Until now, dentists in Hawaii have not had to get a permit or follow any specific state regulations in administering oral sedatives, such as the potent drugs allegedly given to a 3-year-old girl who died Jan. 3 after falling into a coma in the dentist’s chair.

Starting Monday, that will change when new rules take effect to close that gap.

Across the country, more and more children are being sedated for dental procedures, but oversight varies from state to state. The use of general anesthesia, a drug-induced loss of consciousness, is strictly regulated everywhere. But milder forms of sedation are left up to the dentist in some states.

"Most states do address all types of sedation, all the way through general anesthesia, and the required training and documentation for each of those," said Dr. Joel Berg, immediate past president of the American Academy of Pediatric Dentistry.

Hawaii Administrative Rules on Dentistry have long required dentists to get advanced training and written authorization from the state Board of Dental Examiners to administer general anesthesia and intravenous-conscious sedation. They also require dentists to have proper facilities and staff to handle problems and emergencies in such cases.

But the regulations had been silent on oral sedatives, which can induce mild or moderate sedation, depressing the central nervous system.

On Jan. 16, however, Gov. Neil Abercrombie signed new rules requiring dentists to complete comprehensive postgraduate training that meets American Dental Association guidelines and obtain permits before administering "moderate conscious sedation," whatever the mode of drug delivery. The rules were approved by the Board of Dental Examiners in July and have been undergoing administrative review since then.

"The Hawaii Dental Association has worked for several years with the Board of Dental Examiners and other oral health stakeholders in Hawaii to help propose rule changes, which include the section on sedation and general anesthesia," Dr. Lili Horton, president of the HDA, said in a written statement Friday in response to a query from the Honolulu Star-Advertiser.

"The HDA supports state regulations that limit the practice of sedation and general anesthesia to qualified, appropriately trained and skilled dentists in a properly equipped facility and with an adequate monitoring protocol and qualified support personnel."

Dentists will be required to complete 60 hours of instruction, be supervised while handling at least 20 moderate sedation patients, have clinical experience in managing compromised airways, and be proficient in advanced cardiac life support to get approval to administer moderate conscious sedation.

Finley Boyle, a cheerful girl with no fear of the dentist, suffered cardiac arrest after heavy sedation at the office of Dr. Lilly Geyer at Island Dentistry for Children in Kailua on Dec. 3, according to a lawsuit filed by her parents, Ashley and Evan Boyle. She had severe brain damage and died a month later, said her mother, who is a registered nurse.

The youngster had been given liquid sedatives to swallow by an office staffer even before the dentist arrived, Boyle said. She got "really loopy" and was carried to the dentist’s chair, where Geyer prepared two teeth for "baby root canals." 

In the waiting room, Boyle said she learned something was wrong only when emergency responders arrived. The staff had already summoned a pediatrician from down the hall to help revive Finley. An oncology nurse, Boyle said she later learned Finley had been given heavy doses of Demerol, hydoxyzine and chloral hydrate, as well as nitrous oxide.

"They totally overdosed her," Boyle alleges.

An autopsy was performed but results are still pending from the medical examiner.

Cases like Finley’s appear to be rare. Dan Galanis, epidemiologist for the state Health Department’s Injury Prevention and Control Branch, searched Hawaii’s death certificate database, which covers 1991 through 2012, and found no cases of children who had died as a result of dental anesthesia.

The girl’s mother feels that if basic precautions had been taken, she would still be alive.

According to Boyle, records show Finley’s vital signs were normal at the start of the procedure, but after 26 minutes a second reading showed oxygen saturation — a measure of the amount of oxygen being carried by the body’s red blood cells — of 65 percent with a downward arrow. A healthy reading is typically not lower than 95 percent.

"If they had simply had Finley on something as basic as an oxygen saturation monitor — they clip easily onto your finger — had they simply left that on her finger, the machine will beep and let you know if the level drops below 95 percent," she said.

During moderate sedation, oxygen saturation and heart rate must be continuously monitored, according to the American Academy of Pediatrics and the American Academy of Pediatric Dentistry. Their guidelines, issued in 2006, note that children under age 6 "are particularly vulnerable to the sedating medication’s effects on respiratory drive, patency of the airway and protective reflexes."

"It is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation," they note.

The dentist should be trained in advanced pediatric airway skills, and while the dentist is working, another person must be responsible for monitoring the patient and be available to help rescue the child.

Berg said the guidelines were sent to state dental boards across the country a couple of years ago. Hawaii’s rules governing dentistry were last updated in 2002.

"Sedation is safe when done properly," said Berg, dean of the University of Washington school of dentistry. "It’s an extremely safe procedure and it’s an important part of managing children for restorative dentistry. When the guidelines of the American Association for Pediatric Dentistry have been followed, there has not been an incident."

The Regulated Industries Complaints Office of the state Department of Commerce and Consumer Affairs is investigating Geyer. Her dental business has shut down and her lawyer, John Nishimoto, would not discuss the case or her credentials.

"As this matter is now the subject of a pending lawsuit, it would be inappropriate for me or my client to comment on any of the unproven allegations that have been reported to the media," Nishimoto said.

Hawaii’s Board of Dental Examiners also would not speak about the case or state regulations.

"The dental board can become the deciding body on a licensee’s status and cannot comment on any matter that might come before the board for consideration," said Brent Suyama, spokesman for the Department of Commerce and Consumer Affairs.

Geyer, formerly known as Lilly Tsou, graduated from Temple University’s School of Dentistry in May 2004. She practiced dentistry in Pennsylvania before moving to Hawaii, and soon landed in the news.

Tsou was one of five dentists who hired a law firm and threatened to sue the Hawaii Board of Dental Examiners over its plans to administer a new licensing exam, according to a June 2005 article in Pacific Business News. They wanted to be licensed by credential or by regional exam.

She received her license to practice as a dentist in Hawaii a month later. After years of complaints about Hawaii’s dental exam, which had an estimated 50 percent failure rate, the state began using a national exam in 2007. To be licensed to practice dentistry in Hawaii today, dentists must pass the American Board of Dental Examiners’ dental examination.

Geyer, 36, is not a member of the Hawaii Dental Association, the professional organization to which more than 90 percent of Hawaii dentists belong. Nor is she listed in the American Academy of Pediatric Dentistry’s directory.

While dentists with general licenses may treat patients of all ages, pediatric dentists are specialists with at least two more years of training. Geyer’s practice, Island Dentistry for Children, catered to children, with flavored gloves and a TV visible from the dentist’s chair.

Boyle said she brought her daughter to Geyer for her first-ever dental visit in November. She said she was shocked when the dentist told her that Finley had 10 cavities and needed four "baby root canals," also known as pulpectomies. Later, while her daughter lingered in a coma, a different dentist performed an exam, including X-rays, and concluded that Finley had just a few cavities.

Boyle aches with the loss of her only child, who used to cheer her up when things were tough.

"She was just the happiest little girl, completely healthy her whole life," she said. "If I was ever upset, she would just come up and rub my arm and say, ‘Don’t worry, I’m here.’"

"These past three weeks have definitely been the hardest of my life," she said late Thursday. "I try to just take it one day at a time."