A Wide Range Discussion with Dr. Fred Quarnstrom: Dental Ethics, Regulations and Professional Turf Wars
By: Michael W. Davis, DDS
Dr. Michael W. Davis practices in Santa Fe, NM. He currently chairs the district dental society peer-review committee, and is active as an expert witness on dental legal cases. He has authored numbers of articles relating to clinical dentistry, dental ethics, and protections for the public.
INTRODUCTION
Recognized as an expert, Dr. Quarnstrom’s many accomplishments include: his current private practice, a faculty member at 3 dental schools, quality assurance consulting, independent expert testimony, and speaker. He has also held positions on what is the equivalent to the dental board in Washington state and Western Regional Examining Board. Dr. Quarnstrom graduated from the University of Washington in 1964 and completed a residency program in General Anesthesia at Washington Hospital Center, Washington D.C. in 1967.
INTERVIEW
Dr. Davis: Dr. Quarnstrom, a number of years ago, you completed a residency program in anesthesiology. You went on to utilize sedation services for your patients, and taught sedation courses, to fellow dental professionals. We both see how dental sedation can be a very helpful adjunct in the practice of dentistry.
What concerns do you have relating to weekend seminar sedation courses, often offered hotel conference rooms? What are the dangers to the public, as well as professionals offering sedation, for marginally trained and minimally emergency equipped dental clinics? Do you have specific concerns relating to the public health and safety; is the public being protected or it is buyer beware? What are the regulating agencies who are setting the standards and rules, and do you feel there is “agency capture” at work?
Are you concerned that it seems violators of sedation rules and regulations of state dental boards, far too often receive little or no disciplinary actions, and what advice do you have for state dental boards?
What advice can you offer to the public, whereby they can more actively protect themselves and their families? What advice do you have for the professional who chooses to offer sedation to patients?
Dr. Quarnstrom: First, I along with a Doctor of Pharmacy and a Professor Emmeritis teach weekend courses in the use of nitrous oxide and oral CONSCIOUS sedation. There is heavy emphasis on CONSCIOUS. We do not teach multiple drugs. When you add a little of drug A plus a little of Drug B plus maybe a little of drug C, D, and/or E. There is simply no research to suggest what the results will be. Personally, I have taught 245 nitrous oxide courses and 110 oral conscious sedation courses. 
Nitrous Oxide is very safe. You really only need to know a few things. Never give more than 50% nitrous for more than a minute. Always check your system to be sure the gases have not been switched.
I know of one near death from switched gas in a surgery office doing IV sedation/general anesthesia and another 70 cases, where gases were switched but there was no damage to the patient.
In the oral surgery office the one patient was under general anesthesia. The surgeon expected him to be unconscious. He discounted the fact that the pulse oximeter reading dropped as low as 35%. His staff had asked him several times if they should call the paramedics. The third time he agreed. But the oxygen levels had been very low for too long. 95% to 98% is the normal saturation at sea level. You should get concerned if it drops to 90%. The patient who was an a student and star athlete ended up with severe neurologic and vision problems.
In the other 70 cases patients either got too relaxed or went to sleep.The dentists have been taught when this happens you should take the mask off and get them breathing room air and they quickly returned to normal with no residual problems. I published research 15 years ago to show it was safe to do this. If a dentist insisted on giving the patient 100% Oxygen and the gas lines are switched they would be giving 100% nitrous oxide. You need a minimum of 30% oxygen when being sedated preferably it would be 70 to 80% oxygen. I have taught for 40 years— “if something is wrong take the mask off”.
The final thing you need to know. IF THE PATIENT BECOMES UNCONSCIOUS OR STOPS REACTING TO VERBAL COMMAND, TAKE OFF THE MASK. If in doubt it is never wrong to call 911. My patients who are paramedics plead with me to tell the dentists at our courses that they will not get into trouble for calling 911. As they state, “Our save record goes way up if we get there while the patient is still alive”.The ADA guidelines and most states require a 14 hour course to administer nitrous oxide sedation.
Two of us did nitrous courses for one of the national organizations. They insisted we take an hour break in the morning and afternoon so they could sell equipment and other courses. We quit after a year because that made the course a 10 hour course and as such it did not meet the state’s regulations.
I have a strong bias against stacking doses of oral sedation. I have reviewed cases where 0.5mg of triazolam was given every 15 to 30 minutes to a total dose of 3 mg. It takes about 60 minutes to see the maximum effect from one dose. In these cases you are into the 3rd dose before you know the effect of the first dose. There have been a number of deaths using this approach. The patient got into general anesthesia and desaturated due to depressed respiration.
If you are going to sedate children you need an anesthesia residency or a pediatric dentistry residency with lots of time in an OR doing general anesthesia. Kids are not little adults.They get into trouble quickly and easily and are very difficult to rescue. There have been multiple deaths around the country from children being sedated with oral drugs. One of the parents whose child died has created a website dealing with this problem.
I have seen some regulations that can only be described as stupid. If you want to do moderate sedation, use two different drugs you must have done 20 cases of supervised oral conscious sedation. That makes the course about a 14 day course. So long as the patient stays conscious or the drug is reversed if they START TO LOSE CONSCIOUSNESS, moderate sedation can be quite safe.This is not true if you are using multiple doses or multiple different drugs.
One state is about to enacting a regulation that will require a blood pressure measurement pre and post nitrous and an anesthesia record showing the percentage of nitrous that was used as the case progressed. They do not require this for local anesthesia.
Patients do have syncopy (fainting) from the injection of local anesthetics but in 50 years I have never seen it with nitrous oxide. This tells me no one on this Board had any experience giving nitrous sedation. While there is nothing wrong with taking a blood pressure pre and post nitrous, if we are being logical it should be required for local anesthesia where there is a greater risk.
I often ask for a show of hands at the courses I teach:
“How may of you never take a Blood Pressure?” The show of hands is about 10%.
“How many once a year?” That runs about 30%.
“How many every 6 months?” About 40% do.
“How may on each appointment?” The response is about 15%.
Two state Boards allows high school dropouts to start an IV, inject general anesthesia drugs and monitor general anesthesia.They do need a 30 hour weekend course. I had a full year general anesthesia residency and over 1100 cases before I could do the same.
For the patient, it is buyer beware. We had 8 deaths in the State of Washington that were discovered by a local Seattle newspaper. One Surgery office had 2 deaths. Not one of these practitioners were sanctioned by the Board. In fact 4 of them occurred while I was on the board and not one of them came to the board. They were either closed by the State or after a review by one board member who had no anesthesia background. In fact even if you go to the board’s website it is close to impossible to find out if any one has died in a dental office.
If you want general anesthesia for your dentistry, I would insist that a medical or dental anesthesiologist give the anesthesia. No MD would take out your appendix and do general anesthesia at the same time. The risk of tooth extraction is miniscule compared to the risk of general anesthesia. The incidence of death is very small, but it is 100% if it is you or your child, and dead is for a very long time.
The most probable cause of a problem is loosing an airway, depressing breathing and not being able to assist the patient by breathing for them until they are back to normal. Every office should have a bag-valve-mask that allows them to assist your breathing, if it should become necessary. We always demonstrate this skill at our courses. I will call for a volunteer and then ask them to breathe for me. I have never had a participant in the last 30 years who was able to do this. Anyone at the course who is willing, is allowed to breathe for me and I suggest they go back to their office and breathe for their staff and have the staff breathe for them. This skill should be practiced on a regular basis.
In 50 years of doing sedation I have never had to breathe for anyone but I would not want to need this skill and have someone die because I did not know how the use the equipment that I am required to have in my office.The regulations state that I must have the bag-valve-mask but it is not specified how often I must practice with it.
Dr. Davis: I realize you’ve audited a great many patient records, certainly in your former capacity with the Washington State Dental Health Care Quality Assurance (Washington’s state dental board), as well as with an insurance trust. I would argue, that the dental profession as a whole, is largely in denial or ignorant of rampant fraudulent billings and over-treatment, by our less than ethical colleagues.
Can you confirm this as a significant problem, within the dental profession? Do you find lawmakers and government regulators actively seeking to clean up (for lack of a better word) the dental profession? Could you offer three or four examples, of the more outrageous scams and excuses made by violators: the dangers and the outcomes?
Dr. Quarnstrom: I once sent 25 problem offices to our Board. I included several records for each office showing violations of trust, doing unnecessary dentistry or doing dentistry that would fail. All cases were sent back to me with a stern letter. They would not review any case unless the patient complained and I should not have sent the cases to the Board. We do have permission granted by the insurance form they submit to release names in such a case.The Board not only did not sanction the offending dentists they protected them.
We had offices where 95% of what they submitted we rejected. We had dental school professors on our team who also reviewed these cases. We asked for x-rays, and could see nothing. We asked for photos and copies of charts, again, we could see no need for a crown, and found no documentation of need.
Consistently, in 95% of the cases submitted for crowns, there simply was no data to suggest crowns and buildups were actually needed!
It should be noted that we were never pressured to save the union trust money. In several cases dental offices or groups unionized all the assistants and dentists became union members. Clearly a union brother and sister would not screw another union member.Two of us were fired for not approving unnecessary, damaging dentistry.The union protected their member dentists and not their members.
Dr. Davis: Dr. Quarnstrom, I’m particularly frustrated by state regulatory dental boards, which are charged with the responsibility of protection of the public interest. Increasingly it’s evident, state dental boards are protecting the interests of corporate America and company shareholders, and are ignoring their obligation to public health and safety. By the licensing of dental professionals, certifying the professionals understand the rules and regulations, are ethically acceptable and qualified to treat patients—the public reasonably assumes the dental boards are there to protect public health and welfare.
Please describe problems and where boards are lacking, as well as your recommendations for positive improvements to empower and enhance our dental regulatory boards.
Dr. Quarnstrom: The Board is to protect the health and welfare of the citizens of the State. However if a patient complains, their complaint is first looked at by 3-4 Board members. If they say there was no violation, the case is dropped. In the next step, the case goes to one member of the Board who reviews the patient’s records and advises 3-4 other members if there is a problem. They can then vote to close the case. In one of the death cases the Board member talked to a surgeon who told him deaths can happen. He decided to close the case with no action. If the case goes beyond this, it goes to a hearing, 3-4 members of the board sit as a jury with a judge, court reporter and witnesses. So the dentist has 3 chances to be cleared. The patient loses if the case is rejected at the first two hearings. The patient cannot appeal the Board’s decision.
In one death case a dental anesthesiologist was asked to review the resuscitation attempt. The resuscitation was well done, but failed. The problem was patient selection. The patient had anesthesia airway problems when she had her hips replaced. The MD anesthesiologist had to reverse the drugs; let her wake up; and have a tracheotomy done before they could do her general anesthesia. She told the surgeon this and showed the scar on her neck from the trach. She was given general anesthesia in the dental office and was dead 5 minutes later because they could not breathe for her either. The expert tried to discuss “case selection” which was really the problem and was told the state only wanted him to review the resuscitation.
We had a dentist who had his license suspended because his lap top computer was found to have many kiddy porn images. He was removed from the Air Force and it was because of this action we removed his license. He went to court and sued. The state’s attorneys did not go to court and defend our action. The dentist got his license back and practices to this day.
Another dentist was massaging women’s breasts to cure TMJ problems. We pulled his license. He went to court and we had to have a second 3 day hearing and pulled his license again. He also had a license in another state where I understand he went on to continue his practice.
I had a dentist submit a request to do 7 porcelain inlays/onlays. He stated the patient had buzzing emulating (his word) from the fillings. I suggested he should evaluate the buzzing for pulsation or frequency shift. There might just be an imbedded message from the great beyond. Needless to say we did not approve the replacements.
I called another dentist because I simply could not figure out what he was doing with an implant. His responded, “I am a Christian dentist.” I said, well I am glad you have a faith, but what are you doing? He said, “I am a Christian, I do not have to say anything!”. Click, the phone went dead.
Dr. Davis: We’ve both discussed on other venues, the problematic ethics with a number of our colleagues. Certainly, the graduating student loan debt, and the need to immediately generate substantial sums of income is a problem. The limited employment opportunities for numbers of dentists, especially recent graduates, forces many to work for corporate dental service organizations, which often impose production quotas and have bonus goals, unbeknownst to their patients. Others seem to “invent” the need for dental services, which can seldom be substantiated via radiographic or photographic evidence. The lack of oversight with our Medicaid program also seems to invite abuse of disadvantaged children and taxpayers.
Do you feel junior dental colleagues are as much the prey, as patients have become? What mechanisms, if any, can be employed to encourage and enhance dental ethics? Do you find professionals seek ethical guidance, or are more inclined to defend questionable treatment within their practices, and those of colleagues (“circle the wagons” attitude)? What can patients do, to best protect themselves?
Dr. Quarnstrom: I taught an ethics course along with a bunch of other practicing dentists. The course was done Winter quarter of the Senior Year. I think ethics should be part of the interview process to get into dental school and should be part of the training every year. In talking with friends who graduated with some of our bad actors, they tell me it was clear from their freshman year that they would not let need or necessity get in the way of doing an expensive procedure.
There are many smaller towns in our state where a dentist would be very successful and make a good living without making up dental needs. These towns need dentists. However, dentists tend to want to practice in the large city particularly the bedroom communities that where the rich folks live. In Seattle the closer your dental office is to Microsoft or Amazon the higher the fees will be and the more dentistry you will need. A DDS or DMD is not a license to take advantage of people.
Dr. Davis: Why did you write your book, “Open Wider: Your Wallet Not Your Mouth - A Consumers Guide to Dentistry”?
Dr. Quarnstrom: I simply got sick and tired of seeing patients being taken advantage of. Myself and a couple of my patients wrote it. It took over a year to put together and cost me $2,000 to have it formatted so Amazon could print and sell it. I have lost count of how many we have sold; but so far it is less than 100 books. We get $3 per sold book. I have seen 1600 hate mails from dentists who read bits of it on the Amazon website.
CONCLUSION
Dr. Davis: Dr. Quarnstrom, I want to thank you for your time and effort to answer these difficult questions. These are questions, which few in dentistry’s leadership are willing to answer.
I also want to thank you for your years of service, to the public and our profession of dentistry. I realize some in the dental profession have targeted you, for your courage in speaking out. Too many influential colleagues have never realized, that in service to the public, and the best interest of our patients, is concurrently acting in the best interest of dentistry.
Dr. Quarnstrom’s Final Thoughts: We need a specialty of Anesthesiology in dentistry. There is a turf war going on. Surgeons do not want general dentists to do sedation for fear we will start taking out 3rd molars. The specialty of Dental Anesthesiology has been blocked at the ADA three times in the last 20 years. Dental Anesthesiology qualifies as a specialty in all ways, there is a journal, there are formal residencies, there is research being done, and there is a formal certification test. The only thing missing is enough political clout to get the ADA House of Delegated to vote for it.
I practice in a modest to low income, multiracial multiethnic area of Seattle. I have made a very comfortable living. I have had a very diverse career from being a dentist on a beachhead in Vietnam, doing a general anesthesia residency in Washington DC., and teaching sedation courses for 47 years; some 700 total presentations. I have published over 40 research and opinion papers. I have done union insurance reviews for 20 years and served on our disciplinary board for 4 years. In the last 10 years I have served as an expert on 40 dental malpractice cases. In 90% of these, I worked for the patient who was injured.
I have seen the dark side of dentistry. With the advent of advertising, success is often related more to the public relations firm you employ than the quality of your diagnosis skills and technical ability to provide needed dentistry. I must have 1-2 ads a week come across my desk or computer on how to increase my production in only 30 days. The courses that attract the most attendees are those that promise how to market, how to sell, how to get financing for patients, how to generate patients who will agree to those procedures that are related to the most profit.
Sadly, we have gone from a “needs” profession—“You have decay and need a filling.” To a “if I can sell it you must need it” profession.
This is my 51st year as a practicing dentist. Why am I still working? First I enjoy dentistry. I am pretty good at it. I enjoy teaching. Many of my patients have been with me for over 30 years some even 45 years. I would miss them. I simply really enjoy what I do. –
“Open Wider: Your Wallet Not Your Mouth - A Consumers Guide to Dentistry” can be purchased following this link on Amazon.com.
Related Featuring Dr. Fred Quarnstrom:
Why no one stopped dentist accused of massive overtreatment, Nov 2013
Enough scrutiny in dental deaths, July 2008