NFPA Journal - January/February 2018 - 81

given its own chapter in the code, and
experts hope the move will serve as a
clear indication of the careful consideration these systems warrant.
"Dental systems have received little
regulation compared to medical ones
when it comes to NFPA 99," said Neil
Gagne, a medical gas verifier who is a
member of the Piping Systems technical committee for NFPA 99 and
helped write the new chapter on
dental gas and vacuum systems.
"There's been so much effort dedicated to ensuring category 1 and
2 gas and vacuum systems that
are found in hospitals, surgical
centers, and urgent care centers
are safe, and unfortunately not as
much effort has been dedicated to
the fast-changing dental industry.
Most people are unaware of how
complex the procedures are and
varying level of anesthesia that
dentists and oral surgeons are
administering in an office setting."

Serious sedation
In August, when Dr. Jonathan Wong,
a dentist anesthesiologist, ordered
vacuum pumps for his dental practice
in Norfolk, Virginia, which specializes
in sedation dentistry, he wasn't happy
with the equipment he received from
the dental supplier. The pumps, which
power dentists' suction tools, weren't as
powerful as those provided by a medical supplier-what you'd find in, say, an
ambulatory surgical center or a hospital. And that worried Wong.
While the lower-powered pumps can
perform duties like sucking up blood,
water, and fragments of teeth from
a patient's mouth-and are actually
better in a more traditional dental
setting-it's risky to employ them in
situations where patients are sedated
to the point of unconsciousness, when
they can be prone to aspirating. In
fact, the pumps don't meet NFPA 99's
criteria for use during the type of sedation Wong's office performs. "What
if a patient starts aspirating or has a
blocked endotracheal tube? You need
to be able to draw enough vacuum
when you need it to be able to suction
that out," Wong said in an interview in
November.

When he confronted the supplier
about it, he said the response was along
the lines of, "We didn't realize you
guys do this level of anesthesia." It's a
common misconception, Wong said,
despite evidence suggesting a rise in
the use of anesthesia during dental procedures over the last 15 years or so.
A study published in 2012 in Anes-

such as endoscopic retrograde cholangiography [which combines an upper GI
endoscopy with x-rays]," according to a
study published in the World Journal of
Gastrointestinal Endoscopy in 2013.
More of that anesthesia is being
administered in office settings. When
he first started in the industry 13 years
ago, Gagne recalls that maxillofacial

"A normal building safety checklist
that happens with hospital facilities
or ambulatory surgery centers is the
NFPA 99 med gas system checklist and
verification, and that's not happening
in these dental offices."

thesia Progress, the journal of the
American Dental Society of Anesthesiology, found that dental professionals
in North America had noticed an
increased demand for dentist anesthesiologist services from 2002 to 2012,
particularly for procedures involving
children. Wong thinks a number of
cultural changes account for the spike.
Foremost, he said, is a generation of
parents that does not want their children to be "traumatized" by a trip to
the dentist. "It used to be, if a dental
procedure needed to be done, it was
just done," Wong said. "Times have
changed. Now parents are saying, 'I
don't want my child to remember anything from this.'"
A rise in office-based anesthesia
has been seen across medical fields,
not just in dentistry. "As a society,"
Wong contended, "we're requesting
more anesthesia" for everything from
tooth fillings to minor gastrointestinal
procedures. The trend also reflects
advancements in medicine that lead
to more complex procedures. "As [gastrointestinal] procedures have become
more complex and lengthy, additional
medications became essential for
adequate sedation. Oftentimes deep
sedation is required for procedures

and oral surgeries that required deep
sedation or anesthesia were done in
hospitals, where there were anesthesiologists and a variety of patient
safeguards and staff close at hand.
"Then, two things happened," Gagne
said. "Hospitals got too busy and
dentists and oral surgeons found it
hard to secure operating rooms for
their procedures, and the cost was
often quite expensive when they did.
So they started expanding what kind
of anesthesia they were providing in
their offices... The problem with that
is, if something goes wrong during a
procedure, like an adverse effect from
anesthesia, that office setting doesn't
have the same safeguards in place that
NFPA 99 requires for category 1 gas
and vacuum systems that are found in
most hospitals. More often than not
they'd simply call 911. For me, that's a
scary situation."
In dentistry, the trend has been
rather grimly reflected by way of news
reports of injuries and deaths in the
dental chair. Prompted by the death of
a 4-year-old boy in 2013, a 2015 investigative series by The Dallas Morning
News estimated that a dental patient
dies about every other day in the United
States-a rough calculation based only
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Table of Contents for the Digital Edition of NFPA Journal - January/February 2018
