The looming battle over sedation dentistry
Plus: Duke Energy exec on security of electric grid; February rezonings detail apartment and townhome plans; Wilhelmenia Rembert likely to be new commissioner; Join Ledger bracket contest 🏀
Good morning! Today is Monday, March 14, 2022. You’re reading The Charlotte Ledger, an e-newsletter with local business-y news and insights for Charlotte, N.C.
Need to subscribe — or upgrade your Ledger e-newsletter subscription? Details here.
Today’s Charlotte Ledger is sponsored by Augustine Literacy Project-Charlotte (ALP), connecting aspiring readers and volunteer tutors to build literacy skills that change students’ lives. Learn more and register for ALP’s virtual Rise and Read Event on March 23.
After at least 5 deaths linked to dental sedation since 2012, N.C. regulators are proposing strict new rules. Would they increase safety, or just drive up costs?
By Michelle Crouch
When Henry Patel, a cardiologist in Wilmington, went in for a tooth implant in July 2020, he didn’t think twice about allowing his oral surgeon to administer intravenous sedation.
During the procedure, however, the healthy 53-year-old’s oxygen saturation and heart rate dropped to dangerous levels, according to an investigation by the North Carolina Board of Dental Examiners. Then Patel stopped breathing. The surgeon, Mark Austin, tried to insert a breathing tube, but it went into Patel’s stomach, dental board documents say. Austin’s staff called 911, but they did not start CPR before paramedics arrived, according to the documents.
By then, 20 minutes later, Patel had no pulse. He was rushed to a local hospital but never regained consciousness. He died a few days later.
“I never thought I would go into a dental office and come back out a widow at age 47,” Patel’s wife, Shital Patel, said. “How could this happen?”
Patel is one of at least five North Carolina patients in the last decade to die of complications from dental sedation. A sixth death in Wake County from November 2021 is under investigation, and at least one other N.C. patient suffered permanent brain damage as a result of anesthesia complications, according to dental board records.
Although such cases are rare, the outcry over Patel’s death has prompted the dental board to propose new regulations that would dramatically change the way dentists and oral surgeons in North Carolina administer sedation.
If enacted, the new rules would be the strictest in the nation, according to a spokeswoman for the American Association of Oral and Maxillofacial Surgeons.
Dentists and oral surgeons, however, have sent dozens of letters opposing the changes, and they packed a February hearing to argue against them. They say there is no evidence the rules would increase safety, and they would drive up costs for patients.
The proposed changes “are not based on science,” said Bryan Neuwirth, an oral surgeon in Hickory who is president of the North Carolina Society of Oral and Maxillofacial Surgeons. “They will not enhance patient safety and will only do harm to our patients’ access to care.”
Henry Patel (left) with his family. Patel, a Wilmington cardiologist, died in 2020 after being sedated for a tooth implant. Patel was nicknamed “the ninja” by his colleagues for his ability to handle complicated heart cases. (Courtesy of Patel family)
How dental anesthesia is like no other
When a patient has other types of surgery, a physician does the operation while a second person with anesthesia training — usually an anesthesiologist or a certified registered nurse anesthetist (CRNA) — administers drugs and monitors the patient’s response.
But that’s not always the case with dental surgery.
Under the rules in North Carolina and every other state, dentists and oral surgeons who have received special anesthesia training are not required to have a second trained person present when they put a patient under.
Instead, dentists act as both the anesthesiologist and the surgeon during a procedure.
Critics say allowing them to serve in both roles concurrently endangers patients. They question how a dentist can vigilantly monitor vital signs when they are focused on the inside of a patient’s mouth performing a procedure such as a root canal, implant or tooth extraction.
Rob Harper, a cardiologist who worked with Patel and supports the stricter rules, said dentists should have to adhere to the same standard as doctors, especially since dental offices have less life-saving support than hospitals.
“There should be a single standard across healthcare,” he said.
A requirement for a second sedation provider
The dental board is proposing a number of rules to enhance sedation safety, including requiring dentists to use a special instrument to measure carbon dioxide levels in a patient’s breath and requiring them to abide by maximum recommended dosages for anesthesia drugs.
But the rule generating the most controversy would require a second person with anesthesia training to monitor a dental patient during sedation.
If a patient is under light or moderate sedation, the second person could be a registered nurse or a dental assistant with special anesthesia training, the proposal says.
But if the dentist uses Propofol — a powerful, commonly used sedation drug — the second person would need to be someone with more training, such as an anesthesiologist, a CRNA, or a second dentist who holds a sedation permit.
Bobby White, the board’s CEO and legal counsel, said dentists often use Propofol for moderate sedation, in which patients are in a dreamlike state but still breathe on their own. Administering the right amount can be tricky, he explained, because it’s easy for patients to slip into a deeper, unintended level of sedation that stops their breathing.
‘Follow the label’
White said the wording for the proposed rule actually just requires dentists and oral surgeons to follow the FDA-approved instructions for Propofol. Those instructions specifically say the person administering the drug “should not be involved in the surgical procedure.”
“The drug says on the warning label that if you use it, you should get someone to help you,” White said. “We are just saying, ‘Follow the label.’”
The American Society of Anesthesiologists also says patients should be continuously monitored by a second trained professional anytime they are put under moderate or deep sedation.
No law requires dentists and oral surgeons to follow the Propofol label. North Carolina would be the first state to require a separate anesthesia provider during an office-based dental or oral surgery procedure, a spokesperson for the American Association of Oral and Maxillofacial Surgeons said.
Harper, Patel’s former colleague, said he believes Patel may not have died if a second person with anesthesia training had been present. He worries dentists don’t have enough experience resuscitating patients when things go wrong.
“If you don’t know how to reverse the effects of a complication, then you shouldn’t be doing the procedure at all, or at least you should be in a hospital surrounded by people who can,” Harper said.
Dentists: Oral surgery is already safe
Oral surgeons and dentists say a secondary anesthesia provider isn’t necessary because dental sedation is exceedingly safe, and deaths are rare. “In over 3 million anesthetics in North Carolina, there were six deaths — an extremely low number,” said Debra Sacco, an oral and maxillofacial surgeon who practices in Chapel Hill.
There is no national registry of sedation-related dental deaths. A 2017 Mayo Clinic analysis of 17,634 dental sedations found no deaths and 16 adverse events — a complication rate of 0.1%.
In North Carolina, there have been 27 reported adverse occurrences since 1990 that resulted dental patients being transferred to a hospital, the dental board said.
Sacco described the dentists and oral surgeons whose patients died as “outliers” who were not following established standards of care, and who are no longer practicing.
Mark Austin, the oral surgeon who operated on Patel, permanently lost his North Carolina dental license in August 2021 after a dental board investigation. In addition to taking actions that caused Patel’s death, Austin was also improperly prescribing narcotics to his staff and using them himself, according to a dental board consent order.
Austin did not respond to a request for comment.
Wes Parker, an oral surgeon in Davie County, said if the new rules pass, they would make it difficult for him to practice.
“Being in a rural and low-income North Carolina county, there are no readily available secondary anesthesia providers, nurse anesthetists, dental anesthesiologists or medical anesthesiologists that can come to my office, especially on short notice,” he said.
In addition, the increased cost would prompt many patients to delay or forgo dental work they need, he said.
“Patient care will be delayed and access to care will be diminished,” Parker said. “Delays in care for a dental infection can result in significant complications, hospitalization and even death.”
N.C. legislature may have final say
The North Carolina Board of Dental Examiners is expected to vote on the stricter standards in April. After that, the new rules will be sent to the General Assembly’s Rules Review Commission, which will vote whether to approve them based on whether they are clear, necessary and within the dental board’s authority.
No matter how the commission votes, if 10 people file written objections to the new rules (which is likely, White said, given the strong opinions on both sides), the proposal will be sent to the state legislature for a final decision.
That means N.C. lawmakers could make the final call on the change, and it may be months before the issue is decided.
No matter what happens, Shital Patel said she hopes sharing her husband’s story will prompt patients to ask questions before they agree to dental sedation such as: Will another dentist, anesthesiologist or CRNA be in the room if something goes wrong? What type of drugs are you using and are they reversible? Who will monitor my vital signs? What are your emergency procedures?
“Even though my husband was a physician, we didn’t think to ask this type of question,” Shital Patel said. “Let’s all learn something from this. Maybe there have been only a few deaths, but even one death is too many.”
Michelle Crouch is a freelance writer and a regular contributor to The Ledger who often writes about healthcare. Send her story tips at michellecrouchwriter@gmail.com.
Today’s supporting sponsors are T.R. Lawing Realty…
… and Whitehead Manor Conference Center, a peaceful, private, and stress-free space for your organization’s next off-site meeting or event. Conveniently located in South Charlotte, Whitehead Manor is locally owned and operated and provides modern meeting capabilities with attention to stellar service!
Quotable: How secure is our electric grid?
Stephen De May, president of Duke Energy’s utility operations in North Carolina, speaking at the Hood Hargett Breakfast Club last week in response to a question from the audience:
Q. With all that’s going on, could you speak for a moment about the security of our grid and the efforts Duke is taking to ensure that?
De May: Grid security is not, fortunately, just a utility-by-utility undertaking. As we have seen several times in our history, we have an incident on one part of the grid and it cascades pretty far and wide.
Grid security is actually a national program. Duke Energy invests a lot of money on its own, but it also invests a lot of money to stay in compliance with national standards around grid cybersecurity.
I can only tell you that we think we are doing a good job of that. Years ago, we shifted from just preventing a mishap to recovering from a mishap. You can’t always prevent bad actors. But if something were to happen, we have a plan to recover from it quickly.
I would say that it is a very immediate concern for us right now, because of what’s going on, and some of the bad actions that could come from that. We are paying close attention to it, and we have made large investments over the years on this.
Watch it NOW: The latest Ledger Live online event ‘Set to jet? – What to know about the new world of travel’ ✈
In case you missed it last Thursday night, we had an engaging and information-packed online panel discussion with three local travel professionals about planning and taking vacations as Covid recedes.
This event, which was exclusive for Ledger members, was held in partnership with our friends at Jumbo, a Charlotte company that builds live-streaming platforms.
We covered lots of ground during the event, including:
the latest advice on handling Covid restrictions, when both leaving and returning to the U.S.
what you need to know about getting travel insurance
some top picks for destinations (including panelists’ fun ideas for a fall getaway)
what it’s like on a cruise ship these days
how the war in Ukraine is affecting global travel
how far ahead you need to book, and what’s happening with the cost of travel
Our panelists were Karen Shelton, owner of My Path Unwinding Travel and Luxury Travel PhD, Roni Fishkin of Mann Travels and Lora Schapiro of Tauck. The Ledger’s Cristina Bolling moderated the event.
Check it out here! Not a Ledger member? Join us as a paying Ledger member today, and take advantage of the many benefits and smart coverage we offer!
➡️Ledger members, if you have an idea for a future Ledger Live topic, contact Ledger managing editor Cristina Bolling.
February rezonings 🔥: More than 2,000 new housing units
It’s time for our monthly installment of “Where are developers building apartments and townhouses now?” — otherwise known as the monthly rezoning filings with the city.
Each month, The Ledger provides details of all of the rezonings sought by developers in the previous month — before they are published on the city’s main rezoning website. This gives residents information on planned developments near them, and it gives people in the industry insights on trends.
In February, developers filed rezoning plans with the city for more than 2,000 housing units. The plans include:
Townhomes in east Charlotte, Mallard Creek, Ballantyne and near Huntersville
Apartment complexes on Carmel Road and Monroe Road
An office tower in SouthPark
And much more! The list is available to Ledger members.
Ledger March Madness Bracket Challenge 🏀
Brackets for the NCAA Men’s Basketball Tournament came out last night, and The Ledger is running a bracket contest. You’re welcome to join, with a chance to win some fabulous prizes — and, perhaps even more valuable, bragging rights.
Don’t worry — we checked with our lawyers, and it’s on the up-and-up. It costs nothing to enter and is open to all Ledger readers.
To enter, complete an ESPN bracket online (it’s free, but you’ll need an account) and join a private group we set up called “The Charlotte Ledgerers.” The password: LEDGER.
The prizes:
1st place: $100 Harris Teeter gift card
2nd place: $75 Harris Teeter gift card
3rd place: $50 Harris Teeter gift card
4th place: 6-month Ledger membership/extension ($50 value!)
5th place: 3-month Ledger membership/extension ($25 value!)
6th-10th place: 10 Charlotte Ledger pens
(They are some good-looking, high-quality pens.)
You can enter up to 2 brackets per ESPN sign-in. Once you create a bracket, make sure you link it to the group (TheCharlotteLedgerers) for it to count. The games start Thursday around 12:00 p.m.
We’ll keep you updated over the next few weeks. Let the games begin!
In brief:
Convenience store expansion: Wawa, a convenience store chain popular in the Northeast, says it plans to open sites in North Carolina by the end of 2024. The company gave no further details. (WSOC)
Commissioner replacement: Mecklenburg County commissioners will vote Tuesday on naming Wilhelmenia Rembert to a seat on the county commission, replacing Ella Scarborough, who is on medical leave. Rembert, a Democrat, served on the commission from 2004-2006 and is a former member of the Charlotte-Mecklenburg Board of Education. (WSOC)
Video shows lead-up to bus driver shooting: Police released video footage that shows the moments leading up to the fatal shooting of Charlotte Area Transit System driver Ethan Rivera last month. The videos show Rivera and the driver of a Honda Pilot yelling and cursing at each other while stopped at a red light in the minutes before the shooting. The suspect was later arrested in Kansas and is awaiting extradition. (Observer)
Charlotte FC scores first goal: Charlotte’s new Major League Soccer team scored its first goal in franchise history on Sunday, from 19-year-old North Carolina native Adam Armour. The team lost 2-1 in Atlanta, and its record dropped to 0-3. (Fútbol Friday, with videos of first goal)
Bounty offered on Bradford pear trees: Several North Carolina agencies have started a “Bradford Pear Bounty” program that provides new native trees to people who cut down Bradford pears in their yards. “In addition to emitting a strong, distinctive stench, Bradford pears can breed with other varieties of pear trees and spread in natural forests, replacing native trees and creating ‘food deserts’ for birds,” an N.C. State researcher said. (Associated Press/WFAE)
CROSSWORD SOLUTION: Here’s the solution to Saturday’s crossword puzzle. You can view all the puzzles and solutions at the Ledger Crossword page.
Taking stock
Unless you are a day trader, checking your stocks daily is unhealthy. So how about weekly? How local stocks of note fared last week (through Friday’s close), and year to date:
Need to sign up for this e-newsletter? We offer a free version, as well as paid memberships for full access to all 4 of our local newsletters:
➡️ Opt in or out of different newsletters on your “My Account” page.
➡️ Learn more about The Charlotte Ledger
The Charlotte Ledger is a locally owned media company that delivers smart and essential news through e-newsletters and on a website. We strive for fairness and accuracy and will correct all known errors. The content reflects the independent editorial judgment of The Charlotte Ledger. Any advertising, paid marketing, or sponsored content will be clearly labeled.
Like what we are doing? Feel free to forward this along and to tell a friend.
Social media: On Facebook, Instagram, Twitter and LinkedIn.
Sponsorship information: email brie@cltledger.com.
Executive editor: Tony Mecia; Managing editor: Cristina Bolling; Contributing editor: Tim Whitmire, CXN Advisory; Contributing photographer/videographer: Kevin Young, The 5 and 2 Project