William Thomas Morton was a dentist in Boston in the 1800’s. In 1846 he administered diethyl ether to patient, Ed Abbott, who enjoyed the first painless surgery – the removal of a neck tumor by surgeon, John Warren. This is how anesthesiology began – with a dentist. However, the dental profession has moved far away from their formative role in anesthesiology.
Today, dental anesthesiology is one of the forgotten dental specialties – it is not a board certifiable specialty and the median income is well below other specialties in dentistry. Unfortunately, research has shown that debt encumbered dental school graduates tend toward more lucrative specialties and this is a threat for dental anesthesiology.
Now I want to tell you about a patient of mine whom we will call Nigel. Nigel is a recovering alcoholic with 23 carious teeth. As a teenager he also abused drugs and had very poor oral health habits. However, I’m pleased to tell you he is getting his life together again. He has been married for 8 years and last month he had his first child. Moreover, he started a business 6 years ago and it is really flourishing. When we completed his oral examination we found that he needed 15 fillings, 3 extractions, 2 implants and 5 crowns – something he could easily afford with his new financial situation.
He is not nervous about dental care but he is a very busy man – he has limited time to attend dental appointments and averages 1 to 2 appointments per month. Unfortunately, this means that Nigel’s treatment will get stretched out which introduces risks of disease progression and loss of motivation by the patient. What if we could offer him all his treatment in one visit under general anesthetic or intravenous sedation?
Unfortunately, many dental offices are not set up for GA or IV and, as we discussed, few oral health experts are trained in anesthesiology in the United States. Society and the dental profession tend to restrict GA and IV for patients who are very apprehensive and difficult to treat. We encourage GA or IV for complex wisdom tooth removals but what if your patient just wants a lot of simple restorative work completed rapidly? This could increase patient satisfaction, increase demand for the profession of dental anesthesiology and could eventually put to rest historical views of perceived pain when you visit the dentist. Of course, we must balance this with the increased risks of GA and IV (the latter of which is pretty safe and may be the best option). However, insurance mechanisms don’t support this kind of dental care.
If Nigel wants to maximize his insurance benefit (which has a $3,000 annual limit) he will have to stretch out his treatment over a decade which is unrealistic and ridiculous. However, imagine if the insurer covered all of Nigel’s care in one appointment. It may completely change Nigel’s overall health outcomes, however, insurers don’t see the value of this. They don’t see the value even though insurance claims data has shown that when gingival disease is treated, a patients’ annual diabetic costs reduce by $2,840; a patients’ stroke costs reduce $5,681; and a patients’ pregnancy complication costs reduce $2,433. There are financial benefits to the insurer of incentivizing good oral health!
We need to move towards patient centered care – not what’s best for the insurer or the dentist. This may mean following pathways we never used to….like changing our concept of who may benefit from a General anesthetic or an intravenous sedation. Remember, a dentist was the first person to complete successful anesthesia!