There are various indications for deep sedation and general anesthesia (DS/GA) in dentistry, including anxiety associated with dental treatment, pre-cooperative age, traumatic or extensive dental procedures, and cognitive impairment or motor dysfunctions.1–3 Although many of the patients who fall into these categories require DS/GA in order to facilitate dental treatment, not all of them are able to receive DS/GA. There are a number of reasons why patients may experience barriers in accessing DS/GA for dentistry, and recent research at the University of Toronto, Faculty of Dentistry, aimed to determine what these reasons are. A survey of Ontario patients who had recently received DS/GA for dental procedures was conducted to assess the factors that patients believe are the most significant barriers to accessing DS/GA. The results and implications of this study will be summarized in this article.
The survey respondents identified added cost and lack of insurance coverage of DS/GA as the top barriers to access to DS/GA. This finding is consistent with Ontario dentists’ opinions, as previous research has shown that these providers also believe the added cost and lack of insurance coverage of DS/GA are the top barriers in preventing access to DS/GA.4 Many insurance programs still do not cover DS/GA for dental treatment, although it is an essential service for many patients. Some insurance programs cover DS/GA, but only for specific treatments, such as exodontia. This is also not ideal, as research has shown that there are many procedures and treatments other than exodontia for which patients require DS/GA.1 The majority of survey respondents in this study paid out-of-pocket for the DS/GA services they received, as their insurance program did not cover DS/GA services.
Long wait times to receive care was the next most-frequently identified barrier. The majority of the survey respondents experienced a wait time of one to three months, but nearly 40% of the respondents experienced wait times of greater than 3 months, and some respondents even experienced wait times of greater than one year. Furthermore, two-thirds of respondents experienced a driving time of greater than one hour to get to their appointment. Both the reported long wait times, and the long travel distances in this study suggest lack of availability of DS/GA providers, which was also identified as a significant barrier.
Furthermore, patients who reside in Northern, Central, and Eastern Ontario were nearly six times more likely to report “longer wait times” as an important barrier, which may suggest inadequate access in areas other than the Greater Toronto and Hamilton area. Similarly, parents of pediatric patients were more likely to report longer wait times as an important barrier. This may be related to the fact that pediatric patients are one of the largest utilizers of sedation services in dentistry, and that anecdotally, not all DS/GA providers in Ontario treat children.5 Finally, patients who experienced longer driving times to their appointment were more likely to report “lack of providers of DS/GA” as an important barrier.
This research was the first study to determine which factors patients believe are significant barriers to accessing DS/GA for dental treatment, and it has important implications in the areas of dental public health, health policy, and healthcare provider education.
The results of this study suggest that the added cost and the lack of insurance funding for DS/GA are major barriers to accessing DS/GA, which is consistent with results from previous research.4 This finding is important to both public and private stakeholders, including the Canadian Life and Health Insurance Association. DS/GA is an essential service in dentistry, and limitations on the insurance coverage of these services should be reviewed. Critically, previous studies have shown that the cost of dental surgery under DS/GA is much less in community-based clinics compared to hospital operating rooms.6,7 Therefore, funding sources which support community-based care may be the most cost-effective. However, increasing the number of community-based clinics would likely increase costs to patients, as anesthesia and facility fees are not covered by the Ministry of Health and Long-Term Care in community clinics. This reiterates the importance of increasing funding of DS/GA and removing restrictions on the coverage of these services by private dental insurance providers.
Previous research also concluded that dentists’ attitudes towards and lack of knowledge of DS/GA are major barriers in patients’ access to these services.4 Thus, dentists need more education regarding the indications, risks and benefits, supply and demand of DS/GA, as well as the procedures for which patients require DS/GA. Dental education of this topic should be improved in professional school settings, and also in continuing education programs. Improving education of healthcare providers will also improve patient education regarding DS/GA, and it will likely have meaningful improvements in access to care. OH
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References
- Chanpong B, Haas DA, Locker D. Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesth Prog. 2005;52(1):3-11. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=15859442.
- Gordon SM, Dionne R a, Snyder J. Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Spec Care Dentist. 1998;18(2):88-92. http://www.ncbi.nlm.nih.gov/pubmed/9680917.
- Boyle C a, Newton T, Milgrom P. Who is referred for sedation for dentistry and why? Br Dent J. 2009;206(6):E12; discussion 322-3. doi:10.1038/sj.bdj.2009.251.
- Adams A, Yarascavitch C, Quinonez C, Azarpazhooh A. Access to deep sedation and general anaesthesia services for dental patients?: A survey of Ontario dentists. J Can Dent Assoc. 2017; (In Press).
- Hicks CG, Jones JE, Saxen M a, et al. Demand in pediatric dentistry for sedation and general anesthesia by dentist anesthesiologists: a survey of directors of dentist anesthesiologist and pediatric dentistry residencies. Anesth Prog. 2012;59(1):3-11. doi:10.2344/11-17.1.
- Rashewsky S, Parameswaran A, Sloane C, Ferguson F, Epstein R. Time and cost analysis: pediatric dental rehabilitation with general anesthesia in the office and the hospital settings. Anesth Prog. 2012;59(12):147-153. doi:10.2344/0003-3006-59.4.147.
- Lalwani K, Kitchin J, Lax P. Office-Based Dental Rehabilitation in Children With Special Healthcare Needs Using a Pediatric Sedation Service Model. J Oral Maxillofac Surg. 2007;65:427-433. doi:10.1016/j.joms.2005.12.057.
Soheil Khojasteh obtained both his DDS and MSc in Dental Anesthesia from the University of Toronto, Faculty of Dentistry. He is currently providing care in private practice, and he is also a part-time clinical instructor at the University of Toronto, Faculty of Dentistry.
RELATED ARTICLE: Barriers to Deep Sedation and General Anaesthesia in Dentistry
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