The challenges facing the future of dental anesthesiology

Like many other areas of health care, dental anesthesiology is wrapped up in a changing and increasingly challenging environment.

Consider these:

The implementation of Caleb’s Law, which highlights the need for continuous improvement to ensure safe care
An increase in demand for anesthesia services because of the Affordable Care Act and Medicaid expansion
A decrease in access to anesthesia services in hospitals due to the COVID-19 pandemic
A dynamic financial and political health-care environment that impacts operations and care delivery decisions

All four points provide opportunities and urgency for new methodologies, agents, and technology to alleviate painful and anxious experiences for patients and families. They are also increasing demand for anesthesia delivery outside the hospital operating room and leading to a call for greater transparency and the highest level of safety. Together, they are presenting challenges and pushing for change in the anesthesiology system within oral health.

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Anesthesiology is vital to oral health

Anesthesiology is a significant part of the overall oral health marketplace—perhaps more significant than you think. According to a CareQuest Institute analysis of the IBM Watson MarketScan¹ national dental claims database, in 2019, codes for general anesthesia and sedation services (GA/sed) with the dental care provided during anesthesia services accounted for 7% of the total 65,827,534 procedure codes in commercial and Medicaid claims data sets (5% of commercial, 11% of Medicaid). (This database is representative of a national sample, so there is expected variation in utilization depending on type of coverage, reimbursement, state regulations, and insurance carrier.)

Restorative care, oral surgery, and prevention/diagnostic codes were the top three most-billed with anesthesia services. In Medicaid, endodontics and periodontics round out the top five, while implant services and periodontics are more common within the commercial plans. When all dental care services rendered with a GA/sed code are combined, the estimated spend within the 2019 data set for both commercial and Medicaid is approximately $450 million or 12% of all costs (8% of commercial and 21% of Medicaid).

Given the size and financial impact of GA/sed within oral health, creating and maintaining a predictable infrastructure for anesthesiology is critical. And it needs attention now.

The urgency of adding more capacity

When the Affordable Care Act was enacted in 2010, all children under age 19 needed dental insurance. Given that dental caries is the number one childhood chronic disease, there is more demand for access to care and anesthesia services. The COVID-19 pandemic just made things tougher. It added additional pressure, making it even more challenging to access the limited services that exist. Throughout the pandemic, we’ve found reduced access for dentists in those operating rooms.² It’s a growing national problem³ tied to the financial pressure hospitals are facing. With the strain these systems are under, hospital systems are going to look for opportunities that are economically prudent. So, access that used to be there, to be able to go to a hospital operating room for anesthesia services, is not as accessible as it used to be. It extends a waitlist and wait times that were already long.³

There are significant issues with these long wait times. Individuals often are in pain at the time of an anesthesia referral and remain in pain throughout their wait as the oral disease progresses. Oral pain and infection have been linked to poor academic and work performance,⁴ income loss, and decreased quality of life. It is vital to patient care to engage with the caregivers or patients and effectively manage pain and infection⁵ during the wait for anesthesia services and treatment plan completion.

Another concerning trend is individuals who need repeat administration of general anesthetic. This adds additional volume to a system already stretched thin and builds pressure⁶ on this service, ultimately prolonging overall wait times. When individuals are observed with repeat GA/sed appointments, the causes of the ongoing chronic disease are not being addressed,⁷ and the patient is most likely trapped in a continuum of acute care management.

A focus on safety and vigilance

Anesthesiology has been used within dentistry for more than a century as a way of carrying out effective dental treatment in children, anxious adults, and individuals with differences. The utilization of GA/sed during dental care has demonstrated safety⁸ and comparable adverse event⁹ rates found in medicine. However, severe events or deaths during dental care are almost always preventable and carry a higher expectation of safety for the patient and from health-care organizations than with other chronic diseases.

In response to the tragic deaths of two children who received dental treatment while under anesthesia, California put into effect Caleb’s Law¹⁰ in 2017. While the final bill did not include a mandate that an independent anesthesia provider administer GA/sed during dental care, the law set policy that improved reporting requirements related to adverse events that has spread to other states, created oversight for a patient-oriented informed consent process, and amped up a national dialogue on how to continuously improve the safety of dental care.

In 2019, the American Academy of Pediatric Dentistry updated its anesthesia guidelines¹¹ to make sure there is the highest level of safety and commitment for the treatment of children. According to the recommendations, general anesthesia and deep sedation must be administered by a qualified anesthesia provider—i.e., a medical anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist, or second oral surgeon. A second clinician must also be present during anesthesia and have the skills to assist in an emergency and monitor the patient. The formation of the Dental Patient Safety Foundation,¹² along with new programs aimed at improving provider safety training,¹³ demonstrate slow but growing accountability within dentistry.

Maintaining and improving on safety and established guardrails will be important as patients and providers increase demand for access while tackling capacity issues and workforce shortages.

Finding ways to increase equity and access

As capacity is constrained and access recedes, underserved populations can experience significantly more hurdles in acquiring needed care as well as enhanced disparities. There is limited data and reporting on the impact that racial, disability, socioeconomic, or environmental factors have on access to and outcomes of GA/sed for dental care. More mixed methods of research are needed to better understand the current state and the need for improvement. Recent information from CareQuest Institute researchers¹⁴ may highlight some areas for future review:

Black children are more likely to receive general anesthesia (GA) or sedation for nonsurgical dental procedures than children of other races.
Children with behavioral disabilities are more likely to receive GA than other children.
Rural patients with commercial insurance are slightly more likely (6.3%) to have a sedation-related claim compared to urban patients (5.0%).
Medicaid-insured patients were 20% more likely to be given nitrous oxide (N₂O) and 80% less likely to utilize GA than commercially insured patients.

Disparities and inequitable distribution of care delivery, mixed with a need to improve cultural competencies, negatively impact overall health and foster a fragmented system of care. This fragmentation makes it difficult and more expensive to effectively scale social programs and limits access to anesthesia care.

Pivoting to the future

The solutions—to costs, capacity, access, and safety—won’t be straightforward or easy to implement. But we’re at the opportunity of a pivot point, a fork in the road, right now, and the challenges aren’t going to get any easier to solve in the future.

Right now, there are only a few dental anesthesia training programs in place,¹⁵ given that anesthesiology was recognized as a dental specialty¹⁶ only two years ago. Add this to the limited amount of all licensed and trained individuals to perform anesthesia services, the need for proliferation of a modern oral health workforce is apparent. Today, we have fewer people and places to do the same job—not just in dentistry but also in hospital systems.

Making sure that all individuals with appropriate training are being utilized to the highest level of training, understanding opportunities to advance GA/sed education of dental assistants and hygienists, and looking at ways to utilize a multidisciplinary team will contribute to meeting the need for a safe GA/sed experience to effectively treat oral disease.

Beyond improving the number of care providers through education and training, we need the proliferation of preventive approaches and earlier oral health interventions to decrease initial demand for anesthesia services and reduce repeat use of GA/sed. Although parents have stated they wanted to understand a range of interventions to avoid repeat GA/sed in the future,⁷ prevention strategies and messaging often fail to produce sustained disease management and are not often implemented by caregivers or patients. This speaks to a need to change communication strategies to impact home self-care and better define the preventive oral health roles of the care team, including anesthesiologists.

But these alone can’t ensure a better future for dental anesthesiology. The answer, the pivot in the right direction, is improving the system. We need to make it easier for interprofessional teams to communicate. We need to improve access for underserved populations and resource-constrained settings to make sure patients are not waiting days, weeks, or months for care. We need to take steps to create better training and a stronger, more confident workforce.

Ultimately, dental anesthesiology is a vital part of the oral health system and an important pathway to overall health for many individuals. It’s our job to keep that pathway safe and clear.

References

IBM MarketScan Research Databases. IBM. https://www.ibm.com/products/marketscan-research-databases/databases
Burger D. Pediatric dentists sound alarm about being denied OR access. American Dental Association. August 31, 2020. https://www.ada.org/en/publications/ada-news/2020-archive/august/pediatric-dentists-sound-alarm-about-being-denied-or-access
American Academy of Pediatric Dentistry. Pediatric Oral Health Research and Policy Center. Keels, MA, Vo A, Casamassimo PS, Litch CS, Wright R, eds. Pediatric Oral Health Research and Policy Center Policy Brief. Denial of access to operating room time in hospitals for pediatric dental care. April 2021. https://www.aapd.org/globalassets/media/advocacy/ord.pdf
Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health. 2012;102(9):1729-1734. doi:10.2105/AJPH.2011.300478
Antibiotic use for the urgent management of dental pain and intra-oral swelling clinical practice guideline (2019). American Dental Association. ADA Center for Evidence-Based Dentistry. https://ebd.ada.org/en/evidence/guidelines/antibiotics-for-dental-pain-and-swelling
Goodwin M, Sanders C, Davies G, Walsh T, Pretty IA. Issues arising following a referral and subsequent wait for extraction under general anaesthetic: impact on children. BMC Oral Health. 2015;5(3). https://doi.org/10.1186/1472-6831-15-3
Olley R, Hosey M, Renton T, Gallagher J. Why are children still having preventable extractions under general anaesthetic? A service evaluation of the views of parents of a high caries risk group of children. Br Dent J. 2011;210(8):E13. doi:10.1038/sj.bdj.2011.313
Spera AL, Saxen MA, Yepes JF, Jones JE, Sanders BJ. Office-based anesthesia: safety and outcomes in pediatric dental patients. Anesth Prog. 2017;64(3):144-152. doi:10.2344/anpr-64-04-05
Boynes SG, Lewis CL, Moore PA, Zovko J, Close J. Complications associated with anesthesia administered for dental treatment. Gen Dent. 2010;58(1):e20-e25.
“Caleb’s Law” takes effect in California. Delta Dental. May 26, 2017. https://fyi-online.com/2017/05/q-review/
Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatr Dent. 2019;41(4):259-260. https://www.aapd.org/research/oral-health-policies--recommendations/monitoring-and-management-of-pediatric-patients-before-during-and-after-sedation-for-diagnostic-and-therapeutic-procedures/
Dental Patient Safety Foundation. https://www.dentalpatientsafety.org
Ten minutes saves a life! Anesthesia Research Foundation. American Dental Society of Anesthesiology. https://www.adsa-arf.org/tenminutes
Research—driving change with data, analytics, and evaluation. CareQuest Institute for Oral Health. https://www.carequest.org/research
Dental anesthesiology residency programs. The American Dental Board of Anesthesiology. https://www.adba.org/diplomate-resources/residency-programs/
Solana K. Anesthesiology recognized as a dental specialty. American Dental Association. ADA News. March 12, 2019. https://www.ada.org/en/publications/ada-news/2019-archive/march/anesthesiology-recognized-as-a-dental-specialty

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.

Sean G. Boynes, DMD, MS, is the vice president of health improvement for the CareQuest Institute for Oral Health. Contact him at [email protected].