RALEIGH — Potentially “tragic” results could occur because the professional board that regulates the state’s dentists issues sedation permits before it inspects dental facilities, and does not conduct compliance checks to ensure dentists can deliver anesthesia safely and respond to medical emergencies, a state audit concluded.
Further, the audit released Wednesday by the Office of State Auditor determined, the North Carolina State Board of Dental Examiners does not ensure dentists complete continuing education required for administering anesthesia safely.
The audit comes one week after the the U.S. Supreme Court ruled in a lawsuit brought by the Federal Trade Commission that the dental board unfairly restricted trade in violation of federal antitrust law by warning nondentists such as mall kiosk operators and cosmetologists not to provide teeth whitening services.
That ruling will be the subject of a Senate Committee on Program Evaluation meeting next Tuesday, and a meeting of the Joint Legislative Program Evaluation Oversight Committee on March 16.
“We’re anxious to comply” with the audit recommendations, said Bobby White, the dental board’s chief operating officer. The board already was exploring improvements to its policies and procedures prior to the launch of the state audit.
“We’ve had a 25-year track record with these sedation permits and dentists practicing sedation and anesthesia in North Carolina. It’s been very, very safe,” White said. Only 658 of the nearly 6,000 dentists practicing in North Carolina are licensed to provide sedation and anesthesia, he said.
“It’s been such a boon to patients who have had reluctance to go to dentists. At the same time we’ve got to make sure that all dentists are as safe as possible when they practice sedation,” White said.
Having two sedation-related deaths within a year after having no adverse occurrences for 25 years “is extraordinary,” White said. The board’s sedation committee “moved as quickly as possible to address the issue” through reviewing rules changes.
The committee is proposing a rule to discontinue the use of temporary anesthesia permits. It is also developing “a specialized course” of its own to ensure dentists possess an updated command of skills and protocols that go beyond just verifying continuing education requirements, White said.
Paying for ongoing, periodic, risk-based assessments recommended by the audit might pose a financial challenge. The unknown factor is what constitutes a risk-based inspection, and the cost to perform it.
As an occupational licensing board, the organization receives no tax dollars. All revenue derives from licensing applications and renewals, White said.
The Supreme Court litigation consumed a lot of the board’s resources, he said, but with that case ended revenue will no longer need to be used for legal purposes.
“We are very reluctant to raise fees. That’s a last resort for us. If we can do it any other way we will,” by shifting resources, White said.
The eight-member dental board, created in 1879 to ensure only qualified individuals can practice dentistry and dental hygiene in North Carolina, is comprised of six dentists, one licensed dental hygienist, and one member from outside the profession.
According to the audit, “State dental board inspections must ensure that dentists have the proper skills, equipment, drugs, support personnel, and procedures to safely perform dental sedation because the potential consequences from improperly administered dental sedation can be significant and tragic.”
Conceding it is rare, the audit noted four fatalities — two in North Carolina — involving sedation.
In 2013 a North Carolina man died from an overdose of drugs during a tooth extraction for dentures. The dentist failed to consider the patient’s physical condition, gave an improper dose of sedative, and failed to give a rescue drug.
A 57-year-old North Carolina woman died in 2012 of a drug overdose during a tooth extraction. The dentist failed to recognize she was in distress and take appropriate action.
The dental board allows dentists to perform anesthesia and sedation services for up to three months on temporary permits “before verifying through inspection that the dentist has the proper skills, equipment, drugs, support personnel, and procedures to safely perform dental sedation,” the audit stated.
Some dentists could be providing substandard practices that threaten public safety as a result. The board has no way of knowing if the dentist is competent to monitor blood pressure, pulse, respiration, and patient recovery; determine and administer drug dosage; treat respiratory or cardiac “untoward reactions”; use CPR; and ensure sterilization.
The audit noted the dental board recently improved its permitting policy by reducing temporary permit times from six months to three.
“The board does not conduct periodic on-site inspections of the 618 dentists with sedation permits to ensure that they remain in compliance with board policies,” according to the audit’s second finding.
“In fact, the board does not conduct periodic on-site inspections of any of the 4,617 dentists licensed and actively practicing in North Carolina,” the audit stated.
Without periodic checks, auditors said, dental office personnel might not have documented annual life-support training for each procedure performed; patients administered minimal conscious sedation might not be evaluated properly for medical risks prior to the procedure; equipment might not be maintained correctly; and dentists, staff, and facilities might not be able to provide proper ventilation and oxygen with an appropriate device.
The audit’s third finding was that the dental board does not verify mandatory continuing education hours for sedation services. As a result, dentists might not have the proper information and training “to protect public health and safety.”
Dan E. Way (@danway_carolina) is an associate editor of Carolina Journal.