Written by Mark Cannon, DDS, MS Wednesday, 31 January 2007 19:00
Although most parents know that babies should get rid of the bottle at the age of one, and should never go to sleep while clutching a bottle, many simply can’t stop indulging their little bundles of joy. Or, many simply give up so that the family can get some much-needed sleep. The guilt hits hard, however, when these parents take their toddlers to the pediatric dentist and find out that they need up to 20 restorations, crowns, and/or extractions—and have to be admitted to the hospital for a treatment that will help to reverse the damage caused by early childhood caries (ECC).
Pediatric dentists, however, often find themselves walking a fine line when working with families facing this problem. On the one hand, dentists know they need to tell parents what they don’t want to hear: that it is necessary to perform complicated hospital-based procedures on their young children. On the other hand, dentists understand when parents balk, citing the emotional trauma that undergoing a hospital procedure might cause their young children.
The solution? Office-based treatment of ECC. Indeed, our practice—Associated Dental Specialists, a four-dental specialist group in Long Grove, Ill—has found that offering in-office treatment of ECC is much more amenable to families and, therefore, increases the likelihood of parents securing necessary care for their children.
A look at the prevalence and seriousness of ECC demonstrates why it is so important for dentists to emphasize prevention and, when necessary, offer office-based treatment options to children. Perhaps even more important, however, an examination of how our practice overcame the hurdles to offering office-based treatment—particularly the challenges associated with the delivery of anesthesia in the office setting—provides a roadmap for other practices interested in offering a more patient-friendly ECC treatment option to young children and their families.
Early childhood caries is the most prevalent chronic disease of early childhood and is a major cause of school absenteeism, according to the US Department of Health and Human Services.1 As a matter of fact, studies show that as many as 38% of children 1 to 2 years of age and 56% of children 2 to 3 years of age develop ECC.2 Within certain economically disadvantaged groups, about 80% of infants and preschoolers have been found to have ECC.3 According to the Centers for Disease Control and Prevention, more than 4 million children are affected nationwide.4 ECC is characterized by extensive, rapidly progressive, deep decay of the upper primary incisors and often the primary molars. These decayed teeth may become necrotic and cause alveolar abscesses to develop, leading to a cellulitis of the surrounding soft tissues. The abscesses can be painful and cause harm to underlying, developing permanent teeth. Worse yet, ECC can cause disfigurement and interfere with a child’s ability to eat.3
As a matter of fact, left untreated, ECC can lead to serious illness, infection, and pain, which in turn can impair weight gain and speech while leading to learning and eating problems. As a result, ECC can increase school absenteeism and negatively affect children’s and families’ quality of life. What’s more, some studies have shown that the bacteria can cause early damage to the blood vessels of the heart, leading to early cardiac diseases.5-7 It could be one of the contributing factors to incidences where otherwise perfectly healthy people suffer a cardiac arrest while participating in everyday activities.
Of course, the first line of defense against ECC is prevention. Dentists should encourage parents to bring their children in for their first dental visits as soon as the first tooth erupts, which usually occurs between the ages of 6 months and a year. Infant oral health visits are recommended by age 1 and include oral hygiene instructions to the parents on how to care for their infant’s teeth.8 Since the bacteria that infect the child’s mouth most often come from the primary caregiver, the mother is also instructed on how to reduce harmful bacteria in her own mouth.9 An example of this would be the use of a xylitol-based chewing gum, as xylitol has been shown to inhibit harmful bacteria growth.10
Many adjuncts exist to help maintain good infant oral health that may only be prescribed by a pediatric dental health provider, such as MI Paste (GC America), a paste consisting of casein phosphopeptide (a milk-derived protein vehicle), and amorphous calcium phosphate.11 In addition, dentists should advise parents to water down juice gradually in the baby bottle, to slowly reduce the volume of nighttime feedings, and then to increase the time between feedings, gradually eliminating the nighttime feedings altogether. Pediatric dentists should then recommend that the baby bottle be gradually replaced with feedings from a cup, with the goal of discontinuing the use of the bottle when children reach age 1.12
Although prevention is important, pediatric dentists (at least until prevention efforts start to eliminate or substantially reduce the incidence of ECC) need to find ways to effectively treat their young patients who develop ECC. The problem? Families often avoid treatment for a number of reasons.
First, the idea of subjecting young children to a procedure or series of procedures where anesthesia might be required is difficult for parents to fathom.13 Although it is possible to treat ECC with sedation, for many reasons dentists should consider general anesthesia when treating pediatric patients with this potentially dangerous problem:
• Sedation is far less reliable and less safe than controlled general anesthesia.
• The quality of care is much better with general anesthesia because the dentist can treat the child without having to constantly adjust for the child’s movement and without having to coach and encourage the child.
• All treatment can take place in one appointment, allowing the child to receive care in a timely manner. Without general anesthesia, children are often required to come in to the dental office for multiple treatments, which may ultimately exacerbate the level of anxiety.
Second, the thought of admitting their children to the hospital for treatment makes parents even more squeamish. Forcing their young toddlers to undergo a hospital-based procedure simply doesn’t sit well with many parents who want to do everything they can to protect their children from unpleasant or traumatic experiences. In addition, some parents feel especially guilty because ECC is often caused or at least exacerbated by parents allowing their children to take a bottle to bed or to consume sugar-laden beverages.
Finally, treatment costs could discourage some parents from pursuing treatment. And, the cost of treatment doubles when patients are hospitalized, further deterring parents from pursuing this option.3
Performing full-mouth rehabilitation in the hospital setting can also pose challenges for dentists. Most troubling is the fact that it is often difficult to schedule children for dental treatment in the hospital. Most hospitals set aside certain times and days for dental procedures. As a result, dentists might have to wait months to schedule patients. The wait, of course, is bad for patients who are suffering from a condition that is getting progressively worse. The pain could become more severe, the teeth could begin to abscess, and the infection could damage the bone and permanent tooth buds underneath. It is very distressing to see cases where medical insurance or hospital-created delays force the extraction of teeth that could have been saved at an earlier time.
THE SEARCH FOR A SOLUTION
Because many of these obstacles delayed or prevented our practice from providing necessary treatment to young patients, the pediatric dentists in our group started to think about what we could do to make treatment easier for our young patients and their families.
Certainly, performing the procedures in our office would help to lessen the stress that families experience with ECC treatment procedures. The office setting, especially in pediatric practices such as ours, is very calming for patients and their families. The office is decorated to appeal to children, and we provide a number of child-friendly diversions such as video games, a saltwater fish tank, and child-friendly television programming. In addition, in the office setting we would be able to have better control over the scheduling of procedures, thereby providing more timely and effective care to our patients.
Before offering ECC treatment procedures in the office setting, however, we had to overcome one major obstacle: we needed to find a safe, effective, and financially feasible way to provide anesthesia to our young patients. So, we weighed the following options:
Gain the credentials to administer the anesthesia during the procedures. Although laws differ from state to state, dentists can become certified or licensed to provide all types of anesthesia to their patients, including general anesthesia. Although dentists who undergo these training and certification programs are likely to be qualified to administer anesthesia, doing so while performing dental procedures would be extremely difficult.
Tap the services of hospital-based anesthesiologists. While these anesthesiologists certainly have the skills and expertise necessary, we realized that they might not have the right orientation to work in an office setting. In the hospital, anesthesiologists typically only provide service during the actual operations, whereas in the office setting we would want the anesthesiologists to provide preoperative and postoperative support to patients.
Use a certified registered nurse anesthetist (CRNA) to provide anesthesiology. Although CRNAs are certainly qualified to administer anesthesia, the thought of being the only doctor in the room—and possibly the building—didn’t sit well with us from a patient safety standpoint. We worried that it would be difficult for the CRNA and dentist to handle emergencies without the many common back-up resources available in hospitals, including a bevy of other anesthesiologists and emergency medicine specialists. With this option, the supervising dentist would still have to gain the credentials to administer general anesthesia. In addition, with a CRNA, the dentist would have to supervise the entire procedure, including the anesthesia. As a result, we would be taking on more legal risk when compared to being in the office with a physician anesthesiologist.
With these options, we would also have to invest and maintain expensive anesthesiology equipment. According to Ellison C. Pierce Jr, MD, a Harvard anesthesiologist and founding president of the Anesthesia Patient Safety Foundation, to ensure safety, and thereby protect ourselves from liability, our practice would have to be equipped with “a respirator, monitoring de-vices, state-of-the-art anesthesia machine and resuscitation apparatus that is commonly found in hospitals.”3
THE WINNING CHOICE
Finally, however, we discovered Mobile Anesthesiologists, an office-based anesthesiology service based in Chicago. This option would enable us to cost-effectively and safely provide general anesthesia for our young patients. With Mobile, we have been able to bring top quality equipment and expertise into our practice without making a significant up-front investment. Now, when we schedule ECC treatments or any other procedure requiring general anesthesia, Mobile dispatches an anesthesiologist and nurse, who bring along everything needed to anesthetize and recover a patient safely. Mobile Anesthesiologists is the only AAAHC-accredited (Accreditation Association for Ambulatory Health Care) ambulatory anesthesiology practice in the Midwest, and one of only 2 nationwide. The anesthesiologists are skilled in administering all types of anesthesia including general, regional, and IV sedation. In addition, Mobile provides everything needed, including drugs, supplies, equipment, and emergency equipment. Plus, Mobile is capable of handling any emergency such as cardiac arrest, airway problems, or malignant hyperthermia.
Using such a service has resulted in a number of benefits for our practice:
Better service and improved quality. Offering an office-based option to children who need to undergo ECC procedures makes it possible for more families to get needed treatment for their children. Instead of avoiding treatment because they don’t want to traumatize their children or because of cost concerns, parents are much more likely to pursue the treatment in an office-based setting.
In addition, because the anesthesiologists are capable of properly and safely providing anesthesia for our patients, we are able to work uninterrupted in performing treatment for ECC. As a result, we are typically able to provide all treatment during one visit, as opposed to scheduling several outpatient visits. Also, because the anesthesiologists are accustomed to working in the outpatient setting, they are tuned into patient concerns. Therefore, they work closely with our young patients and families, making them feel comfortable before and after their surgical procedures.
Reduced liability concerns. Because Mobile is an accredited practice—and carries its own liability insurance—the option enables dental groups to perform outpatient surgeries without incurring additional anesthesiology-associated liability.
Decreased start-up costs. The fact that Mobile brings its own anesthesia and emergency equipment is also an attractive economic benefit, saving our practice from having to invest in such equipment or from using substandard equipment.
Improved scheduling. No longer dependent on the availability of operating suites at hospitals, we are now able to schedule our procedures to provide treatment to patients in a timely manner. In addition, the scheduling flexibility makes it possible for the dentists in our practice to schedule procedures to meet their needs as well.
1. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at: http://www.surgeongeneral.gov/library/oralhealth. Accessed January 2, 2007.
2. Douglass JM, et al. Estimates of caries prevalence of toddlers 12-36 months of age. Community Dent Oral Epidemiol. In press.
3. Chisick M. Protect Your Children From Baby Bottle Tooth Decay by Seeing a Dentist Early. Aberdeen Proving Ground, Md: US Army Center for Health Promotion and Preventive Medicine; 1998.
4. Beltran-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism and enamel fluorosis—United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. Aug 26, 2005;54:1-43. Available at: http://www.cdc.gov/MMWR/preview/mmwrhtml/ss5403a1.htm. Accessed January 2, 2007.
5. Scannapieco FA, Bush RB, Paju S. Association between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Ann Periodontol. 2003;8:38-53.
6. Ford PJ, Gemmell E, Timms P, et al. Anti-P. gingivalis response correlates with atherosclerosis. J Dent Res. 2007;86:35-40.
7. Gibson FC III, Yumoto H, Takahashi Y, et al. Innate immune signaling and Porphyromonas gingivalis- accelerated atherosclerosis. J Dent Res. 2006;85:106-121.
8. Goepferd SJ. Infant oral health: a protocol. ASDC J Dent Child. 1986;53:261-266.
9. Ramos-Gomez FJ. Clinical considerations for an infant oral health care program. Compend Contin Educ Dent. 2005;26(5 suppl 1):17-23.
10. Milgrom P, Ly KA, Roberts MC, et al. Mutans streptococci dose response to xylitol chewing gum. J Dent Res. 2006;85:177-181.
11. Hicks J, Flaitz C. Amorphous calcium phosphate-casein phosphopeptide paste: effect on enamel caries formation. Abstract 0501. Presented at: ADEA/AADR/CADR Meeting & Exhibition; March 8-11, 2006; Orlando, Fla. Available at: http://iadr.confex.com/iadr/2006Orld/techprogram/abstract_73073.htm. Accessed January 11, 2007.
12. Ersin NK, Eronat N, Cogulu D, et al. Association of maternal-child characteristics as a factor in early childhood caries and salivary bacterial counts. J Dent Child (Chic). 2006;73:105-111.
13. Savanheimo N, Vehkalahti MM, Pihakari A, et al. Reasons for and parental satisfaction with children’s dental care under general anaesthesia. Int J Paediatr Dent. 2005;15:448-454.
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