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CDS Member News and ArticlesProfessional News Articles : : ON PRACTICE MANAGEMENT by Janyce Hamilton : So when do you need to bring in a dental anesthesiologist? So when do you need to bring in a dental anesthesiologist?March 30, 2009 For decades, dentists have confronted the challenge of dealing with patient concerns and apprehensions about procedures. For the most part, “behavioral modification” with a healthy dose of tender loving care has been the standard for dealing with so-called difficult patients; it is a formula that still serves the dentist well and will continue to do so. But certain circumstances and conditions of the patient of may require the dentist to partner with a specialist. Only a few full-time dentist anesthesiologists Board Certified in Anesthesia for Dentistry are located in Chicago; Michael Higgins, DDS, is one of them. Dr. Higgins is an associate professor of anesthesiology at the University of Illinois Hospital. In this column, Dr. Higgins, Morton Rosenberg, DDM, professor of oral and maxillofacial surgery at the Tufts University School of Dental Medicine and head of the Division of Anesthesia and Pain Control, and Zajaria Messieha, DDS, a clinical associate professor of anesthesiology the University of Illinois Chicago Colleges of Medicine and Dentistry, will discuss a number of issues related to use of the services of the anesthesiologist in dentistry. Anesthesia caregiver types“I love what I do. I thoroughly enjoy the practice of dental anesthesiology, and I feel I’ve made a real difference in the lives of many patients and their families who otherwise would not have had access to comprehensive dental care without the availability of an advanced anesthesia provider,” Dr. Higgins said. He completed a 3-year post-doctorate training program at Catholic Medical Center, New York, and Illinois Masonic Medical Center, Chicago. All dentists can, by law, administer nitrous oxide analgesia and/or minimal oral anesthesia, also known as anxiolysis. With a Sedation Permit A issued by the Illinois Department of Financial and Professional Regulation, dentists are allowed to administer mild sedation (or conscious sedation), whereby the patient is awake but sedate. With a Sedation Permit B (most commonly held by oral surgeons and dental anesthesiologists), deep sleep sedation and general anesthesia can be administered. A dentist anesthesiologist who has successfully completed a two-year dental anesthesia residency can perform the entire spectrum of sedative and anesthetic care for patients of other dentists. Patient types who make good candidates for anesthesia careThe kinds of patients receiving anesthesia typically include these categories:
Phobic. Without anesthesia care, these patients will not accept any dentistry or perhaps only limited, palliative care. A history of increased, generalized anxiety or use of prescription anxiolytics and antidepressants is often one clue to dental phobia. “Interestingly, as these patients get older, they don’t seem to outgrow their dental anxieties. Rather, with the onset of middle age, they seem less able to cope with their fears and anxieties,” Dr. Higgins said. Problems with local anesthesia. Some patients express an inability to get numb, may have a history of allergy or adverse reactions/risks to local anesthesia including vaso-vagal syncope or cardiac arrhythmia. What’s more, some dental surgical procedures are simply too long or invasive to be well tolerated with local anesthesia alone.
Small children with cooperation issues and hovering “helicopter” parents wanting complete sedation. Some of the more nervous parents of today might be viewed as excessively protective, and thereby object to any physical or verbal restraint techniques, while demanding to be present during all treatments. There is a solution: sedation. Said Dr. Higgins: “Parental expectations and attitudes concerning dental treatment have changed over the years for the 2- to 6-year-olds. Parents are rejecting physical management techniques: ‘don’t touch my child, don’t make my child cry, don’t restrain them!’ often to the point of involving the authorities. In addition, with the continuing phase-out of amalgam restorations, the increased use of composite resins for children require a cleaner, drier, bloodless field putting an ever greater demand on the Dentist. So, if their child needs bonding or other extensive care, there may be only one way: anesthesia.”
Special needs patients. As a small child an uncooperative special needs patient — be it physically or mentally challenged — may be able to be treated by a general dentist, pediatric dentist or orthodontist with or without simple sedation capabilities. But as these children grow into adolescence and adulthood, the dentist, the staff and patients themselves may risk harm without proper pharmacologic behavior management available—that is, a deeper level of sedation. When treating special needs patients, beyond the immediate accomplishment of dental treatment, another important goal is to reduce the chances of unpleasant recall so that the patient will not be unduly frightened or traumatized and remain cooperative for future examination and, perhaps, minimal care can be provided without anesthesia. Consider a patient with mental retardation, autism or Alzheimer's disease. “If you are comfortable administering an agent such as triazolam with or without nitrous, it might be sufficient to provide certain levels of dental care. However, for a significantly mentally challenged person with combative tendencies this simple regimen may prove inadequate for many dental procedures!” Dr. Higgins said. It has been a common experience that once these patients are “asleep,” and a thorough oral exam with diagnostic quality X-rays can be achieved, much more decay and disease may be revealed than is seen with a compromised radiographic image or in a quick visual exam on an agitated patient. Practice settings: Dental office vs. hospitalWith so few dental anesthesiologists, a free-standing dental anesthesia practice makes little sense. It would be too much travel time to have other dentists drive over to meet and treat their own patients, who also had to travel. There would have to be 40-50 dentists doing this each month to make it cost-effective. Plus, dentists are most comfortable using their own staff, equipment and instrumentation rather than those found in a surgicenter or other facility. Therefore, dentist anesthesiologists either provide care in hospitals or typically bring all their own equipment and travel to multiple dental offices to provide services. They have developed somewhat unique techniques for providing safe, office anesthesia care. Interestingly of note, there is no history of mortality or serious morbidity from office based anesthesia provided by a board certified dentist anesthesiologist. Hospital-based care is excellent, but the fees are set by the hospital and tend to be relatively high vs. in-dental office anesthesia. Another issue is that many dentists simply don’t have hospital privileges. To a smaller degree is the concern about nosocomial and cross infection risks in hospitals. One dental anesthesiologist who does have hospital privileges because he teaches from a university with a hospital is Dr. Rosenberg. In a dental clinic that is hospital-affiliated, professors such as Dr. Rosenberg teach tomorrow’s dental anesthesiologists to meet with patients prior to their surgeries to assess their health history and current risks, and to review the care options. “Together we make a decision that is in the patient’s best interest,” Dr. Rosenberg explained. This is an in-person consultation. With the explosion of out-patient surgery, hospital- as well as office-based anesthesiologists now utilize Preoperative Assessment Testing clinics (PAT) that follow a prescribed evaluation profile in the days or weeks before a procedure. This PAT approach is compared to the “old days” when patients were admitted the night before, seen and evaluated, and then discharged the day after surgery. Likewise, dentist anesthesiologists practicing in the office setting tend to see their patients immediately preceding sedation. There is, however, weeks ahead of the appointment always a telephone and other electronic exchanges between the patient, the anesthesiologist, and the patient’s physician(s) prior to surgery. The anesthesiologist always must review the patient’s chart medical history, any indicated laboratory assays, and follow-up any necessary medical consultations as well as any other treatment records to predict the risks and anticipate other challenges. “We communicate with the patient ahead of time so they know what to expect, how to prepare, and what they need to do prior to their procedure,” Dr. Higgins said. This provides the added benefit of sorting out any unanticipated medical issues in advance, thus preventing last minute cancellations. In dental offices, some dentist anesthesiologists administer general anesthesia using nasal intubation so there isn’t a mouth tube in the dental surgeon’s field. Anesthesiologists in hospitals may have less experience doing nasal intubation than they do administering oral intubation, and therefore may be uncomfortable with the technique, particularly in small children. Education-wise, a dentist anesthesiologist has graduated from a postgraduate dental anesthesiology program of at least two years. Dr. Rosenberg explained that dental anesthesiology is not yet an official specialty of dentistry. However, the Commission on Dental Accreditation has recently decided to accredit postgraduate programs that meet their standards — good news that might make it easier to eventually become its own official specialty.
An oral surgeon DDS/DMD provides sedative/anesthesia care as an operator/anesthetist, but usually does not offer anesthesia services to the patients of other dentists. What costs are involved?Dentists are curious about the additional anesthesia costs on top of their treatment. While neither of the dentists interviewed had exact figures to share, several factors are involved in fee determination including time, medications, patient physical status, age, etc. By convention, anesthesiologists are required by third party payers to use this somewhat complex system of “unit” billing, but fees typically are approximately one-third the cost of hospitalized care. A more accurate estimate can be obtained by calling a dentist anesthesiologist and asking for prices. For those wondering if the addition of an anesthesia fee would make it more difficult for a patient to afford a procedure: a patient should be presented with available options and their associated costs before making an informed decision. Availability of medical insurance coverage depends on the patient’s status and the service provided. State laws usually mandate coverage for medical necessities and small children requiring anesthesia for dental surgery. It might be patchwork, but it’s there. Advised Dr. Higgins: “There’s usually some out-of-pocket expense. We are often requested to contact a patient’s medical insurance carrier and file a “pre-determination of benefits” to see what they’d cover. Operator of a mobile office-based anesthesia practice Dr. Messieha, says his mobile practice is a “team” — he and a registered nurse care for the patients who are receiving anesthesia. As far as a determination of “cost-effectiveness” goes, Dr. Messieha said dentists should remind their patients that the “extra fee” for using a dental anesthesiologist is smart economics. “By paying extra and getting treatment now versus delaying current dental needs, the needs grow into more expensive problems. For example, they may lose teeth, have dangerous abscesses that can affect their airways requiring emergency treatment, and even orthodontic problems.” This month Dr. Messieha’s anesthesia team will provide general anesthesia to a 3-year-old in a pediatric dental office. This is a child without special needs or behavioral issues out of the ordinary. “We treated her older sister, who doesn't even remember the dental appointment! So the 3-year-old's parents wanted to be sure their daughter was also spared the psychological trauma of fighting the dentist who has a long appointment scheduled consisting of cleaning, endodontics and stainless steel crowns and restorations.”
Some parents retain bad memories of their own dental care as children when they were restrained and forcibly received treatment. These unpleasant feelings can create anxiety when bringing their own children to the dentist, fearing they are exposing them to a potentially similar experience. When a dental anesthesiologist is available, the problem is solved. Dentistry in the forefrontA dental anesthesiologist’s sole job is taking care of the patient. “To its credit, the dental profession has been out on the forefront to try to protect the public and promote safe and respectable anesthesia control in the dental office,” Dr. Rosenberg said, and some of those rules he helped write. Every state has comprehensive rules and regulations, and the ADA does too. All the guidelines are there. The problem comes in when people don’t follow the guidelines. If the practitioner has a bad outcome, it’s because they didn’t follow proper protocol. They are very rare. The few cases are high profile. Anesthesia in dentistry is safer than driving a car; in fact, there is a higher risk of being stricken by lightening each year than death from anesthesia in dentistry, according to both sources interviewed for this report. Dentists do, however, have to stay within limitations. The message is this: treat your patient appropriately, always stay within your circle of comfort, and know that the dental anesthesiologist is out there if you find yourself pushing the envelope of your skills to treat patients that need sedation.
Janyce Hamilton is an award-winning Chicagoland freelance dental
writer and editor. Send suggestions for topics to be covered, or any
comments on this column, to review@cds.org.
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