. While the Director of Medical Services shall look into any case of medical negligence, implementation of basic facilities protocol can be done after the approval of the government, he said.

Fiber reinforced dental fillings to replace amalgam
Amalgam, commonly called as ‘silver filling’,  is used for dental fillings due to its strength, wear resistance and ease of use. However, dentists recommend reducing the use of due to its potential toxicity and other side effects.

The main reasons include the low flexural strength of glass ionomer cement, the intrinsic grey colour of amalgam and the fact that amalgam contains mercury as one of its components demand the need of alternate fillings.

“Formation of mercury vapours is toxic and can be harmful to the patient. The amalgam filling is very technique specific. However, fiber-reinforced fillings easily blend with the tooth structure. Also, they provide enough strength and last longer,” said Dr Santhoshini Reddy, dentist, Apollo White Dental.

A new alternative to amalgam is Cention N, which is a metal-free filling material and inexpensive alternative to amalgam and glass inonomer materials in restorative dentistry.

“Cention N offers toothcoloured aesthetics together with high flexural strength. The new filling material belongs to the materials group that prevents demineralisation, but also facilitates remineralization of the enamel structure. Cention N is remarkably simple to use. The product is applied without having to use a primer, varnish or curing light. Only dosing, mixing, filling and finishing is required,” said Dr. Philipp E. Schneider, dental specialist.

Pre-anaesthesia evaluation must in cardiac patients
Pre- anaesthesia evaluation becomes significant in case of cardiac and geriatric patients, as there are certain risk factors that need to be considered before any dental procedure on them.  Cardiovascular drugs are known to have fatal drug interactions and should, therefore, be evaluated carefully.
 
Initial evaluation of the cardiac patient should include a detailed history of cardiovascular disease, medications, duration and treatment history, the severity of disease, and its complications.

“Reported incidence of fatal complications in sedation anaesthesia in dentistry in the USA is one in a million across all age groups. Stratification by age may reveal a higher incidence in older people. Therefore, baseline investigations as part of pre-anaesthetic evaluation are necessary to avoid such circumstances,” said Dr George Thomas, former editor, Indian Journal of Medical Ethics.