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Araceli Avila never dreamed that her daughter's life might be at risk during a visit to the dentist. But on June 12, Daleyza Hernandez Avila, 3, died during a dental procedure. The dentist sedated Daleyza to keep the toddler from wriggling while she was getting crowns and having a tooth pulled. The little girl never woke up.
Now, Araceli wants to warn other parents about the dangers that she wasn’t aware of. “I’m looking for justice so what happened doesn’t happen to other mothers,” she told Sacramento NBC affiliate KCRA. “So they don’t have to feel the same pain I feel after losing my daughter.”
After several recent tragic cases, there are demands for different practices from the influential American Academy of Pediatrics, according to a report by NBC News national correspondent Kate Snow, which first aired on "Sunday Night with Megyn Kelly."
Dr. Wendy Sue Swanson of Seattle Children's Hospital and a spokesperson from the influential pediatricians group is sounding the alarm about sedating children for oral surgery.
"If we can prevent one more child from an adverse event or a death, we’ve got to try,” Swanson told NBC News.
It's unclear how many children — or adults, in general — have died in the U.S. during dental procedures. The state boards that oversee dental practice in America usually don’t make that kind of information public.
But earlier this month, a Texas high school student died about a week after undergoing anesthesia to have his wisdom teeth removed. And last summer, two children lost their lives after undergoing extensive dental procedures.
According to a Dallas Morning News investigation in 2015, a dental patient dies nearly every other day in the United States. That’s more than 1,000 people over the course of five-and-a-half years.
The numbers on deaths are only estimates and with millions of dental procedures performed each year on children ages 2-17, such tragedies are very rare.
But one thing is certain, “there are too many of them,” said Dr. Michael Mashni, a dentist with anesthesia training who practices in California.
Without data on deaths from all the state boards it’s impossible to determine where the problems are and how to fix them, Mashni said.
“There’s really no legitimate oversight,” said Dr. Jay Friedman, a California-based dental consultant and author. “And there are very few sanctions. You have to do something really bad before anything gets done about it.”
In Friedman’s experience, many young children are being over-treated by their dentists. And children are more likely to be over-treated if they are under full sedation, he said.
Children can choke more easily
The danger isn't from local anesthesia such as Novocain or numbing gels. General anesthesia —when the patient is unconscious — can be risky in young children and some dentists may not recognize the danger quickly enough, said Dr. Karen Sibert, an associate clinical professor of anesthesiology at the University of California, Los Angeles.
“Children have small airways and they choke more easily than adults,” Sibert said. “It doesn’t take much to obstruct a small child’s airway. Their vocal cords can close. They can choke on a little bit of blood.”
In a hospital or an ambulatory surgery center, there are medical support systems to help a child in distress. In an office setting,"by the time anyone gets there, the child is in such deep trouble, it’s too late,” said Sibert.
Parents whose sedated children died during dental procedures often say they were unaware that death was a possibility. And while there may have been a consent form including that danger, many don’t absorb the information in the dentist’s office, Friedman said.
Given the risks associated with sedation, "the dentist should have a frank discussion with the parents on the risks and benefits of anesthesia for treating the underlying disease," said Dr. Jim Nickman, president of the American Academy of Pediatric Dentistry. "We advise members to use extreme caution when they're looking at sedating a child less than 3. For those under the age of 2, I would recommend anesthesia be done in a hospital setting."
Before child undergoes any serious dental procedure:
Ask lots of questions
Parents should ask questions until they have no more, and they should always feel they have all the information they need to give consent for an elective procedure, said pediatrician Swanson.
Experts suggested these questions:
1. What procedure are you going to do and do you have to do it?
2. How much training have you had? Get up and walk out if somebody says, "Oh, I took a weekend course and I just started doing this, but it's going to be OK," said Dr. Roger Byrne, an oral surgeon in Houston.
3. Are you going to sedate my child? If so, what medicines are you going to use? Be sure the doctor doesn't understate the anesthesia being given. Answers like "it's only a few pills" or "it's just something that relaxes you" are red flags, said Dr. Louis K. Rafetto, past president of the American Association of Oral and Maxillofacial Surgeons.
4. Will there be a separate provider for general anesthesia in the room? "I would insist on a separate qualified anesthesia professional looking after my child," Sibert advised.
5. How much experience does this person have caring for kids my child’s age?
6. How will my child be monitored during the procedure? Be sure there will be vigilant monitoring. Ask if the office has EKG, blood pressure, pulse oximetry and end tidal carbon dioxide monitors, Rafetto said.
7. Who is going to be in the room if something goes wrong? The staff should be prepared to recognize and respond to crisis situations. It also is appropriate to ask about the office's safety record, he added.
8. Are you going to use a Papoose Board — a temporary restraint?
9. What kind of recovery setup do you have?
Get a second opinion
Instinct matters, so if you feel unsettled, consult another doctor, Swanson said.
“Get a second opinion if it's not a crisis — and very little dental work is a crisis,” Sibert added. “Parents can also simply ask, ‘Can this wait a year or two?’”
Consider the setting
Parents should have a healthy respect for deep sedation and general anesthesia in an outpatient setting, where there's very little help available if something goes wrong, Sibert said. They should ask if it would be better to take the child to an ambulatory surgery center, where an anesthesiologist would be present.
If the procedure is being done in an outpatient clinic without a pediatric anesthesiologist, make sure it’s low risk, Swanson noted. Sibert would have no problem with her grandsons having a procedure in a dentist's office if all it would require is “local anesthesia, nitrous, and cartoons.”
After the procedure
Kids can come out of sedation a little slower than adults and need prolonged observation, Swanson said. Before you go home, make sure your child is no longer sedated — he’s not falling asleep and not slowing his breathing, Swanson noted.
If your child is in the backseat for the car ride home, make sure there's someone who can be there beside him to watch him and make sure his airway doesn't get closed off or he doesn't slow his breathing while you’re driving home, Swanson said.
"There are events where children have had sedation, get in a car seat or a car, their respiratory rate goes down and they're just quiet and someone may not know," she noted.
Two adults accompanying a child are ideal for this situation.
For those uncomfortable with the idea of general anesthesia, "there are other options that can work, for example having the parent hold the child in a blanket to keep him still — like you'd do in the emergency room if the child required stitches," Nickman said.
Ultimately Friedman isn’t convinced that the benefits of sedation outweigh the risks.
“In my opinion, there’s no excuse to give any of these kids general anesthesia,” he said.
NBC News national correspondent Kate Snow contributed to this report.