February 1, 2013
by Peter Nkansah, DDS, Dip. Anaes., Specialist in Dental Anaes. (Ont.)
In 280 BC and 279 BC, King Pyrrhus led his army to victories against the Romans in two separate battles during the Pyrrhic War. Although his armies were victorious, they were also decimated in number and were eventually overrun. Their experience has led to the term “Pyrrhic victory” when recounting battles that maybe never should have been fought.
In October 2012 in San Francisco, the American Dental Association’s House of Delegates voted to not support the application from the American Society of Dental Anesthesia (ASDA) to recognize the specialty of Dental Anesthesia. This vote, the final step in the ADA’s process to recognize specialties, was close, but as the adage goes, “close only counts in horseshoes, hand grenades and nuclear war”. The process, particularly the last vote, was interesting (some would say suspect) because the application had already been supported by the Council on Dental Education and Licensure, the Dental Education Reference Committee, the Committee on Recognition of Specialties and Interest Areas in General Dentistry, as well as the ADA Board of Trustees. Yet, the House still voted it down. As was the case here in Canada a few years ago, the most vocal opposition came from our colleagues in Oral and Maxillofacial Surgery. Why is this, and how did this opposition derail the application process? I’m not really sure. In some ways the practices of dental anaesthetists and oral surgeons are quite similar, with the respective practitioners being able to provide operator-anaesthesia, albeit for different types of procedures. So what part of this idea did they (specifically the American Association of Oral and Maxillofacial Surgeons (AAOMS)) oppose exactly?
The stated arguments were based on claims of decreased patient safety, increased costs to patients and the restriction of access to anaesthesia for all dentists and, as a result, a reduction of service to the patients who would want or need sedation dentistry. There was the argument that anaesthesia was a core skill for dentistry and therefore could not be distinct, even with advanced training. To be clear, the applications here and in the U.S. both lauded the skills, training and practice of our oral surgery colleagues as well as other dentists who had taken an active interest in anaesthesia for dentistry. Both applications stated that anaesthesia services should be offered by dentists to whatever level was appropriate from their training. Both applications stated the need for more dentists to provide sedation, as the need currently outstrips supply. Specialty status would, presumably, mean that more attention would be paid to sedation dentistry at the undergraduate level, as opposed to limiting the practice of sedation dentistry to specialists only. After what I’m sure was vigorous debate, these arguments against the specialty of Dental Anesthesia were put aside for reasons of merit. Then, unfortunately, the argument became political, and logic was set aside. At that time, in my humble opinion, a campaign of misinformation was undertaken. For instance, the Florida Society of Oral and Maxillofacial Surgeons warned on their website that a positive vote would, “significantly impact your ability to deliver anesthesia to your patients”. Later an interesting spin on a positive statement about oral sedation from the application was turned into a threat to anaesthesia as practiced by oral surgeons.
So at the end of the day, the application did not succeed, Dental Anesthesia is not a nationally-recognized specialty is the U.S. or in Canada, and life goes on as the status quo prevails. But, as Heraclitus first noted around 500 B.C., “everything flows, nothing stands still”. While he was talking about the cosmos, the idea has filtered down to us here on earth as “the only constant is change”.
In North America, with the exception of the province of Ontario, sedation/anaesthesia has not been defined as a part of dentistry. Further, neither the Canadian Dental Association nor the American Dental Association is willing or now even able to change that. Following their respective votes, both organizations stopped or were stopped from considering applications for future specialties. So now the status quo means that this service that so many dentists and patients use, need and want is unprotected under the umbrella of dentistry. Within dentistry this may not be much of an issue, however, what if the next challenge to anaesthesia for dentistry comes from outside dentistry? For any of a variety of reasons, our healthcare colleagues in medicine will challenge anaesthesia by dentists some day. Their opening salvo will be that anaesthesia belongs solely in the domain of medicine, and that nothing outside of Ontario says otherwise. If the fight gets nasty enough, they’ll stop participating in the hospital training of oral surgeons and dentist-anaesthesiologists. Or maybe there will be a mishap involving sedation dentistry that makes the government sit up and take notice. In that scenario and likely in the public eye, to which governments are exquisitely sensitive, we will all be “just dentists” and the government may be serving the public well by limiting or eliminating anaesthesia by us, irrespective of training.
I’m not trying to make enemies or to pick a fight, but I am disappointed by the actions of CAOMS here and by AAOMS in the U.S. They won their battles, but at what cost? Someday, some way, anaesthesia will have to be included in the definition of dentistry or the service could be lost to us. The challenge is unique, because unlike periodontics or paediatric dentistry or any other specialty of dentistry, no external group can claim dominion over those services. Further, dentistry has shown the ability to co-exist. To wit, the creation of endodontics as a specialty did not stop me from doing root canal treatments, but if I get into trouble or come across a difficult case, I know who to turn to. The creation of the specialty of dental anaesthesia in Ontario in 2007 has not affected oral surgeons or other dentists using sedation in the province, so the model has been shown to work. To the political bodies of oral surgeons out there, the next time this topic comes up, as it is sure to, consider supporting it. It’ll be good for dentistry, good for our patients, and good for the public. Otherwise, it may be as King Pyrrhus stated, “If we are victorious in one more battle … we shall be utterly ruined”. OH