The results of this study indicate that children receiving dental rehabilitation under deep sedation/general anesthesia receive their sedation from multiple providers. When children receive general anesthesia in the operating room, the results indicate that they are likely to receive their anesthesia from a physician anesthesiologist or nurse anesthetist. When children receive the same level of deep sedation/general anesthesia in a clinic-based setting, the results of who provides that care are not as consistent as for the operating room anesthesia provider. The respondent's list of deep sedation/general anesthesia providers for clinic-based dental rehabilitation included oral maxillofacial surgeons, physicians other than anesthesiologists, dentist anesthesiologists, nurse practitioners, and physician anesthesiologists. What makes this finding interesting is the emphasis on clinic-based deep sedation/general anesthesia for dental rehabilitation in the overall behavior management techniques of graduating pediatric dental residents. When asked which sedation procedures graduating pediatric dental residents performed most often, ie, minimal/moderate sedation (excluding nitrous oxide sedation), deep sedation/general anesthesia, or both, the responses indicated that graduates leave their training programs with the most experience in deep sedation/general anesthesia. The results showed that 52% of pediatric dental residents graduate with deep sedation/general anesthesia as the most frequent case experience, and 26% graduate with equal experience in minimal/moderate sedation and deep sedation/general anesthesia. Only 22% of pediatric dental program directors indicated their residents graduated with more experience in minimal/moderate sedation (excluding nitrous oxide) than with cases under deep sedation/general anesthesia ().
Pediatric dentistry residents' average sedation experience during training.
The practice of dental providers serving also as the sedation provider has long been evident in the practice of dentistry. This practice though is a particularly delicate one when it comes to deep sedation and the pediatric patient. The potential for life-threatening airway obstruction, hypoventilation, apnea, laryngospasm, and cardiopulmonary impairment have made it standard practice to have a separate sedation provider from the operating pediatric dentist during the treatment of pediatric patients under sedation beyond the level of moderate sedation. This practice of simultaneous operator/anesthesia administrator has been on the decline as both recent state regulations and US dental schools begin to limit this practice.5,12
When asked to comment on the historical need for dentist anesthesiologists by pediatric dentists, 44% of respondents said they had seen an increase in requests for dentist anesthesiologist services by pediatric dentists in the past 2 years, 60% reported an increase in the past 5 years, followed by 71% who reported an increase in requests for dentist anesthesiologist services by pediatric dentists in the past 10 years. The expected future demand by pediatric residency directors for dentist anesthesiologist services to pediatric dentists was thought to increase by 64% of the respondents' estimation, while 36% of directors estimated there would be no change in the need for dentist anesthesiologist services. Predicting the future need of dentist anesthesiologist is an uncertain task, but these results show pediatric dentistry residency directors are considering the need and recognize a trend of increased need for dentist anesthesiologist services over the past decade.
Two questions addressed by these findings are where these deep sedation/general anesthesia cases occur and who provides the service. Ninety-eight percent of pediatric dentistry program directors indicated that their residents treat patients under deep sedation/general anesthesia, and 69% percent of those did so in the operating room exclusively. However, it is the remaining 31% of pediatric dentistry residents who are the focus of the following discussion. When pediatric dentistry directors were asked, “Do your pediatric dentistry residents provide dental treatment under clinic-based deep sedation/general anesthesia?” 37% answered yes with 88% using the services of a dentist anesthesiologist. Additionally oral and maxillofacial surgeons, physician anesthesiologists, nurse anesthetists, physicians other than an anesthesiologist, and pediatric dentists were used less than 18% of the time (). These results show that the majority of deep sedation/general anesthesia cases are treated in the operating room by physician anesthesiologists. These results also show that clinic-based deep sedation/general anesthesia is the main environment for dentist anesthesiologists, but only approximately one third of pediatric dental graduates complete their programs with experience in this form of behavior management in the clinic environment under the direction of a dentist anesthesiologist ().
Directors: Years Credentialed to Practice Dental Anesthesia
Pediatric Dentistry Programs Using Clinic-based Deep Sedation/General Anesthesia and Type of Anesthesia Provider
The second survey in this research project focused on dentist anesthesiology residents and what type of patients they treat in conjunction with multiple dental specialties. Dentist anesthesiology residency directors indicated a tie between oral and maxillofacial surgery and pediatric dentistry as the specialties most requesting their residents' services for deep sedation/general anesthesia, with only one director indicating general dentistry as the primary dental specialty requesting those services. Pediatric dentistry residency program directors recognize a trend of increasing need for dentist anesthesiologists' services over the past decade. These responses could be affected by the proximity of other training programs within their hospital or university and not by need-based alone. If the dentist anesthesia residency program was in a hospital that also had an oral and maxillofacial surgery residency and a general practice residency but not a pediatric dentistry program, the data could be swayed to the specialties with easy access to the dentist anesthesiology residents.
Pediatric dentistry by definition is the dental specialty for children and adolescents, but approximately 80% of pediatric dental patients are not referred to a pediatric dentist but are instead managed by general or family dentists. The 20% of pediatric dental patients who are seen by pediatric dentists are often less than 6 years of age and have primary dentitions. When dentist anesthesiology residency directors were asked, “How many of their residents' deep sedation/general anesthesia patients were under 6 years of age?” 33% of respondents estimated that less than one quarter of their patients were less than 6 years of age, and 44% estimated that more than a quarter but less than one half were in this category, while 22% believed that greater than three quarters of their deep sedation/general anesthesia patients were less than 6 years of age (). The precooperative but often age-appropriate behavior of many pediatric dental patients makes them candidates for deep sedation/general anesthesia. Indications for deep sedation/general anesthesia in the pediatric dental patient include protection of the developing psyche, negative behavior during an attempt at chair-side treatment, and the need for extensive treatment. In all cases the risk versus the benefits must be weighted and proper behavioral management must be selected in coordination with the patients' and parents' desires.
Pediatric dentists are the specialists most often trained to meet the need of patients with special health care needs (SHCN). SHCN is defined by the American Academy of Pediatric Dentistry as any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. Given the high degree of exposure that many residents in both pediatric dentistry and dental anesthesiology have to this special population, they become a necessary treatment team in providing dental services to patients with SHCN.5,12–,14
Wolff et al15
showed that the more residents are exposed to patients with SHCN during their training, the more positive their feelings were towards being able to treat and meet the challenges these patient presented in practice.5,15
Five of 9 dentist anesthesiology residency directors responded that 1 to 25% of their deep sedation/general anesthesia dental cases were administered to patients with SHCN, while 4 of 9 directors estimated that 26 to 50% of their residents' deep sedation general anesthesia dental cases were administered to patients with SHCN.
The evidence presented here indicates the potential for a team approach to dental rehabilitation for this special population of pediatric dental patients. A unique relationship, the authors believe, exists between the patient populations that pediatric dental residents and dentist anesthesiology residents treat. The survey by Boynes et al5
on the practice characteristics among dental anesthesia providers indicates that when data were categorized according to their main practice activity, the dentist anesthesiologists and pediatric dentists had the highest mean number of patients with SHCN in a sedation/anesthesia practice per month. The study by Boynes et al5
did not limit the sedation to deep sedation/general anesthesia but does show support for this unique sedation-surgery interaction as dentist anesthesiologist and pediatric dentist coordinate their efforts in the dental rehabilitation of patients with SHCN.
The authors recognize the limitations of this survey-based research. Many responses were highly variable and not often centered on one conclusive answer. The response rates for both groups surveyed were above 50%, which is good, but the 9 dentist anesthesiology and 46 pediatric dentistry residency directors contacted provided a relatively small total number of people surveyed.