Historical Selection: Peskin Robert M. Contemporary intravenous anesthetic agents and delivery systems: Propofol. Anesth Prog. 1992;39:178–184.

It was a great honor to receive the 2025 Heidbrink award. It was also a privilege to be asked to select an article from the archives of Anesthesia Progress and to provide my commentary on its impact on anesthetic practice. As I reviewed the Anesthesia Progress archives, I focused on who Dr. Jay Heidbrink was to assist me in selecting an article. Dr. Heidbrink did not settle for “what is” but rather sought “what is possible.”

Ultimately, I chose to select an article authored by an esteemed care provider and teacher, Dr. Robert Peskin, which was titled Contemporary Intravenous Anesthetic Agents and Delivery Systems: Propofol, published in 1992.¹ To my younger colleagues, this selection may be an interesting article choice as propofol is the standard intravenous (IV) anesthetic agent used today by the medical and dental professions to induce and maintain anesthesia, particularly in ambulatory practice. However, in 1992, practice for sedation and general anesthesia for dentistry was different. Methohexital was the primary intravenous (IV) agent used by most private dental practitioners to induce and maintain anesthesia which was delivered with incremental boluses or “bumps” as most were not familiar with IV infusion pumps. Although midazolam was introduced to anesthetic practice in the mid-1980s, many practitioners were still using diazepam as their primary benzodiazepine, and meperidine was routinely used by many as their opioid of choice. These medications (methohexital, diazepam, and meperidine) had negative characteristics that providers were forced to tolerate or attempt to mitigate. Although propofol was being used within the University of Connecticut Department of Oral and Maxillofacial Surgery when I first joined the faculty in 1992 as well as in many other academic institutions at that time, propofol didn’t experience a significant increase in usage amongst private practice dental providers until after the methohexital shortage that occurred approximately a decade later. Dr. Peskin’s 1992 article was insightful and published 10 years before the majority of the dental profession recognized and appreciated the superiority of propofol compared to methohexital and incorporated it into their clinical practice.

Dr. Peskin stated in his article that “dentists have long been on the forefront in the development and utilization of intravenous anesthetic techniques.” When I graduated from dental school in 1984, dentistry was indeed the leader in ambulatory anesthesia. Since then, we have observed significant strides amongst our anesthesia colleagues. My concern with Dr. Peskin’s statement is whether it remains as true today as it was in the past. Dr. Peskin’s article was published in 1992. Propofol was routinely used in the operating rooms by our medical anesthesia colleagues with the literature touting its qualities that make it advantageous for ambulatory anesthesia. However, many years passed before dentistry demonstrated a significant transition from methohexital to propofol.

A series of closed claims articles in the anesthesia literature published in the late 1980s and early 1990s reported the highest contributor to anesthetic morbidity and mortality to be respiratory compromise with a lack of respiratory exchange (not oxygen saturation) being the weakest link.² Capnography was demonstrated to be an effective method to achieve ventilatory monitoring.³ The American Society of Anesthesiologists (ASA) adapted capnography as a standard for basic monitoring for moderate sedation and deep sedation in 2011. However, the adoption of such a standard was not approved by the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the American Dental Association (ADA) until 2014 and 2016, respectively. The Commission on Dental Accreditation (CODA) educational standards in “patient safety” for residency training have also lagged several years behind the adoption of similar standards by the Accredited Council for Graduate Medical Education (ACGME). Oral and maxillofacial surgery is the only area in dentistry with a resemblance of such a patient safety standard, and it was just implemented in 2025.

When contemplating what article to select along with any comments I would make, I reviewed the articles selected by my esteemed colleagues who received the Heidbrink award prior to me. I noticed a similarity in the articles that I reviewed in that many focused on something that would optimize patient care and outcomes, representing the principles of Dr. Heidbrink. Dr. Donald Berwick, a globally recognized authority on health care quality and improvement, stated that “everyone who works in healthcare has two jobs: to take care of patients and to improve how we take care of patients.” To improve how we take care of patients, we must understand the concepts of patient safety. The practitioner must understand the two concepts of safety as described by Hollnagel. Safety 1 “ensures that as few things as possible go wrong.” This approach is reactive and addresses the past. Many of the articles on anesthesia safety published in the dental literature retrospectively assess patient outcomes, which reflects the safety 1 concept. However, what was safe in the past does not necessarily translate to what is safe now or tomorrow. Safety 2, alternatively, is a proactive approach and “ensures as many things go right as possible.” It asks: what are the factors that allow successes to become reality?⁴

When assessing our practices, we must recognize that “what could go wrong almost never does.” This is fortunate; however, are we always recognizing the near misses and accidents? To paraphrase Henry Louis Berson, “do we see what we want to see and do not see what we do not want to see?” We must, therefore, ask ourselves “do we pay enough attention to what could go wrong?” I am not debating the quality of care provided by the profession but rather the understanding that with such a great quantity of cases performed annually, even a low incidence of adverse events amounts to a significant concern. Therefore, we must ask ourselves “if everything is being done to achieve the least possible risk.”

I have had the privilege of training in both dental anesthesiology and oral and maxillofacial surgery. These are great professions, and I have tremendous respect for my colleagues in both specialties. I know of no colleague who has willfully disregarded the care and safety of their patient. But good patient care is dependent on patient safety, and we must challenge ourselves to ask if our practices are “safe enough” and “can we do better?” The entire dental profession must continuously assess what is being done and what adaptations are required to ensure positive outcomes.

Anesthesia has a long history with dentistry. It is important to our practices. Is the profession still at the forefront of anesthesia development as suggested by Dr. Peskin? In my opinion, there are areas of patient safety that are ripe for further study. Such areas include anesthetic pharmacology (e.g., remimazolam) and team-based practice (e.g., simulation for the office team, minimal training standards for anesthetic staff). There are opportunities to lead and address these challenges and control the profession’s destiny. Change is necessary for progress, but, unfortunately, change frequently leads to resistance. Dr. Leape suggests that waiting for “incontrovertible proof of effectiveness before recommending a practice would be a prescription for inaction.”⁵ It is best that the dental profession lead and make these changes before an outside entity directs such action. In a fast-advancing field, moving forward slowly can be equivalent to moving backwards.

The American Dental Society of Anesthesiology (ADSA) represents all dentists interested in dental sedation and general anesthesia. Patient safety is best achieved by working together.

Respectfully submitted,