The recent death of a 3-year-old girl who went into a coma after visiting the dentist’s office raises questions about the regulation of children’s dentistry in Hawaii and whether the state is doing enough to prevent a similar incident from happening in the future.

The dentist, Lilly Geyer, who operated the now-closed Island Dentistry for Children in Kailua, may have misrepresented herself as a highly qualified practitioner capable of doing intense medical procedures on children.

Based on publicly reported details, several experts interviewed by Civil Beat are also questioning the kinds and amounts of medications that were reportedly used on the 38-pound child.

The state Department of Commerce and Consumer Affairs’ Regulated Industries Complaints Office is conducting an investigation into the dentist’s office, according to department spokesman Brent Suyama.

He said the department and Board of Dental Examiners won’t comment pending their findings.

The parents of the girl, Finley Boyle, filed a lawsuit in December contending she suffered a cardiac arrest and severe and permanent brain damage after visiting licensed dentist Geyer’s Kailua office to undergo four root canals for 10 cavities at an appointment on Dec. 3. Office staff gave the child improper amounts of medications, including the opioid Demerol, and were ill-prepared to deal with the emergency once she stopped breathing, according to the lawsuit.

Finley died a month later.

Now, questions are being raised about whether Geyer should have been advertising herself as a “children’s dentist” and whether the state is providing effective oversight to make sure dentists are not deceiving the public about their practices and qualifications.

Pediatric dentists do a rigorous and competitive two-year residency program in which they get training in specific skills such as child sedation; general dentists aren’t required to do a residency program.

The state doesn’t maintain records indicating whether or not Geyer is a certified pediatric dentist because it only issues one type of general license for dentists, regardless of whether a dentist has extra specialty training, Suyama said.

According to a Department of Commerce and Consumer Affairs licensure database, Geyer’s license was first issued in 2005 and set to expire in 2015. She also once used the name Lilly Tsou, according to the state. Her records show one pending complaint from 2013 but it’s unclear whether it’s related to the Finley Boyle case.

However, Geyer is not listed in the American Academy of Pediatric Dentistry’s directory, which contains dentists who are members in good standing with the academy.

The Department of Commerce and Consumer Affairs through the Hawaii State Board of Dental Examiners oversees dentists in the state, issuing and renewing licenses based on requirements such as a graduate dental degree, satisfactory performance on the dental exam and as many as 32 hours of continuing education courses. But the department primarily sticks to ensuring the dentists keep up with renewal requirements as well as investigating complaints, according to Suyama.

The question of regulation “is always just kind of dicey,” Suyama said. “We don’t want to over-regulate.”

But the state does little to ensure they are engaging in good business practices, according to dentists and other experts interviewed by Civil Beat.

One problem is billing themselves as specialists when they haven’t gotten the extra training.

The Finley Boyle incident demonstrates that the Hawaii State Board of Dental Examiners should should do more to regulate dental practices, says Michael Rethman, a dentist living in Hawaii who stressed he’s not privy to the details of this particular case. Rethman is vice president of scientific research of the American Dental Association Foundation and has overseen several other national dental organizations.

“In my opinion the state board should spend a lot less time focusing on trying to keep qualified dentists out of Hawaii and spend more time making sure the dentists here are behaving appropriately,” said Rethman, arguing that the dental board invests too much energy in making it difficult for dentists to acquire licenses versus regulating them once they’re issued.

“The real problem here is that the public doesn’t know the difference,” he said. The industry “is not set up to do a lot of things that are really sensible.”

Joel Berg, dean of the University of Washington’s School of dentistry and a former president of the American Academy of Pediatric Dentistry, described pediatric dentistry programs as highly competitive and comprehensive, with training in topics ranging from general anesthesia to restorative care. Any dentist who goes through the pediatric dentistry program should be highly certified to administer sedation, he said, pointing to guidelines developed by the pediatric dentistry academy and American Academy of Pediatrics.

He said state boards should do a better job of ensuring consumers can make informed decisions — creating speciality licenses as is done in states such as Illinois and Oregon.

“In terms of public confusion, that is a prevalent problem,” Berg said.

‘Dentistry for Children’?

John Nishimoto, the attorney representing Geyer, declined to say whether Geyer received extra training in pediatric dentistry, citing the pending lawsuit.

“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,” he said.

Gregory Tom, one of the attorneys representing the Boyles, said the law firm also is declining comment on the lawsuit.

But several dentists say what’s been reported publicly as well as alleged in the family’s lawsuit suggests Geyer didn’t have the training to handle very young children.

Geyer advertised her practice as dentistry for children, given the office’s name, and detailed her expertise on a now-defunct website.

An archived version of Geyer’s website describes Island Dentistry as “a dental office that focuses on the dental health of children.” It also touts Geyer’s extensive training, including a Doctor of Dental Medicine degree from the Temple University School of Dentistry; certification in Basic Life Support, Advanced Cardiac Life Support and Pediatric Advanced Life Support; and attendance at annual meetings for pediatric dentistry, oral surgery and sedation industry. The website doesn’t, however, say whether Geyer attended a pediatric dentistry residency program.

Experts now question whether Geyer misled parents — particularly because office staff, according to the lawsuit, had to summon a pediatrician whose office is in the same building once the girl went into cardiac arrest.

Brent Ching, a pediatric dentist at Kapiolani Medical Center, says it’s also the responsibility of advertising media to hold dentists accountable. He said media such as the Yellow Pages allow professionals to market themselves however they want as long as they pay the tab; that means a general dentist without special training could easily market him or herself as a pediatric specialist.

“I just think that the public was misled on many occasions here, and it’s because advertising media has allowed this to happen,” Ching said. “All the avenues allow (Geyer) to market herself that way.”

He pointed to certain dentists who in past years have been listed as specialists in publications such as Honolulu Magazine even though they lack the specialty training. Geyer herself was listed in the magazine’s “Best Dentists in Hawaii List 2013” — but in this case under the “General Dentistry” category.

Ching said it’s primarily the responsibility of dentists themselves and advertising media to ensure the public isn’t deceived, though he acknowledged the role of the state dental board in ensuring safe dentistry as well.

Deadly Sedation

The death also raises concerns about the use of sedation on young children. Reliable statistics on the number of children who’ve died because of dental sedation aren’t available, though some media outlets have reported that the practice accounted for at least 31 child deaths between 1997 and 2012.

Dentists need to be certified to administer sedation in Hawaii, a credential that requires successful completion of a course that covers at least 10 categories of anesthesia and clinical experience, among other prerequisites. They then need to get written authorization from the board and renew that authorization every two years. Suyama didn’t say whether Geyer complied with those requirements.

Ching — whose pediatric residency included a three-month anesthesia rotation as well as in-house sedation on patients over the two-year course — said he has never administered sedation at his practice, which opened in 2000.

In “conscious sedation” — which according to legal documents appears to be what Finley received — young children lose their inhibitions and can become difficult to control, Ching said.

“It’s a lot harder to take action when you start to see oxygen saturation go down,” he said, adding that the risk of a child dying during a mismanaged dental-office sedation is small but far more likely than when general anesthesia is used on a child at the doctor’s office.

Ching said most children can be safely treated using injections of a local anesthetic, while a few may require nitrous oxide, or laughing gas.

The lawsuit and media reports contend Geyer’s office used a mixture of drugs, including the Demerol and hydroxyzine and chloral hydrate. Rethman called that “an interesting potpourri” and said he is appalled by what appears to have been minimal monitoring of Finley’s vital signs, which according to the lawsuit was inconsistent. Monitoring with an apparatus such as a pulse oximeter — the sensor placed on a person’s finger that sounds an alarm when oxygen levels are low — is key because it’s hard to tell a patient’s state when that person shuts his or her eyes, according to Rethman.

Both Rethman and Berg, the UW dean, said sedation can be really useful in certain cases.

“You have to have a means of monitoring that patient either electronically or visually — and the only way you can do it visually is if they’re conscious,” Rethman said. “None of these drugs kill directly — they’re not toxic — but what these drugs do do is suppress respiration. If you suppress respiration enough, that’s toxic.”

A previous version of this story included a photo of the Hawaii Dental Association’s building even though the association is not involved in this case. Lily Geyer is not a member of the HDA, which represents 970 dentists practicing in Hawaii. The HDA sent this press release days after Finley Boyle died:

“The Hawaii Dental Association expresses our deepest sympathies to the family of Finley Boyle during this very difficult time. Like many others in our community, we have been closely following the tragic news. The health, safety and welfare of children are top priorities of our members. The practice of sedation/anesthesia by licensed dentists is regulated by the State of Hawaii, and to ensure the highest safety measures for patients undergoing sedation, the American Dental Association and the American Academy of Pediatric Dentistry have established guidelines for appropriately trained and qualified dentists.

The Hawaii Dental Association is committed and is continuously working to assure that community professional standards are met in all areas of dental practice, especially in the area of patient safety. We also encourage the public to speak with their dentists and to feel free to ask questions about their background and credentials, treatment plans and treatment options.”