Treatment planning for adult oral rehabilitation starts before cases are scheduled and continues after the discharge phase. Practitioners providing dental care must be competent in all phases of dentistry and comfortable in the operating room setting. Dental caries risk assessment and medical risk assessment are important in developing comprehensive and predictable treatment plans. Oral rehabilitation in the operating room for patients who have special needs is a growing concern. Coordinating medical procedures with oral rehabilitation procedures while patients are under general anesthetic is an efficient use of sedation. A systematic approach for treatment plan consideration is explored for oral rehabilitation cases using general anesthesia or monitored anesthesia care.
Patients referred for general anesthesia dentistry usually need oral rehabilitation. This article addresses care of adult patients who have exhausted options for treatment in a routine setting, assuming that all means to achieve dental care have been tried and that oral pathology requiring attention exists in the mouth. This article discusses adult patients who are cooperative but cannot tolerate the dentistry because of medical compromise, psychologic reasons, or developmental or intellectual disabilities (DD/ID).
Treatment planning for dental general anesthesia cases has many considerations for patients, dentists, and facilities. Hippocrates stated, “[you] cannot treat what you cannot diagnose.” A dental diagnosis is dependent on medical and psychologic diagnoses. There are many approaches and philosophies to planning treatment for a case. A surgeon’s responsibility is to be accountable and responsible in delivering care. Knowing the endpoint of the dental care requires attention and observation of patients. Patients, caregivers, and legal guardians who are well informed of the whole hospital process and expectations are key to a pleasant and memorable experience. This article does not suggest that any described process is the standard of care, but allows practitioners to make their own best-suited plans for their patients.
Operating room preparation
The art of treatment planning for operating rooms requires quick, decisive thinking and awareness of limitations. Suggested treatment planning considerations and some current techniques that have been beneficial are discussed. Treatment planning has benefited from recent advances in technology and science in terms of equipment and materials. The limiting factors of operating room consideration are time and finances. Considerations of postoperative care immediately after efficient and predictable operating room dentistry are provided.
There is a wide range of adult patients who present for oral rehabilitation using general anesthesia or monitored anesthesia care. Some are medically compromised, some are developmentally delayed, and some exhibit extreme dental fear. Patients who have current radiographs and can tolerate preoperative examinations provide practitioners a distinct advantage in preparing for oral rehabilitation cases and coordination of other disciplines. When patients are noncooperative and require sedation, however, dentists must be able adapt to those situations. Every attempt should be made to evaluate a patient’s oral condition in order to proceed to scheduling the hospital visit. Practitioners must be able to create a treatment plan, deliver services, and have assurance that what is done will achieve a positive outcome.
In the past, oral rehabilitation under general anesthesia meant extracting everything that had pathology or may have had pathology. Now, many patients and their care providers desire restorative options or even conventionally restoring their mouth to preserve dignity. Increasing numbers of persons who have DD/ID and are integrated in the community are part of the work force. Teeth are important not only for eating but also for employment and self-esteem.
The age of adult patients, from adolescent to geriatric, can be a major determinant of final treatment. As the population ages, there are more complicated health concerns, including dementia and polypharmacy. Patil and Patil outline some of those concerns: “The dentist is concerned with the emotional and psychological state of the patient, for it is an essential component of treatment and the success of the treatment often depends on the emotional state of the patient. It is thus important for the dentist to be aware of practical- problem-oriented approach that helps in patient management and in maintaining and improving dental health as part of total healthcare services available to the elderly.”
Oral health is essential for total health of the body, according to the Surgeon General’s report of 2000. Practitioners deciding whether or not general anesthesia or monitored anesthesia care is the suitable method to safely treat a patient cannot focus solely on the oral cavity. If a patient is noncompliant in a routine setting for dentistry, the same noncooperation may exist for the patient’s other medical disciplines. Annual examinations often are abbreviated for patients who have special needs because of a physician’s inability to attain full cooperation from those patients. Consultation with a patient’s primary care provider may generate a collaboration of additional services while the patient is under anesthesia. Additional services may be as simple as blood tests or more complex, including otolaryngologic, optical, gynecologic, podiatric, or cardiac examinations or procedures, such as transesophageal echocardiograms, cardioversions, and EKGs. Treatment planning for multidisciplinary cases requires coordination of medical and dental specialists for dates and times.
The dental case is the primary admission, with the various subspecialties interposed accordingly. Practitioners may decide to bring to the operating room dental specialists, such as a periodontist, endodontist, orthodontist, and oral surgeon, for procedures beyond their comfort level. Each specialist needs to be on medical staff or obtain temporary privileges, secure informed consents, and make financial arrangements in advance. Cases need to reflect any additional time required and the modification of table set-up.
For hospitals that have oral maxillofacial and dental services, there may be a portable dental cart, X-ray head, and developer. In some cases, hospitals may have digital radiography software and hardware connected to a computer. If a hospital does not have an X-ray head, practitioners must supply their own. Most hospitals have a radiology department that can provide head films, such as lateral cephalometric, Waters view, or submental vertex. Equipment availability at hospitals can vary for dental procedures. Some hospitals store and share their instrument set-ups and have all the instruments necessary for procedures from oral surgery to restorative dentistry, whereas others have only a few instruments for emergency oral surgery. Dental cart, dental hand pieces, ultrasonic scaler, and dental instruments and supplies may be items that a practitioner needs to supply.
Hospital staffing for an operating room requires that a scrub nurse and circulating nurse be present in addition to an anesthesiologist and surgeon. In some hospitals, the scrub nurse is well versed in dental procedures but not in others. A trained dental assistant who meets the criteria for assisting in an operating room usually can be brought in to work as a scrub nurse if permission and paperwork are completed in advance. A trained dental assistant is advantageous in dealing with dental materials and assisting.
Hospital dentists of today must carefully weigh the time it takes for dental procedures and the prognosis of the teeth that are treated. Providing hospital dentistry services requires a substantial amount of time, especially if there is coordination with financial concerns, medical subspecialties, and care providers. The paperwork and financial arrangements for the hospital, preoperative work-up, additional physicians’ appointments, and laboratory work are significant. For practitioners who bring in their own staff and equipment to the operating room, there is additional paperwork, setting up the operating room, breaking down the room, and maintaining the supplies and equipment. Practitioners also are responsible for preoperative and postoperative evaluation of patients, dictation, and making sure proper consent and medical clearance are available. Preoperative work-up and waiting for an operating room can add additional hours to a case.
In order to see patients at set times and minimize the possibility of being bumped from time slots, clinicians who have a substantial number of hospital cases desire block time. Block time is reserved time allocated in the schedule for surgeons to fill with their patients, providing they use the time in a regular manner. A utilization review committee reviews these requests and assigns the block times. Time utilization in an operating room is important in order to be considered for future block time. If a surgeon fails to keep the schedule full or uses the block time inadequately, that surgeon loses the privilege. Therefore, a reasonable estimation of time is approximated from patient evaluation information.
Patients and caregivers must prepare in advance for the time required for preoperative appointments and day of surgery and postoperative visits. Transportation of patients and coordination of withholding oral food and fluids status must be assured. There should be no misunderstanding that operating room times require a serious commitment. On rare instances, patients may stay overnight for observation after a procedure.
Before scheduling a case, a dentist must have a good working relationship with patient, caregiver, and legal guardian. Not only is it a legal requirement of hospitals to secure informed consent, it is essential for patients or legal guardians to understand the importance of surgical consent and the need to follow-up with instructions, such as medical clearance and presurgical instructions. Each hospital has specific guidelines on dealing with patients who are not able to sign for themselves and are not conserved. Patients or legal guardians should be well informed of the philosophy and potential treatment options prior to scheduling an operating room. For patients who are having radiographs taken while under general anesthesia, some practitioners are requested to leave the operating room once radiographs are taken to discuss a case with a caregiver or guardian. Leaving an operating room to discuss a case can take time from an operator and extend the time a patient is under general anesthesia. If the philosophy is explained in advance, such as fixing teeth that can be fixed and extracting teeth that no longer are restorable, there should not be a need to come out to discuss the case.
Preparing for the Assessment Appointment
Make sure patients or caregivers are aware of the need for an assessment appointment. The goal is to explain the actual hospital dentistry process, evaluate dental and medical needs, and review postoperative care instructions. If possible, dental radiographs should be attempted and a thorough examination performed. If a patient is fearful or has DD/ID, it may be helpful to have a caregiver or parent familiarize the patient by introducing the concepts of counting teeth and having the patient practice opening the mouth and brushing. Having patients practice these at home helps desensitize them for similar activities in a dental office hospital. They should bring their current medications, medical records, dental X-rays, and notes and information on previous surgeries. In addition, they can bring something that comforts them or allows them to be distracted, such as a familiar toy or music.
Treatment planning for the operating room does not start at the hospital—it starts at the initial assessment. Patients are assessed beginning with external characteristics and continuing with internal characteristics. Patients’ physical coordination and dexterity may provide insight to their physical agility for postoperative preventive dental care. Much of the dentistry to be accomplished requires practitioners to have a good estimation of how the dental work will survive in successive years. Some major considerations are a patient’s tolerance to following-up dental care in a routine setting; the patient’s ability to have preventive care; and physiologic changes in the oral cavity with respect to habit, medications, and stability of the medical condition.
There are several ways of determining compliance, using direct observation and asking probing questions of caregivers of patients who are unable to cognitively understand. Generally, the more compliant a patient, the more elaborate a treatment plan can be, such as a fixed crown and bridge or implants. For patients who are less compliant or more medically complex, less sophisticated dental care is considered. Quality dental care is provided for all patients in a customized approach.
A careful dental, medical, and cooperation risk assessment helps minimize multiple hospital visits for the same procedures. The goal of the oral rehabilitation visit should be to bring patients to optimal dental health and a strategy to maintain their oral health.
Working with Patients Who Have Special Needs
When working with patients who have specials needs, dentists must take adequate time to review medical health history, dental history, and current medications. Patients who have special needs may include those in the geriatric population and those who have Alzheimer’s disease. Smith and colleagues summarize, “The assessment of dental treatment needs must take account of the clinical dental status of the subjects, their demands for treatment and their oral handicaps.” Whenever possible, patients are the most direct and reliable source in obtaining detailed information; the next best source is caregivers or guardians. Find out what makes patients feel nervous or uncomfortable; sharing a patient’s dental experience is a good way to get to know the patient.
Whether or not patients are cooperative and cognitive or uncooperative and combative, approach patients carefully and do not make sudden movements. Do not do anything to patients without getting their permission. The adage, “inform before you perform,” is a good rule of thumb. Safety to patients and dental teams should dictate how care is delivered. In situations where patients are combative, a team should not be put in a position in which they feel endangered. There are no absolute protocols in dental assessment except to try to make a good assessment. When in doubt, ask, “What is in the best interest of the patient?” It may be that a caregiver or parent is present to calm a patient or can assist in having a patient cooperate until the patient is more familiar with the surroundings. The clinical examination may take place in a private area of the waiting room while the patient is watching television. There is an emphasis on the importance of obtaining a thorough examination in order to properly plan a case from the time estimate to deciding which other subspecialties need to be involved. A patient’s cooperation level determines the level of treatment options.
Preparing the Dentist
Dentistry in an operating room is not much different from dentistry in an office, other than limitations of operating room bed position. Dentists should be familiar with the equipment available if they are new to a hospital. Any electrical items brought to an operating room area may require a hospital engineering department for clearance (sometimes a week in advance), and any medications, such as local anesthetic, brought into an operating room also must be cleared with an operating room supervisor. If there are essential instruments required, it is best to take them for sterilization and disinfection in advance. Disposable items, such as gauze, sutures, local anesthetics, dressing, and sutures, and equipment, such as surgical hand pieces and electrosurgery units, may be available but the sizes or delivery system may not be a dentist’s preference. A preference card usually is established for surgeons so that nurses can supply the room and set it up according to preferences.
As professionals, dentists should practice only within their comfort level and training. Hospital dentists who offer an array of services must be proficient and kept abreast of the various techniques, including endodontic, periodontic, restorative, and oral surgical, or refer to specialists. As Carrotte notes, for instance, pertaining to root canal treatment: “[its] techniques probably develop and change more frequently than any other area of dental practice and it can be hard for the busy general dental practitioner to keep up to date.” Being a safe practitioner means knowing limits and having contingency plans. It is prudent to classify treatments as those most necessary having first priority and those least necessary having last priority. Do not overcommit or promise what may not be able to be delivered.
Preparations for unexpected situations may be (1) restorative: unsupported tooth structure leading to extraction, inability to isolate for composite restorations, or unexpected odontogenic fractures; (2) endodontic: perforation, missed canal, separated instrument, or poor obturation; or (3) surgical: inability to remove entire portion of root, dislodging fragment into the sinus cavity, or iatrogenic outcomes of hard or soft tissue.
Postoperative considerations should include minimizing pain, swelling, nausea, postextraction alveolitis (dry socket), and fractured restorations. In the recovery room (postanesthesia care unit), pain and nausea are managed by anesthesiologists through a systemic approach, usually using narcotic and antiemetics, respectively. Numazaki and colleagues provide a recommendation: “Prophylactic dexamethasone 8 mg is effective for the prevention of nausea and vomiting after dental surgery and in the management of postoperative pain. Increasing the dose to 16 mg provides no further benefit.” Pain can be from a nasal tube, laryngeal discomfort, or the procedures. Nausea may be from medications, swallowed blood, or low blood sugar. Most noncooperative patients who require oral surgery for dental care are more likely to need sutures that dissolve. Ice packs to the side of the face help with facial swelling, depending on a patient’s tolerance of cold packs.
For most procedures, consideration of finances is a concern. Insurance limitations can affect ideal treatment and should be addressed prior to surgery. The business of doing dentistry cannot be ignored; otherwise, a practice is stressful and unsatisfactory. Planning time in an operating room includes determining where financial arrangements and insurance paperwork are cleared. Failure to have the necessary paperwork completed in advance may result in large bills to patients or practitioners.
Costs for patients
In order for patients to have restorative treatment, there are fixed costs of the dental procedures. Those procedures must be maintained through frequent visits to a dentist; patients need to tolerate prevention procedures. If insurance or patients do not support the prevention model, such as paying for additional cleanings or chemotherapeutic supplies, restorations are at risk for premature failure. Premature failure in a restoration can result in another hospital dentistry encounter and possibly an extraction. Therefore, it is imperative that patients or caregivers be fully aware that prevention requires care that is not always a covered benefit. The more elaborate the dental procedure, the more investment in time and preventive visits is required. In order for patients to have a fixed bridge, for example, patients must be able to tolerate prophylaxis and flossing under the fixed prosthesis. In the case of implants, patients must be able to tolerate periodic radiographs and possible adjustments in a clinic. Patients who wear removable prostheses must be able to communicate fit and function and have the ability to remove their appliance and clean their mouth.
Most outpatient “come and go” surgeries proceed as planned. On occasion, patients may be admitted overnight for observation, with corresponding increased overnight costs for patients and additional costs for caregivers.
Costs for dentists
Dentists who are at a hospital without an established dental or oral surgery department may need to equip their own practice at the hospital. Dental supplies and equipment are obvious cost items for dentists to consider. The return on investment on dental supplies and equipment must have criteria that give the best final long-term results. Quality equipment may last longer than economical equipment, especially if the items are mobile. When possible, time-saving measures are a cost-containing ingredient; for example, a digital X-ray system may be a large initial investment but when it saves operators waiting times of 30 to 40 minutes per case and reduces frustrations of waiting while having the benefit of enhanced radiography, the cost is justified. Parks agrees: “The expenses associated with converting to digital radiographic imaging are considerable.” Saving time equates to efficiency in patient care, with less time under anesthesia and, for cases that are paid with Medicaid, it means greater chance of breaking even.
The choice of dental materials for restorative dentistry should match the needs of patients as it relates to their risk assessment.
Costs to the hospital
In order for dentists to maintain hospital privileges, cases should flow in an expedient manner. Each hospital case incurs an hourly cost for the hospital; if reimbursement for that care is dramatically less than the cost of the care, there results a challenge in seeing more patients. Therefore, a clinician’s responsibility is to aide in the process of a smooth and efficient course of hospital admission. A smooth case is one in which a patient has all paperwork completed and shows up to the hospital early, not late. In addition, a procedure should finish at the time anticipated at scheduling, patients should have a “painless” recovery period, and discharge should be within a reasonable time without too much excitement. Working closely with an anesthesiologist to assure adequate pain and nausea control in the recovery room is important for expedient discharge.