Emerging Demand in Pediatric Dentistry for Office-Based General Anesthesia by Dentist Anesthesiologists in the United States-Juniper Publishers
Juniper Publishers-Journal of Anesthesia
Abstract
Pediatric dentists have traditionally relied upon
self-administered sedation techniques to provide office-based sedation.
The use of dentist anesthesiologists to provide office-based anesthesia
is an emerging trend. Recent research have examined and compared these
two models of office-based anesthesia services a survey evaluating
office-based sedation of diplomates of the American Board of Pediatric
Dentistry (ABPD) found that over 70% of board-certified US pediatric
dentists use some form of sedation or anesthesia in their offices.
Furthermore, less than 20% administer IV sedation and 20 to 40% use a
dentist anesthesiologist. Therefore, the first purpose of this review is
to explore the use of office-based sedation and anesthesia by pediatric
dentists practicing in the United States. The second purpose of this
review is to identify what graduate training programs in pediatric
dentistry and dental anesthesiology are addressing to meet the future
demands for deep sedation/ general anesthesia services required for
pediatric dentistry.
Introduction
Office-based sedation and anesthesia is a critical
component of the modern pediatric dental practice. This is especially
true for the management of special populations that include patients
with cognitive impairments, developmental delay, precooperative age and
other conditions that limit the effectiveness of the traditional
behavior management techniques used by pediatric dentists. Some
pediatric dentists provide minimal or moderate sedation while
simultaneously performing dentistry on these patients. Although this
practice of operator- administered sedation has been a cornerstone of
pediatric dental practice for generations, there are profound
limitations to depth and effectiveness of sedation that can be provided
using this technique [1-3].
Treatment of preschool children with early childhood
caries is another major indication for office-based sedation and
anesthesia. Early childhood caries is a major public health issue in the
United States. Dental caries, the most common chronic childhood disease
in the United States, affects approximately 1 in every 4 children under
the age of 12 [4]. Pain and infection related to dental caries results in the loss of 51 million school hours each year [5].
Operator-administered moderate sedation for children with early
childhood caries is often only minimally effective. The limited depth
and short working time of selfadministered sedation techniques limit the
pediatric dentist's ability to treat this population.
When general anesthesia is required for the treating
special populations, or children with early childhood caries, pediatric
dentists have three options: treat the child in hospital, an ambulatory
surgery center, or have office-based anesthesia performed in their
office by a dentist anesthesiologist. All three options can be performed
safely and effectively, however there are significant differences
between the three options regarding cost and efficiency. The most
expensive option is hospital- based general anesthesia, where combined
facility, operating room and personnel charges for a single case of
pediatric dental rehabilitation can cost several thousands of dollars [6].
Hospital-based general anesthesia is also the least efficient option.
Traveling outside of the office requires the dentist to suspend patient
visits in his private practice while he travels to and from the
hospital. Scheduling is more constrained, and wait times of up to
several weeks can elapse between the request for operating room time and
actual treatment [7].
Scheduling restraints on the operating room time, which must provide
priority to more urgent surgeries often make hospital treatment less
productive for the dentist than rendering that treatment in her private
office [8].
Ambulatory surgery centers usually charge lower
facility costs than hospitals, and may have more accommodating
schedules, but travel out of the office is still required [9].
In addition, very few ambulatory surgery centers possess the
specialized armamentarium required for dentistry, making it more
difficult for the center to accommodate dental cases as compared to more
common, minor outpatient surgeries [10].
Personnel in ambulatory surgery centers must respond to a variety of
surgeries and surgeons, and may not possess the training and experience
required for optimal delivery of dental care.
Office-based anesthesia is both the least expensive
option for the patient and most productive for the pediatric dentist,
since no travel outside of the office is required, treatment is
accomplished with armamentaria that is optimally-suited for dentistry,
with personnel that are very familiar with dental procedures. The
addition of a dentist anesthesiologist to the care team would seem to
add to the efficiency of office-based dentistry for pediatric dental
rehabilitation, however little specific information about dentist
anesthesiologists working with pediatric dentists has been published.
Dentist Anesthesiologists are a group of dentists
that have undergone a two to three years of hospital-based anesthesia
training in an accredited residency program. The residency includes
training to proficiency in all major forms of anesthesia delivery, and
specific training in office-based anesthesia. Dentist anesthesiologists
work extensively with pediatric dentists, providing, among other
services, office-based general anesthesia for preschool children with
Early Childhood Caries (ECC.) A 2010 survey of the American Society of
Dentist Anesthesiologists showed that work provided for pediatric
dentists accounted for more than 60% of the average dentist
anesthesiologist practice [11].
Dentist anesthesiologists provide broad range of anesthesia services,
ranging from moderate sedation to general anesthesia. Despite these
advantages, however, the number of dentist anesthesiologists practicing
in the United States is relatively small and certain areas of the
country have limited access to their services [12].
This review examines the practice characteristics of
office-based sedation and anesthesia performed in United States
pediatric dental offices. Specific attention is given to the utilization
of dentist anesthesiologists. A broad range of data was collected that
compared the use of self-administered sedation services by pediatric
dentists, the use of dentist anesthesiologists for office-based
anesthesia, and the economic aspects of these practices.
Use of Dentist Anesthesiologists by Pediatric Dentists in the United States
In a recent study by Olabi et al. [13],
Diplomates of the American Board of Pediatric Dentistry (ABPD) were
surveyed anonymously regarding their experience with dentist
anesthesiologists with respect to the practitioner gender, age, years in
practice, US. region of practitioner practice, number of years as a
Diplomate of the ABPD, use of in office sedation, use of IV sedation,
use of dentist anesthesiologist, and their comments on the use of a
dentist anesthesiologist [13].
Fifty percent of respondents (N=246) had been Diplomates for 5 or less
years. However the largest age group among respondents was 51+ years
(N=173, 35%) followed by the 31-35 year olds (N=108, 22%) and the 36-40
year olds (N=97, 20%). With regard to years in practice, 35% (n=172) had
been in practice 21 or more years, followed by the 0-5 years in
practice group (N=99, 20%) and the 6-10 years in practice group (N=104,
21%). This suggests a bimodal distribution of age and years in practice
among the Diplomates who completed this survey, with early career and
late career pediatric dentists making up the largest groups.
Diplomates of the American Board of Pediatric
Dentistry were queried for practices related to administering any form
of sedation in office, administering IV sedation in office, using a
dentist anesthesiologist, and those who would utilize a dentist
anesthesiologist if one were available. Respondents were later
classified by gender, age, years in practice, practice type, region were
they practice, and years as a Diplomate of the ABPD, the following
results were reported:
a.Gender
More female respondents (N=77, 39%), as compared to
male respondents (N=59, 23%), reported they used a dentist
anesthesiologist (p< .01). There was no significant difference
between the male and female respondents with regards to administering
sedation in office, administering IV sedation in office and using a
dentist anesthesiologist if one were available.
b.Age
The 51+ year old respondents were less likely,
compared to all other age groups respondents, to administer IV sedation
(p< .01), use a dentist anesthesiologist (p< .01) and would use a
dentist anesthesiologist if one were available (p< .01). There was
no statistical significant difference among age of respondents in
administering some form of in office sedation.
c.Years in Practice
Respondents that have been in practice for 21+ years
were least likely to use IV sedation in their office (12%, p< .01)
and among the least likely to use a dentist anesthesiologist (25%, p<
.01). There was no statistical significant difference between years in
practice and administering some form of sedation in office and using a
dentist anesthesiologist if one were available.
d.Practice type
The group type of practice was the least likely (63%,
p< .01) to administer some form of in office sedation. There was no
statistical significant difference in practice type when administering
IV sedation, using a dentist anesthesiologist, and using a dentist
anesthesiologist if their services were available.
e.U.S. Region of practitioner practice
From a regional perspective, the South West region
were the most (88%, p< .01) to respond that they administered some
form of in office sedation. District 6 (West) respondents were the most
to report that they administered in office IV sedation (39%, p<
.01), employed the services of a dentist anesthesiologist (59%, p<
.01) and would use a dentist anesthesiologist (78%, p< .01) if one
were available. It is interesting to note that the desire to utilize a
dentist anesthesiologist, if available, is consistently higher than the
number of pediatric dentists providing their own anesthesia in every
region of the country.
Years as a Diplomate of the ABPD
Respondents that have been board certified for 16-20
and 21+ years were the least to administer in office IV sedation (8%,
p< .01) respectively, and would utilize the services of a dentist
anesthesiologist if one were available (47%, p< .01 and 53%, p<
.01 respectively). There was no statistical significant difference among
ABPD respondents in administering some form of in office sedation and
employing a dentist anesthesiologist.
Graduate Pediatric Dentistry Programs
Graduate programs in pediatric dentistry provide a
critical influence on the sedation practices of new pediatric dentists.
In an effort to identify ways in which to address the demands for
sedation and anesthesia in tomorrow's pediatric dental practice, Hicks,
et al. [14],
conducted an anonymous electronic survey of current United States
graduate programs in pediatric dentistry and dental anesthesiology [14].
Surveys were directed to pediatric dentistry graduate program directors
and to identify and quantify the types of deep sedation and general
anesthesia experiences pediatric dentistry residents were receiving. The
study also queried dental anesthesiology program directors to identify
and quantify the clinical experiences of Dental Anesthesiology (DA)
residents and determine which dental specialties have the highest demand
for office-based deep sedation/general anesthesia by a dentist
anesthesiologist.
Pediatric Dentistry Program Directors:
Ninety-eight percent of pediatric dentistry programs treat patients by
deep sedation/general anesthesia, with 69% of these occurring in an
operating room (OR) environment only, and 29% of pediatric dentistry
programs performing deep sedation/general anesthesia in both a clinical
and OR setting. Forty three percent of pediatric dentistry programs use
the services of a Dentist Anesthesiologist (DA) of the 43% that use DAs,
26% provide clinic based mild/moderate sedation, 68% provide clinic
based deep sedation/general anesthesia, 37% provide operating room based
deep sedation/general anesthesia. Fifty-two percent of programs do not
use the services of dentist anesthesiologist. When pediatric dentistry
residency directors were asked, compared to 2, 5, and 10 years ago, have
you seen an increase, decrease, or no change in the request for DA
services by pediatric dentists, 44% have seen an increase in the past 2
years, 60% have seen an increase in the past 5 years and 71% have seen
an increase in the past 10 years. Sixty-four percent of pediatric
dentistry residency directors anticipate an increased need for deep
sedation/general anesthesia services provided by a dentist
anesthesiologist. Pediatric dentistry residency directors reported that
the greatest barriers to incorporating the services of a dentist
anesthesiologist into the treatment of pediatric dental patient were
state/dental anesthesia regulations followed by costs associated with
the service.
Dental Anesthesiology Graduate Program Directors:When
Dentist Anesthesiologist directors were asked which of the following
dental specialties request your services for deep sedation/general
anesthesia most, residency directors responded Oral and Maxillofacial
Surgery-44%, Pediatric dentist- 44%, and General dentist-11%. When
weighed for frequency, pediatric dentistry requested their services
most. When asked, compared to requests from 2, 5, and 10 years ago, 56 %
perceived an increase in the past 2 years, 63 % saw an increase in the
last 5 years and 88% had saw an increase in the last 10 years. When
dentist anesthesia directors were asked what percentage of your
resident's dental deep sedation/general anesthesia cases are performed
on children with special health care needs, results were, 1-25% reported
by 56% or directors and 26-50% reported by 44% of directors.
When directors were asked what percentage of your
resident's dental deep sedation/general anesthesia cases are performed
on children under 6 years of age, the results were 1-25% of cases were
on children under 6 years old reported by 33% of directors. Forty-four
percent of directors said 26-50% their resident's deep sedation/general
anesthesia cases were performed on children less than 6 years of age.
Additionally 22% of dental anesthesiology residency directors indicated
that 75100% of their resident’s deep sedation/general anesthesia cases
were on children under 6 years of age.
Barriers to dentist anesthesiologist for pediatric dentistry:
When anesthesia directors were asked what you perceive as the greatest
barrier to incorporating the services of a dental anesthesiologist into
the treatment of pediatric dental patients, awareness of the services
provided by dentist anesthesiologists and access to their services were
the top two factors limiting the use of dentist anesthesiologists by
pediatric dentists.
Dental rehabilitation under hospital-based general anesthesia vs. office-based general anesthesia
Clinical outcome studies of anesthesia providers
provide additional quantitative information for pediatric dentists when
choosing to treat their patients under hospital-based anesthesia or
office-based anesthesia. Saxen [15]
compared outcome data for both using the National Clinical Outcomes
Registry (NACOR) database and the Society for Ambulatory Anesthesia
Clinical Outcomes Registry (SCOR). Seven thousand one hundred and
thirty-three (7,133) office-based general anesthetics by dentist
anesthesiologists were compared to 106,420 hospital-based anesthetics.
Children below the age of six received the greatest
proportion of general anesthetic services rendered by both dental
anesthesiologists and hospital-based anesthesia providers. These general
anesthesia services were primarily provided for complete dental
rehabilitation of early childhood caries. Anesthesia for complete dental
rehabilitation in the office-based setting by dentist anesthesiologists
was significantly shorter than comparable care provided in the hospital
operating room and surgery centers [15].
Time and Cost Analysis
Regardless of the venue, general anesthesia for
pediatric dental rehabilitation is often costly and third party
reimbursement poor. Given the high prevalence of early childhood caries
and the need to treat it early and aggressively, cost will remain as a
significant factor for many in determining where dental rehabilitation
of early childhood caries should be performed. In 2012, Rashewsky et al.
[16]
performed a crosssectional, retrospective study of 96 cases pediatric
dental rehabilitation performed in either a hospital operating room or
office-based environment. Highly significant differences in cost, total
anesthesia time and recovery room time were found. After controlling for
anesthesia time and procedures, general anesthesia performed in Stony
Brook University Hospital operating room was 13.2 times more expensive
than general anesthesia performed in the School of Dental Medicine
office- based environment [16].
Discussion
This review of the emerging need in pediatric
dentistry for office-based general anesthesia indicates that female
pediatric dentists, that were Diplomates of the American Board of
Pediatric Dentistry (ABPD), were more likely to employ a dentist
anesthesiologist than males. In general, practitioner age did not show
any difference in administering some form of in office sedation.
Additionally, most pediatric dentists administered some form of in
office sedation, a finding that correlates with a study by Boynes et al.
[17] that evaluated the practice characteristics among dental anesthesia providers in the United States [17].
They concluded that the enteral sedation technique of moderate sedation
was the most frequently used sedation/ anesthesia technique used by
pediatric dentists (63%). Boynes et al. [17]
also noted that dentist anesthesiologists differ from all other dental
anesthesia and sedation providers in that the large majority only
provide anesthesia and avoid performing dental procedures while
simultaneously delivering anesthesia. For this reason, dentist
anesthesiologists provide a unique point of reference when comparing
their outcomes to medical anesthesia providers in hospitals that deliver
anesthesia in the same way.
This review also found that the longer ABPD
practitioners have been in practice and practiced in a group setting the
less likely there are to use IV sedation, use a dentist
anesthesiologist and utilize dentist anesthesiologists if their services
were available. There are many factors that could lead to these
findings. The newest ABPD members could have more training in IV
sedation and are therefore more comfortable in using IV sedation. From a
regional practice perspective there was a difference in the clinical
practice and administration of IV sedation by ABPD respondents. One of
the reasons could be the different sedation/anesthesia laws associated
with each state.
With respect to graduate program directors in
pediatric dentistry and educational aspects of the current and future
interaction of pediatric dentists and dentist anesthesiologists,
thirty-seven percent of pediatric dentistry programs use clinic-based
deep sedation/general anesthesia for dental treatment in addition to
hospital-based deep sedation/general anesthesia. Eighty-eight percent of
those programs use dentist anesthesiologists for administration of
office based general anesthesia in a clinic-based setting.
Pediatric dentistry residency directors perceive a
future change in the need for office based general anesthesia services
provided by dentist anesthesiologists to pediatric dentists. Sixty-four
percent anticipate an increase in need for dentist anesthesiologist
services. Additionally, pediatric dentistry residency directors reported
that the greatest barriers to incorporating the services of a dentist
anesthesiologist into the treatment of pediatric dental patient were
state/dental anesthesia regulations followed by costs associated with
the service.
Dentist anesthesiologist program directors, when
asked compared to 2, 5, and 10 years ago, have you seen an increase,
decrease, or no change in the request for DA services by pediatric
dentists, 56 % reported an increase in the past 2 years, 63 % reported
an increase in the last 5 years and 88% reported an increase in the last
10 years. When dentist anesthesiologist directors were asked what you
perceive as the greatest barrier to incorporating the services of a
dental anesthesiologist into the treatment of pediatric dental patients,
dental profession awareness and access to the services of a dental
anesthesiologist were the top two responses.
Predicting the future need of dentist
anesthesiologists is an uncertain task, but these results show pediatric
dentistry directors and dental anesthesiology directors are considering
the need, and they recognize a trend of increased need for dentist
anesthesiologist services over the past decade.
Conclusion
The literature reviewed evaluated here indicates the
potential for a team approach to dental rehabilitation for this special
population of the pediatric dental patients. A unique relationship, the
authors believe, exists between the patient populations that pediatric
dental residents and dentist anesthesiology residents treat. The survey
by Boynes et al on the Practice Characteristics among Dentist Anesthesia
Providers, indicates that when data results were categorized according
to main practice activity, it was revealed the dentist anesthesiologists
and pediatric dentists had the highest mean number of patients with
SHCN in a sedation / anesthesia practice per month [17].
Boyne's study did not limit the sedation to deep sedation/general
anesthesia but does show support for this unique sedation-surgery
interaction as dentist anesthesiologist and pediatric dentist coordinate
their efforts in the dental rehabilitation of patients with SHCN.
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