Shortening-The-Line: Reducing the Need for Sedation and General Anesthesia for Dental Care for People with Disabilities

ABSTRACT

Background

Many people with disabilities face significant barriers to obtaining dental care in the traditional dental office and clinic environment.

Literature and Program Review

A 2009 consensus statement developed by the Special Care Dentistry Association described multiple strategies that can be used to achieve and maintain oral health for people with disabilities. The statement concluded that many of these strategies are underused because of lack of awareness and training and inadequate reimbursement. Newer reports have also reached similar conclusions. Now, advances in workforce, policy, dental materials and techniques, telehealth technologies, and delivery systems have opened up tremendous potential to better reach people with disabilities, employ prevention and early intervention strategies early in the disease process, and improve and maintain oral health.

Conclusions

Employing these advances can significantly reduce the need for sedation and general anesthesia and allow many people with disabilities to maintain oral health in community sites and regular dental offices and clinics. The “shorten the line” framework describes planned demonstrations of these principles.

KEYWORDS:

• Community health
• access to care
• dental care delivery systems
• oral health systems
• underserved population
• people with disabilities
• workforce

Introduction

Access to oral health services and obtaining and maintaining good oral health has been challenging for many people with disabilities. One result of this problem is long waiting lines for dental treatment using sedation and general anesthesia that are common in many locations across the country.

This paper presents background about oral health care and oral health for people with disabilities and information about the reasons that these long lines exist. It also presents a framework for a “shorten-the-line” system that has been developed at the California Northstate University College of Dental Medicine in conjunction with multiple community organizations.

Background

The number and percent of the population with disabilities is growing.¹ The Centers for Disease Control (CDC) has estimated that over one-quarter (27%) of the U.S. population has some type of disability.² Lack of access to oral health care and consequent oral health problems for people with disabilities is a long-standing and significant problem.³ A specific concern has been the mismatch between the number of people with disabilities referred for dental care using sedation or general anesthesia and the availability of those resources, a concern that has persisted for decades.⁴

The primary social service system providing services for people with developmental disabilities in California is the California Department of Developmental Services which oversees coordination and delivery of services for Californians with developmental disabilities through a statewide network of 21 community-based, nonprofit agencies known as Regional Centers.^5,6 These Regional Centers provide assessments, determine eligibility for services, and offer case management services for people with developmental disabilities. As of March 2023, there are approximately 428, 913 people enrolled in this system, with just over 12,000 registered within the last 36 months.⁷

Barriers to Access

Barriers to accessing oral health care and maintaining good oral health for people with disabilities are largely due to the limited number of providers that are willing and able to provide needed services, as well as medical and physical conditions and behavioral limitations of the individual that make dental care in dental offices challenging.⁸ Other problems include a high demand for services compared with limited supply which results in people being placed on waiting lists, issues with accessibility, accommodation, affordability, acceptability, in office-based treatment settings, and inadequate training and reimbursement for dental providers.⁹ In addition, dental anesthesiologists have cited restrictive state regulation of equipment and transportation of sedatives as constraints for providing timely, appropriate dental care to those with developmental disabilities.¹⁰

Preventive and Minimally Invasive Strategies

The 2009 consensus statement developed by the Special Care Dentistry Association (SCDA) concluded that many people who were referred for dental care using sedation or general anesthesia might have been able to maintain oral health in other ways if alternative strategies had been available and reimbursable.⁴ The statement also described multiple strategies that could be used to achieve and maintain oral health for people with disabilities. These strategies include minimally invasive techniques and training dentists to use non-pharmacological treatments to manage anxiety and support treatment. Since then, other sources have described ways that the use of noninvasive and minimally invasive techniques that delay or remove the need for traditional restorations are gaining momentum.^11,12

Prevention methods include “daily mouth care” activities such as brushing, flossing, fluoride application, and reducing the frequency of ingestion of cariogenic foods on a daily basis. Adopting these practices requires collaboration with caregivers, parents, patients, and support by dental staff. In addition, the inclusion of the minimally invasive treatments described below can reduce development of disease and are less time-consuming, more cost-effective long-term, and are associated with less anxiety and discomfort for the patient. These strategies should be used as the first line of treatment, before invasive restorative dental approaches for oral disease management for patients with special needs. These techniques, however, are often underused due to a lack of awareness and training and inadequate reimbursement.^4,13

Sedation and General Anesthesia

While sedation and general anesthesia have been used for many decades for treating people with disabilities, these techniques also pose a number of risks. These risks include decreased alertness, sleepiness, agitation, restlessness, or unpredictable behavior, impaired judgment, reduced motor coordination, nausea or vomiting, and exacerbation of gastro-esophageal reflux disease (GERD).¹⁴ Patients with developmental disabilities are at increased risk for complications due to comorbidity with other conditions.¹⁵ Conditions such as Down’s Syndrome, intellectual disability, dental phobia, abnormal gag reflex, and hypertension are all associated with patients experiencing lower oxygenation during dental treatment using intravenous sedation.¹⁶ Other concerns include the increased likelihood of drug-drug interactions in people taking multiple medications, and delayed recovery from sedation. Also, pulmonary complications can lead to an increased risk of atelectasis, infection, the necessity for prolonged mechanical ventilation, respiratory failure, exacerbation of underlying chronic lung disease, and bronchospasm. In general, dental care using sedation and general anesthesia involves amplified risk among people with disabilities and complex medical and physical conditions.¹⁵

Other concerns with dental treatment using sedation and general anesthesia include consent and safety when using these techniques.¹⁶ For example, in some cases obtaining information about an individual’s medical history can be challenging which could mean that an extensive pre-anesthesia work up including cardiac and/or pulmonary examinations might need to be performed prior to scheduling a procedure. Additionally, dentists must provide information about benefits and risks when using these procedures to those who are authorized to give consent.¹⁷ Furthermore, the harm of delayed access to oral care for people with special needs exacerbates their conditions and further limits the benefits of general anesthesia.¹⁸ It has been observed in some groups that those with deteriorating oral conditions can see a decline in their systemic health.^16,19

Shortening the Line for Sedation and General Anesthesia

The problem with too many people with disabilities being referred to too few resources, resulting in long waiting times for service has been reaffirmed recently in a report developed by the Sacramento Medi-Cal Dental Advisory Committee (MCDAC).²⁰ The 2019 report was called Painful Realities: General Anesthesia Access in Sacramento GMC Dental Managed Care and was published in June 2020. The findings and recommendations in the report were similar to the earlier Special Care Dentistry Consensus Statement and recognized that some children and adults with disabilities were receiving recommendations or referrals to have dental care performed with sedation or general anesthesia that might not have needed this type of care had alternative methods for providing oral health services been available.

The problem of more demand for sedation and general anesthesia to address oral health problems compared to the availability of those services is widespread. However, as described earlier, there have been promising advances in workforce, policy, dental materials and techniques, telehealth technologies, and delivery systems that include teledentistry that can help address these issues²¹ These developments have increased the potential to reach people with disabilities, employ prevention and early intervention strategies early in the disease process, and improve and maintain oral health.

Other important advances with the potential to “shorten-the-line” for sedation and general anesthesia include minimally invasive strategies, materials, and methods for preventing and treating oral diseases without the need for traditional restorations. These include fluoride varnish, silver diamine fluoride (SDF), resin sealants, resin infiltration, chemomechanical caries removal and atraumatic restorative treatment.^11,22

There have also been advances in training and scope-of-practice laws, which allow allied oral health professionals including dental hygienists to perform procedures such as the application of SDF and placement of Interim Therapeutic Restorations (ITRs). Currently, hygienists in every state can administer SDF. However, the supervision requirements vary state-by-state, with some states allowing the hygienist to decide to use SDF independently and some states requiring a dentist to determine that SDF should be used and provide instructions to hygienist to use it.²³ The same variation in supervision requirements exists with the placement of ITRs. In California and several other states dental hygienists are allowed to place ITRs, but only after receiving instructions from a dentist to do so.²⁴ However, in systems where a dentist can review records and provide instructions virtually, the concerns about the requirement for a dentist review and provide instructions are minimized.

Another important advancement contributing to the ability to “shorten-the-line” is an increased understanding of the value of behavioral support techniques such as desensitization to help people using a gradual introduction to oral health care that can, over time, allow them to receive oral health services without the need for pharmacological approaches such as sedation and general anesthesia.^25,26 In California, the Medi-Cal Dental Program will pay for additional time required to complete a covered procedure using CDT code D9920.^27,28

There has also been progress in the ability to bring oral health services to people in community locations such as residential facilities, day programs, and other locations where people receive general health, educational, and social services. This includes deploying members of the oral health team in community locations connected to dental offices and clinics using telehealth-connected teams. An example of this is the Virtual Dental Home System, a structured mechanism to deliver oral healthcare to vulnerable populations by expanding the reach of dental professionals and incorporating telehealth technologies.^29,30

All of these advances have created the ability to design a system to “shorten-the-line” of people waiting for dental care using sedation and general anesthesia by keeping many people healthy using other methods.

The impact of applying the strategies described here is exemplified in the story of a 26-year-old man with intellectual disabilities who had had all of his previous dental care performed under general anesthesia. Although he has verbal skills, he was nervous when he entered a dental office and seemed unresponsive to instructions. Previous dental care providers had deemed him “uncooperative” for care in a dental office and referred him for treatment using general anesthesia. When he was able to be part of a Virtual Dental Home program, a dental hygienist was able to see him in his residential facility. As can be seen in Figure 1, he was very cooperative in his familiar environment. With a slow approach and in his familiar environment, the dental hygienist was able to capture a full set of radiographs and photographs and other records. The dentist was able to complete a remote examination, and the dental hygienist was able to perform prevention and early intervention procedures. The dentist can verify that he is healthy and determine with the hygienist a suitable re-care schedule. It is likely that he will never have to have dental care using sedation or general anesthesia again.

Figure 1. Dental records collection in a residential facility.

A Framework for Shortening-The-Line

The remainder of this article describes a framework for applying the methods and strategies listed above to the long-standing problem of the mismatch between the number of people referred for oral health care using sedation and general anesthesia and the availability of these services. The framework was developed from decades of experience in this area by Dr. Paul Glassman, one of the authors of this paper, and refined though MCDAC workgroups, focus groups with behavior support specialists and dentists, and planning meetings with representatives from California’s Regional Center System.³¹

CNU and representatives from several Regional Centers conducted focus groups with behavior support specialists and dentists to determine their views and predictions about the success of several potential strategies. An important principle that emerged is the conclusion that it is important to include a variety of strategies in the framework since many of the individual strategies that have been and can be used produce minimal impact when used alone. It is also recognized that for some people, the safest and most effective way to receive dental services is through the use of sedation or general anesthesia. However, there are many people who are currently referred for dental care using sedation or general anesthesia who could have dental services performed and maintain good oral health if alternatives to the use of sedation and general anesthesia were readily available.

The “shorten the line” framework that has been developed includes the following components and general concepts:

• Behavior, physical, and psychological support involving community-based desensitization programs conducted by dental hygienists supported by behavior support specialists.²⁶

• Medical or minimally invasive management of dental disease involving the use of techniques described above, applied in community settings, and used to keep as many people as possible healthy in the community site without needing to make a trip to a dental office or clinic.^11,12

• Community-based care delivery systems such as the Virtual Dental Home.^13,24,29,30 This system allow dental hygienist and assistants working in community sites to communicate and collaborate with dentists working in dental offices and clinics.

• Integrated community-clinical linkage programs.³² This term refers to linkages created to help connect health care providers, community organizations, and public health agencies so they can improve patients’ access to preventive and chronic care services.

CNU is now working with several California Regional Centers to start demonstration projects that involve the principles and concepts described above. Steps in implementing these projects include the following specific activities:

• Training for oral health professionals in providing oral health services for people with complicated physical medical or developmental conditions, particularly those with developmental disabilities.

• Training for oral health professionals in modern concepts of minimally invasive dentistry – sometimes referred to as “medical management” of oral health problems.

• A system of training and support for desensitization procedures that can be applied in community settings and in oral health offices and clinics supported by behavior support professionals.

• Deployment of community-based teams of dental hygienists and assistants that perform assessment, desensitization, dental prevention, and early intervention procedures, as well as support for adoption of “Mouth-Healthy Habits” people with disabilities and caregivers This will bring these much-needed services to residential facilities, day programs, and other locations employing telehealth-connected teams using Virtual Dental Home concepts.

• A community-based resource mapping, care navigation, and referral system that uses dental hygienists and assistant/navigators to identify individual’s oral health and treatment support needs and make targeted referrals to providers and resources most likely to provide successful treatment without the use of sedation or general anesthesia.

• A care coordination system that ensures that when patients are referred to dental offices, the dentist will receive the background materials including: health history and information about how to keep the health history updated; consent for procedures and information about how to obtain initial consent and additional consent that may be needed; support for appointment making, transportation, and other resources to ensure that appointments can be scheduled and kept as planned.

• A payment system that supplements procedure or encounter-based payment by recognizing and paying for additional time and expertise needed for traditionally noncovered services that take additional time with patients with complex conditions such as desensitization and caregiver education.

The overarching goal of these demonstrations will be to show that costly, complex and risky sedation and general anesthesia procedures can be avoided for many people currently referred for dental care using those pharmacological approaches. This will provide support for policy and reimbursement change to better support this approach.

Conclusion

It is predicted that the “shorten-the-line” system described here could significantly reduce the number of people being referred for dental care using sedation and general anesthesia. This will “shorten-the-line” and reduce wait times for those individuals who do require sedation or general anesthesia. It will reduce the cost of care when treatment services are required and improve the ability to keep many people healthy without the need for sometimes risky sedation and general anesthesia services.

Summary

Many people with disabilities face significant barriers to obtaining dental care in the traditional dental office and clinic environment. A 2009 consensus statement developed by the Special Care Dentistry Association described multiple strategies that can be used to achieve and maintain oral health for people with disabilities. The statement concluded that many of these strategies are underused because of lack of awareness and training and inadequate reimbursement. Newer reports have come to similar conclusions. Now, advances in workforce, policy, dental materials and techniques, telehealth technologies, and delivery systems have created tremendous potential to better reach people with disabilities, employ prevention and early intervention strategies early in the disease process, and improve and maintain oral health. Employing these advances can significantly reduce the need for sedation and general anesthesia and allow many people with disabilities to maintain oral health in community sites and regular dental offices and clinics. The “shorten the line” framework describes planned demonstrations of these principles.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Amanda-Rae Williams

Amanda-Rae Williams is a second-year dental student at California Northstate University College of Dental Medicine. She earned a Bachelor of Arts in Economics with a minor in chemistry at CUNY Lehman College. She also has a Master of Science in Biology from New York University.

Aban Yaqub

Aban Yaqub is a second year dental student at California Northstate University College of Dental Medicine. She earned a Bachelor of Science Degree in Interdisciplinary Sciences with a concentration in Health Diversity from the University of Illinois at Urbana-Champaign.

Paul Glassman

Paul Glassman is a Professor and Associate Dean for Research and Community Engagement at the California Northstate University College of Dental Medicine in Elk Grove, CA and Professor Emeritus at the University of the Pacific, Arthur A. Dugoni, School of Dentistry in San Francisco, CA. He has served on many national panels including the Institute of Medicine’s (IOM) Committee on Oral Health Access to Services which produced the IOM report on Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Dr. Glassman has had many years of dental practice experience treating patients with complex conditions and has published and lectured extensively in the areas of Hospital Dentistry, Dentistry for Patients with Special Needs, Dentistry for Individuals with Medical Disabilities, Dentistry for Patients with Dental Fear, Geriatric Dentistry, and Oral Health Systems reform. Dr. Glassman has been PI or Co-PI on over $35 million in grants and contracts over the last 30 years devoted to community-service demonstration and research programs designed to improve oral health for people with disabilities and other underserved populations. Dr. Glassman is a pioneer and has led the national movement to improve oral health using telehealth-connected teams and Virtual Dental Homes.

Valerie Phillips

Valerie Phillips is as Assistant Professor and Director of the Office of Research and Community Engagement at California Northstate University College of Dental Medicine. She graduated with her BS in Dental Hygiene from Oregon Institute of Technology in 1987 and from Eastern Washington University with a MS in Dental Hygiene in 2013. In 2022 she became licensed as an RDHAP in California.