The Need and Demand for Anesthesia Services in Dentistry. Thesis

Transcription

1 The Need and Demand for Anesthesia Services in Dentistry Thesis Presented in Partial Fulfillment of the Requirements for the Degree Masters of Science in the Graduate School of The Ohio State University By Joshua Jackstien Dentistry Graduate Program The Ohio State University 2012 Research Committee Members: Dr. Simon Prior Advisor Dr. Megann Smiley Dr. Robert Rashid 1

2 Copyright by Joshua Jackstien

3 Abstract The aim of this study was to further investigate the need and demand for sedation and general anesthesia (GA) in the field of dentistry and to gain a better understanding of the feelings and attitudes patients have with regards to receiving dental care and the possibility of receiving adjunct anesthesia services in coordination with their dental treatment. This was accomplished through the surveying of 180 patients who presented for emergency dental care at the Ohio State University s and Indiana University s dental emergency clinics over a 2 month period. We found the incidence of respondents to our survey who reported being very afraid of dental treatment (16.9%) to be consistent with those found in other studies. We found that 48.6% of respondents reported delaying dental care on more than 5 occasions and 81% delaying care on more than 1 occasion. Two major factors responsible for this delay were cost (87.5%) and fear (48.8%). Those who were very afraid were significantly more likely to delay care on > 5 occasions (P=0.036) and of this same group, 76.7% were never offered sedation while 69% had never been offered GA as an adjunct to their dental care. We found that 55.2% of those described as very afraid were unaware that sedation or GA was available for their care, and that the inverse relationship comparing fear/anxiety levels to the knowledge/availability of anesthesia services was found to be statistically significant (P=0.038). ii

4 Our results also showed that when respondents were asked if they were likely to choose sedation or GA in the future as a supplement to their dental treatment 83.4% of all respondents said yes, with 87% of those in the somewhat fearful/very fearful category indicating yes. Interestingly 76.8% of those in the not at all afraid category indicated that they would like to receive sedation or GA for future dental care. 63% of those patients likely to choose some form of adjunct anesthesia for their future treatment stated general anesthesia would be their preference. This comparison of likely future use and preference for general anesthesia was found to be significant (P<0.0001). Conclusion: In this patient population, the level of fear/anxiety still played a significant role in the delaying of dental care and there is a significant positive relationship that exists between patients being unaware that sedation and GA were available for dental treatment and their level of fear and anxiety. The studied patient population also had a strong preference for GA when considering the use of adjunct anesthesia services for future dental care. iii

5 Dedication This document is dedicated to my family. iv

6 Acknowledgments I would like to acknowledge Dr. Simon Prior for his dedication to the profession of anesthesiology, for his passion to educate the anesthesia providers of the next generation His constant motivation, assistance and high expectations did not go unnoticed and they were very much appreciated. I would also like to acknowledge Dr. Robert Rashid for his knowledge, time and skill in the preparation of the necessary statistical analysis that was done for this research project. I would also like to thank Dr. Kyle Kramer for his dedication to this project and to the field of anesthesiology. I would also like to acknowledge those individuals who worked hard distributing the surveys to patients at The Ohio State University and the University of Indiana. v

7 Vita Brighton High School B.A. Business Admin., University of Utah DMD, Temple University Kornberg School of Dentistry 2010 to present...graduate Teaching Associate, Department of Oral Maxillo-Facial Surgery, The Ohio State University Fields of Study Major Field: Dentistry vi

8 Table of Contents Abstract... ii Dedication...iv Acknowledgments v Vita..vi Fields of Study vi Table of Contents...vii List of Tables viii List of Figures....ix Chapter 1: Introduction 1 Chapter 2: Methods.. 7 Chapter 3: Results 9 Chapter 4: Discussion Chapter 5: Conclusion 25 Appedendix A: Survey...27 References vii

9 List of Tables Table 1: Age By Distribution... 9 Table 2: Education Distribution Table 3: Forms of Payment Table 4: Estimated Household Income Table 5: Prevalance of Delaying Dental Care Table 6: Factors Contributing to Delaing Care Table 7: Self Reported Fear Levels...12 Table 8: Extent Patients Agreed Sedation/GA be Available Table 9: Patient s Preference for Anesthesia Type viii

10 List of Figures Figure 1: Fear Level versus Delayed Treatment Figure 2: Awareness of Sedation/GA & Patient's Fear Level...14 Figure 3: Likely Future Use of Sedation/GA Versus Preference of Anesthesia Type..16 ix

11 Chapter 1: Introduction Over time dentists have used many different forms of anesthesia for the purpose of eliminating pain and discomfort associated with treatment, one of the most popular forms has been the use of local anesthetics. Although a number of methods exist for administering local anesthetic solutions, a nerve block and local infiltration remain the most common techniques used in dentistry today. Dentistry is a profession that arguably administers the greatest number of these local anesthetic techniques. However, it remains an unfortunate coincidence that while the purpose of the local anesthetic is to reduce the sense of pain and discomfort of a procedure, its mode of administration and associated experience is in itself the cause of emotional and psychological pain and anxiety for many patients. A recent survey found that 25% of adults still expressed fear of the injection of local anesthetic 1. The feelings of fear and anxiety have long been associated with the field of dentistry and this fear may extend farther than just the injection of local anesthesia. The results of a telephone survey in 1983 showed that 29% of respondents reported moderate to high levels of fear and anxiety with almost half of those in this group avoiding dental treatment altogether 2. A more recent study, completed in 1998, showed nearly 30% of respondents reported moderate to high levels of fear/anxiety and that an inverse 1

12 relationship existed between this fear and the frequency of dental visits 3. After comparing these two studies, completed almost 15 years apart, one may conclude that despite all the advancements in dental techniques, materials and equipment, dentistry may still be failing in the area of managing patient fear and anxiety levels; both which are a known hurdle to receiving appropriate oral care. A retrospective analysis of more than 200 articles and 19 studies involving more than 10,000 adult patients was conducted in 2003 in an attempt to analyze these trends in dental anxiety. The results showed surprising stability in self reported dental anxiety scores over a 50 year period 4. Collectively these studies may indicate failures or difficulties in the provision of dental care that are still not being addressed, many of which lead to a common concern, whether we are using to the full potential, all available anesthetic resources &/or techniques available to the field of dentistry in order to progress assist in alleviating this ongoing problem. Sedation and general anesthesia have been used in both medicine and dentistry for many years as an adjunct to treat patients with pervasive feelings towards receiving certain medical and dental procedures. There are no studies comparing the preference and demand for sedation/general anesthesia for medical procedures to those of dental procedures, nor is there any data concerning the progress of fulfilling the demand and preference for these services between medicine and dentistry. It is a recognized and interesting dichotomy that there exists in medicine, a recognized specialty and an elevated number of anesthesia providers but in dentistry no such recognition exists and 2

13 only a few dedicated anesthesia providers, despite the public subject of dentistry being persistently associated with some of the worst pictures of pain, fear and anxiety. Authors have attributed this to patient populations being unaware of adjunct services such as anesthesiology, and their availability for dentistry; however, it may also be due to the lack of recognition of the dental/anesthesia providers and the need and demand for such services. One area of dentistry, apart from oral surgery, that consistently employs the use of sedation and general anesthesia is that of pediatrics and special-need patients, where behavior and patient cooperation sometimes prohibit the provision of necessary care. The most current research published in 2012 indicated that over 70% of board certified pediatric dentists use some form of sedation in their offices, with 60-70% indicating that they would employ a dentist anesthesiologist if one were available 5. Although these treatment modalities are well associated with the treatment therapies of pediatric dentistry and oral surgery, there has yet to be clearly defined a need and demand for advanced anesthesia services in those individuals who are fearful and anxious, or for those who would just prefer it as an adjunct to their dental treatment. In the general population, a few isolated studies have looked at the emergency patient population and their need and demand for adjunct anesthesia services, concluding that during this acute interaction between patients and dentistry, there exists a high expressed demand for such services and that the availability of these services did not match the demand and that further studies were required to determine the need as opposed to expressed demand

14 The purpose of this study was to extend the research that has already been conducted on similar groups of patients presenting for urgent care in an attempt to elucidate further the question of the need and demand for advanced anesthesia services in this field of dentistry, specifically for those patients who may be fearful and avoiding treatment altogether as well as for those who might prefer these services to improve their comfort level during treatment of general oral disease. For this study we wanted to focus on patients who presented for emergency dental care. Our goal was to evaluate their feelings towards receiving dental care, to identify possible reasons for their delaying care and in particular, to better record their understanding of advanced anesthesia services in an attempt to discern any disparity between services that are desired and those that are readily available. Opinions vary among dental professionals and patients as to the need and place of sedation and general anesthesia within the vast scope of practice. Some feel that it is a necessary and a seemingly important part of the practice of dentistry while others feel that its risks don t outweigh the benefits and thus should not be used. There are of course many who find themselves in the spectrum between these extremes and one of the goals of this research was to help better define these prevailing feelings within our target population. Chanpong et al published a recent study in Anesthesia Progress, assessing the need and demand for anesthesia in dentistry in the Canadian population 8. After comparing and extrapolating their results to the US population, they estimated over 4

15 15,000,000 Americans missed, cancelled or avoided dental treatment due to fear and anxiety. The authors further calculated that approximately 25,000,000 Americans would be interested in sedation or general anesthesia for dentistry with 85,000,000 being interested in theses services depending on cost. When focusing on patients in severe pain requiring root canal treatment, this study stated that over 40,000,000 people would definitely be interested in sedation or GA and perhaps 90,000,000 patients being interested depending on the cost 8. A United States survey (1998) from the National Institute of Dental Research found that 40 percent of the population they researched indicated that they would go to a dentist more frequently if sedation or general anesthesia were available 3. This same research team concluded that there was an unmet need for anesthesia services, and that this unmet need acted as a barrier to the provision of dental care which could be ameliorated with an increase with the use of advanced anesthetic services. A further national survey conducted by Dr. Raymond Dionne et al (1998), found a threefold difference between the use of sedation and general anesthesia in dentistry and the preference for these treatment modalities 1. This research sought to identify and compare patient s feelings toward receiving dental care and to determine if there was a correlation between their level of fear and their avoidance of dental treatment; the research population consisted of patients presenting to two similar emergency dental clinics. The project also sought to quantify the need and demand the study population had for anesthesia services in dentistry, their understanding of the availability of these services and to determine if there was a discrepancy between 5

16 the number of patients that would prefer adjunct anesthesia and those who received it. These objectives were investigated by means of a patient survey provided at two similar emergency dental departments. The population to be studied was chosen with the thought that this patient cohort may have delayed or avoided dental treatment in the past. A multicenter study design was constructed in an attempt to eliminate bias that might exist in a single center model. 6

17 Chapter 2: Methods This multicenter research was conducted in the emergency departments at both The Ohio State University College of Dentistry and the Indiana University School of Dentistry. After approval was received from both the Ohio State and Indiana University Institutional Review Boards, a 23 question survey consisting of closed ended, multiple choice and rank/scaling type questions was distributed to volunteer patients, to obtain data about feelings these patients had towards receiving dental treatment and their attitudes towards receiving sedation and/or GA for their dental care. Our target population was patients 18 years or older who were seeking emergency dental treatment of any kind from two similar emergency departments at two similar institutions. Demographical information; including gender, age, education level, ethnicity, income level and form of payment was obtained in order to further classify and identify statistically significant relationships that may exist within this patient group. The survey was given to each individual, 18 years or older who presented for emergency treatment of any kind. The survey contained no identifiable information and each patient was instructed to fill out the survey and return it in the envelope provided, this was done to help eliminate any discomfort the patient may have had with revealing certain demographical information. The patients received the survey at the time of their 7

18 emergency check-in, completion of the survey was optional and they were informed that their treatment would not be influenced by their decision to complete or not complete the questionnaire. The completed surveys were returned to the emergency admissions desk and stored in a secure place until a member of the research team could collect them. The data was organized by a member of the research team in a categorical fashion, and then analyzed using the statistical software package SAS 9.2 (SAS Inc; Cary NC). The frequency and distributions of the recorded categorical data were determined. The data was further analyzed to check for any statistically significant relationships that may exist between multiple variables. The association of select variables was done using a Pearson s Chi-Square test with Monte Carlo estimates for p-values as well as with Fisher s Exact Tests. A probability value of 0.05 (p<0.05) was set as representing a significant difference of the measured parameters. 8

19 Chapter 3: Results The final number of completed surveys was 180. The number of patients choosing not to participate was not recorded, thus patient participation cannot be calculated exactly, however, comparing the average number of patients who typically present for emergency treatment at these centers and may have received the survey to the number of surveys that were returned and analyzed we estimate patient participation to be 45-55%. Three of the five centers at which we planned on using to collect data were unable to participate for a variety of reasons; therefore, we were unable to achieve our goal of 730 completed surveys in the appropriate time. Of the total surveys completed 72.2% were completed at Ohio State University. The distributions for gender were 54.5% male and 45.5% female. The frequencies of the respondents by age are shown in table 1 and the frequencies for education level in table 2. Age in Years Percentage > Table 1 Age Distribution 9

20 Degree Earned Percentage Less than high School 7.4 High School 55.4 College 31.4 Masters or PhD Equivalent 5.71 Table 2 Education Distribution The final results regarding Ethnicity/Race revealed 56.1% of the respondents were Caucasian, 35% African American with 8% reporting something other than the aforementioned. The results showing payment forms for dental treatment and estimated annual household income can be seen in tables 3 and 4. The majority of patients, 62.8%, reported paying for their dental care out of pocket and 61.3% reported earning <$20,000. Form of Payment Percentage Medicaid/Public Assistance 29.1 Private Insurance 8 Out of Pocket 62.8 Table 3 Forms of Payment for Dental Care Annual Household Income Percentage <$20, $20,000 - $40, $40,000 $60, >$60,000 5 Table 4 Estimated Annual Household Income 10

21 The self-reported delaying of dental care was assessed by having the patients mark the answer they most agreed with. The results showed that 48.6% admitted to delaying care on more than 5 occasions and 81% delaying care on more than one occasion (table 5). Delaying of Dental Care Percentage > 5 Occasions 48.6 > 1 but < 5 occasions 32.4 Once or Never 19.1 Table 5 Prevalence of Delaying Dental Care In order to determine the reasons that may have played a role in the delaying of care, patients were asked to determine whether they strongly agreed, agreed, were neutral, disagreed or strongly disagreed with specific factors (Table 6). Of the 128 people who reported delaying care on more than 1 occasion, 87.5% strongly agreed/agreed that cost was a factor in their delay and 48.76% strongly agreed/agreed that fear/anxiety was a factor in their delay of necessary dental care. Reasons for Delaying Care SA/A% N% D/SD% Cost/Finances Fear/Phobia Transportation Lack of Time in Overall Schedule Inability to Schedule a Time Table 6 Factors Contributing to Delaying Care (SA=Strongly Agree, A=Agree, N=Neutral, D=Disagree, SD=Strongly Disagree) 11

22 The prevalence of fear and anxiety was assessed by the question How would you classify your feelings towards receiving dental treatment? Of those who responded, 41.1% reported either being somewhat afraid (24.2%) or very afraid (16.9%). Self Reported Fear Level Frequency Percentage Not at all Afraid A Little Afraid Somewhat Afraid Very Afraid Total: Table 7 Self Reported Fear Levels From patients responding to both questions, those who reported being very afraid had a greater tendency to have delayed receiving dental care on more than 5 occasions (72.4%) compared to those who reported being not at all afraid (33.3%) (Figure 1). This was found to be a statistically significant trend (chi-square, P < 0.05). Tendency for Treatment Delay vs Fear Level Percentage of Patients 100% 80% 60% 40% 20% 0% None Little Some Very <1/None >1/<5 Times > 5Times Self Reported Fear Level Figure 1 Fear Level vs. Treatment Delay 12

23 In order to assess the availability of adjunct anesthesia services, patients were asked whether sedation (described as medicine through an IV or a pill that makes you less anxious), or general anesthesia (described as being able to go completely to sleep) were ever offered as an option for any of their dental needs in the past. A substantial, proportion (68.5%) of respondents said they were never offered a form of conscious sedation for their dental care in the past with 67% indicating they were never offered GA for their dental care in the past. With regards to those individuals who reported being very afraid (30), 76.7% indicated that they were never offered sedation and 69% reported that they were never offered GA for any dental care in the past. In addition, patients were also asked if they were aware that sedation and GA might be an option for dental care. Overall 64% responded that they were aware that it might be an option for dental care, however, of those who classified themselves as being very afraid, 55.2% reported being unaware that adjunct anesthesia services were available for dental treatment and another 40% of those reporting being somewhat afraid (43) also claimed to be unaware of these services (Figure 2). The results also indicated that those with higher fear levels had a significantly lesser awareness of the availability of anesthesia (chi square P < 0.05). 13

24 Awareness of Sedation/GA and Fear Level 100% 80% Percentage of Patients 60% 40% 20% 0% None Little Some Very Unaware of Sedation/GA Aware of Sedation/GA Self Reported Fear Level Figure 2 Awareness of Sedation/GA and Patient Fear Level Assessing the likelihood that this particular population would prefer sedation or GA as an adjunct for future dental care they were asked Are you likely to choose to receive sedation or GA as a supplement to your dental treatment in the future? Of those who responded, 83.4% indicated they would. It was seen that 87% of the 69 respondents who reported being somewhat or very afraid indicated they would choose sedation or GA for their dental treatment in the future. It is interesting to note that 76.8% of the 56 respondents reporting not at all afraid indicated they were also likely to choose these services in the future. In order to better understand patients attitudes towards advanced anesthesia services (sedation/ga) in the field of dentistry, patients were asked to indicate the extent to which they agree or disagree that these advanced services should be available for particular 14

25 dental procedures (Table 8). Only 13.4% of respondents agreed that sedation/ga is not necessary for any kind of dental treatment with an overwhelming majority agreeing that these services should indeed be available as an adjunct for most dental procedures. Dental Treatment SA/A% N% D/SD% Dental Exam and Cleanings Fillings, Crowns, and Caps Root canal therapy (Endodontic) Surgery of the gums or implants Extraction of teeth other than wisdom teeth Not necessary for any kind of dental treatment Table 8 Extent Patients Agreed That Sedation/GA Should be Available for Dental Treatment (SA=Strongly Agree, A=Agree, N=Neutral, D=Disagree, SD=Strongly Disagree) Assessing the preference this population had for particular types of anesthesia, patients were simply asked Assuming cost is not an issue, if a dentist offered you sedation or general anesthesia for your dental care which would you choose?, with no additional information concerning risk or benefit. Table 9 indicates the percentage of patients who preferred the different forms of anesthesia that may be available over receiving local anesthesia alone. Types of Anesthesia (Possible Answers) Percent Take a pill that would make you relaxed and less anxious 17.1 Receiving a medicine through an IV that makes you sleepy, but still 22.2 awake Receiving a medicine through an IV that puts me completely to sleep 60.7 Table 9 Patient's Preferences for Anesthesia Types (percent indicating desire for a particular type) 15

26 The distribution shows that the majority of respondents preferred to be put completely to sleep, or in other words chose general anesthesia. This response was compared to those who indicated that they were likely to choose sedation or GA for future dental treatment and the results showed that > 63% of those preferring anesthesia other than local would choose general anesthesia as an adjunct to their dental treatment (Figure 3). This shows a noteworthy demand for general anesthesia in comparison to both IV and oral conscious sedation. The higher preference for GA was found to be statistically significant (chi square P < ). Patients Who Are Likely to Choose vs. Preference of Anesthesia Type GA 63% Oral Sedation 15% IV Sedation 22% Oral Sedation IV Sedation GA Figure 3 Likely Future Use vs. Preference of Anesthetic Type 16

27 Chapter 4: Discussion One of the main focuses of this research was to identify the attitudes/feelings these patients had towards receiving dental treatment as well as their opinions towards the use and availability of sedation and general anesthesia as an adjunct to dental care. It was estimated that this patient population would possess a higher level of fear/anxiety, as many times patients will delay receiving regular care until the level of pain and discomfort exceeds that of their negative feelings towards dental treatment. The results of this survey found that 17% of respondents reported being very afraid of dental treatment. Compared with other studies that were done on similar populations, as well as those done on the very different population of the general American dental patients, the percentage of patients who regarded themselves as very afraid remains quite consistent, ranging from 12% to 15% However, comparing our emergency population and other studies involving emergency dental patients to the studies involving more general populations, we found moderate levels of dental fear to be increased; therefore, a higher overall fear level was seen in the emergency population This finding supports our initial assumption that this population does indeed have a higher percentage of fear/anxiety compared with other population subsets. 17

28 We also found that the emergency patient population had a higher incidence of delayed dental treatment due to fear. Our study found that 47.6% of our overall emergency patient population strongly agreed/agreed that fear/phobia was a factor that was influential in their decision to delay care. This finding is consistent with other projects that studied emergency populations, which found 43% of their researched group cited fear/anxiety as a reason for delaying the making of a dental appointment 6. Comparing these findings, with studies done to assess fear/anxiety levels and treatment avoidance of the general American and Canadian populations we see a large difference, there only 7.6% (Canadians) and 14.8% (Americans) admitted that fear/anxiety was a reason for delaying or postponing dental care. Understanding this difference may prove to be influential in directing efforts to remedy such avoidance patterns 1 8. It is interesting to note that in the Canadian study, when isolating only those who considered themselves highly fearful, 49.2% demonstrated patterns of avoidance, which is similar to the overall percentage of the respondents in our study. This information suggests that those who present for emergency dental care may be a group with a higher overall fear level and a substantially higher likely hood of delaying necessary dental treatment. This finding may be an important consideration during the development of future treatment programs, in particular for patient/provider educational programs and models of health care that aim to specifically identify and treat patients belonging to groups known to be at a higher risk of avoidance

29 The results of our study found a statistically significant trend between self-reported fear levels and the delaying of care, which are also consistent with the findings of other studies This correlation showed an inverse relationship between a patient s fear level and the amount of times a patient has delayed dental care (Figure 1). We also found a statistically significant relationship between self-reported fear levels and the awareness of sedation and general anesthesia for dental treatment (Figure 2). Of those who reported being not at all afraid, only 32.7% were unaware that sedation/ga were options for their dental care. This was less than those who reported being very afraid, in which 55.2% reported being unaware that sedation and GA were options for their dental treatment. The correlation between a patients fear level and the likelihood that they might delay treatment is interesting but not surprising, however the relationship shown to exist between the patients fear level and the lack of patient awareness of adjunct anesthesia services is disconcerting. This suggests that the effort of the dental profession in bringing necessary treatment to the population may be failing at one fundamental level, that of anxiety or fear control and the comfortable provision of treatment. Multiple studies have found that these services help to significantly reduce fear levels and ultimately increase a patient s likelihood of receiving dental care, especially within groups classified as fearful In order to help alleviate the barrier that fear/anxiety creates, further discussion regarding the need for increased public/practitioner awareness along with increased availability for such services needs to be undertaken. Our results may reveal a possible lack of available 19

30 anesthesia services for patients of the dental profession to access. Should a patient be fortunate enough to arrive at a practice where the practitioner does assess and respond to a patient s fear and anxiety there still may be no opportunity for that practitioner to access sedation or other advanced anesthesia services. Our findings also suggest that there is still an opportunity for the dental profession to improve its recognition of patients for whom sedation or GA would be a clear benefit. Since identifying these patients can be difficult it may be appropriate, assuming the patient is reasonably healthy, to offer these services to all patients and allow them to decide for themselves if it is necessary for their treatment. Health care providers are taught that health care is a collaborative effort between the providers and their patients. They are instructed to disclose all available and reasonable treatment options and allow the patient to decide which way they would like their care to precede. The results of our survey found that a significant percentage of the total researched patient population indicated that they were never offered sedation (68.5%) or GA (67%) for their dental treatment. Interestingly, of those who classified themselves as very afraid, or in other words considered in need of such services, a large percentage indicated that they were never offered sedation (76.7%) or GA (69%) as an option for their dental care. This finding supports the suggestion that anesthesiology services should be presented, by dental care providers, to all patients. It is apparent that many who may benefit from such services are sometimes not routinely identified. The word need is a very interesting term that has been a continuing topic of discussion. The word need has different meanings for different people. It has been defined as; a lack 20

31 of something wanted or deemed necessary, a duty or obligation, an urgent want, or a necessity arising from the circumstances of a situation or case. It certainly can be argued that adjunct anesthesia services in the case of those who are very afraid may be classified as a need and the demand may then exist for its use. Along those same lines, some may find it difficult to classify those who are not at all afraid as being in need of such services and might say that no such demand exists. Conversely, what has yet to be specifically defined is the preference for such services within dentistry. Our study found that of those who classified themselves as being somewhat afraid / very afraid, 86.9% said they were likely to choose to receive sedation or general anesthesia as a supplement to their dental treatment in the future. This finding is not surprising, as one would perhaps expect those who are fearful would likely prefer sedation/ga for their dental care. What is interesting to note is that of those 42 respondents who classified themselves as being a little afraid, 88.1% indicated that they were likely to choose sedation or GA and of those 56 respondents who classified themselves as not at all afraid, a surprising 76.8% said they were likely to choose sedation or GA as a supplement to their dental care. It can be argued that the phrase likely to choose cannot be specifically defined as a preference for an item or service, and although the phrase preference for in itself can be debated, the response results certainly warrant additional attention and discussion so that this recorded demand may be better understood and ideally aligned with a better matched supply in the future. 21

32 Multiple studies have made similar conclusions; the supply of adjunct anesthesia services does not currently meet the perceived need and demand within the field of dentistry The results of our survey also attempted to determine patient s desire for sedation or anesthesia based upon the actual procedure being performed (Table 8). For a similar selection of dental procedures, Chanpong et al, in his Canadian study found a discrepancy between patients preference for sedation/ga and the availability of sedation/ga for particular dental procedures 8. This might indicate that the professionally perceived need for such services does not meet the actual public demand. Studies have also indicated that both the need for anesthesia services in dentistry and specialized anesthesia providers will likely increase in the near future This increase in demand for anesthesia services may be due in part to the increasing popularity and viability of office-based anesthesia services which studies have shown to be a safe, convenient and a cost effective alternative to the traditional hospital/surgery center model of anesthesia care The increased utilization of office-based anesthesia may help to alleviate some of the barriers that have been discussed previously. For most of our investigation, sedation and general anesthesia were placed together as one response. However, one specific question attempted to elucidate our patient s preference for different anesthetic options. The results demonstrated clearly that general anesthesia was the preferred choice (Table 9). It is important to note the question qualifier, assuming cost is not an issue, when interpreting this significant finding. Those patients who were likely to choose sedation or GA as an adjunct to their dental 22

33 treatment in the future were much more likely to choose general anesthesia (GA) than other forms of sedation (Figure 3) (chi square P < ). As seen in table 6, the two most identified factors responsible for delaying dental care were cost (84.5%) and fear/phobia (47.6%). A consumer report survey conducted in January 2012 also indicated that, consumers worry about pain when it comes to the dentist, but the financial burden of yet another medical expense is the greatest concern of all 20. If we can assume for a moment that the use of sedation and GA could help remove the factor associated with fear/phobia, we must also recognize that such services must lead to an increase in the total cost of care, even when the more cost efficient officebased anesthesia services are used. This increase in cost does nothing to help the 84.5% of those who recorded cost as a major factor in the delaying of appropriate dental care. The cost of health care has been, and continues to be, a heavily researched topic which includes how the delaying of necessary dental care may ultimately increase the cost of proper care in the future. With this in mind, the increased cost of sedation/ga for those who require or prefer it, may possibly save money by permitting earlier and more comprehensive treatment of oral and dental disease. Insurance companies have continually argued that these services are not medically necessary for dental treatment and routinely deny reimbursement. Dr. Flick and Dr. Clayhold from the University of Illinois argued that it should be the patient and the practitioner who determine what is medically necessary and not the insurance companies 21. The topic of whether sedation 23

34 and GA should be covered in the dental arena warrants further research and discussion. In medicine the use of these tools seems to be socially and academically accepted, and indeed a respected method for improving access to necessary treatment for anxious and phobic patients. There seems to be no logical reason for approaching the dental patient with a lesser standard of care. 24

35 Chapter 5: Conclusion This study indicates that within our researched population of emergency dental patients the percentage of patients who classified themselves as very afraid (17%) was similar to those found in the different populations (12-17%) However, a greater percentage of moderate fear levels were seen in our emergency patient population with an increased number reporting fear/anxiety being a factor in their delaying of dental care (Table 6). It was found that a statistically significant relationship exists between a patient s fear level and the likelihood of the avoidance of dental care (Figure 1). We also found a significant inverse relationship that existed between a patient s fear level and their awareness of the availability of sedation/ga for dental treatment (Figure 2). This information indicates that dentistry, as a whole, may need to improve its efforts in the recognition of those who may clearly benefit from sedation/ga and better increase the availability of such services for all patients who require or prefer adjunct anesthesia for their dental care. In addition to the large percentage of patients in the fearful category that would likely choose sedation/general anesthesia in the future, there were a significant percentage of patients in the low fear category who indicated that they were also likely to choose sedation and general anesthesia for dental treatment in the future suggesting a preference for such services regardless of fear level. Further investigation into this finding is warranted in order to better align the supply of these services to the demand. Our results also 25

36 indicated that of those who were likely to choose advanced anesthesia for dental care in the future, a statistically significant percentage would prefer general anesthesia if given the choice of conscious oral or IV sedation as a supplement to their dental treatment (Figure 3). 26

37 Appendix A 27

38 Dear Patient, This survey is for research purposes and your decision to complete it will in no way effect the treatment you receive. Estimated time to complete survey is 3 minutes. Your honest responses are very important to us and will help improve the way dentistry is delivered in the future allowing us to better serve you and the rest of the general public. (Please fill in the box corresponding to your response.) 1)Gender: Male Female 2)Age: >65 4) Ethnicity/Race: White/ Caucasian Black/African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Hispanic/Latino Other 3)Education: (Highest degree earned) Less than high school High school College Masters or PhD Equivalent 5) How do you pay for the majority dental treatment? Medicaid or another public assistance program Private insurance Out of pocket 6) What is your estimated annual household income? Less than $20,000 $20,000 to $40,000 $40,000 to $60,000 $60,000 to $80,000 $80,000 to $100,000 Greater than $100,000 7) Have you ever received dental care in the past? Yes No 8) Mark the box for the option you most agree with. I have delayed receiving dental treatment on greater than 5 occasions I have delayed receiving dental treatment on more than one but less than 5 occasions I have only delayed receiving dental treatment once I have never delayed receiving dental treatment 28

39 9) Please indicate to what extent the following factors have been influential in your decision to delay dental treatment. (SA= Strongly agree, A= Agree, N= Neutral, D= Disagree, SD= Strongly Disagree) SA A N D SD Costs/Finances Fear/Phobia Transportation Lack of time in my overall schedule Inability to schedule an appointment for the times offered by the dentist s office 10) How would you classify your feelings towards receiving dental treatment? Not at all afraid A little afraid Somewhat afraid Very afraid Terrified 11) Were you aware that sedation (medicine through an IV or a pill that makes you less anxious) or general anesthesia (being able to go completely to sleep) may be an option for dental care? Yes No 12) Were you ever offered sedation (medicine through an IV or a pill that makes you less anxious) as an option for any of your dental care needs in the past? Yes No 13) Were you ever offered general anesthesia (being able to go completely to sleep) as an option for any of your dental care needs in the past? Yes No 14) If you were offered sedation or general anesthesia, which have you actually received for your dental care needs in the past? Oral sedation (a pill that makes you less anxious) IV Sedation (medicine through an IV that makes you less anxious) GA (medicine through an IV or breathing a gas that puts you completely to sleep) I have received more than one of the options listed above in the past for my dental care I chose not to receive either sedation or general anesthesia for my dental care 29

40 15) Which dental treatments did you receive sedation or general anesthesia for? Exams/cleanings Fillings/crowns/caps Root canal therapy (Endodontics) Surgery of the gums or placement of dental implants (Periodontics) Removal of teeth other than wisdom teeth Removal of wisdom teeth only I have not received sedation or general anesthesia for any dental procedure 16) Is it likely that you would ever choose to receive sedation or general anesthesia as a supplement to your dental treatment in the future? Yes No 17) Indicate the extent to which you agree or disagree that sedation or general anesthesia should be available for each of the following dental procedures. (SA= Strongly agree, A= Agree, N= Neutral, D= Disagree, SD= Strongly Disagree) Dental exams and cleanings Fillings, crowns and caps Root canal therapy (Endodontics) Surgery of the gums or placement of dental implants Removal of any teeth (other than wisdom teeth) Removal of wisdom teeth only It is not necessary for any kind of dental treatment SA A N D SD 18) If sedation or general anesthesia was offered to you for your dental care in the past, but you chose not to receive it, indicate the extent to which you agree or disagree that each of the following factors was influential in your decision. (SA= Strongly agree, A= Agree, N= Neutral, D= Disagree, SD= Strongly Disagree) Cost/Finances Fear/Phobia Transportation Other complicating Health Issues Experience level of the dentist concerning sedation or general anesthesia Other (specify): SA A N D SD 30

41 19) Indicate the extent to which you agree or disagree that you would feel comfortable receiving sedation or general anesthesia by a trained anesthesiologist for your dental treatment in each of the following situations. (SA= Strongly agree, A= Agree, N= Neutral, D= Disagree, SD= Strongly Disagree) In dental offices In a dental school operatory In an operating room of a dental surgery center In an operating room of a hospital SA A N D SD 20) If insurance did not cover the cost of sedation or general anesthesia, what is the most you would pay out of pocket for one appointment to receive sedation or general anesthesia for your dental care? $0 (I would not pay anything out of pocket) $1-$100 $100-$250 $250-$400 $400-$550 >$550 21) Assuming cost is not an issue, if a dentist offered you sedation or general anesthesia for your dental care which would you choose? Only a shot that would numb the local area and the teeth without sedation or general anesthesia Take a pill that would make you relaxed and less anxious Medicine through an IV that makes you sleepy, but still awake Medicine through an IV that puts me completely to sleep 22) Has any close friend or relative ever received sedation or general anesthesia for dental care? Yes No 23) If yes, indicate your perception of the experience they had with receiving sedation or general anesthesia for dental care? Positive experience(s) Negative experiences(s) There were some positive and some negative aspects of their experience(s) They did not feel positive or negative about their experience(s) - they were neutral I do not know how they felt about their experience(s) 31

42 References: 1 Raymond D, Gordon S, McCullagh L, Phero J. Assessing the Need for Anesthesia and Sedation in the General Population. J Am Dent Assoc. 1998, 129: Gatchel, R, Ingersoll B, Bowman L, Robertson M, Walker C. The Prevalence of Dental Fear and Avoidance: a Recent Survey Study. J Am Dent Assoc. 1983, 107: Gordon S, Dionne R, Snyder J. Dental Fear and Anxiety as a Barrier to Accessing Oral health Care Among Patients with special Health Care Needs Spec. Care Dentist Mar-Apr;18(2): Smith T, Heaton L. Fear of Dental Care: Are We Making Any Progress? J Am Dent Assoc. 134: Olabi N, Jones J, Saxen M, Sanders B, Walker L, Weddell J, Schrader S, Tomlin A. The Use of Officebased sedation and general anesthesia by board certified pediatric dentists practicing in the US. Anesth Prog Spring;59(1): Allen E, Girdler N. Attitudes to Conscious Sedation in Patients Attending an Emergency Dental Clinic. Prim Dent Care Jan;12(1): Baker R, Farrer S, Perkins V, 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 Jan;13(1): Chanpong B, Haas D, Locker D. Need and Demand for Sedation or General Anesthesia in Dentistry: A Natinoal Survey of the Canadian Population. Anesth. Prog : Gatchel R. The Prevalence of Dental Fear and Avoidance: Expanded adult and Recent Adolescent Surveys. J Am Dent Assoc : Smudski J, Perspectives of Dental Education. Anesth Prog Jan-Feb: Rubin G, Kaplan A. Perspectives from a Hospital Based Program. Anesth Prog Jan-Feb: Heaton L, Carlson C, Smith T, Baer R, Leeuw R. Predicting anxiety during dental treatment usin patient s self-reports. J am Dent Assoc : Milgrom P. Perspectives from a Dental School-Based Fear Clinic. Anesth Prog Jan-Feb: Gatchel R. Perspectives from a Community-Based Research Program. Anesth Prog Jan-Feb: Haywood P, Karalliedde L. General Anesthesia for Disabled Patients in Dental Practice. Anesth Prog : Hicks C, Jones J, Saxen, Maupome G, Sanders B, Walker L, Weddell J, Tomlin A. Demand in Pediatric Dentistry for Sedation and GA by Dentist Anesthesiologists: A Survey of Directors of Dentist Anesthesiologist and Pediatric Dental Residencies. Anesth Prog Spring;59(1):

43 17 Yagiela J. Office-Based Anesthesia in Dentistry. Past, Present and Future Trends. Dent Clin North Am Apr;43(2): Yagiela J. Making Patients safe and comfortable for a Lifetime of Dentistry: Frontiers in Office-Based Sedation. J Dent Educ Dec;65(12): Tarver M, Guelmann M, Primosch R. Impact of Office-Based IV Deep Sedation Providers Upon Traditional Sedation Practices Employed in Pediatric Dentistry. Pediatr Dent May-Jun;34(3): PR Newswire.com. Consumer Reports Survey: Consumer Delaying Dental Care Due to Cost. Jan. 3, Flick W, Clayhold S. Who Should Determine the Medical Necessity of Dental Sedation and GA? A Clinical Commentary Support by Illinois Patient and Practitioner Surveys. Anesth Prog :