Chapter 13
Working with a Dentist Anesthesiologist
Staying in the dental office is much more convenient for both dentists and patients than going to a hospital operating room. Anesthesia and dental services may be delivered in a dental office at significantly lower costs than in the hospital operating room. With health care dollars at a premium, health care “reform” well on its way in the United States, and more people paying out of pocket for dental services, hospital operating room use for otherwise healthy pediatric dental patients may decline. There now is a trend toward in-office deep sedation and general anesthetics in some geographical regions (Olabi et al. 2012). This chapter focuses on the reason for that trend, as well as how to work with a dentist anesthesiologist.
As has been described elsewhere in this text, the levels of sedation to anesthesia within medicine and dentistry are: minimal sedation, moderate sedation, deep sedation and general anesthesia. Both minimal sedation and moderate sedation are “conscious” techniques. A hallmark of a conscious technique is that the patient responds to verbal commands or light tactile stimulation. In the case of minimal sedation, the patient responds normally to verbal commands or light tactile stimulation. In the case of moderate sedation, the patient responds purposefully to verbal commands or light tactile stimulation. If minimal to moderate sedation fails, the next level is deep sedation or general anesthesia. For these levels, the pediatric dentist has to consider whether the patient will be treated in the dental office or in the hospital.
Educational Requirements for a Dentist Anesthesiologist?
Many years ago, there were no formal requirements for dentists to be able to administer any form of sedation or anesthesia. Likewise, there were no guidelines for dentists in the area of sedation and anesthesia. The “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students” were first published in 1972 by the American Dental Association (ADA). In the 1985 update of the guidelines, the concept of “deep sedation” was introduced, and training required to perform this level of anesthesia was deemed to be the same as for general anesthesia (Peskin 1993). These documents have been updated many times since the original version and will continue to be updated as needed in the future.
The training to be licensed and permitted to administer minimal to moderate oral sedation may be obtained in almost all pediatric dental residencies or through a variety of continuing education courses. To be licensed and permitted to administer deep sedation or general anesthesia, the training may only be obtained in specific residencies today. The training requirements for deep sedation and anesthesia are the same. For dentists in the United States, the completion of a dental anesthesiology or oral and maxillofacial surgery residency is required in order to obtain a permit to administer general anesthesia. It is not possible to obtain training to administer deep sedation or general anesthesia in a continuing education course. Several pediatric dentists have also completed dental anesthesiology residencies, but the overwhelming majority of pediatric dentists have been trained only to the level of either minimal or moderate oral sedation.
Deep sedation and general anesthesia can be considered equal to one another. Both deep sedation and general anesthesia are “unconscious” techniques in which the patient does not respond to verbal command or light tactile stimulation. The only technical difference is that in deep sedation the patient does respond purposefully following repeated or painful stimulation, whereas in general anesthesia the patient cannot be aroused, even following painful stimulation. Pediatric dental patients often have local anesthesia administered in addition to deep sedation or general anesthesia, which muddies the difference between the two.
Hospital-Based Versus Office-Based Treatment
When minimal to moderate oral sedation fails in the pediatric dental office, deep sedation or general anesthesia may be indicated. Many pediatric dentists currently take these patients to the hospital. Consequently, patients incur extremely high costs and dentists lose productive time in the office. Mass (1993) compared the costs for a typical one-hour dental case of office-based anesthesia versus hospital-based anesthesia. He found that in the early 1990s the hospital fee approximated $1,900 while the office-based case would typically cost $150. As of 2009, the Albany Medical Center stated that the cost of office-based anesthesia remained less than 10% of the cost of hospital-based anesthesia for dental procedures.
The spread between hospital-based anesthesia and dental office-based anesthesia pricing still exists today. Rashewsky and colleagues (2012) determined that the hospital operating room expense for a pediatric dental patient was 13.2 times the expense of office-based anesthesia. At Stony Brook Medicine, dental patients requiring treatment with general anesthesia received dental care in either an outpatient facility at the Stony Brook School of Dental Medicine or in the Stony Brook University Hospital ambulatory setting. Rashewsky examined the time and cost for ambulatory American Society of Anesthesiologists (ASA) Class I pediatric patients receiving full-mouth dental rehabilitation using general anesthesia in these two locations. They reviewed ninety-six patient records for ASA I patients aged 36–60 months. There were significant differences in cost, total anesthesia time, and recovery room time. The average total time (anesthesia end time minus anesthesia start time) to treat a child at Stony Brook University Hospital under general anesthesia was 222 ± 62.7 minutes, and recovery time (time of discharge minus anesthesia end time) was 157 ± 97.2 minutes; the average total cost was $7,303. At the Stony Brook School of Dental Medicine, the average total time was 175 ± 36.8 minutes, and recovery time was 25 ± 12.7 minutes; the average total cost was $414. This study provides evidence that ASA I pediatric patients can receive full-mouth dental rehabilitation using general anesthesia under the direction of dentist anesthesiologists in an office-based dental setting more quickly and at a lower cost than in a hospital operating room. This is very promising for patients with the least access to care, including patients with special needs and those without insurance (Rashewsky 2012). To some extent, the economic barrier is lowered.
So what are other advantages and disadvantages of treating pediatric dental patients in the hospital operating room versus the dental office? Having provided anesthesia services in both settings, the authors of this chapter know both systems well. To begin, there is a need for both types of treatment. Unfortunately, the choice is often determined by what is available to the practitioner or how the practitioner was originally trained. Many pediatric dentists, especially those trained some time ago, only consider the hospital operating room option.
While the hospital operating room is safe, it is often not the most ideal place to treat many pediatric dental patients. It is a burden for the pediatric dentist to bring all of the drugs, supplies and equipment needed for an operating room case. In some cases, hospitals charge a facility fee. Hospitals may not have a wide variety of surgical instruments and dental supplies—the dentist has to use what is available. The hospital operating room can also be inefficient. Dental cases are low priority electives in a medical setting, so it is not unusual for a dental case to be “bumped” in order to place a higher priority emergent medical case in the operating room where the dental case was scheduled. Hospital operating rooms also take a significant amount of time to “turn over.” Cleaning and replenishing supplies takes much more time compared to the typical dental office.
The Dentist Anesthesiologist
The anesthesia provider for the vast majority of hospital operating rooms will be either a physician anesthesiologist or, more commonly in the United States, a certified registered nurse anesthetist. There are few dentist anesthesiologists working in hospital operating rooms providing anesthesia services. While physicians and nurses can and do provide safe general anesthesia, they lack an understanding of dentistry compared to a dentist anesthesiologist. Most dentist anesthesiologists will provide intraoral local anesthesia when appropriate for the case, or will at least be available for consultation regarding the feasibility.
Dentist anesthesiologists are comfortable with providing nasally intubated general anesthesia. Some physician anesthesiologists and certified registered nurse anesthetists are less comfortable with nasal intubation and may offer only oral intubation or a laryngeal mask airway (LMA). Neither oral intubation nor an LMA offers the access to the oral cavity, the ability to check occlusion, and the all-around ability to perform ideal dentistry that a nasally intubated pediatric dental case provides. Dentist anesthesiologists are trained as dentists first, acquiring their anesthesia training later. Dentists know dental procedures. Physician anesthesiologists and certified registered nurse anesthetists do not. Dentist anesthesiologists understand that local anesthesia provides post-operative pain control for pediatric dental patients and that longer-acting opioids such as morphine or hydromorphone are not indicated. When physician anesthesiologists and certified registered nurse anesthetists provide deep sedation or general anesthesia for pediatric dentists, they often do not understand this simple concept and sometimes administer large amounts of opioids. This leads to excessively prolonged recovery and unnecessary post-operative nausea and vomiting. Neither of these tends to build patient confidence, nor are they practice builders.
Dentist anesthesiologists are trained to work with patients on whom open airway procedures are performed and are therefore much more comfortable than physician anesthesiologists and certified registered nurse anesthetists who lack such training. Sharing the patient’s airway is a normal, daily occurrence for a dentist anesthesiologist, but it is a very foreign concept to most non-dentists performing anesthesia. Most physician anesthesiologists and certified registered nurse anesthetists are not comfortable performing anesthesia outside of a hospital operating room and are unfamiliar with mobile anesthesia practice.
Dentist anesthesiologists understand the private practice of dentistry; they understand the dental environment and strive to maintain a nurturing atmosphere when invited to participate in the care of pediatric dental patients. The atmosphere and expectations in hospital operating rooms are quite different from a private dental office and physician anesthesiologists and certified registered nurse anesthetists often do not understand this distinction. There is also one very interesting statistic regarding patient safety. Since the first dental anesthesia residency was established in 1949, when a dentist anesthesiologist has provided anesthesia in another dentist’s office, there has not been a single patient death—ever. The same cannot be said for a physician anesthesiologist or a certified registered nurse anesthetist. In summary, some have said that when compared to physician anesthesiologists, dentist anesthesiologists are safer, more approachable, less patronizing, and more understanding of the dental process and needs of the dentist.
Additionally, the operating table in an operating room offers fewer options to the pediatric dentist. The ability to place the operating table in an exact location and position is often compromised, unlike a dental chair in a dental office. Room lighting and suction are often more difficult to manipulate in an operating room, and sometimes something as simple as a saliva ejector may not be able to be accommodated.
Pediatric dental patients and their parents or guardians know the pediatric dental office; they know where it is located and they know the office staff. Taking their child to a hospital for dental care can be daunting. Usually, they don’t know the system or what to expect. The hospital is generally a less nurturing and less comfortable environment than the private office or clinic. As noted by Rashewsky (2012), patients treated in the hospital spend much more time in non-productive activities, such as prolonged waiting times in a pre-opera/>
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