Nineteen months after the tragic death of Jerusalem Mayor Uri Lupolianski's two-year-old grandson due to dental treatment, a Health Ministry investigation committee has recommended that the Jerusalem dentist who treated the boy, Dr. Shlomit Hovav-Bach, be brought before a disciplinary board.
The ministry said on Sunday that the four-member committee - headed by Dr. Shoshana Shpirer, deputy head of the pediatric high-risk dentistry unit at Sheba Medical Center - also made "practical recommendations" to the ministry's dental health branch and the Israel Dental Association "to prevent a recurrence of such eventualities."
In January 2005, Yair Lupolianski - son of the mayor's son Ya'acov (Kobi) and his wife Leah (Lali) - died on his second birthday from rare complications from oral sedation at the Ramot quarter clinic of Hovav-Bach, a specialist in pediatric dentistry.
The toddler was treated for four rotten front teeth, which had to be replaced by crowns. Hovav-Bach said she gave a lower-than-recommended dose of the sedative, midazolam syrup, during the treatment. Seriously decayed front teeth in this age group are usually due to a child keeping a bottle of milk or sweetened drink in its mouth for hours at a time, especially during sleep.
Seeing that Yair did not wake up after the treatment, the dentist immediately began resuscitation and called a Magen David Adom mobile intensive care unit, whose paramedics administered the antidote when they arrived. But it was too late.
Yair died at Hadassah-University Medical Center and was buried that night with the four new crowns in his mouth. After consultation with the family's rabbis, the haredi family refused to allow an autopsy before the funeral, so the investigation had to be carried out without pathological data.
The ministry, which did not release the entire report but only a statement to the press, said the child received oral midazolam followed by a mixture of oxygen and laughing gas via inhalation. The device that measured oxygen levels in the blood did not continuously monitor the child's depth of anesthesia or respiration, the committee said.
The sensor, "worn on the finger and meant for adults and teenagers and less for children aged two, was problematic because it was not suited to the finger's size." In addition, the model used by the dentist was old, without the ability to sound a warning in an emergency, and when the sensor falls from the finger, the device turns itself off for several seconds.
The investigation committee said diagnosis of his cessation of breathing was "too late" and that there were shortcomings in the "process of resuscitation in the clinic." Thus they recommended that the investigation process continue with a formal hearing.
The ministry did not explain why it took so long for the committee to present its recommendations, but 19 months is considered "quick" for such committees, whose members work as volunteers.
Neither the toddler's parents nor Mayor Lupolianski and his wife Michal had blamed the dentist publicly at the funeral on Jerusalem's Har Hamenuhot. The father, a kollel (yeshiva for adult men) student, said in a eulogy for his second child that "God gives and God takes away."
A graduate of the Hebrew University-Hadassah Dental School, Hovav-Bach was described after the tragedy as "extremely dedicated to her patients, talented and professional" by Prof. Yossi Shapira, head of pediatric dentistry at the dental school.
"She is absolutely distraught over the death," said Shapira. "She had an antidote, a monitor and all other requirements for giving sedation to her patients in the clinic. She worked by the book. A religious woman who lives in Efrat with her husband and five children, she feels terrible."
Shapira added that midazolam syrup "is the drug of choice for this and other procedures on children and adults around the world. It is used daily at emergency rooms on children who need stitches, on adults who undergo colonoscopy and for many other procedures. Complications are extremely rare," he said after the funeral, "but such things can happen with any procedure. Dental care is a type of medical intervention."
The first case of a death from dental care occurred in the mid-'80s, when Prof. Yosef Anais, an experienced Jerusalem dentist, gave a small girl a suppository as a sedative along with barbiturates and other drugs and left her unsupervised after the dental treatment. He was convicted of negligence, served a six-month prison sentence and the ministry suspended his license for two years.
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