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Letters: Peds & anesthesia

March 05, 2012

By Mark A. Saxen, D.D.S., Ph.D., and James E. Jones, D.M.D., M.S.D., Ed.D., Ph.D.

We applaud the report on the findings of the National Center for Health Statistics, "Children’s Unmet Dental Need" (Feb. 6 ADA News). The story confirms the often understated reality that cost remains a significant barrier to dental care for millions of American children. This set of statistics is particularly relevant and troubling in our current economic climate.

For the past seven years, we have participated in and studied a collaboration that dramatically reduces the cost of treating early childhood caries in young children. Children with early childhood caries represent a particularly vulnerable population in terms of aggressive development of dental disease and the cost of treatment.

Early, comprehensive treatment is critical for the effective management of early childhood caries, and has been shown to improve the quality of life for children while intercepting the exponential escalation of health care costs associated with the lack of treatment. For many of these patients, general anesthesia provides the best way to provide comprehensive care in a timely and effective manner (according to the American Academy of Pediatric Dentistry’s Reference Manual Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options).

Pediatric dentists typically have two choices when opting to treat a patient under general anesthesia. The first is to have treatment performed in a hospital setting. A second option is to have general anesthesia performed by a dentist anesthesiologist in an office-based setting. When pediatric dentists treat these patients under office-based general anesthesia with a dentist anesthesiologist, treatment is accomplished at a fraction of the cost. The efficiency of office-based dental anesthesia services stems from the comprehensive training of dentist anesthesiologists, who train two or more years in a hospital-based residency program. This training allows dentist anesthesiologists to draw from a wide spectrum of appropriate anesthetic options and apply them to the treatment of dental patients.

When combined with a pediatric dentist’s extensive experience with treating patients under general anesthesia, a maximum amount of dental treatment can be provided in a minimum amount of time. It is not uncommon for general anesthesia costs to be 50 percent or less than the cost of comparable anesthesia care performed at a hospital.

In addition to the cost savings, studies performed at the Indiana University School of Dentistry found that the behavior of children at recall visits following office-based general anesthesia was improved as compared to treatment under hospital based general anesthesia or treatment performed without general anesthesia (Fuhrer CT, Weddell JA, Sanders BJ, Jones JE, et al., Effect on Behavior of Dental Treatment Rendered Under Conscious Sedation and General Anesthesia in Pediatric Patients; Pediatric Dentistry (2009), 31(7) 389-394). The comprehensive training of board-certified dentist anesthesiologists is also a primary factor in their exemplary safety record.

The utilization of dentist anesthesiologists among pediatric dentists is a growing trend. A recent survey of 494 board-certified U.S. pediatric dentists found that 20 to 40 percent use a dentist anesthesiologist while 60 to 70 percent would use a dentist anesthesiologist if one were available (Olabi N, Jones JE, Saxen MA, Sanders BJ, et al., The Use of Office-Based Anesthesia by Board Certified Pediatric Dentists Practicing in the United States; Anesthesia Progress, in press). Dentist anesthesiologists work with all types of dentists; however, pediatric dentistry comprises a large percentage of most practices, reflective of the need for general anesthesia services within this specialty (Hicks G, Jones JE, Saxen MA, Maupome G, et al., Future Demand for Dentist Anesthesiologists in Pediatric Dentistry Sedation; Anesthesia Progress, in press).

One may ask why the profession as a whole has not been more aware of this trend, since access to care is an area of intense interest to the dental profession. The relatively small number of board-certified dentist anesthesiologists is due in large part for this. Another under-appreciated contributing factor is the lack of documentation of dental anesthesia services within our current CDT code taxonomy. As Dr. Jim Richeson, chair of the ADA Council on Dental Benefit Programs pointed out, it is important for CDT coding to provide an accurate and complete description of current dental practice, because the codes are used for much more than reimbursement from dental insurance companies. CDT codes provide the basis for examining usage patterns for dental services and other forms of research ("ADA Creates New Committee, Process to Maintain CDT Code," Jan. 16 ADA News).

Dentist anesthesiologists provide several thousand office-based general anesthetics to pediatric dentists each year; yet without specific coding, it is hard to examine or track the full extent and impact of their practice. We are encouraged by the creation of the Code Advisory Committee by the Council on Dental Benefit Programs and look forward to closing the coding gap that exists for dental anesthesia services.

The team effort of pediatric dentists and dentist anesthesiologists is a great example of how dentistry is working to provide increased access to care for the very young, special care patients, and other vulnerable and challenged Americans. We encourage a wider public discussion of success stories like this to show that dentistry continues to rise to the challenge of strong and meaningful participation in the changing world of 21st century health care.