Criteria for Treatment of Children Under General Anesthesia by Pediatric Dentists and Parents

THESIS

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University

Elizabeth Sutton Gosnell DMD

Graduate Program in Dentistry

The Ohio State University

2011

Master's Examination Committee:

Professor Sarat Thikkurissy DDS, MS, Advisor

Professor Dennis McTigue DDS, MS

Professor Megann Smiley DDS, MS

Professor Simon Prior DDS, MS

Elizabeth Sutton Gosnell

2011

Abstract

Purpose: As of 2011, 70% of all states (35/50) have legislation outlining criteria for the use of general anesthesia (GA) to manage early childhood caries (ECC). Criteria are inconsistent, with varying age, health and disease requirements. The purpose of this study was to compare parental and pediatric dentist criteria for treatment of dental disease under GA.

Method: This case cohort series surveyed caregivers at both a large urban tertiary hospital and also at a suburban private pediatric dental practice. Caregiver responses were compared to results from an electronic survey sent to Board-certified members of the

American Academy of Pediatric Dentistry (AAPD).

Results: Data were collected from 195 parents 631 dentists. Parents believe that children

(a) from ages 3-4, (b) with 2-4 carious teeth or (c) requiring 2-4 extractions or restorations all immediately qualify for GA; all significantly different (P<.0001) from surveyed dentists, who felt the above did not provide a solely adequate criteria. Thirty- two percent of parents felt that a developmental delay automatically qualified a patient

ii for GA, significantly more than the 12% of dentists (P<.0001). Parents and dentists did agree that a behavior problem at any age qualified a patient for GA (P=<.78). When asked “who was most qualified to determine appropriateness for treatment of dental cavities under GA?” both parents and dentists ranked dentists first, and insurance companies last. However, parents ranked themselves above physicians, while dentists ranked physicians higher. This difference was significant (P<.0001). Pediatric dentists report they consult the AAPD guidelines first when considering a child for general anesthesia, followed by state legislation and insurance company reimbursement last.

Fifty-five percent of pediatric dentists report they have delayed urgent/ emergent care waiting for insurance pre-authorization.

Conclusion: Board certified pediatric dentists were less likely to have specific tooth number or disease-criteria for GA than parents. Most pediatric dentists referred to the

AAPD guidelines for GA, with less than 10% citing state legislation as their first choice.

Twenty-seven percent of parents felt they were most qualified to request GA, while 11% of parents felt physicians were most qualified.

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Dedication

This document is dedicated to my husband William who has shown me boundless love

and unwavering support through this entire process.

Acknowledgments

Thank you to my entire thesis committee who has given me support and guidance through the entire thesis process. A special thank you to my thesis advisor for keeping me focused and giving me constant support and encouragement.

Vita

May 2001 ...... Dutch Fork High School

2005...... BS Chemistry, University of South

Carolina

2009...... DMD, Medical University of South Carolina

2009 to present ...... Pediatric Dental Resident, The Ohio State

University and Nationwide Children‟s

Hospital

Fields of Study

Major Field: Dentistry

Pediatric Dentistry

Table of Contents

Abstract ...... ii

Dedication ...... iv

Acknowledgments...... v

Vita ...... vi

List of Tables ...... x

List of Figures……………………………………………………………………………xii

Chapter 1: Introduction ...... 1

1.1: Dental Caries in Children: Epidemiology and Morbidity……………………...... 1

1.2: Treatment Modalities for Dental Disease in Children- General Anesthesia…………7

1.3: Determining "Appropriateness" of General Anesthesia for Dental Rehabilitation...... 8

1.4: Impact of the Dental Home on GA Utilization……………………………………...11

1.5: State Legislation and Insurance Coverage for Dental Rehabilitation under GA……13

Chapter 2: Methods………………………………………………………………………16

Chapter 3: Results……………………………………………………………………….17

3.1: Pediatric Dentists- Demographics…………………………………………………..17

vii

3.2: Use of Sedation/ General Anesthesia among Pediatric Dentists……………………18

3.3: Resources Utilized by Pediatric Dentists……………………………………………19

3.4: Patient Specific Criteria for GA use in Children……………………………………20

3.4a: Age…………………………………………………………………………………20

3.4b: Minimum Number of Teeth………………………………………………………..20

3.4c: Patient Health Status……………………………………………………...... 21

Section 5: Parents- Demographics……………………………………………………….22

3.5a: Analysis by Ethnicity………………………………………………………………22

3.5b: Analysis by Education……………………………………………………………..22

3.5c: Analysis by Recruitment Site………………………………………………………23

3.6: Parental Concern for General Anesthesia…………………………………………...23

3.7: Appropriateness of General Anesthesia for Children………………………...... 24

Chapter 4: Discussion……………………………………………………………………38

4.1: Current use of General Anesthesia…………………………………………...... 38

4.2: Decision to use General Anesthesia…………………………………………………42

4.3: Location for the provision of GA…………………………………………………...45

4.4: Parents- Patient specific criteria for GA…………………………………………….46

4.5: Influence of Demographics and Location…………………………………………...48

4.6: Finances of going to GA…………………………………………………………….49

4.7: Parent Data Finding: 'Don't Know'………………………………………………….50

4.8: Appropriateness of GA for Children………………………………………………..50

4.9: Analysis of State Legislation………………………………………………………..51

viii

4.10: Analysis of Study…………………………………………………………...... 52

References……………………………………………………………………………….54

Appendix A: General Anesthesia State Legislation……………………………………..57

Appendix B: Dentist Survey…………………………………………………………….70

Appendix C: Parent Survey……………………………………………………………...74

List of Tables

Table 1. Pediatric Dentist demographics……………………………………………….25

Table 2. Use of Sedation/ GA use among Pediatric Dentists…………………………..26

Table 3. Rank the following in order from highest priority to lowest priority when

considering GA for dental treatment………………………………………….28

Table 4. Pediatric Dentists: When a child has suffered trauma, which of the following do

you consider before the child is put under general anesthesia for dental

treatment? Rank the following in order of most important (1) to least important

(4) in consideration………………………………………………………………28

Table 5. Pediatric dentists: Patient specific responses………………………………….29

Table 6. Pediatric Dentists: What do you consult when considering GA for treatment?

Rank the following from most important (1) to least important (3)……………31

Table 7. Parental demographics…………………………………………………………31

Table 8. Parental responses……………………………………………………………..32

Table 9. Parental responses- qualifier questions……………………………………….35

Table 10. Pediatric Dentists- Which of the following groups is most qualified to

determine the appropriateness of general anesthesia for treatment of dental

caries/ cavities? Rank the following from most appropriate (1) to least x

appropriate (4)…………………………………………………………………37

Table 11. Parents- Which of the following groups is most qualified to determine the

appropriateness of general anesthesia for treatment of dental caries/ cavities?

Rank the following from most appropriate (1) to least appropriate (4)………..37

List of Figures

Figure 1. Early childhood caries morbidity and mortality pyramid……………………...3

Figure 2. Multifactorial model of early childhood caries………………………………...6

xii

Chapter 1: Introduction

1.1: Dental Caries in Children: Epidemiology & Morbidity

Dental caries remains the most common chronic childhood disease, with an estimated prevalence five times that of asthma6. A hallmark of modern-day dental disease is a notable disparity in prevalence, with eighty percent of dental caries being localized in

25% of children. The majority of these children are from families of lower socioeconomic status. Dental caries prevalence has been associated with age, income, and minority status6, 32. It has been estimated that approximately 20% of preschoolers,

50% of second graders, and 67% of ninth graders have experienced tooth decay6. Data from the 1999-2004 The National Health and Nutrition Examination Survey (NHANES) indicated the prevalence of dental caries for children 2-5 years old increased from 24% in

1988-1994 to 28% in 1999-2004. The survey also indicated that 72% of decayed or filled tooth surfaces (dft) remain untreated18. In the 1988-1994 NHANES data, two-year old children defined as being in poor and near-poor families had an average of 0.5 dft per child. Similarly, five-year olds from poor and near-poor families had an average of 2.7 dft per child. This is in great contrast to the data for children from non-poor families where five-year olds had less than 1.0 dft. However, the caries-economic association is not conclusive, as data suggests that, regardless of economic status, children that have tooth decay experience the same level of severity18.

According to a 2003 survey of children that were recently enrolled in the State

Children‟s Health Insurance Program (SCHIP), these children have poorer health status, higher health care needs, higher use of outpatient and inpatient services, more frequent use of specialty services, and higher health care costs than the general population of children34. The year before the children enrolled in SCHIP, 27% to 62% of the children had an unmet health care need. The majority of these unmet needs were a result of financial barriers, followed by practice-level and system-level barriers34.

Studies have reinforced that dental care has remained the most common unmet health care need in children. Children with no dental insurance are three times more likely to have an unmet dental need than children with public or private insurance6,17,31.

The direct financial burden of early childhood caries (ECC) is difficult to determine. In 2006, the Medical Expenditures Panel Survey found that 19.4% of children under age five required dental care resulting in total expenditure of $729 million. A

California study of emergency department visits showed that for children 0-5 years of age, the rate of visits for preventable dental conditions ranged from 189-222 per 100,000 from 2005-2007. A Texas study showed that children younger than 5 years of age had

636 emergency room dental visits between 1997 and 2001, of which 73% were for non- traumatic dental problems21.

Aside from the tooth-specific morbidities, dental disease can have additional physical, functional, and behavioral consequences. Figure 1 shows a proposed morbidity and mortality pyramid for ECC. The pyramid has a broad base and narrow apex

2 representing this disease‟s low fatality rate but high rate of dysfunction. There are many tiers involved, of which not all have been quantified by data19.

Figure 1: Early childhood caries morbidity and mortality pyramid19.

Parents of children seeking emergency dental care reported that 19% of the children experienced interference with play, 32% with school, 50% with sleeping, and 86% with eating. There also has been a reported relationship between ECC and failure to thrive among children, a condition of poor growth. Episodic dental pain has been shown to

3 affect up to 20% of preschoolers19. In a study of 4-year olds with caries, children were more likely to be absent from school, were more ashamed to smile, had difficulty eating, and were more likely to select a sad face when asked how they feel about their teeth22.

Several studies have cited the effect of dental pain on school performance in children.

Children aged 5-7 years lose an estimated 7 million school hours annually related to dental problems and/or visits, many of which are a consequence of dental caries23. One survey reports more than one out of ten school children experienced dental pain. Another study shows a correlation between poor systemic and oral health with a poor school performance. A study in Michigan reports loss of sleep, the inability to concentrate in school, and absences from school all caused by dental caries-related pain19.

Children with special health care needs (CSHCN) are “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally34.” The estimated national prevalence of CSHCN is between

14.8% and 18.2%. “Access to dental care for these individuals is often influenced by attitudes and willingness within the dental team, financial considerations, self-image problems, medical conditions, or physical access37.” In the year 2000, a survey was conducted to assess parental and dentist views regarding access to dental care for people with special needs. Thirty-eight percent of these subjects used a general dental practitioner, 35% used community dental services, and 27% used hospital services.

Parents reported a longer waiting period for hospital services, but also reported a high rate of satisfaction with dental care37. A 1989 survey of parents of children with special

4 health care needs found that 50% of respondents had problems obtaining dental care with

25% of individuals citing the high costs of treatment. In addition to cost issues, 17% had difficulty finding a dentist who would see their child, 12% reported transportation problems, and 6% reported difficulty accessing the building37. This data shows the broad impact of ECC, which affects the child, family, community, and health care systems, depicted in Figure 2 below. The figure shows child, family, and community levels that contribute risk factors for children‟s oral health20. This model elucidates the complexity of children‟s oral health in the context of their environment today.

Figure 2: Multifactorial model of early childhood caries25.

There are many factors to consider when planning a child‟s dental treatment.

These include; the child‟s general health, oral health, behavior, and distance to a dentist.

The option of deferment / no treatment also must be discussed with parents. However, in cases of extensive tooth decay, the choice of no treatment may result in facial cellulitis,

6 subsequent admission and hospitalization and in rare occasions has lead to airway compromise and death. In a recent retrospective study, the mean hospital admission stay and associated hospital costs were significantly reduced when facial cellulitis was treated with antibiotics and prompt surgical intervention by the dental team. The mean length of stay with this approach was 2.08 days, compared to the 2006 Kids‟ Inpatient Database

(KID) of 3.4 days, lowering the mean hospital costs from $8998 for KID to $416620.

1.2: Treatment Modalities for Dental Disease in Children – General Anesthesia

For the overwhelming majority of children, successful behavior management in the dental office is accomplished through communicative behavior management techniques (tell-show-do, modeling, positive reinforcement) and nitrous oxide. In children where communicative techniques are unsuccessful, more advanced behavior management techniques include; passive immobilization, moderate sedation, and general anesthesia (GA). Dentists who practice these techniques have additional training beyond the traditional pre-doctoral dental curriculum. State and Federal guidelines, as well as dental literature outline the appropriateness of these advanced techniques. „The importance of general anesthesia in dentistry is illustrated by the fact that in excess of 5 million persons annually receive general anesthesia on an ambulatory basis in the United

States, the overwhelming majority of these in outpatient dental settings (private practice, surgery centers). About 16% of all general anesthetics administered in the United States annually are administered in order to provide dental care30.

In children who require more than three conscious sedation appointments, treatment with general anesthesia has been shown to provide a cost-savings11. In a survey of parents following their child‟s GA visit, “all reported improvements in (their) child‟s quality of life, with fewer children experiencing symptoms (such as dental/oral pain, eating problems, interrupted sleep, or irritability), or behavioral problems following dental treatment. Many of these children had experienced chronic dental pain with difficulty eating and sleeping prior to receiving dental treatment8,19.”

A 1991 study of 933 patients revealed the scope of caries, followed by behavior management problems and the patient‟s mental or physical condition as the most common reasons for dental treatment under general anesthesia9,35. The most common reasons cited for treatment of special needs children under GA are; extensive treatment needs, followed by negative behavior, and underlying medical condition2. Thus, the reasons for patient referral to have dental work completed while under general anesthesia are the same between children with and without special health care needs.

1. 3: Determining “Appropriateness” of General Anesthesia for Dental Rehabilitation

Aside from the child-specific variables of dental disease, there are also family level and community level specifics, a theory outlined by Fisher-Owens in 200725.

Among community-level variables (Figure 2) include insurance coverage and state regulations governing the use and indications for dental rehabilitation under general anesthesia. In 2011, 35 states and Puerto Rico had enacted legislation governing general anesthesia (GA) for dental rehabilitation. There is a lack of consensus concerning the

8 criteria to be used to define conditions where dental rehabilitation under GA is appropriate, with several states adopting amendments to GA legislation in recent years12.

Guidelines developed by the American Academy of Pediatric Dentistry (AAPD) do not carry legislative authority, but rather are „consultative‟ and not strictly adhered to by states. The AAPD guidelines state;

“(GA) may be indicated for the patient who lacks the ability to cooperate, whether this is because of the child’s age, anxieties, level of psychological maturity or presence of a medical, physical/mental disability or developmental delays. The decision to use GA must take into consideration alternative behavior management modalities, dental needs of the patient, the effect on the quality of dental care, the patient’s emotional status, and the patient’s medical status13”.

Furthermore, specific criteria are stated as;

“The goal of general anesthesia in the pediatric dental patient is] to eliminate cognitive, sensory, and skeletal motor activity to facilitate the delivery of quality comprehensive diagnostic, restorative, and/or other dental services. The indications for general anesthesia, according to the AAPD, include the following: 1) patients who are unable to cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability, 2) patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy, 3) the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent, 4) patients requiring significant surgical procedures, 5) patients for whom the use for deep

9 sedation or general anesthesia may protect the developing psyche and/or reduce medical risks, and 6) patients requiring immediate, comprehensive oral/dental care3”.

Researchers at the University of North Carolina in Chapel Hill evaluated the use of GA in 3298 pediatric patients over an 18 year-period (1990-2008). The study showed a steady increase in the number of children treated under GA during this time period14, suggesting the practice of pediatric dentistry is changing, with more children having their dental work completed under GA. Two possible reasons for this shift are an increasing number of parents that appear to accept GA and changes in dentists‟ selection criteria for the use of GA. In a recent survey of parents concerning their attitude towards behavior management techniques used in pediatric dentistry, general anesthesia was ranked 3rd, after tell show do and nitrous oxide. This represents a significant generational shift from previous years, in which, parents ranked general anesthesia as one of the least acceptable methods of behavior management, alongside passive immobilization (papoose board).

Parental attitudes toward general anesthesia have changed, and the recent survey shows that acceptability of general anesthesia is increasing7. In another survey, the most important reasons for parental acceptance of treatment under GA for their child was the failure of previous attempts to carry out dental treatment because of the child‟s fear and behavior, followed by the child‟s pain experience4. Another reason buoying the acceptance of GA is the relatively large margin of reported safety. General anesthesia, when carried out by qualified anesthesiology professionals, has been demonstrated to be a relatively safe procedure, with an approximate mortality rate of 1.4 in every 1 million cases5.

1.4: Impact of the Dental Home on GA utilization

“The American Academy of Pediatric Dentistry (AAPD) advocates the concept of a dental home for all infants, children, adolescents, and persons with special health care needs38.” This concept is derived from the American Academy of Pediatrics (AAP) definition of a medical home which states pediatric primary health care is best delivered where “comprehensive, continuously accessible, family-centered, coordinated, compassionate, and culturally-effective care is available and delivered or supervised by qualified child health specialists”. Health care provided to patients in a medical home environment is more effective and less costly in comparison to emergency care facilities or hospitals. Strong clinical evidence exists for the efficacy of early professional dental care complemented with caries-risk assessment, anticipatory guidance, and periodic supervision. Children who have a dental home are more likely to receive appropriate preventive and routine oral health care. Referral by the primary care physician or health provider has been recommended, based on risk assessment, as early as 6 months of age, 6 months after the first tooth erupts, and no later than 12 months of age. This provides time-critical opportunities to implement preventive health practices and reduce the child‟s risk of preventable dental/oral disease36. The policy on the dental home was adopted by the AAPD in 2001. Since then, health professionals have increased referrals to pediatric dentists at a younger age. As a result, dentists are diagnosing early childhood caries

(ECC), and severe early childhood caries (S-ECC) in younger children. ECC is defined

11 as, “presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger36.” In 2003, the American Academy of Pediatric Dentistry defined severe early childhood caries (S-ECC) as any sign of smooth-surface caries in children younger than

3 years old. From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or a decayed, missing, or filled score of >4 (3 years old), >5 (4 years old), or >6 (5 years old) surfaces constitutes S-ECC. A

2004 North Carolina study of 53,591 Medicaid-enrolled children from birth to age 5 showed that children who had their first preventive dental visit by age 1 were more likely to have subsequent preventive visits and less likely to have restorative and emergency visits. For example, an estimated 100,000 to 250,000 pediatric dental sedations

(combined conscious sedations and general anesthesia) are performed each year30. Also, there has been an increase in the number of surgeries performed at ambulatory / outpatient surgery centers; so that treatment of children under GA is no longer limited to the hospital setting30.

The patient‟s age, dental needs, disabilities, medical conditions, and/or acute situational anxiety may preclude the patients being treated safely in a traditional outpatient setting. These patients may be denied access to oral health care when insurance companies refuse to provide reimbursement for sedation/GA and related facility services.

Resolution 1989-546 from the American Dental Association states that;

“insurance companies should not deny benefits that would otherwise be payable solely

12 on the basis of the professional degree and licensure of the dentist or physician providing treatment is provided by a legally qualified dentist or physician operating within the scope of his or her training and licensure10.” The AAPD guidelines underscore the fact that the dentist providing the dental home/oral health care for the patient determines the medical necessity of sedation/general anesthesia consistent with accepted guidelines on sedation and general anesthesia.

1.5: State Legislation & Insurance Coverage for Dental Rehabilitation under GA

Prior to 1995, private medical insurers were not required by law to cover hospital costs associated with dental treatment under GA. A 2002 study showed that only 40% of cases were reimbursed by public insurance systems15. There is a high variance among state criteria for reimbursement. These are often based on age, medical status, and definition of disease, as well as proposed interventions. According to a Medical

Expenditure Survey in 1996, twelve billion dollars were spent on children‟s dental care.

Payment came primarily from out-of-pocket (47%), and private insurance with copayments (45%), rather than from public funding (8%)16.

State legislation requiring insurance companies to pay for general anesthesia dental services was first passed in 1999, in North Carolina. In the pre-legislation period

(1997-1998), there were 1370 non-Medicaid dental visits and 2487 Medicaid dental visits, according to a NC study. In the post-legislation period, there was a significant increase in the dental visits by non-Medicaid (2195, a 60% increase) as well as Medicaid

13 patients (3316, a 33% increase)1. This suggests that state legislation can have a direct positive impact on improving access to care for children.

Within each state without criteria-specific legislation governing the use of GA for dental rehabilitation, dentists rely on multiple points of information. These include;

(a) The procedures that insurance will cover (specific ADA Codes)

(b) What caregivers are able to pay out of pocket for treatment

should receive care under GA33.

The decision to use GA during dental treatment can place an enormous financial burden on families that do not have GA covered by their insurance company. In 1996, estimates of the cost to treat a child with 2 to 5 carious lesions were $408 and $1725 for those with 16 to 20 lesions. General anesthesia to facilitate dental treatment may add

$1500 to $6000 to the cost of dental care26-29. Additionally, parents may have different perspectives regarding GA and what they consider to be valid reasons to qualify their child for the procedure. In an Iowa study, Medicaid-participating children under age 6 who were treated for ECC in hospital or outpatient care settings represented less than 5% of those receiving dental care but 25-45% of the dental resources17.

Given the complexity of the issues related to the increasing use of GA for dental work, including changes in legislation, differences in criteria between states and the possible differences in parental and dentist views, determining an appropriate set of criteria for dental rehabilitation under GA is challenging.

The overall objective of this study is to investigate pediatric dental practitioner perceptions of criteria for dental rehabilitation under GA and compare these perceptions to those of parents. Specific aims of this study include;

i) Determine similarities and differences between the criteria used by parents

and dentists and use this knowledge to better provide for the child patient

population.

ii) Improve awareness among dentists of parental views on the subject so that

they can better serve their patients and increase access to care by

supporting policy changes.

Chapter 2: Methods:

A questionnaire was used to examine parents‟ attitudes regarding the appropriateness of general anesthesia as an adjunct to complete needed dental treatment for a child. Completion of the survey was voluntary and no incentives were given to parents. A standard script was read to the parents who chose to participate; a cover sheet was also provided explaining the research study prior to their completion of the survey.

A second page gave a summary of each treatment option the dentist may recommend to assist in the provision of dental treatment for the child. These treatment options included nitrous oxide, conscious sedation, and general anesthesia. The questionnaire used variables from state legislations across the US. Caregivers were surveyed at a large urban tertiary hospital (Nationwide Children‟s Hospital, Columbus, OH) and a suburban private pediatric dental practice. Caregiver responses were compared to results from an electronic survey sent to Board-certified members of the American Academy of Pediatric

Dentistry (AAPD). The reliability and validity of the survey was tested by pilot studies.

The dentist pilot study was conducted at Nationwide Children‟s Hospital. Thirty pediatric dentists that saw patients in the Dental Surgery Center were asked to complete the survey and give feedback. Fifty parents that presented for hygiene appointments were surveyed at Nationwide Children‟s Hospital for the pilot study. Feedback and responses were used to further edit the survey prior to the final study.

Chapter 3: Results

3.1: Pediatric Dentists- Demographics

Data were collected over a 4 month period from September 20, 2010 to February

1, 2011. The first email was sent in September and one month later a second email was sent to those recipients who had not yet responded. Surveys were electronically sent through Survey Monkey to 1925 Board Certified Pediatric Dentists. A total of 1929 surveys were emailed, 44 of those recipients blocked the site and 4 email addresses no longer active. Thus from 1881 recipients, 692 initiated the survey, with 632 completing the survey for an overall response rate of 33.6%. The gender breakdown of the responding Pediatric Dentists (PD) was 55.7% male and 44.3% female. A total of 518

(82%) of PD‟s reported their ethnicity as Caucasian, followed by 64 (10.1%) Asian-

Pacific Islander, 31 (4.9%) Hispanic/Latino and 19 (3%) African American. Nearly half

(45.6%) of the PD‟s reported graduating from their training program 2000-2010 with half

(50.8%) graduating from a Combined Hospital-University based program, followed by

209 (33.1%) graduating from a Hospital-based program and 102 (16.1%) from a

University-based program. Following graduation, most practitioners 282 (44.6%) worked primarily in a group practice, with 258 (40.8%) in solo practice. Seventy-nine (12.5%) of responders worked in an academic setting and 13 (2.1%) worked in the military/armed forces. Most practitioners (58.9%) worked in a suburban setting, with 30.4% in an urban and 10.8 % in a rural setting. For full demographic tabulation – see TABLE 1.

3.2: Use of Sedation /General Anesthesia among Pediatric Dentists

Four hundred twelve pediatric dentists (65.2%) indicated that they did use oral/intravenous conscious sedation in their practice. Eighty-eight percent (561) had not had a patient suffer a medical urgency or emergency related to sedation in their office, but 71 (11.6%) reported they had. Seventy-seven percent indicated that they use general anesthesia services at least one time per month. Of the PD‟s who utilize general anesthesia services, over half (58.9%) operate in a hospital setting, with 25.2% utilizing an outpatient surgery center and 15.9% using general anesthesia services in a dental office. The majority of responders (302/ 47.8%) did report that their use of general anesthesia had remained the same over the past 10 years, with 36.1% (228) noting their use had increased, and 16.1% (102) reporting use had decreased. Most providers (79.5%) use a MD or CRNA anesthesiologist in a hospital or surgery center for their anesthesia services, followed by a DDS/DMD dentist anesthesiologist in their office (9.3%) and an

MD anesthesiologist in the dental office (6.7%). Most PD‟s (250/39.6%) were not sure whether recognition of dental anesthesia as a specialty would significantly improve access to pediatric GA services for dentistry, whereas 174 (27.5%) think it would improve access and 208 (32.9%) do not think it would improve access to care. An endotracheal tube was the most commonly reported airway management technique used

(408/ 64.6%), followed by a nasopharyngeal airway (nasal trumpet) (172/ 27.2%). Forty- seven (7.4%) reported using an open airway technique with a throat screen. When asked

18 if they would „defer treatment rather than use GA in a healthy child due to risks of GA?‟,

520 (82.3%) answered „No‟, 75 (11.9%) answered „yes‟, and 37 (5.9%) answered „don‟t know.‟ If insurance coverage was not available, most responders (296 / 46.8%) would use a payment plan for general anesthesia, followed by multiple conscious sedations (279

/44.1%), and multiple treatments without any sedation (57/ 9%). When asked if they agree with the statement, „States should have legislation with criteria for treatment of dental caries/cavities under GA‟, 47.9% (303) said „yes‟ and 40.5% (256) said „no.‟

When asked if they think state legislation governing criteria for GA increases access to care or decreases it, the majority, 47.2% (298), said „don‟t know.‟ Details of use of sedation and anesthesia services are provided in TABLE 2.

3.3: Resources utilized by Pediatric Dentists

When asked “What do you consult when considering GA for treatment (ranking question)?”, most PD‟s cited the AAPD guidelines for use of general anesthesia as published in the AAPD reference manual (341/ 75.8%). After the AAPD reference manual, dentists selected „Insurance Company Reimbursement‟ as what they consult first

(47/12.1%). Lastly, pediatric dentists reported they consult „State Legislation, criteria for

GA‟ (37/9.8%). The most common „second rank‟ was state legislation criteria for GA

(presented in APPENDIX 1), selected by 62% of PD‟s. Over half (55.1% / 348) of dentists noted they had delayed delivery of what they considered urgent/emergent care under GA waiting for insurance pre-authorization.

When Pediatric Dentists were asked to „Rank in the order of priority when considering general anesthesia for treatment‟, the highest ranked choice was „Behavior

Issues‟ (222/35.1%), followed by „Underlying Medical Conditions‟ (190/30.1%). Details of this question are presented in TABLE 3.

When asked about a child who had suffered a dento-facial trauma and what considerations rank as most significant, 52.7% (333) of PD‟s cited „Extent of Trauma‟, followed by Behavior (29.7% / 188). Details of this question are presented in TABLE 4.

3.4: Patient Specific Criteria for GA use in Children

Please note responses to patient specific criteria questions presented in TABLE 5.

3.4a: Age

A set of questions in the dentist survey (APPENDIX 2), inquired about patient- specific criteria that would be used as decision-making factors for general anesthesia use.

Most PD‟s (297 / 47%) felt that the phrase „complex dental disease‟ often used in state legislation language, is most appropriate to describe a situation of 4-6 carious lesions,

207 (32.8%) stated it described a child with more than 6 carious lesions, and 128 (20.3%) reported it described a situation with 1-3 carious lesions. Of those who responded (210 /

33.2%) that there was a specific age under which full mouth dentistry in a healthy child was best done under GA, most (61.5% /131) felt that under 3 was most appropriate.

Fourteen percent (31) felt that any age less than 5 is best. Sixty-six percent (416) felt that difficulty coping / behaving for dental treatment at any age was a qualifier for GA to provide necessary dental treatment.

3.4b: Minimum Number of Teeth

Most dentists (544 / 86.1%) did not feel that there was a „minimum number of teeth‟ that qualified a child for GA services, while of those who felt there was, the most

20 common response was 3-4 teeth (29 / 37.7%). Most dentists (572 / 90.5%) did not feel there was a minimum number of restorations that qualified a patient for GA. When asked if there was a specific number of teeth that would need to be extracted, 96.8% (600) felt that there was no specific number of extractions necessary. When asked if a child had a dental emergency involving one permanent tooth, 90% (569) felt that treatment in a clinic setting should be attempted before general anesthesia. When the question was modified to ask about a child with a tooth-related facial swelling which was note severe, but in which local anesthesia might not be optimally effective, 13.4% (85) felt that the best treatment would be under general anesthesia, whereas 71.7% (453) felt that GA would not be the best treatment. Additionally, when asked if treatment of dental cavities should always be attempted in a clinic setting before treatment under GA, 10.1% (64) agreed and

87.7% (554) disagreed. In a follow-up question, PD‟s who felt that treatment should be attempted in a clinic setting first were asked if there was a specific number of times treatment should be attempted in a clinic setting/in office before treatment under GA. The majority (52/ 78.8%) responded once. Dentists were asked if they would approve a

„healthy, cooperative 8 year old with 5 interproximal carious lesions being treated under

GA based SOLELY on parental request‟, 85.8% (542) answered „no‟.

3.4c: Patient Health Status

Most dentists (551 / 87.2%) felt that a developmental disability alone did not qualify a patient for GA. Sixty-two percent (392) did feel that a „behavioral problem at any age‟ was a qualifier for GA use. Underlying medical conditions was one of the most commonly high-ranked reasons for considering GA; 30.1% (190) ranked this first and

25% (158) ranked this second with a rating average (2.54) second only to „Behavior

Issues‟(2.42).

3.5: Parents- Demographics

Data was collected from 196 parents in three distinct settings; Hospital hygiene

(94), Hospital emergency dental clinic (46), and private practice (55). Please refer to the parent survey in APPENDIX 3. The majority of caregivers (127 /64.7%) were female.

There was no difference between the Hospital (H) and private practice (PP) groups in terms of gender (p=0.245). Most caregivers who reported ethnicity were Caucasian

(50%). Significantly more of the Hospital caregivers were African American than in the private practice group (p<0.0001). When asked about education levels, 47.6% of the total parents who responded reported a college education, with 35% having a high school education, <1% not having completed high school, and <1% having completed some graduate school. Significantly more of the PP group had finished College/Graduate

School (p<0.0001). Forty-five percent of caregivers responded living in a suburban setting. Significantly more of the H population lived in either a rural or urban area

(p=0.005). Parental demographics by group are presented in TABLE 7, and frequencies of parent responses presented in TABLES 8 and 9.

3.5a: Analysis by Ethnicity

When caregiver data was analyzed by ethnicity, significantly more of the

Caucasians lived in a suburban area (p=0.002). Otherwise there were no significant differences in answers to questions or concerns by ethnicity.

3.5b: Analysis by Education Level

After combining the categories „less than high school‟ with „high school graduate‟ and „college‟ with „graduate school‟, the caregiver data was analyzed by education level.

Significantly more of the higher education level caregivers reported living in a suburban area (p=0.009). Significantly more of the lower education level caregivers were comfortable using general anesthesia for a facial swelling (p=0.039). Also a significantly higher number of children with caregivers from lower education levels had a history of previous general anesthesia for dental treatment (p=0.03)

3.5c: Analysis by Recruitment Site

Caregiver data was analyzed by site of recruitment (H or PP). Aside from the differences noted in the demographic section above, significantly more of the H- caregivers felt that there was a minimum number of „teeth to be treated‟ required for GA to be indicated than the PP-caregivers (p-0.04). Significantly more of the H-children had a history of previous GA than the PP-children (p=0.002).

3.6: Parental Concern for General Anesthesia

Within both recruitment sites, 28.6% of caregivers reported having concerns about general anesthesia; there were no statistically significant associations by caregiver gender/residence or education level. When individual comments were assessed, they were stratified into one of four categories; child age-related concern, general anesthetic medication concern, side effect concern, child medical issue-related concern. Most caregiver concerns (67 / 82.7%) involved side effects, followed by (8 / 9.1%) general anesthetic medication concerns.

3.7: Appropriateness of General Anesthesia for children

Both the dentists and caregivers were asked;

“Which of the following groups is most qualified to determine the appropriateness of general anesthesia for treatment of dental caries/ cavities? [Rank from most appropriate to least appropriate].

The options were; parents, dentists, insurance companies and physicians. See

TABLE 10 for a full presentation of findings. Most dentists (571 / 90.5%) felt that dentists were the most appropriate person. The most common „second choice‟ was

Physicians (357 / 58.1%), the most common third choice was „Parents‟ (345 / 55.8%) and the most common fourth choice was „Insurance Companies‟ (536 / 88.7%). The average ratings were; Dentists (1.2), Physicians (2.4), Parents (2.6) and Insurance Companies

(3.8). The dentist responses were analyzed against the parent responses using the Mann-

Whitney nonparametric test. There were no significant differences in the ranking between the two groups. The least amount of difference was in the top ranking, both groups selected dentists as the most appropriate (p=1). The least difference, although still not statistically significant was in the ranking of physicians (p=0.14). Dentists tended to rank physicians above parents, while parents (although slightly) had the opposite result. When the overall ranking of physicians versus parents was assessed between the two groups, there was no statistically significant difference (p=0.12).

Gender Male Female 352 280 (44.3%) (55.7%)

Ethnicity Caucasian African Hispanic/Latino Asian or American Pacific Islander

518 (82%) 19 (3%) 31 (4.9%) 64 (10.1%)

Community Rural Suburban Urban Practice 68 (10.8%) 372 (58.9%) 192 (30.4%) Majority of Time Type of Solo Group Academic Military/ Practice Armed Forces 258 282 (44.6%) 79 (12.5%) 13 (2.1%) (40.8%) Residency Hospital- University- Combined Program based based Hospital and University 209 102 (16.1%) 321 (50.8%) (33.1%) Year Before 1970-1979 1980-1989 1990-1999 2000-2010 Graduated 1970 from 8 (1.3%) 78 (12.3%) 114 (18%) 144 (22.8%) 288 Residency (45.6%) Table 1: Pediatric Dentist Demographics

Regularly (at least Yes No Don’t one time each Know month) treat children 492 140 0 under GA (77.8%) (22.2%) Do you use oral/ IV Yes No conscious sedation 412 220 (65.2%) (34.8%) Had a patient suffer Yes No a medical 71 561 urgency/ER related (11.2%) (88.8%) to sedation in your office In past 10 yrs, has Increased Decreased Remained your GA use inc, the same dec, or stayed the 228 102 302 same (36.1%) (16.1%) (47.8%) In what setting do Hospital Outpatient Dental you most often treat Surgery Office children under GA Center 290 124 78 (58.9%) (25.2%) (15.9%) Which provider do MD Anes CRNA in DDS/DM MD/ DDS/ Provide you use most often in dental dental D Anes in CRNA DMD own to treat children office office office Anes in Anes in anesthesi under GA Hospita Hospital a l or or surgery Surgery center Center 33 (6.7%) 3 (.6%) 46 (9.3%) 391 18 (3.7%) 1 (.2%) (79.5% ) What airway Open Endo- LMA Naso- management airway tracheal (laryngeal Pharyn technique is most with tube mask geal often used for your throat airway) airway GA cases screen (nasal trumpet ) 47 (7.4%) 408 5 (.8%) 172/ (64.6%) 27.2%

Table 2: Use of Sedation/ GA among Pediatric Dentists Continued

Table 2 continued

Defer treatment Yes No Don’t rather than use GA Know in a healthy child 75 520 37 (5.9%) due to risks (11.9%) (82.3%) If insurance Multiple Multiple Payment coverage is not treatments conscious plan for available, what is without sedations GA your next option for sedation treatment 57 (9%) 279 296 (44.1%) (46.8%) Would recognition Yes No Don’t of dental anesthesia Know as a specialty 174 208 250 improve access to (27.5%) (332.9%) (39.6%) pediatric GA for dentistry States should have Yes No Don’t legislation with Know criteria for treatment 303 256 73 of dental cavities (47.9%) (40.5%) (11.6%) under GA State legislation Increases Decreases Don’t governing criteria Know for GA increases or 185 149 298 decreases access to (29.3%) (23.6%) (47.2%) care

Answer Options 1 2 3 4 5 6 7

179 27 27 26 34 166 173 Cost (28.3%) 277 11 35 31 48 160 70 Insurance Coverage (43.8%) Distance to Dental 307 23 10 22 45 166 59 Office (48.6%) Number of 87 167 cavities/teeth that 160 147 28 26 17 (13.8%) (26.4%) need treatment Underlying Medical 190 158 145 77 31 17 14 conditions (30.1%) 222 167 122 59 20 21 21 Behavior Issues (35.1%) (26.4%) Urgency of 222 72 68 126 61 53 30 Treatment (35.1%) Table 3: Rank the following in order from highest priority to lowest priority when considering GA for dental treatment

Answer Options 1 2 3 4 Extent of Trauma 333 (52.7%) 168 (26.6%) 79 (12.5%) 52 (8.2%) Other Surgeries to be completed and 68 (10.8%) 90 (14.2%) 111 (17.6%) 363 (57.4%) "piggyback" possible Behavior 188 (29.7%) 201 (31.8%) 168 (26.6%) 75 (11.9%) Pain Level 43 (6.8%) 173 (27.4%) 274 (43.4%) 142 (22.5%) Table 4: Pediatric Dentists: When a child has suffered trauma, which of the following do you consider before the child is put under general anesthesia for dental treatment? Rank the following in order of most important (1) to least important (4) in consideration.

Specific age under Yes No Don’t which GA is best Know 210 396 26 (4.1%) (33.2%) (62.7%) What age under 3 4 5 Any age Any age which GA is best less than 5 less than 7 131 32 (15%) 3 (1.4%) 31 (14.6%) 15 (7%) (61.5%) Minimum number of Yes No Don’t teeth for GA Know 75 (11.9%) 544 13 (2.1%) (86.1%) What is the Less than 3-4 5-6 More than minimum number of 2 6 teeth for GA 2 (2.6%) 29 24 (31.2%) 22 (28.6%) (37.7%) Number of teeth Yes No Don’t requiring extraction Know for GA 16 (2.6%) 600 4 (.6%) (96.8%) Minimum number of Less than 3-4 5-6 More than teeth requiring 2 6 extraction for GA 0 5 (29.4%) 7 (41.2%) 5 (29.4%) Number of Yes No Don’t restorations for GA Know 50 (7.9%) 572 10 (1.6%) (90.5%) Minimum number of Less than 3-4 5-6 More than restorations for GA 2 6 2 (3.9%) 14 11 (21.6%) 24 (47.1%) (27.5%) Developmental Yes No Don’t disability alone Know qualify for GA 79 (12.5%) 551 2 (.3%) (87.2%) Table 5: Pediatric Dentists: Patient specific responses Continued

Table 5 continued

Behavioral problems Yes No Don’t Know at any age qualify for 392 (62%) 229 (36.2%) 11 (1.7%) GA Dental ER with 1 perm Yes No Don’t Know tooth, GA before 34 (5.4%) 569 (90%) 29 (4.6%) attempting in clinic Tooth-related facial Yes No Don’t Know swelling not severe, 85 (13.4%) 453 (71.7%) 94 (14.9%) local may not be effective, would GA be best treatment Defer treatment rather Yes No Don’t Know than use GA in a 75 (11.9%) 520 (82.3%) 37 (5.9%) healthy child due to risks Should treatment of Yes No Don’t Know dental cavities always 64 (10.1%) 554 (87.7%) 14 (2.2%) be attempted in clinic before GA How many times 1 2 More than 2 should treatment of 52 (78.8%) 10 (15.2%) 4 (6.1%) dental cavities be attempted before GA Is difficulty coping Yes No Don’t Know with/ behaving for 416 (65.8%) 196 (31%) 20 (3.2%) treatment at any age a qualification for GA Would you approve a Yes No Don’t Know healthy cooperative 8 56 (8.9%) 542 (85.8%) 34 (5.4%) yo with 5 interproximal cavities for GA based solely on parental request Ever delayed treatment Yes No Don’t Know of urgent/ emergent 348 (55.1%) 253 (40%) 31 (4.9%) care under GA waiting for insurance pre- authorization

Answer Options 1 2 3 AAPD guidelines for GA 341 (75.8%) 54 (12%) 55 (12.2%) State Legislation, Criteria for 37 (9.8%) 235 (62%) 107 (28.2%) GA Insurance Company 47 (12%) 117 (30%) 226 (57.9%) Reimbursement None of the Above 192 (88.1%) 7 (3.2%) 19 (8.7%) Table 6: Pediatric Dentists: What do you consult when considering GA for treatment? Rank the following from most important (1) to least important (3)

Gender Hospital Private All Parents p-value Hosp N= 122 Practice PP N= 48 All N= 170 Male 34 (27.9%) 9 (18.8%) 43 (25.3%) .245 Female 88 (72.1%) 39 (81.3%) 127 (74.7%) Ethnicity N=100 N=45 N=145 African Am 37 (37%) 3 (6.7%) 40 (27.6%) Caucasian 59 (59%) 39 (86.7%) 98 (67.6%) <.0001 Asian 2 (2%) 2 (4.4%) 4 (2.8%) Hispanic 2 (2%) 1 (2.2%) 3 (2.1%) Residence N=127 N=54 N=181 Urban 43 (33.9%) 9 (16.7%) 52 (28.7%) Rural 35 (27.6%) 11 (20.3%) 46 (25.4%) Suburban 49 (38.6%) 34 (62.9%) 83 (45.9%) .005 Education N=137 N=54 N=191 Did not complete HS 12 (8.6%) 1 (1.9%) 13 (6.8%) High School 60 (43.8%) 7 (12.9%) 67 (35.1%) College 53 (38.7%) 38 (70.4%) 91 (47.6%) <.0001 Graduate 12 (8.8%) 8 (14.8%) 20 (10.5%) school Table 7: Parental Demographics

Table 8: Parent responses

Question HOSPITAL PRIVATE PRACTICE TOTAL p-value Hosp vs. Pvt Pract Yes (n/%) (n/%) No (n/%) know Don’t Yes (n/%) (n/%) No (n/%) know Don’t Yes (n/%) (n/%) No (n/%) know Don’t

1.Is there a specific age 88(62.8) 12(8.6) 40(28.6) 33(63.4) 7(13.5) 12(23) 121(63) 19(9.9) 52(27.1) 0.418 under which it is best to fix all cavities at once under general anesthesia? 2.Is there a minimum number 70(50) 36(25.7) 34(24.3) 29(53.7) 13(24.1) 12(22.2) 99(51.0) 49(25.2) 46(23.7) 0.847 of teeth requiring treatment that qualifies a child for 32 general anesthesia? 3.Is there a minimum number 78(55.7) 30(21.4) 32(22.9) 26(48.1) 21(38.9) 7(12.9) 104(53.6) 51(26.3) 39(20.1) 0.04 of teeth that must be taken out that qualifies a child for general anesthesia? 4.Is there a number of fillings 65(46.8) 41(29.5) 33(23.7) 25(46.3) 21(38.9) 8(14.8) 90(46.6) 62(32.1) 41(21.2) 0.474 that automatically qualifies a child for general anesthesia? 5.Does a suspected 47(33.8) 51(36.7) 41(29.5) 15(27.8) 27(50) 12(22.2) 62(32.1) 78(40.4) 53(27.5) 0.199 developmental disability alone qualify for dental treatment under general anesthesia? 6.Are behavioral problems at 65(46.8) 46(33.1) 28(20.1) 22(40.1) 23(42.6) 9(16.7) 87(45.1) 69(35.8) 37(19.2) 0.29 any age a qualification for general anesthesia? Continued

Table 8 continued

7.If a child had a dental 57(41.3) 61(44.2) 20(14.5) 22(40) 28(50.9) 5(9.1) 79(40.9) 89(46.1) 25(12.9) 0.617 emergency involving one permanent tooth, would you consider general anesthesia appropriate BEFORE attempting treatment awake in a clinic setting? 8.If a child had a tooth-related 79(57.2) 27(19.6) 32(23.2) 26(48.1) 15(27.8) 13(24.1) 105(54.7) 42(21.9) 45(23.4) 0.222 facial swelling which is not severe, but in which numbing medicine may not work completely, would the best treatment be under general anesthesia? 9.Do you believe there is a 34(24.3) 69(49.3) 37(26.2) 13(24.1) 29(53.7) 12(22.2) 47(25) 92(48.9) 49(26.1) 0.848 risk of severe health problems related to treatment of cavities 33 under general anesthesia 10.Should treatment of dental 95(69.3) 23(16.8) 19(13.8) 37(67.3) 10(18.2) 8(14.5) 132(68.8) 33(17.2) 27(14.1) 0.831 cavities always be attempted in a clinic setting BEFORE treatment under general anesthesia? 11.Is difficulty coping with / 70(51.5) 40(29.4) 26(19.1) 25(45.5) 22(40) 8(14.5) 95(49.7) 62(32.3) 34(17.8) 0.285 behaving for dental treatment at any age a qualification to go under general anesthesia to fix dental cavities? Continued

Table 8 continued

12.Do you agree with the 60(44.1) 44(32.3) 32(23.5) 23(41.8) 22(40) 10(18.2) 83(43.9) 64(33.9) 42(22.2) 0.478 following statement? “States should have laws/legislation with criteria for treatment of dental cavities under general anesthesia.” 13.Do you have easy 122 11(8.0) 4(2.9) 51(92.7) 2(3.6) 2(3.6) 173(90.1) 13(6.8) 6(3.1) 0.355 (ready) access to dental (89.1) care for your child? 14.Do you have easy 70(51.1) 31(22.6) 36(26.3) 28(51.9) 4(7.4) 22(40.7) 98(51.3) 35(18.3) 58(30.4) 0.064 (ready) access to general anesthesia services for dentistry? 15.Is the distance to a 44(31.9) 79(57.2) 15(10.9) 11(20.4) 39(72.2) 4(7.4) 55(28.6) 118 19(9.9) 0.105 34 dentist a significant factor (61.5) in your decision for general anesthesia for your child? 16.Has your child had 56(40.3) 79(56.8) 4(2.9) 9(16.4) 43(78.2) 3(5.5) 65(33.5) 122 7(3.6) 0.002 dental treatment (62.9) completed while under general anesthesia? 17.Have you ever had 83(61.5) 49(36.3) 3(2.2) 34(61.8) 18(32.7) 3(5.5) 117(61.6) 67(35.3) 6(3.2) 0.865 treatment while under general anesthesia for any procedure or dentistry? 18.Have you or anyone in 26(18.6) 107 7(5) 6(10.9) 48(87.3) 1(1.8) 32(16.4) 155 8(4.1) 0.202 the family had a (76.4) (79.5) complication with general anesthesia treatment?

Qualifier Questions HOSPITAL PRIVATE TOTAL (n/%) PRACTICE (n/%) (n/%) 1b. Choose age range category for GA. 0-2 4(7.3) 5(26.3) 9(12.2) 3-4 24(43.6) 4(21.1) 28(37.8) 5-6 16(29.1) 1(5.3) 17(22.9) Any age less than 5 11(20) 9(16.4) 20(27.0) <7 Any age less than 18 2b. What is the minimum number of teeth for GA? <2 20(29.9) 8(27.6) 28(29.2) 3-4 35(52.2) 15(51.7) 50(52.1) 5-6 6(8.9) 3(10.3) 9(9.4) >6 6(8.9) 3(10.3) 9(9.4) 3b. Minimum number of teeth that must be taken out for GA? <2 34(46.6) 8(30.8) 42(42.4) 3-4 26(35.6) 16(61.5) 42(42.4) 5-6 9(12.3) 1(3.8) 10(10.1) >6 4(5.5) 1(3.8) 5(5.1)

Table 9: Parent Qualifier Responses Continued

Table 9 continued

4b. What is the minimum number of fillings for GA? <2 23(37.1) 5(20) 28(32.2) 3-4 24(38.7) 13(52) 37(42.5) 5-6 9(14.5) 4(16) 13(14.9) >6 6(9.7) 3(12) 9(10.3) 10b. How many times should treatment be attempted? 1 33(40.7) 20(62.5) 53(46.9) 2 32(39.5) 9(28.1) 41(36.3) >2 16(19.8) 3(9.4) 19(16.8) 16b. In what setting has your child had GA? Hospital 17(34.7) 1(14.3) 18(32.1) Outpatient surgery 15(30.6) 2(28.6) 17(30.4) center Dental office 17(34.7) 4(57.1) 21(37.5)

Answer 1 2 3 4 Options Parents 10 (1.6%) 233 (37.7%) 345 (55.8%) 30 (4.9%) Dentists 571 (90.5%) 21 (3.3%) 7 (1.1%) 32 (5.1%) Insurance 26 (4.3%) 5 (.8%) 37 (6.1%) 536 (88.7%) Companies Physicians 16 (2.6%) 357 (58.1%) 225 (36.6%) 16 (2.6%) Table 10: Pediatric Dentists- Which of the following groups is most qualified to determine the appropriateness of general anesthesia for treatment of dental caries/ cavities? Rank the following from most appropriate (1) to least appropriate (4).

Answer 1 (N=161) 2 (N=141) 3 (N=141) 4 (N=143) Options Parents 44 (27.3%) 40 (28.4%) 53 (37.6%) 9 (6.3%) Dentists 97 (60.2%) 50 (35.5%) 5 (3.5%) 2 (1.4%) Insurance 2 (1.2%) 2 (1.4%) 12 (8.5%) 127 (88.8%) Companies Physicians 18 (11.2%) 49 (34.8%) 71 (50.4%) 5 (3.5%) Table 11: Parents- Which of the following groups is most qualified to determine the appropriateness of general anesthesia for treatment of dental caries/ cavities? Rank the following from most appropriate (1) to least appropriate (4).

Chapter 4: Discussion

4.1: Current use of General Anesthesia:

Seventy-seven percent (492) of the pediatric dentist respondents regularly treat children under GA (at least one time each month). Forty-seven percent (302) of the pediatric dentists report their GA use has remained the same over the past 10 years, whereas 36.1% (228) reported their GA use has increased and only 16.1 (102) has decreased their GA use. The most common reasons reported as to why pediatric dentists‟ use of GA has increased include; a significant rise in incidence of severe early childhood caries (S-ECC) seen in practice, a growing trend in uncooperative behaviors seen in children and parents more accepting of general anesthesia. In addition, many pediatric dentists noted modern parenting styles to be a significant contributing factor to their increased use of GA. For example, it was reported that parents want a positive experience for their child and do not want to see them cry or fuss during treatment.

Parents are concerned about the „traumatic‟ emotional experience of the dental visit.

Thus, more parents are less tolerant of the various behavior management techniques (ie.

Passive immobilization) outlined in the AAPD behavior guidance clinical guidelines7,39.

Many practitioners made a direct correlation between the change in children‟s behavior to changes in parenting styles as well as changes in social norms for accepted behaviors.

Behavior management by parents has decreased; children have more control in the household and are more strong-willed and defiant. According to Lawrence et al (1991), parents were more willing to accept a behavior management technique if they were properly informed prior to its employment. In addition, the study showed that general

38 anesthesia was the least acceptable behavior management technique whether parents were informed or not. In contrast, Eaton et al (2005) performed a similar study assessing parental attitudes toward behavior management techniques. They found that parents ranked general anesthesia the third most acceptable behavior management technique behind tell-show-do and nitrous oxide analgesia. This change in acceptability among parents coincides with practitioners‟ views in their practices as well. There seems to be an increasing acceptance of general anesthesia for the treatment of children in dentistry.

Other reasons noted for the rise in GA use include the following: easier access to hospitals/ surgery centers/ and in office general anesthesia providers, practitioners less willing to accept the risks of sedation, unreliable outcomes of sedation, less deep sedations performed in office, changing sedation requirements by the Board, less acceptance of sedation by parents, and an increase in the number of special-needs patients in their practices. Some practitioners noted that state legislation prohibits insurance denial, thus GA can be used more often for these patients, depending on their location.

For those practitioners whose use of GA has decreased over the past 10 years, the most common reasons cited were less insurance coverage for the procedure and facility fees and subsequent cost of GA to the families. The present economy was noted by a few practitioners as having an impact on their practice and the ability of parents to pay for these procedures. Practitioners noted that if they were in an area where less/ no Medicaid was seen in their practices, they performed less GA; they cited less need as a reason.

Thus, SES of the community is a contributing factor to the needs seen in pediatric dentists‟ practices. One practitioner from Colorado made the following note about

39 insurance companies, “Many companies are self-funded so they are allowed to skirt the state law mandating coverage for general anesthesia. In addition, many employers are selecting less expensive insurance plans with very large deductibles (several thousand dollars) which parents cannot pay. My recommendations for GA are not less, just the acceptance rate due to lack of coverage for GA or inability to pay the large deductibles.”

There were several practitioners that voiced concern of the over-use/ inappropriate use of GA in current pediatric dentistry practices. The concern noted is that behavior management and parental management techniques are not being used as effectively today. One responder reported, “We are jumping too quickly to fix the holes in the teeth under general anesthesia than trying to train children to cope and parents to understand our role as a pediatric dentist. If we are going to make a difference as a pediatric dentist and making the apprehensive children become good adult patients, general anesthesia is not the route we should always be taking.”

Sixty-five percent (412) of respondents use oral/ IV conscious sedation in their practices and 34.8% (220) do not use sedation. When asked „Had a patient suffered a medical urgency/ emergency related to sedation in your office‟, 11.2% (71) said „yes‟ and

88.8% (561) said „no‟. Of the practitioners who responded to explain the sedation urgency/emergency, the majority reported: laryngospasm, respiratory depression, decreased oxygen saturation, seizures, syncope, and paradoxical reactions to sedatives.

Other urgencies/emergencies reported included: aspiration, vomiting, wrong dose administered, apnea, lost airway, respiratory arrest, and in one case, death. Sedations in the office present risks to the child that the practitioner must be willing and prepared to

40 accept. From the practitioners‟ responses, the trend in practices today appears to be away from deeper sedations toward a controlled treatment environment with an anesthesiologist present, whether it is for IV sedation or general anesthesia.

According to the American Academy of Pediatrics, „the goals of sedation and general anesthesia in the ambulatory patient care are 1) patient welfare, 2) control of patient behavior, 3) production of positive psychological response to treatment, 4) return to pretreatment level of consciousness by time of discharge40.‟ Whereas, as stated previously, the AAPD indications for general anesthesia are, „“The goal of general anesthesia in the pediatric dental patient is to eliminate cognitive, sensory, and skeletal motor activity to facilitate the delivery of quality comprehensive diagnostic, restorative, and/or other dental services. The indications for general anesthesia, according to the

AAPD, include the following: 1) patients who are unable to cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability, 2) patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy, 3) the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent, 4) patients requiring significant surgical procedures, 5) patients for whom the use for deep sedation or general anesthesia may protect the developing psyche and/or reduce medical risks, and 6) patients requiring immediate, comprehensive oral/dental care3”. The American Society of Anesthesiology guidelines for ambulatory anesthesia and surgery focus on patient care parameters, such as pre-anesthesia evaluation by anesthesiologist, staff and nursing requirements, etc.

Thus, from these guidelines, the ASA guidelines focus on patient safety and optimal

41 outcomes, not indications for general anesthesia. The AAP guidelines are broad and non- specific and, with regard to the decision to recommend general anesthesia, they leave the practitioner a large amount of flexibility. However, the AAPD guidelines, while still broad, are more specific than the other association guidelines on when to recommend general anesthesia.

4.2: Decision to use General Anesthesia

Pediatric dentists reported they refer to the AAPD guidelines most often when considering GA for their patients (341, 75.8%). Sixty-two percent (235) ranked state legislation governing the use of GA, ranking this as second most important source for guidelines. The least important resource was the insurance company responsible for the patient reimbursement, with 57.9% (226) ranking this third. Interestingly, 192 of the respondents reported they use none of the above listed available resources when considering GA for their patients. This may suggest that a number of pediatric dentists are concerned that guidelines could restrict them in their clinical decision-making process. This group of dentists most likely prefers to use their own expertise and clinical judgment when deciding if a child would best be treated with general anesthesia.

However, a guideline that practitioners use to decide which patients they recommend for general anesthesia is important, especially as parental acceptance is increasing with possible requests for its use in practice along with the decreasing cooperative nature of children today.

Respondents were asked to rank, in descending order, reasons for considering

GA. The most frequent response was behavior issues, followed by underlying medical

42 conditions, and then the number of cavities/ teeth that needed treatment. Ranked as a low priority was distance to the dental office, insurance coverage, and cost to the family. It is interesting that pediatric dentists ranked these as low priority when to families these hold high importance considering time missed from work due to driving long distances and the potential increment of cost insurance may not cover. However, this data must be analyzed with respect to the other options available to be ranked by the dentists. When pediatric dentists are considering GA, it is most logical/ ethical they would consider the behavior of the child first, followed by their medical conditions and the dental treatment needed prior to their consideration of payment form. In contrast, state legislation governing GA criteria for dental treatment outlines need by developmental disability in the majority of states with legislation (31), followed by age (24), underlying medical conditions (22), and behavior (10).

The majority of pediatric dentists, (62.7%, 396) stated there is no specific age under which GA is best. Of the respondents who reported there is a specific age under which GA is best (33.2%, 210), 61.5% (131) said that this was under the age of 3. When asked if there should be minimum number of teeth requiring treatment, requiring extraction, or requiring restoration in order to rank GA as the best treatment, an overwhelming 86.1% (544), 96.8% (600), and 90.5% (572) respectively said „no‟. Some states use the term „complex dental condition‟ as a criterion for GA. When respondents were asked to define a complex dental condition, the majority, 47% (297), answered „4-6 carious lesions.‟ This was followed by 32.8% (207) that answered „more than 6 carious lesions.‟ However, it seems to be a moot point because most pediatric dentists do not feel

43 a minimum count of teeth requiring treatment serves as a good indicator for the use of

GA. Eighty-five percent of pediatric dentists reported they would not approve a healthy cooperative 8 year old child with 5 interproximal cavities for GA based solely on parental request. Parents may be requesting this treatment modality more often for their child for fear of them having a traumatic experience or not wanting to see their child upset, but majority of dentists state they would treat this child in a clinic setting. It is interesting that the majority of pediatric dentists do not feel there is a specific age under which GA is best and state legislation governing use of GA often uses age as a consistent criterion.

Twenty-three out of 33 states indicate age in the criteria, with the most common age being 5 (8 states), followed by age 7 (6 states). The youngest age indicated is 4

(Connecticut) and the oldest age indicated is 19 (Indiana). If the goal of state legislation is to give leeway for clinicians to make their own judgment, it seems to follow that the age would be higher in most states than the age pediatric dentists reported under which

GA would be best (age 3). However, the extremely fearful, uncooperative adolescent would be outside of several states‟ criteria based on age alone. This coincides with the response that 65.8% (416) of respondents say difficulty coping with/ behaving for treatment at any age is a qualification for GA. A large majority of pediatric dentists,

87.7% (554) agree that treatment of dental cavities should always be attempted in a clinic setting before GA is considered and 78.8% (52) report treatment should be attempted one time before GA is recommended. When pediatric dentists were asked to rank, from most important to least important, what they consider when a child has suffered trauma before recommending they be treated while under GA, they reported the extent of trauma first,

44 followed by behavior, pain level, and other surgeries to be completed. In the state legislation, a common criterion stated is „a child that has suffered extensive facial or dental trauma.‟

Fifty-five percent (348) of pediatric dentists reported they have delayed treatment of urgent/ emergent care under GA waiting for insurance pre-authorization. From this data, it is not surprising that when pediatric dentists were asked whether state legislation governing criteria for GA increases or decreases access to care, 47.2% (298) reported they „don‟t know‟. However, 47.9% (303) answered „yes‟ states should have legislation with criteria for treatment of dental cavities under GA. A possible explanation of these conflicting answers is that dentists recognize the potential that state legislation may provide in insurance approval, but the specific criteria listed may prevent the care from being authorized. Also, as noted by a respondent, insurance companies may be able to go around state legislation if they are privately funded.

4.3: Location for the provision of GA

Of the responding pediatric dentists, 58.9% (290) treat their pediatric patients requiring GA in a hospital setting. Twenty-five percent (124) use an outpatient surgery center most frequently and 15.9% (78) their dental office. When asked, „which provider do you use most often to treat children under GA‟, the vast majority of respondents,

79.5% (391), reported an MD Anesthesiologist or CRNA in a hospital or surgery center setting. The next most frequently reported provider was the DDS/DMD Anesthesiologist in the dental office (9.3%, 46), followed closely by MD Anesthesiologist in the dental office (6.7%, 33). Sixty-four percent (408) of respondents reported an endotracheal tube

45 used for airway management during their GA cases. The next most common airway management technique reported was the nasopharyngeal airway (27.2%/ 172), followed by an open airway with throat screen (7.4%/ 47). This data shows the majority of GA cases are being performed in a hospital setting, but it seems that there is an increasing use/ need for providers in outpatient surgery centers and dental offices. The greater availability of providers in the dental office and the growing number of surgery centers was given by practitioners as an explanation as to why their GA usage has increased.

From this data, it appears that the DMD/DDS Anesthesiologists may help access to care for children requiring general anesthesia. This is an interesting point because pediatric dentists were split as to whether recognition of dental anesthesia as a specialty would improve access to pediatric GA for dentistry (39.6% don‟t know, 27.5% yes, and 32.2% no). In addition, while airway management is primarily being managed with an endotracheal tube, the use of nasal trumpets and throat screen is higher than expected.

4.4: Parents: patient specific criteria for GA

The majority of parents from both H and PP felt there was a specific age under which it is best to fix all cavities at once under general anesthesia. The most common age reported was 3-4 years (43.6%) by H and 0-2 years (26.3%) by PP. This is in contrast to pediatric dentists, where the majority reported „no‟, there is not a specific age.

Interestingly, state legislation most commonly sites age as a criterion for GA. However, the age most frequently given among states was 5, followed by 7. More parents from the

H felt there is a minimum number of teeth requiring treatment that qualifies a child for

GA, most reporting 3-4 teeth (52.2%). In the state legislation, the wording most often

46 used is, „child has a complex dental condition‟, and does not specify a set number of teeth. The majority of parents from PP felt that a suspected developmental disability alone qualifies for GA (50%, 27), whereas parents from H were split on their views.

Dentists overwhelmingly felt that a developmental disability alone does not qualify a child for GA. This is most likely due to the fact that a developmental disability alone does not mean a child cannot cooperate for dental treatment. Parents may not think this is so. Interestingly, parents did not feel that behavioral problems at any age were a qualification for GA. This is also in contrast to pediatric dentists, who overwhelmingly said the opposite. In addition, state legislation frequently sites behavior as a criterion for

GA. Parents do not want to see their child fuss or have the potential of a „traumatic‟ experience during dental treatment and tend to see their child‟s behavior as better than it may actually be to an outsider39. This conflicts with their thought that if a child has behavior problems or difficulty coping during dental treatment, they do not feel another treatment modality (ie general anesthesia) should be recommended, which would help the child get through the treatment required. In addition, when asked a different way, „is difficulty with/ behaving for dental treatment at any age a qualification to go under GA to fix dental cavities‟, H parents said „yes‟ whereas PP parents were split in their answers.

Parents felt that if a child had a tooth-related facial swelling which is not severe, but in which numbing medicine may not work completely, GA would be the best treatment

(54.7% total parents). Dentists disagree with this statement, with 71.7% (453) reporting

„no‟ to that statement. Perhaps it is due to the fact that the pediatric dentist recognizes the child has a facial cellulitis that needs to be treated urgently and nitrous oxide analgesia

47 may help the child cope during treatment, rather than wait to add-on a GA case for what may be a one-tooth problem. Parents agreed with dentists that treatment should be attempted in a clinic setting, majority reporting one time prior to GA. Parents did not have a consistent view on whether states should have legislation with criteria for treatment of dental cavities under GA. Most likely, this is because parents are not aware of the consequences of having/ not having state legislation on access to dental care for children. Thus, parents feel in general that the driving forces (criteria) to recommend GA for children are: age, number of teeth requiring treatment, developmental disability and a facial swelling not severe, in which local anesthesia may not work completely.

4.5: Influence of Demographics and Location

There were no significant differences in answers to questions or concerns by ethnicity. Significantly more Caucasians and caregivers with higher education level

(college and graduate school) reported living in a suburban area. Also, more caregivers with lower education levels (did not complete high school and high school grad) were comfortable using GA for a facial swelling. This may be a result of the caregivers with a higher education being more aware of risks associated with GA and considering risks/benefits of treatment options. In addition, a significantly higher number of children with caregivers from lower education levels had a history of previous GA for dental treatment. This reflects past studies where ECC is focused on a small proportion of the population in the lower SES group, frequently with a lower level of education. When analyzing data by site of recruitment (H vs. PP), significantly more H caregivers felt there were a minimum number of teeth required for GA than PP caregivers. Also, more

48 children seen at the H had a history of previous GA than PP children. Previous studies have shown the H, in an urban area that takes Medicaid insurances and draws a lower

SES population with a greater incidence of dental disease.

4.6: Finances of going to GA

More children of caregivers from H had dental treatment completed under GA

(40.3%/ 56) than children of caregivers in PP (16.4%/ 9). Parents from PP reported a majority, 57.1%, of the GA cases were done in the dental office. In the H, parents reported the same percentage of GA completed in a hospital setting as a dental office setting. This may be a skewed result, however, because some parents may have perceived their child‟s GA treatment as being completed in the dental office at the hospital because it is directly next to the main clinic area. The state legislations that have passed require insurance companies to cover general anesthesia costs if certain conditions apply. However, even if the state has legislation, if a child is insured by a plan in which the purchaser is self-insured (ERISA plan), they are generally exempt from the state requirements to provide benefits42.

Twenty-eight percent of parents overall, within both sites (H and PP) reported having concerns about general anesthesia. This concern was spread evenly throughout the study population regardless of caregiver gender, patient residence, or parental level of education. Most commonly, parents reported side effects (82.7%) as the primary concern for GA. The second most frequent concern was with general anesthetic medications and this was followed by child age-related concerns and medical issue-related concerns.

These concerns seem valid and, as stated, are consistent between both locations,

49 regardless of demographics. In addition, there is emerging research concerning the potential neurotoxicity of general anesthetics, which may affect brain development, which may lead to lasting cognitive and behavioral deficits42. General anesthesia does not present without risks, so parents are correct to have an appropriate level of concern for their child to undergo the procedure. However, the risks associated with treatment deferral or completing dental treatment on an uncooperative child poses significant risks in themselves and the explanation of this to parents is paramount.

4.7: Parent Data Finding: „Don‟t know‟

A significant finding in the parent data is that a proportion (higher than expected) of parents chose „don‟t know‟ for many questions. For example, the questions asking about patient-specific ideas (age, number of teeth, etc) approximately 25% of parents from the hospital and 18% of parents from private practice chose „don‟t know.‟ The questions they seemed more confident to answer regarded their access to dental care and if they or their child has had general anesthesia. This is significant because it shows that a large number of parents do not know when their child should be recommended for or receive GA to address their dental needs. Parents must rely on the dentist to explain and use their best judgment when recommending a child for GA. Thus, it is important the dentist not only has a rationale for the recommendation, but can inform the parent why it may be necessary for their child in a way they can understand.

4.8: Appropriateness of GA for children

Pediatric dentists and caregivers were asked, „Which of the following groups is most qualified to determine the appropriateness of general anesthesia for treatment of

50 dental caries/ cavities? (Rank from most appropriate to least appropriate).‟ The choices were parents, dentists, insurance companies, and physicians. There was no significant difference in ranking between pediatric dentists and parents as to who is most qualified to determine appropriateness of GA for children. Dentists ranked in the following order: dentists, physicians, parents, then insurance companies. Both groups selected dentists as the most appropriate. Dentists tended to rank physicians over parents and parents had the opposite tendency, however this was not significant. As stated earlier, parents look toward the dentist for their professional opinion and clinical judgment with respect to GA appropriateness. Parents may think they are slightly more appropriate than a physician, which may show that parents feel physicians are not be directly involved in the child‟s oral health care. However, this tendency was not significant.

4.9: Analysis of state legislation

From the responses by dentists, the state legislation should include criteria containing: behavior, underlying medical conditions, trauma and unsuccessful attempts at treatment in a clinic setting. From parent responses, the state legislation should include criteria containing: age, minimum number of teeth requiring treatment, behavior, unsuccessful attempts at treatment in a clinic setting, and developmental disability. In my opinion, the state legislation should be broad enough that clinicians can include those patients that may not „fit‟ the typical age or number of teeth for GA if in their best clinical judgment this treatment modality would be best for that child and the dental work required. Therefore, I do not think a minimum number of teeth or age should be criteria.

One criterion that is not currently in the state legislation that I think should be added is

„unsuccessful attempts at treatment in a clinical setting‟, which would include an initial screening appointment with the child. The current laws seem to have good intentions in outlining patients whom GA is most used and requiring private insurance companies to cover these costs. However, what may be beneficial is a clause stating dentists can submit information/ reasoning that will be considered for insurance approval. It is concerning that insurance companies may reject a claim if a child does not meet a criterion by that particular state. It seems in light of this data and information from dentists that state legislation may be a treatment barrier in some instances, but is helpful in approving children for treatment that without the state legislation in effect, would not be approved. In my opinion, what would be ideal and most practical is for every state to adopt the AAPD guidelines as their criteria for insurance approval. Thus, there would be no issue of age of the patient or minimum number of teeth.

4.10: Analysis of study

There are several weaknesses of the current study. First, 45.6% (288) of dentist respondents graduated from their residency program in the period 2000-2010. This young generation of pediatric dentists were trained under different ADA Commission on

Dental Accreditation training standards than previous generations, thus imparting different perspectives and standards of „appropriateness‟. Second, several dentists noted in their response to the survey that they did not feel the questions were worded well or adequately enough in order to respond accurately. Some dentists felt they needed a chance to explain each response because the decision to recommend a child for GA is complex and not based on one criterion. One respondent said,

„I thought your survey was difficult to answer. Hospital cases are usually the least cut and dry of all our patients. Each case needs to be considered on the individual needs of the child, and includes all of those points- medical history, age, extent of treatment needed, cooperation, parent expectations, cost, alternative treatment options, risk of anesthesia vs benefit and previous experiences, not in any particular order. For some children behavior may not be a concern at all but they would still be seen in the hospital for other reasons. For others, maybe behavior/ cooperation is our main reason for hospital treatment.‟ One issue of this topic is that the decision to recommend a child for GA is not straight- forward, as the responder noted. Perhaps another weakness of the study is that open- ended responses were not available for all questions. Interestingly, it has to be noted that in the analysis of parent responses, the number of parent respondents from private practice was significantly less than that at the hospital, which may have skewed results.

Future areas of study should include rural, urban, and suburban groups of parents and compare how they feel about GA criteria. Perhaps those families that do not have ready access to pediatric dentists or GA services would feel differently in their responses.

It would be interesting to question those pediatric dentists that have been practicing for more than 10 years (graduated from residency before the year 2000) and ask them how

GA usage has changed in their practices and how recommendations for GA have changed. When considering the strong feeling from dentists that parent/ child relationships and behavior have changed, it would be interesting to evaluate behaviors clinically and evaluate the best ways to manage children within the current parenting settings.

References

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14. Roberts MW, Milano M, and Lee JY. Medical diagnosis of pediatric dental patients treated under general anesthesia: a 19 year review. J Clin Ped Dent 2009; 33: 343-5. 15. Lewis CW, Nowak AJ. Stretching the safety net too far: waiting times for dental treatment. Pediatr Dent 2002; 24:6-10. 16. Edelstein BL, Manski RJ, Moeller JF. Child dental expenditures: 1996. Pediatr Dent 2002;24: 11-7. 17. Savage MF, Lee JY, et al. Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs. Pediatrics 2004;114(4):418-423. 18. Tinanoff N, Reisine S. Update on early childhood caries since the Surgeon General‟s Report. Adacemic Pediatrics 2009; 9:396-403. 19. Casamassimo P, Thikkurissy S, et al. Beyond the dmft: The human and economic cost of early childhood caries. J Am Dent Assoc 2009; 140:650-7. 20. Thikkurissy S, Rawlins J, et al. Rapid treatment reduces hospitalization for pediatric patients with odontogenic-based cellulitis. Am J Emerg Med 2010; 28(6): 668-72. 21. Ladrillo TE, Hobdell MH, Caviness C. Increasing prevalence of emergency department visits for pediatric dental care 1997-2001. J Am Dent Assoc. 2006; 137: 379-385. 22. Feitosa S, Colares V, Pinkham J. The psychosocial effects of severe caries in 4-year-old children in Recife, Pernambuco, Brazil. Cad Saude Publica 2005; 21: 1550-6. 23. Gift HC, Reisine ST, Larach PC. The social impact of dental problems and visits. Am J Public Health 1992; 82: 1663-8. 24. Matisen GE, Johnson JP. Brain abscess. Clin Infect Dis 1997; 25(4):763-79. 25. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children‟s oral health: a conceptual model. Pediatrics 2007;120(3):e510-e520. 26. Ramos-Gomez F, Huang G, Masouredis C, et al. Prevention and treatment costs of infant caries in Northern California. J Dent Child. 1996;63:108-112. 27. Griffin SO, Gooch BR, Beltran E, et al. Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-7. J Public Health Dent 2000;60:21-27. 28. Kanellis MJ, Damiano PC, Momamy ET. Medicaid cost associates with hospitalization of young children for restorative dental treatment under general anesthesia. J Public Health Dent 2000;60:28-32. 29. Duperon DF. Early childhood caries: a continuing dilemma. J Calif Dent Assoc 1995;23:15-25. 30. Stats and facts. Growth of ambulatory surgical centers continues. Manag Care Interface 2001;14:32-33. 31. US Dept of Health and Human Services. Summary Health Statists for US children: National Health Interview Survey, 2007;10(239):1-89. 32. Fisher-Owens SA, Barker JC, Adams S, et al. Giving policy some teeth: routes to reducing disparities in oral health. Health Affairs 2008;27(2):404- 412. 55

33. Snow P, McNally M. Examining the implications of dental treatment costs for low-income families. JCDA 2010;76(2):1-5. 34. Szilagyi PG, Shenkman E, Brach C, et al. Children with special health care needs enrolled in the state Children‟s Health Insurance Program (SCHIP): Patient Characteristics and health care needs. Pediatrics 2003;112:e508-e520. 35. Vermeulen M, Vinckier F, Vandenbroucke J. Dental general anesthesia: clinical characteristics of 933 patients. J Dent Child 1991;16:222-224. 36. American Academy of Pediatric Dentistry. Reference Manual. Ped Dent 2009; 31(6):10,13,22-23. 37. Prabhu, Neeta; Nunn, June; Evans, J., et al. Access to dental care- parents‟ and caregivers‟ views on dental treatment services for people with disabilities. Spec Care Dentist 2001; 30(2): 35-45. 38. American Academy of Pediatric Dentistry. Oral Health Policy on Dental Home. http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf. Accessed September 1, 2010. 39. Lawrence S, McTigue D, et al. Parental attitudes toward behavior management techniques used in pediatric dentistry. Ped Dent 1991; 13(3): 151-155. 40. American Academy of Pediatrics. Committee on Drugs and Section on Anesthesiology. Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients. Pediatrics 1985;76: 317-321. 41. Kuehn BM. FDA considers data on potential risks of anesthesia use in infants, children. JAMA 2011; 305(17): 1749-50, 1753. 42. Crall J. Behavior management conference: panel II report- third-party payer issues. Ped Dent 2004; 26(2): 171-4.

Appendix A: General Anesthesia State Legislation

State Year Patient Population Affected Who Defines Need Location Other

AL 2010 Child age 8 or under, or Treating Dentist. BC/BS Hospital or Insurer may apply - Child with a physical, medical or mental reserves the right to ambulatory deductibles, co-insurance, compromise consult with the patient's surgical facility network requirements, - Local anesthesia is ineffective due to acute physician for children medical necessity infection, anatomic variation, or allergy older than 8 to confirm determinations and other - Child or adolescent is extremely uncooperative, physical, medical or limitations as are applied unmanageable, anxious or uncommunicative with mental compromise to other covered services. dental needs that cannot be deferred diagnosis. - Child that has sustained extensive oro-facial and dental trauma

57 AR 2005 - Child under 7 who is determined by 2 dentists Provider treating the Hospital or - Health benefit plan may licensed in Arkansas to require necessary dental patient ambulatory apply deductibles, treatment for a significantly complex dental surgical facility coinsurance, network condition requirements, medical - person diagnosed serious mental or physical necessity determinations, condition and other limitations as are - person with significant behavioral problem as applied to other covered determined by the covered person‟s Arkansas services physician - pays for anesthesia and facility charges for services performed Continued

Appendix A continued CA 1998 - Child under 7 Not specified Hospital or - pays for anesthesia and - person developmentally disabled surgery center facility charges for - person whom GA is medically necessary services performed - person‟s clinical status or underlying medical condition of the patient requires dental procedures that ordinarily would not require GA

CO 1998 - Child has a physical, mental, or medically compromising Treating Hospital, -Pays for facility charges condition dentist outpatient surgical for dental care and GA - child has dental needs for which local anesthesia is facility, or other - if coverage is provided ineffective b/c of acute infection, anatomic variations, or facility licensed through managed care allergy pursuant plan, can mandate services -child or adolescent is an extremely uncooperative, be rendered by dentist 58 unmanageable, anxious, or uncommunicative with dental affiliated with carrier

needs deemed sufficiently important that dental care -may require provider to be cannot be deferred pediatric dentist or other - child has sustained extensive or facial and dental trauma qualified dentist that has hospital privileges - does not apply to TMJ treatment CT 1999 - child has a dental condition of significant dental Treating - coverage for GA, complexity that requires certain dental procedures to be dentist or oral nursing, and related performed in a hospital surgeon and hospital services provided - person who has a developmental disability that places the patient‟s in conjunction with in- the person at serious risk primary care patient, outpatient or one- - 2003 amendment: eliminated “child under 4” physician day dental services - anesthesia, nursing, and facility charges are medical expenses Continued

Appendix A continued FL 1998 - child under 8 yo: Licensed Hospital or - that requires necessary dental treatment due to a dentist and the ambulatory significantly complex dental condition child‟s surgical center - has a developmental disability in which patient physician management in the dental office has proved to be ineffective - person has one or more medical conditions that would create significant or undue medical risk in course of delivery of treatment

GA 1999 -child age 7 or younger Not specified Hospital or - pays for GA and facility -person developmentally disabled ambulatory charges - person for which a successful result cannot be expected from surgical center - may restrict coverage to a fully dental care provided under local anesthesia b/c of a accredited specialist in pediatric neurological or other medically compromising condition dentistry or other dentist with 59 -person has sustained extensive facial or dental trauma, unless hospital privileges, not yet otherwise covered by workers‟ compensation insurance completed certification requirements, but has hospital privileges IL 2002 -Child age 6 or under Not specified Hospital or -Coverage is subject to -Person has a medical condition that requires hospitalization or ambulatory limitations, exclusions, or cost- GA for dental care surgical sharing provisions that apply -Person is disabled: chronic disability with following treatment center under the insurance policy conditions: -Does not apply to a policy that -Mental or physical impairment or a combo of impairments covers only dental care -Likely to continue -The dental services do not have -Results in substantial functional limitations in 1 or more of to be covered the following areas of life: -Self-care, receptive and expressive language, learning, mobility, capacity for ind living, or economic self sufficiency

Continued

Appendix A continued

IN 1999 -Child less than age 19 Not specified- Hospital or -Restrict coverage to procedures -Person with physical or mental impairment that use the AAPD outpatient performed by licensed dentist who substantially limits 1 or more major life activities guidelines for surgical center has privileges at the center indications for -Does not apply to TMJ disorder GA treatments IA 2000 -Child under age 5requiring necessary dental treatment Licensed dentist Hospital or due and the child‟s ambulatory to a dental condition or a developmental disability for treating surgical center which the patient management in the dental office has physician proved to be ineffective -Person with 1 or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental

60 treatment

or surgery if not rendered in a hospital or surgical center KS 1999 -Child age 5 or younger Not specified Not specified -Provides coverage for GA, facility -Person who is severely disabled charges -Person has a medical or behavioral condition which -Insurer may apply deductibles, requires hospitalization or GA when dental care is coinsurance, network provided requirements, and other limitations as applied to other covered services KY 2002 -Child under age 9 Dentist or Hospital -Covers payment for anesthesia and -Person with serious mental or physical conditions admitting hospital or facility charges for -Person with behavioral problems physician services performed in a hospital in connection with dental procedures -Does not require coverage for routine dental care, including diagnosis or treatment of disease or other dental conditions and procedures not covered Continued

Appendix A continued

LA 1997 - insured with a mental or physical Dentist consider AAPD Hospital -Does not apply to treatment of TMJ condition requires dental treatment to indications for GA disorders be -Can restrict treatment by specialist in rendered in a hospital setting based on pediatric dentistry or other specialized AAPD guidelines dentists that have hospital privileges -or dentist who completed accredited program with hospital privileges -or dentist not yet completed requirements but has hospital privileges 1998: restricts coverage to certain pediatric dentists

Continued

Appendix A continued

ME 2001 - clinical status or underlying medical condition of an enrollee Not Hospital - provide coverage for GA and requires dental procedures that ordinarily would not require specified facility charges for dental general anesthesia to be rendered in a hospital procedures - enrollees, including infants, exhibiting physical, intellectual or - dental procedures and medically compromising conditions for which dental treatment dentist‟s fee not covered under local anesthesia, with or without additional adjunctive techniques - enrollee has dental treatment needs for which local anesthesia is ineffective b/c of acute infection, anatomic variation or allergy - extremely uncooperative, fearful, anxious, or uncommunicative children or adolescents with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth, or other

62 increased oral or dental morbidity - enrollees who have sustained extensive oral-facial or dental trauma for

which treatment under local anesthesia would be ineffective or compromised MD 1999 - 7 yo or younger Not Hospital or - does not apply to TMJ - developmentally disabled specified ambulatory disorder treatment - ind for whom a successful result cannot be expected from dental care surgical - can limit providers to fully provided under local anesthesia b/c of a physical, intellectual, or other center accredited specialist in medically compromising condition of the enrollee or insured pediatric dentistry, oral and - ind for whom a superior result can be expected from dental care maxillofacial surgery, or dentist provided under GA with hospital privileges - extremely uncooperative, fearful, or uncommunicative child who is 17 yo or younger with dental needs of such magnitude that treatment should not be delayed or deferred - ind for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity

Continued

Appendix A continued

MI 2006 - child requiring multiple ext or restorations MAPD will provide free Hospital or 2006: child age 7 or younger - total of 6 or more teeth are ext in various consults to medical plans surgical center - allows medical plans to quadrants on issues of prior establish reasonable limits - dental treatment needs for which local anesthesia authorization, medical regarding the frequency of use of is ineffective b/c of acute infection, anatomic necessity, or coverage GA variation or allergy determinations under this - extensive oral-facial and/or dental trauma for agreement which treatment under local anesthesia would be ineffective or compromised - patients with concurrent hazardous medical condition MN 1995 - a child under age 5 Not specified Hospital or - coverage for hospitalization and -Person severely disabled dental office anesthesia and treatment -Person has a medical condition that requires rendered by a dentist for a

63 hospitalization or GA for dental care treatment medical condition

MS 1999 - mental or physical condition of the child or Dentist should consider Hospital, - GA physician-supervised mentally handicapped adult requires dental indications for GA in surgical center, provides anesthesia and facility treatment to be rendered under physician-supervised AAPD manual or dental office charges GA - insurer may require review for medical necessity and limit payment of facility charges to certified facilities - coverage subject to annual deductibles or coinsurance established for all other covered benefits within a policy - does not apply to treatment of TMJ disorders - anesthesia services provided by Miss OMFS

Continued

Appendix A continued

MO 1998 - child under 5 Not specified Hospital, surgical - must provide coverage for GA and - person severely disabled center, or office hospital charges or office charges for - person who has a medical or behavioral condition dental care regardless if provided in a which requires hospitalization or GA when dental participating hospital, surgical center, care is provided or office NE 2000 -Child under 8 - Medical Hospital or - may apply deductible or copayment -Person developmentally disabled necessity ambulatory provisions determined by surgical center - coverage may only be provided entity providing through network of preferred coverage (group providers policy, contract, or benefit plan) NV 2003 - child has a physical, mental, or medically Dentist Hospital, surgical - insurer may restrict coverage to GA

64 compromising condition center for provided by specialist in pediatric - has dental needs for which local anesthesia is ambulatory dentistry, dentist qualified in specialty ineffective b/c of an acute infection, an anatomic patients, an with hospital privileges, or dentist anomaly, or an allergy independent certified by a hospital by completion - is extremely uncooperative, unmanageable, or center for of accredited post-grad training anxious emergency - may adjust benefits paid if services - has sustained extensive orofacial and dental trauma medical care, or a rendered by a provider not designated to a degree that would require unconscious sedation rural clinic by or assoc with insurer

NC 1999 - children below age 9 Hospital or - coverage includes anesthesia and - persons with serious mental or physical conditions ambulatory hospital charges necessary - persons with significant behavioral problems, surgical center - deductibles, coinsurance, network where the provider treating the patient certifies that requirements, medical necessity hospitalization or GA is required in order to safely provisions, and other limitations as and effectively perform the procedures apply to physical illness benefits apply here Continued

Appendix A continued

ND 1999 - child under age 9 Not specified Hospital or - coverage under this section - severely disabled ambulatory applies regardless of whether Or who has a medical condition and requires surgery services are provided in a hospitalization or GA for dental care treatment center hospital or ambulatory surgery center NH 1998 - child under age 4 with a dental condition of significant Licensed Day care - coverage for the medically dental complexity which requires certain dental dentist and facility or necessary hospital or surgical day procedures to be performed licensed hospital care facility charges and - person has exceptional medical circumstances or a physician setting administration of general developmental disability as determined by a licensed anesthesia administered by a physician which place the person at serious risk licensed anesthesiologist or anesthetist for dental procedures

65 NJ 1999 - child age 5 or under or severely disabled Not specified Coverage is - coverage for hospitalization or

- medical condition covered by the contract which provided GA requires hospitalization or GA for dental services regardless of where the dental services are provided Continued

Appendix A continued

NM 2007 - insureds exhibiting physical, intellectual, or medically Not Hospital or - coverage is subject to compromising conditions for which dental treatment under local specified ambulatory copayments, deductibles, and anesthesia, with or without additional adjunctive techniques and surgical center coinsurance subject to network modalities, cannot be expected to provide a successful result and and prior authorization for which dental dental treatment under GA can be expected to - provisions do not apply to short- produce superior results term travel, accident-only, or - insureds for whom local anesthesia is ineffective because of limited or specified disease acute infection, anatomic variation, or allergy policies - insured children or adolescents who are extremely uncooperative, fearful, anxious, or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity - insureds with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or

66 compromised - other procedures for which hospitalization or GA is medically necessary

OK 1999 - severely disabled Physician In-patient or - provides coverage for anesthesia - minor 8 years of age or younger who has a medical or out-patient expenses and for hospital expenses emotional condition which requires hospitalization or GA for hospital - subject to the same annual dental care treatment deductibles, copayments, or coinsurance limits

Continued

Appendix A continued

SD - child under age 5 Licensed physician Hospital or - insurer may require prior - severely disabled or otherwise suffers from a dental office authorization developmental disability which places such person - coverage includes anesthesia at serious risk and hospital charges

TN 1997 - child is 8 years old or younger and cannot be Not specified hospital - reimbursement of anesthesia safely performed in a dental office setting expenses, hospital expenses, and physician expenses associated with any inpatient/outpatient hospital dental procedures - benefit subject to same annual deductibles or coinsurance

TX 1997 - patient who is unable to undergo dental treatment The individual‟s Not specified - TMJ disorder diagnosis and in an office setting or under local anesthesia due to physician or dentist treatment covered a documented physical, mental, or medical reason providing the care - does not require a health benefit 67 plan to provide dental services if dental services are not otherwise scheduled or provided as a part of the benefits covered under the health benefit plan

VA 2000 - under age 5 Licensed dentist in Hospital or - covers GA and hospitalization - severely disabled consultation with the outpatient or facility charges - or has a medical condition and requires covered person‟s surgery - restrict coverage for GA admission and GA for dental treatment treating physician facility expenses to those health care providers who are licensed to provide anesthesia services and facilities licensed to provide surgical services Continued

Appendix A continued

VT 2010 - Child 7 years or younger who is determined by a Licensed dentist Hospital or - Health insurance plans may dentist to be unable to receive needed dental treatment in or physician Ambulatory require prior authorization for an outpatient setting and whereby treating dentist depending on the Surgical Center general anesthesia and certifies that patient‟s age and condition or problem situation and by licensed associated hospital ambulatory require hospitalization or general anesthesia in a necessity. anesthesiologist surgical center charges for hospital in order to perform significantly complex dental or CRNA dental care in the same manner procedures safely and effectively. that prior authorization is - Child 12 years or younger with documented phobias or a required for these benefits in documented mental illness, as determined by a physician connection with other covered or mental health professional, whose dental needs are medical care. sufficiently complex and urgent that delaying or deferring - Health insurance plans may treatment can be expected to result in infection, loss of restrict coverage for general teeth, or other increased oral or dental morbidity; for anesthesia and associated whom a successful result cannot be expected from dental hospital or ambulatory surgical care provided under local anesthesia; and for whom a center charges to dental care superior result can be expected from dental care provided that is provided by 1) fully 68 under general anesthesia accredited specialist in pediatric

- A person who has exceptional medical circumstances or dentistry 2) a fully accredited a developmental disability, as determined by a physician, specialist in OMFS and 3) a which place the person at serious risk. dentist to whom hospital privileges have been granted.

WA 2001 - child under age 7 - person‟s Hospital or - coverage includes GA, facility - physically or developmentally disabled with a dental physician must ambulatory charges in conjunction with any condition that cannot be safely and effectively treated in a determine medical surgical center, dental procedure performed dental office or condition risk and dental office - must cover GA in dental - has a medical condition that would place the person at approve procedure office if GA is medically undue risk if the dental procedure were performed in a necessary b/c the covered dental office person is under age 7 or physically or developmentally disabled - may restrict coverage to provider in preferred network Continued

Appendix A continued

WV 2009 - child age 7 or younger - a fully accredited Hospital or - coverage for GA and facility - developmentally disabled specialist in ambulatory charges - individual for whom a successful result cannot be expected pediatric dentistry facility - subject to prior authorization from dental care provided under local anesthesia because of a - fully accredited - coverage may be restricted to physical, intellectual or other medically compromising specialist in OMFS a fully accredited condition of the individual and for whom a superior result can - dentist that has - dental care coverage not be expected from dental care provided under GA hospital privileges required: provisions of this - child who is 12 or younger with documented phobias, or section may not be construed mental illness, and with dental needs of such magnitude that to require coverage for the treatment should not be delayed or deferred and for whom lack dental care for which GA is of treatment can be expected to result in infection, loss of teeth, provided or other increased oral or dental morbidity and for whom a - TMJ disorders not covered successful result cannot be expected from dental care provided - same deductibles, under local anesthesia b/c of such condition and for whom a coinsurance, and other superior result is expected from GA limitations as apply to other covered services

WI 1997 - child under age 5 Not specified Hospital and - covers hospital or surgery - has chronic disability that meets all the conditions under ambulatory center charges incurred and 230.04 surgery center anesthetics provided in - the individual has a medical condition that requires conjunction with dental care hospitalization or general anesthesia for dental care - coverage may be subject to limitations, exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured plan

Appendix B: Dentist Survey

Yes No Don‟t Know 1 Is there a specific age under which full mouth dentistry in a healthy child is best done under general anesthesia? Choose age range category. 1) 0-2 2) 3-4 3) 5-6 4) Any age less than 5 5) < 7 6) Any age less than 18 2 Is there a minimum number of teeth requiring treatment that automatically qualifies a patient for general anesthesia?

If yes, how many? 1) < 2 2) 3-4 3) 5-6 4) > 6 3 Is there a number of teeth requiring extraction that automatically qualifies a patient for general anesthesia?

If yes, how many? 1) <2 2) 3-4 3) 5-6 4) > 6 4 Is there a number of restorations that automatically qualifies a patient for general anesthesia?

If yes, how many? 1) < 2 2) 3-4 3) 5-6 4) > 6 5 Does a developmental disability alone qualify for dental treatment under general anesthesia? 6 Are behavioral problems at any age a qualification for general anesthesia? Continued

Appendix B continued

Yes No Don‟t Know 7 If a child had a dental emergency involving one permanent tooth, would you consider general anesthesia an appropriate treatment modality BEFORE attempting treatment in a clinic setting? 8 If a child had a tooth-related facial swelling which is not severe, but in which local anesthesia might not be optimally effective, would the best treatment be under general anesthesia? 9 Is difficulty coping with/ behaving for dental treatment at any age a qualification to go under general anesthesia to fix dental cavities? 10 Would you defer treatment rather than use GA in a healthy child due to risks of GA? 11 Should treatment of dental cavities always be attempted in a clinic setting BEFORE treatment under GA?

If so, how many times? 1) 1 2) 2 3) >2 12 Is difficulty coping with/ behaving for dental treatment at any age a qualification to go under general anesthesia to fix dental cavities? 13 Would recognition of dental anesthesia as a specialty significantly improve access to pediatric GA services for dentistry? 14 Do you agree with the following statement? “States should have legislation with criteria for treatment of dental caries/cavities under GA.” 15 Would you approve a healthy, cooperative 8 year old with 5 interproximal cavities being treated under general anesthetic based solely on parental request?

16 Do you feel the quality of your dentistry is affected when performed under GA?

Better or worse? 17 Have you ever delayed delivery of what you considered urgent/emergent care under GA waiting for insurance pre- authorization? Continued

Appendix B continued

18 Do you regularly (at least one time each month) treat children under GA? If yes, in what setting? 1) hospital 2) outpatient care center 3) dental office

If yes, choose provider you most often use: 1) MD anesthesiologist in office 2) DDS/DMD anesthesiologist in office 3) MD anesthesiologist in Hospital or surgery center 4) DDS/DMD anesthesiology in Hospital or surgery center 5) Provide own anesthesia 19 When a child has suffered dental trauma, which of the following do you consider before the child is put under general anesthesia for the dental treatment?

[Rank the following in order of most important (1) to least important (4) in consideration.] - extent of trauma - other surgeries to be completed and “piggyback” possible - behavior - pain level 20 Rank the following in the order from highest priority (1) to lowest (not a priority-6) when considering general anesthesia for dental treatment: - cost - insurance coverage - distance to dental office - number of cavities/ teeth that need treatment - underlying medical conditions - behavior issues 21 What do you consult when considering GA for treatment? [Rank the following from most important (1) to least important (3).] - AAPD guidelines for GA - state legislation, criteria for GA - insurance company reimbursement - none of the above 22 Which of the following groups is most qualified qualified to request the use of general anesthesia for dental caries/ cavities? [order from most appropriate (1) to least appropriate (4)] - parents - dentists - insurance companies - physicians 23 In a 3 year-old child, which of the following do you consider as a “complex dental disease”, a term used by insurance companies to qualify for reimbursement? 1) 1-3 carious lesions 2) 4-6 3) >6 Continued

Appendix B continued

24 Do you think that state legislation governing criteria for GA increases access to care or limits it? Choose ONE: 1) Increases 2) Decreases 25 If insurance coverage is not available for general anesthesia, what would be the next option for the treatment? Choose ONE: 1) Multiple conscious sedations 2) Payment plan for general anesthesia 3) Multiple treatments without any sedation 26 In the past 10 years, has your hospital use increased or decreased?

Why? 27 When did you graduate from pediatric dentistry training?

28 Were you trained in a hospital-based, university-based, or combined residency program?

29 Ethnicity

30 Type of practice (solo, academic, associate, partner)

31 Gender

32 Practice community (rural, urban)

33 In which state do you currently live?

34 Do you use oral/ IV conscious sedation in your practice?

35 Have you ever had a patient suffer a medical urgency or emergency related to sedation in your office? Continued

Appendix C: Parent Survey

Yes No Don‟t Know 1 Is there a specific age under which it is best to fix all cavities at once under general anesthesia? Choose age range category. 7) 0-2 8) 3-4 9) 5-6 10) Any age less than 5 11) < 7 12) Any age less than 18 2 Is there a minimum number of teeth requiring treatment that qualifies a child for general anesthesia?

If yes, how many? 5) < 2 6) 3-4 7) 5-6 8) > 6 3 Is there a minimum number of teeth that must be taken out that qualifies a child for general anesthesia?

If yes, how many? 1) < 2 2) 3-4 3) 5-6 4) > 6 4 Is there a number of fillings that automatically qualifies a child for general anesthesia?

If yes, how many? 5) < 2 6) 3-4 7) 5-6 8) > 6 5 Does a suspected developmental disability alone qualify for dental treatment under general anesthesia? 6 Are behavioral problems at any age a qualification for general anesthesia? 7 If a child had a dental emergency involving one permanent tooth, would you consider general anesthesia appropriate BEFORE attempting treatment awake in a clinic setting? 8 If a child had a tooth-related facial swelling which is not severe, but in which numbing medicine may not work completely, would the best treatment be under general anesthesia? Continued

Appendix C continued

9 Do you believe there is a risk of severe health problems related to treatment of cavities under general anesthesia? 10 Should treatment of dental cavities always be attempted in a clinic setting BEFORE treatment under general anesthesia?

If so, how many times? 4) 1 5) 2 6) >2 11 Is difficulty coping with / behaving for dental treatment at any age a qualification to go under general anesthesia to fix dental cavities? 12 Do you agree with the following statement? “States should have laws/legislation with criteria for treatment of dental cavities under general anesthesia.” 13 Do you have easy (ready) access to dental care for your child?

14 Do you have easy (ready) access to general anesthesia services for dentistry? 15 Is the distance to a dentist a significant factor in your decision for general anesthesia for your child? 16 Has your child had dental treatment completed while under general anesthesia?

If yes, in what setting? Choose one. 1) Hospital 2) outpatient surgery center 3) dental office 17 Have you ever had treatment while under general anesthesia for any procedure or dentistry? 18 Have you or anyone in the family had a complication with general anesthesia treatment? Continued

Appendix C continued

19 Which of the following groups should be qualified to request the use of general anesthesia for dental cavities? order from most qualified (1) to least qualified (4)] - parents - dentists - insurance companies - physicians 20 Ethnicity?

21 Gender?

22 Describe your area of residence: - urban - rural - suburban

23 Highest level of education completed - Did not complete high school - High school/ GED - college - graduate school

24 How concerned are you for your child to undergo general anesthesia from 1-3 (1=no concern, 2 = some concern, 3 =greatest concern possible)?

25 If you are concerned, what about general anesthesia concerns you?