Dental Fear in the New Economy

“I was never afraid of anything in the world except the dentist.”
—Taylor Caldwell, author (b. 1900 – d. 1985)

PHYSICAL COST OF DENTAL FEAR
Dental fear (odontophobia) is a real and very debilitating condition that can cause a myriad of health problems. Health problems can increase, from bad breath, tooth decay, and gingivitis to infections that can spread throughout the body.

According to selfhelpcollective.com, dental fear ranks higher than the fear of snakes, fear of needles, and fear of God. It has been reported that approximately 75% of US adults experience some degree of dental fear, from mild to severe.^1-3 Parents describe their children’s dental experience with words such as traumatic, forced, tied-down torture, inhumane, crying, screaming, horror, and terrified.⁴ Negative portrayal of dentistry in mass media and cartoons may also contribute to the development of dental fear. Some patients are so afraid that they avoid dentists and dental care all together. This fear can lead to avoidance and subsequent lack of dental care, creating a situation in which these patients only seek emergency treatment during times of crisis; this usually means more invasive and potentially painful treatment that only reinforces the original fear and avoidance issues.

The focus of anesthesia in dentistry is to allow fearful patients access to a comfortable and nontraumatic dental ex­perience, and to stop creating increasing numbers of patients with dental phobias.

A percentage of 93.7 of dental graduates perceive a need for sedation services in their practice, and, in a study conducted by the University of Pittsburgh School of Dental Medicine, it was revealed that 79% of patients preferred to “sleep” during dental treatment; 40% wanted oral sedation, 35% wanted intravenous sedation, 17% expected nitrous oxide, and 6% other forms.⁵

In 2012, Anesthesia Progress⁶ reported that, “Pediatric dentists cannot find enough dentist anesthesiologists to meet the needs of their patients.” And, “Twenty percent to 40% of survey participants say they currently use a dental anesthesiologist and 60% to 70% say they would use one if one were available.”⁶

Dr. John Liu, clinical assistant professor of dentistry at the University of Washington in Seattle, states, “I find it tremendously helpful to have a dental anesthesiologist…I have used a dental anesthesiologist for more than 20 years, and I don’t know how anybody manages without one.”⁷

FINANCIAL COST OF DENTAL FEAR
The Affordable Care Act has led to decreases in dental benefit reimbursement, indigent care funding for healthcare facilities, and increased need for state and federal funding.⁸ With the new “do more with less” mantra of healthcare systems and businesses, many hospitals are re-evaluating where their biggest expenditures and losses are, system-wide. Many general dentists, pediatric dentists, and oral surgeons are finding that their operating room availability and schedules are being reduced or even canceled. The reason for this is simple: dental surgery is a low-reimbursement procedure for both hospitals and physician anesthesia providers. As a bottom-line approach, many hospitals just cannot afford to continue performing dental in-hospital procedures. Treating a pediatric dental patient in a hospital operating room takes about 222 ± 62.7 minutes, with a recovery time of 157 ± 36.8 minutes until discharge, at an average cost of $7,303 per case. Compared to a dental center time for similar cases of 175 ± 36.8 minutes, with a recovery time of 25 ± 12.7 minutes until discharge, at average case cost of $414.9

FINDING DENTAL ANESTHESIA SOLUTIONS
One way to help dental providers accomplish this is the dental surgeon/dentist anesthesiologist business model. There are numerous articles that tout the benefits of deep sedation/general anesthesia for the general dental surgeon, dental surgical specialists, and oral surgeons. The topics of these articles range from patient safety in-office and practice building to helping decrease the growing need for dental healthcare dollars, while maximizing chairside work time. Furthermore, as the healthcare landscape changes and dentistry is forced to change with it, the ambulatory surgical center (ASC) business model becomes more attractive. In the past decade, we have seen dental medicine on a path to emulate the “medical model” of healthcare, where groups of dental providers pool resources and expand services by housing treatment, dental/oral surgeons, and dentist anesthesiologists under one ASC roof. This new dental frontier is being reinforced by an increasing number of freestanding dental ambulatory surgical centers, and the inclusion of quality indicators. ASC numbers have increased 300% from 1996 to 2006¹⁰ and, while exact dental surgery center numbers are unknown, it is estimated that out of the 3,700 ASCs recorded in 2003, 20% of those included dental centers.¹¹

Another solution would be encouraging general dentists, oral surgeons, and other dental specialists to include a mobile dentist anesthesiologist as a treatment option for patients in their offices. This solution has a twofold benefit for dental providers: (1) the dental operator can focus more attention on the procedure while maintaining the comfort of their office setting, and (2) the patient can benefit from a lower overall cost of the anesthesia service with an anesthesia provider who has clinical competence in the dental procedure being performed.

While dental ambulatory surgical centers staffed with dentist anesthesiologists and mobile dentist anesthesiologist services are available in a few states, imagine the nationwide healthcare dollars that would be saved if dentist anesthesiologists’ services were available in all states.

PHILOSOPHY IN PRE-DOCTORAL DENTAL CURRICULUM
So the question becomes, “If we know dental fear is one of the highest ranking public fears, and we have providers trained to provide higher levels of safe anesthesia in dental settings, why do we limit their use?” One answer can be found by looking at the current anesthesia education, or lack thereof, in pre-doctoral dental education.

According to a questionnaire of dental school graduates in 2003, there was an overriding theme that predoctoral students rarely have enough hands-on sedation and airway management technique training/experience. Furthermore, with the ever-increasing public demand for sedation dentistry, and the increased media attention to dental office emergencies, many students voice that they would have supported increased tuition fees for efficient sedation training or increased anesthesia training by dentist anesthesiologists. Moreover, many feel an expectation that dental schools should be responsible for educating care providers (general practitioners and dental specialists) with appropriate levels of sedation training.⁵

CLOSING COMMENTS
Properly addressing “conquering dental fear in a new economy” requires a step-by-step approach. The start would be increasing anesthesia presence in the predoctoral dental curriculum. Next, have the dental profession increase the visibility of the dental anesthesia specialty. Then have the dental profession help state boards and healthcare systems recognize the financial and safety benefit of dental anesthesia outside the hospital. Lastly, invest time in educating dental providers in how to adopt new business practice models that include dental anesthesia and are suited to the new healthcare environment.

Like any unfamiliar skill, if dental providers are not trained fully in how to work surgically with dental anesthesia, then they will not utilize this valuable resource in practice and fear its potential. Advanced-trained dentist anesthesiologists can provide dental providers the advantage of getting more procedures done in shorter appointment times, reduce patient appointment visits, reduce patient and hospital healthcare costs, and allow more hospital operating rooms to be available to in-hospital services. As advances in oral medicine pave the road for the dental surgeon/dentist anesthesiologist practice model, it becomes equally important to advance the dental curriculum. Furthermore, as the methods of dental reimbursement change, it benefits the profession to adopt new dental business practice models.

References

1. Getka EJ, Glass CR. Behavioral and cognitive-behavioral approaches to the reduction of dental anxiety. Behav Ther. 1992;23:433-448.
2. Kleinknecht RA, Thorndike RM, McGlynn FD, et al. Factor analysis of the Dental Fear Survey with cross-validation. J Am Dent Assoc. 1984;108:59-61.
3. Milgrom P, Weinstein P, Getz T. Treating Fearful Dental Patients: A Patient Management Handbook. 2nd ed. Seattle, WA: University of Washington, Continuing Dental Education; 1995.
4. Mauro T. What is a Papoose Board? specialchil­dren.about.com/­od/equipment/g/papooseboard.htm. Accessed November 14, 2014.
5. Boynes G, Lemak AL, Close JM. General dentists’ evaluation of anesthesia sedation education in U.S. dental schools. J Dent Educ. 2006;70:1289-1293.
6. Olabi NF, Jones JE, Saxen MA, et al. The use of office-based sedation and general anesthesia by board certified pediatric dentists practicing in the United States. Anesth Prog. 2012;59:12-17.
7. Harrison L. Pediatric dentists want anesthesiology help. Medscape. April 6, 2012. medscape.com/viewarticle/761640. Accessed October 24, 2014.
8. Domrzalski D. Hospitals say they’re facing funding crisis. Albuquerque Business First. February 4, 2014. bizjournals.com/al­buquerque/news/2014/02/04/hospitals-say-theyre-facing-crisis.html. Accessed October 24, 2014.
9. Rashewsky S, Parameswaran A, Sloane C, et al. Time and cost analysis: pediatric dental rehabilitation with general anesthesia in the office and the hospital settings. Anesth Prog. 2012;59:147-153.
10. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1-25.
11. Frey F. Ambulatory surgery centers. Encyclopedia of Surgery: A Guide for Patients and Caregivers—A-Ce. surgeryencyclope­dia.com/A-Ce/Ambulatory-Surgery-Centers.html. Accessed Novem­ber 14, 2014.

Dr. Flores graduated from Lamar University in Beaumont, Tex, in 2001 with a bachelor’s degree in biology and in 2004 with bachelor’s degree in nursing. He worked as a registered nurse (RN) in the emergency, cardiovascular intensive care unit, behavioral health, neurotrauma, and rehabilitation departments. As an RN, he concurrently attended dental school at the University of Texas Dental Branch in Houston, earning several awards, including the Anesthesiology Safety Practice Award and the Horace Wells Award for Anesthesiology. After graduation, he attended the University of Pittsburgh School of Dental Medicine, where he completed his specialty training in dental anesthesiology. During his chief residency year, he founded founded the first-ever predoctoral dental anesthesia society, Dentist Anesthesiologist Club for Students. He has received dual board certification in dental anesthesiology and was awarded Diplomate status with the American Dental Board of Anesthesiology and National Dental Board of Anesthesiology, and Fellow status with the American Dental Society of Anesthesiology. He currently serves as the director of Dental Anesthesiology for University of New Mexico Medical Group Ambulatory Surgical Center and is assistant professor for the Advanced Education in General Dentistry residency, focusing on intravenous sedation/general anesthesia education. His professional goals are to complete his masters of healthcare administration degree and help strengthen dentistry’s transition into a field of oral medicine. He can be reached at jflores77@salud.unm.edu.

Disclosure: Dr. Flores reports no disclosures.