Could Dental Death Have Been Avoided?

The death of 24-year-old Marek Lapinski after wisdom-teeth surgery has raised new questions about the safety of propofol, a powerful drug that’s now the most widely used form of IV anesthesia.

According to a patient care report, the software designer from San Diego woke up during the procedure, started coughing, and was given propofol (Diprivan), the surgical anesthetic that killed singer Michael Jackson. When Lapinski went into cardiac arrest, CPR was started and paramedics were called.

When paramedics arrived, the report states, they found two pieces of surgical gauze in Lapinski’s airway when they tried to insert a breathing tube. Lapinski was rushed to the hospital, where he died three days later.

While the cause of Lapinski’s death remains under investigation, his family and friends question the care he received from oral surgeon Dr. Steven Paul. “What’s most shocking is the healthy 24-year-old goes in for an operation as routine as having his wisdom teeth removed and dies in the process,” family friend Tony Keiser told ABC News. “It’s inconceivable.”

Dr. Paul’s lawyer issued a statement saying in part, “Dr. Steven Paul has always provided the highest level of oral surgery care to his patients ... However, safe as oral surgery is in today's environment, no surgical procedure is without risk."

In 2011, two teenagers died after wisdom-tooth extraction, a procedure performed on about 5 million Americans a year. The surgery has also been linked to a wide range of complications, including permanent nerve damage affecting more than 11,000 people annually, prompting some dentists to question if the procedure is even necessary. 

What is Propofol?

Sometimes called “milk of anesthesia,” propofol is an oily white solution derived from soybean oil, fats purified from egg yolks, and glycerol, Harvard Medical School reports. It’s used for general anesthesia and sedation for both human and veterinary surgical procedures.

Administered via IV, it takes effect in as little as 40 seconds—and has become the leading anesthetic used for outpatient procedures, including dental surgery and colonoscopies, according to Joel Weaver, DDS, a dentist anesthesiologist and professor emeritus at Ohio State University.

“Propofol is a sedating hypnotic drug with unique properties,” adds J. David Johnson Jr., DDS, an Oak Ridge, Tennessee oral surgeon and associate professor at University of Tennessee. “It’s very fast acting and produces very profound sedation. And once the procedure is over, the effects wear off very quickly.

In a clinical trial involving more than 25,000 patients, about 11 percent experienced minor side effects from propofol, while fewer than one percent experienced serious drops in blood pressure, nausea/vomiting, slow heart rate, or high blood pressure. Dr. Weaver points out that these side effects are similar to those from other drugs commonly used for anesthesia.

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Is Propofol Dangerous?

“Propofol can be a very dangerous drug because it can cause patients to stop breathing and their blood pressure to drop,” says Ken Solt, MD, of the MGH Department of Anesthesia, Critical Care and Pain Medicine, and lead author of a 2012 study of the drug.

The American Society of Anesthesiologists (ASA) cautions its members that the drug should only be used by medical professionals with extensive training in using general anesthesia, such as anesthesiologists and oral surgeons.

In a position paper, the group warns, “… patients can have extremely variable responses to the drug and some patients can become completely anesthetized, including losing the ability to breathe.”

However, the ASA also reports that when administered by properly trained doctors or oral surgeons, propofol is both safe and effective if proper safety precautions are administered. Those precautions include continuous monitoring of the patient’s heart rate, breathing, and blood pressure with machines and having a medical professional whose sole duty is to watch the patient’s reactions during the surgery.

A large study bears this out, reporting that of nearly 30 million cases in which patients were anesthetized (using various drugs, including propofol) for in-office oral surgery procedures, the rate of death or brain injury was only one in about 365,000, according to OMS National Insurance Company (OMSNIC) Anesthesia Morbidity and Mortality Data (2000-2010).

A new study published in New England Journal of Medicine reported a small rise in risk for aspiration pneuomonia in colonoscopy patients treated with propofol, compared to colonoscopies performed without anesthesia. However the rate of this complication was only 0.22 percent with propofol, versus 0.16 without it.

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What Anesthesia Options Are Available?

There are four main types of anesthesia used in dentistry:

  • Local anesthesia, such as novocaine. Local anesthesia temporarily numbs only a small area by preventing nerve fibers from transmitting pain sensations. 
  • Nitrous oxide (laughing gas). This can be combined with local anesthesia for greater pain relief, notes Dr. Johnson. Nitrous oxide is inhaled through a facial mask and wears off very quickly. However, the effect is relatively mild and just takes the edge off pain. 
  • Oral premedication. Sedative pills such as Valium or Ativan are given before the procedure to provide “conscious sedation” and relax the patient. 
  • IV sedation. Drugs like propofol are given through an IV for maximum pain relief. Although patients who receive these drugs are technically “awake,” they typically don’t remember anything about the surgery.

Should impacted wisdom teeth be removed?

A 2005 systematic review of the scientific evidence reports that there’s no data showing benefits to removing trouble-free (no pain or infection risk) impacted wisdom teeth.

Instead, the study authors recommend “watchful waiting,” in which the patient’s dentist checks the wisdom teeth periodically for such problems as inflammation, infection, gum disease, or damage to adjacent teeth. If these occur, then the problematic wisdom teeth should be removed.

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