This article discusses aspects of providing dental treatment in hospitals to patients with complex medical and/or behavioral problems. Practical information for patient selection for care in a hospital operating room, obtaining hospital privileges, and other aspects of dental care in hospitals are introduced.
Key Points
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To promote oral health for an ever-increasing number of patients with special health care needs (SHCNs), all dentists have a role.
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It is not possible for pediatric dentists to see every patient with special needs throughout their lifetime.
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General dental practices and community clinics are the foundation of dental health care in the United States.
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It is important to train general dentists to care for medically and behaviorally complex patients, to encourage them to seek hospital privileging, including care in operating rooms (ORs), and to support hospital dental programs.
Introduction
Hospital-based dentistry is a rewarding way to contribute to the community and add variety to a pediatric or general dental practice. Hospital training is a requirement in all accredited pediatric dental and general dental residency programs. Once certification is completed, however, many dentists never return to the hospital to provide patient care. This article presents information about providing dental treatment in a hospital. The primary focus is providing dental treatment in a hospital OR. Hospital outpatient dental clinics, inpatient dental consultations, and dental treatment in emergency departments are discussed briefly.
National data demonstrate that the number of children and adults with SHCNs is growing. This increase can be attributed to improvements in medical and surgical care because conditions that were once fatal have become chronic and manageable problems. Concurrently, societal changes have brought inclusiveness to individuals with developmental disabilities; rarely is a child institutionalized for Down syndrome or autism. The percentage of households with children in the United States with 1 or more children with SHCNs increased from 22% to 28% between 2001 and 2008.
Health care for some individuals with SHCNs requires specialized knowledge, increased awareness and attention, and adaptation and accommodative measures beyond what is considered routine. Most patients with SHCNs receive dental care in their community; for a subset of these patients, definitive dental care in a hospital OR or clinic may be the best treatment option.
There are several differences between dental practice within a hospital versus in a clinic or private office. Most differences are due to accreditations and regulations. Hospitals are accredited by The Joint Commission (TJC). Thus, an accredited hospital must follow standards set by TJC. All providers practicing in a hospital must join the hospital professional staff and have hospital privileges, which are specific permissions relating to the area of practice and that meet documentation standards set by TJC.
Introduction
Hospital-based dentistry is a rewarding way to contribute to the community and add variety to a pediatric or general dental practice. Hospital training is a requirement in all accredited pediatric dental and general dental residency programs. Once certification is completed, however, many dentists never return to the hospital to provide patient care. This article presents information about providing dental treatment in a hospital. The primary focus is providing dental treatment in a hospital OR. Hospital outpatient dental clinics, inpatient dental consultations, and dental treatment in emergency departments are discussed briefly.
National data demonstrate that the number of children and adults with SHCNs is growing. This increase can be attributed to improvements in medical and surgical care because conditions that were once fatal have become chronic and manageable problems. Concurrently, societal changes have brought inclusiveness to individuals with developmental disabilities; rarely is a child institutionalized for Down syndrome or autism. The percentage of households with children in the United States with 1 or more children with SHCNs increased from 22% to 28% between 2001 and 2008.
Health care for some individuals with SHCNs requires specialized knowledge, increased awareness and attention, and adaptation and accommodative measures beyond what is considered routine. Most patients with SHCNs receive dental care in their community; for a subset of these patients, definitive dental care in a hospital OR or clinic may be the best treatment option.
There are several differences between dental practice within a hospital versus in a clinic or private office. Most differences are due to accreditations and regulations. Hospitals are accredited by The Joint Commission (TJC). Thus, an accredited hospital must follow standards set by TJC. All providers practicing in a hospital must join the hospital professional staff and have hospital privileges, which are specific permissions relating to the area of practice and that meet documentation standards set by TJC.
Patient selection for dental care in hospitals
Most patients who receive dental treatment in hospitals have SHCNs. A 2010 survey of a hospital outpatient dental clinic found most patients presented with either medical complexity or intellectual/behavioral limitations that prevented their cooperation for dental procedures. For uncooperative patients with SHCNs, dentists may use a continuum of behavior guidance strategies, ranging from simple communicative techniques to oral or parenteral sedation. Pediatric dentists and dentists treating adults with SHCNs have embraced the concept of in-office general anesthesia (GA) for dental treatment where GA is provided by a medical or dental anesthesiologist or by a certified nurse anesthetist, depending on practitioner availability and state practice requirements.
In-office sedation or GA may be unsafe for patients with complex medical conditions and/or severe behavioral limitations. Hospital or university-based dental clinics may be the only venue for these patients to receive care. Clinics that serve this population are not widely available and are not distributed evenly across the United States. For families needing to seek care at these institutions, travel and long wait times can be expected. For adults with SHCNs, dental care may be difficult to access. A study of oral health status of adults with intellectual and developmental disabilities receiving dental care in Massachusetts through state-supported clinics in 2009–2010 found prevalence of periodontal disease was 80% and untreated caries was 32%. A 2012 survey in New York found a 1-year to 2-year wait for dental services in the OR for adults with SHCNs.
Because capacity in hospital dental clinics is limited, they should be reserved for those who cannot be safely treated in the community. Offering a dental home to patients with SHCNs in private dental practices and community clinics for preventive/recall services with the back-up of taking patients with significant treatment needs to the OR is the best way to accommodate the increasing population of patients with SHCNs.
Planning dental care under general anesthesia in a hospital operating room
A comprehensive dental examination, pending behavioral constraints, should be completed to assess treatment needs, such as restorations, exodontia, and periodontal or endodontic procedures, before care under GA is considered. If there are minimal dental needs, the risks of GA do not outweigh the benefits. The American Society of Anesthesiologists risk assessment classification (ASA class) is often used to assess anesthesia risk and to determine the appropriate venue for GA ( Table 1 ). The risk of anesthesia increases with higher ASA status and with certain types of surgical procedures. Dental procedures are generally considered low risk. Risk of GA for patients with SHCNs undergoing dental procedures is presumed higher than in healthy peers but has not been adequately studied. Nearly all ASA class I and mild ASA class II patients can be treated safely with in-office GA.
| Class I | A normally healthy patient with no organic, physiologic, biologic, biochemical, or psychiatric disturbance or disease |
| Class II | A patient with mild-to-moderate systemic disturbance or disease |
| Class III | A patient with severe systemic disturbance or disease |
| Class IV | A patient with severe and life-threatening systemic disease or disorder |
| Class V | A moribund patient who is unlikely to survive without the planned procedure |
| Class VI | A declared brain dead patient whose organs are being removed for donor purposes |
Most patients receiving care in a hospital OR have ASA classification II or III. An example of an ASA II patient appropriate for a hospital setting is a large teenage patient with violent behaviors related to autism. In a hospital, there is sufficient staff to assist with the unpredictable recovery of such a patient. ASA III and IV patients should have care in the hospital ( Table 2 ). It is important to work closely with anesthesia providers and be acquainted with their practice philosophy. Many hospitals offer an anesthesia consultation for patients before the day of surgery. Some patients may be acceptable risks only for anesthesiologists practicing in tertiary-care centers.
| ASA II | ASA III | ASA IV |
|---|---|---|
| Well-controlled asthma Well-controlled diabetes Well-controlled hypertension Corrected arterio or ventricular septal defects with no residual disease Autism Stable mental health disease Pregnant |
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Dentists can approximate a patient’s ASA classification by taking a comprehensive medical history ( Table 3 ). Ambiguous information should be clarified by a discussion with the primary care physician or medical specialist. Additional information needed when planning GA is a history of adverse reaction to GA by the patient or a family member.
| General | Name, date of birth Legal guardian and phone number Height, weight, body mass index Name and phone number of physicians |
| Medications | Name and dose, include over the counter and supplements |
| Allergies | Drugs, food, and environmental, include reaction |
| Hospitalizations | Reason, date, and outcome |
| Surgeries | Reason, date, and outcome |
| Birth history | Complications during pregnancy and/or birth, prematurity |
| Genetic disorders | Name, date diagnosed |
| Head | Ears, eyes, nose, and throat |
| Cardiovascular | Congenital heart defect/disease, heart murmur, high blood pressure |
| Respiratory | Asthma, reactive airway disease/breathing problems, smoking (including second-hand smoke), chronic lung disease, infectious disease of lungs |
| Gastrointestinal | Eating disorder, ulcer, gastroesophageal reflux disease, chronic or transient infections of liver, gastrostomy tube, failure to thrive |
| Genitourinary | Kidney disease |
| Musculoskeletal | Arthritis, scoliosis, joint replacement |
| Neurologic | Seizure disorder, neuromuscular disease |
| Hematologic | Anemia, bleeding disorders, history of blood transfusions, cancer treatment or history of |
| Immunologic | Immunocompromised |
| Behavior | Personality: easy, shy, difficult Developmental or intellectual disabilities Mental health problems |
| Social | Travel constraints Dysfunctional social situation/difficulty with continuity of care |
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