Barriers to Deep Sedation and General Anaesthesia in Dentistry

Dental anaesthesiologists are dental specialists who administer deep sedation or general anaesthesia (DS/GA) to patients in order to facilitate dental treatment. The indications for DS/GA in dentistry are vast and include, but are not limited to: anxiety associated with dental treatment, pre-cooperative age, traumatic or extensive dental procedures, as well as patients with cognitive impairment or motor dysfunctions. 1 Dental anaesthesiologists are responsible for assessing their patients’ medical status and indication(s) for DS/GA, and then administering the appropriate level of sedation, so that patients can safely and comfortably undergo dental procedures. 2

Although there are various indications for DS/GA in dentistry, the three most common patient populations who require sedation for dental procedures are patients who have dental anxiety, pediatric patients, and patients with disabilities. 3–5 Dental anxiety is quite prevalent in North America, as studies have shown 11.2%-11.7% of the U.S. population reports having “high dental fear” and approximately 10% of Canadians reported similar fear levels. 1,6,7 This is of concern, since dentally anxious patients are more likely to avoid regular dental care and neglect their oral health, and consequently, they are more likely to present for emergency dental appointments. 5,8,9 It appears that dealing with this patient population’s anxiety would aid in improving their access to oral healthcare, and DS/GA is the ultimate method for the management of dental anxiety. 1,3,4

With respect to pediatric dentistry, there are many patients who require DS/GA for effective and safe dental treatment 10,11 In fact, in Canada, pediatric dental surgery under general anaesthesia is the most common day surgery procedure done in hospital operating rooms. 12 This creates long wait times for dental treatment for many patients. In the meantime, these patients’ dental health continues to deteriorate, which often necessitates more extensive dental treatment. This is an issue that should be addressed by DS/GA providers, as many of these cases can be done out of hospital, which would decrease the wait times for patients and reduce this burden on the healthcare system. 13

Many patients with disabilities have unique needs which makes the use of DS/GA essential in providing acceptable dentistry. 14 The majority of these patients who require DS/GA are treated in hospital, and once again, long wait times become one of the major factors impacting their access to oral healthcare. A number of reports indicate that these patients often wait as long as one to two years before they can be seen for their dental treatment. 15,16 However, a number of these patients can, and should, be treated out of hospital. A possible solution can be to implement more community-based surgicentres that offer DS/GA for dentistry, as reports have suggested that these centres are less costly to the healthcare system, more accessible to patients, and can reduce wait times for accessing DS/GA services for dentistry. 17

The importance of DS/GA in dentistry cannot be underestimated. Numerous studies have been conducted to show the improved quality of life after dental rehabilitation under GA. 18–25 These studies mostly focus on pediatric patients, and they have shown that there is significantly decreased pain levels, as well as increased ability to eat and sleep. 18,19 Furthermore, considerable improvement in children’s psychosocial skills and improvements in their parental and family activity was noted. 19

Although Ontario is the only Canadian province in which dental anaesthesiology is recognized as a dental specialty, Ontario patients’ access to DS/GA services for dental procedures has not yet been studied formally. However, it is suggested that access to DS/GA in Ontario is inadequate. 26 This seems to be especially prominent in rural populations, patients with special needs, and pediatric patients. 26 In general, there are less providers of DS/GA in rural communities, and these patients have less access to sedation services for dental procedures. 27 There are also fewer hospital-based dental operating rooms, as there are fewer healthcare providers (both medical anaesthesiologists and dentists) in these regions. 28,29 Furthermore, both pediatric patients and patients with disabilities are noted to have inadequate access to DS/GA because of long wait times. 30 Parents have reported wait times of up to one-year for their child to receive DS/GA for dentistry. 30 Thus, it is important to focus DS/GA supply to these patient populations to ensure their access to oral healthcare is not limited.

With respect to the factors that may hinder access to DS/GA, many studies have examined the potential barriers to DS/GA for dentistry. 26 In order to determine the potential barriers to access to sedation services in Ontario, Adams et al. studied the Ontario dentists’ perception of barriers to access to DS/GA services. 26 They found that dentists who utilize DS/GA services identified costs to the patient as the major barrier, and dentists who do not utilize DS/GA services mostly reported that there was no need for these services in their patient base. 26 Thus, dentists’ attitudes are clearly a significant barrier to access to DS/GA services, as 25.5% of dentists never utilize DS/GA, because they feel their patients simply do not need it. 26 This means that a significant patient population who may benefit from sedation services does not have these services offered to them. 26 Interestingly, dentists did not perceive long wait times and travel distances to be a major barrier to access to DS/GA. 26 However, Ontario research has shown that long travel distances and wait times are a significant issue for some patients. 31

Research is currently being conducted at the University of Toronto, Faculty of Dentistry, to explore the factors that patients believe are the most significant barriers to accessing DS/GA. The results of this study will be compared and contrasted to the factors that providers perceive to be major barriers to access to DS/GA. This information will aid healthcare providers and policymakers in determining the true barriers to access to DS/GA services for dentistry, and will hopefully allow for improvements to be made in the overall access to these services. OH

Oral Health welcomes this original article.

References
1. 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.
2. American Society of Dentist Anaesthesiologists. American Society of Dentist Anesthesiologists Parameters of Care The Continuum of Sedation and Anesthesia.; 2013:1-13.
RA D, SM G, LM M, JC P. Assessing the need for anesthesia and sedation in the general population. J Am Dent Assoc. 1998;129(2):167-173.
3. Gordon SM, Dionne RA, 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://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=9680917.
4. Boyle C a, Newton T, Milgrom P. Who is referred for sedation for dentistry and why? Br Dent J. 2009;206(6):E12; discussion 322-323. doi:10.1038/sj.bdj.2009.251.
5. Gatchel R, BD I, Bowman L, Robertson M, Walke C. The prevalence of dental fear and avoidance: a recent survey study. JADA. 1983;107(4):609-610.
6. Smith TA, Heaton LJ. Fear of dental care. Are we making any progress? JADA. 2003;134(August):1101-1108.
7. Baker R, Farrer S, Perkins VJ, Sanders H. Emergency dental clinic patients in South Devon, their anxiety levels, expressed demand for treatment under sedation and suitability for management under sedation. Prim Dent Care. 2006;13(1):11-18. doi:10.1308/135576106775193932.
9. Allen EM, Girdler NM. Attitudes to conscious sedation in patients attending an emergency dental clinic. Prim Dent Care. 2005;12(1):27-32. doi:10.1308/1355761052894149.
10. Ashley PF, Parry J, Parekh S, Al-Chihabi M, Ryan D. Sedation for dental treatment of children in the primary care sector (UK). Br Dent J. 2010;208(11):E21-E23. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=20543774.
11. Taskinen H, Kankaala T, Rajavaara P, Pesonen P, Laitala M-L, Anttonen V. Self-reported causes for referral to dental treatment under general anaesthesia (DGA): a cross-sectional survey. Eur Arch Paediatr Dent. August 2013. doi:10.1007/s40368-013-0071-2.
12. Canadian Institute for Health Information. Treatment of Preventable Dental Cavities in Preschoolers: A Focus on Day Surgery Under General Anesthesia.; 2013.
13. 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.
14. Dougall a, Fiske J. Access to special care dentistry, part 1. Access. Br Dent J. 2008;204(11):605-616. doi:10.1038/sj.bdj.2008.457.
15. Park MS, Sigal MJ. The role of hospital-based dentistry in providing treatment for persons with developmental delay. J Can Dent Assoc (Tor). 2008;74(4):353-357. http://www.ncbi.nlm.nih.gov/pubmed/18538073.
16. Ogilvie M. Bridging a gap in dental care?; Mount Sinai goes where other dentists will not. Toronto Star. June 23, 2009:E1.
17. Mathu KR, Bush HM, Li H-F, Nam L. British Columbia’s Hospital?: 3 Year Summary of Children Receiving Dental Treatment with the Use of General Anesthesia. Vancouver, BC; 2013.
18. Jankauskiene B, Narbutaite J. Changes in oral health-related quality of life among children following dental treatment under general anaesthesia. A systematic review. Stomatologija. 2010;12(2):60-64. http://www.ncbi.nlm.nih.gov/pubmed/20679758.
19. Gaynor WN, Thomson WM. Changes in young children’s OHRQoL after dental treatment under general anaesthesia. Int J Paediatr Dent. 2012;22(4):258-264. doi:10.1111/j.1365-263X.2011.01190.x.
20. Baghdadi ZD. Effects of dental rehabilitation under general anesthesia on children’s oral health-related quality of life using proxy short versions of Ohrqol instruments. Sci World J. 2014;2014. doi:10.1155/2014/308439.
21. Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes and parental satisfaction following dental rehabilitation under general anesthesia. Pediatr Dent. 2001;23(5):419-423. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=11699167.
22. White H, Lee JY, Vann WF. Parental evaluation of quality of life measures following pediatric dental treatment using general anesthesia. Anesth Prog. 2003;50(3):105-110. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2007439&tool=pmcentrez&rendertype=abstract.
23. Jankauskiene B, Virtanen JI, Kubilius R, Narbutaite J. Oral health-related quality of life after dental general anaesthesia treatment among children: a follow-up study. BMC Oral Health. 2014;14(1):81. doi:10.1186/1472-6831-14-81.
24. Cunnion DT, Spiro A, Jones J a, et al. Pediatric oral health-related quality of life improvement after treatment of early childhood caries: a prospective multisite study. J Dent Child. 2010;77:4-11.
25. Yawary R, Anthonappa RP, Ekambaram M, McGrath C, King NM. Changes in the oral health-related quality of life in children following comprehensive oral rehabilitation under general anaesthesia. Int J Paediatr Dent. 2015;(Early View Article):1-8. doi:10.1111/ipd.12200.
26. Adams A, Yarascavitch C, Quinonez C, Azarpazhooh A. Access to deep sedation and general anaesthesia services for dental patients?: A survey of Ontario dentists By Access to deep sedation and general anaesthesia services for dental patients?: A survey of Ontario dentists Graduate Department of Dentistry. 2015.
27. Friedman C, Harrison R, Hulland S, Schroth R. Report on Early Childhood Caries.; 2010.
28. Meyer SP. A Spatial Assessment of Dentist Supply in Ontario, Canada. Can Geogr / Le Géographe Can. 2014;58(4):481-498. doi:10.1111/cag.12103.
29. Pitblado JR, Pong RW. Geographic Distribution of Physicians In Canada. Sudbury, Ontario, Canada; 1999.
30. Chung SS, Casas MJ, Kenny DJ, Barrett EJ. Clinical Relevance of Access Targets for Elective Dental Treatment under General Anesthesia in Pediatrics. JCDA. 2010;76:1-7.
31. Koneru A. Access to Dental Care for Persons With Disabilities in Ontario: A Focus on Persons with Developmental Disabilities. 2008.

About the Author
Dr. Soheil Khojasteh obtained his DDS from the University of Toronto, Faculty of Dentistry. He is currently practicing as a general dentist and completing the dental anaesthesiology specialty training program at the University of Toronto, Faculty of Dentistry.