Combining procedures under general anesthesia.

The American Academy of Pediatric Dentistry recognizes the importance of hospital-based general anesthesia (GA) for the treatment of pediatric dental patients: (1) who are unable to cooperate; (2) who experience signifi cant anxiety; (3) for whom local anesthesia is ineff ective; (4) requiring signifi cant surgical procedures or immediate comprehensive oral care; and (5) for whom GA may protect the developing psyche and/or reduce medical risks.1 Restorations placed under GA for treatment of early childhood caries have been reported to be of higher quality than those placed while utilizing conscious sedation.2 Both dentists and parents have increasing interest in GA for treatment of uncooperative pediatric dental patients. Although there is a risk of adverse events with each exposure to GA (including sore throat, nausea/vomiting, having memory of the procedure, death, and brain damage), treatment in the operating room (OR) is generally safe. Treatment in the OR, however, is costly for patients and families, the health care system, and society as a whole. The 2% of Medicaid-eligible children who receive such treatment account for 25% of Medicaid dental expenditures. Optimizing the use of facilities and personnel enhances eff orts to manage the increasing costs of surgery. A study of anesthesia costs concluded that increasing OR effi ciency and decreasing time in the hospital off ered the most promise for reducing costs.11 Costs associated with hospital treatment under GA have been the subject of multiple reports. In addition to medical and dental fees, there are family costs (ie, lost wages while bringing a child to the dentist) and societal costs (children missing school) of treatment under GA. Those who can least aff ord to miss work and school disproportionately need to take time for dental care. It has been demonstrated that GA can be more effi cient than repeated visits for restorative care. Although it seems intuitive that combined care should result in both time and cost savings, there has been minimal exploration of combining dental and medical treatment under GA in the literature. A pediatric dentist reported coordinating treatment for 4 patients who had dentistry combined with other surgeries and provided a rationale for combined treatment in the OR. In a 6-case series of multiple proce1Dr. Stapleton is a pediatric dentist in private practice in Springfi eld Oregon; 2Dr. Sheller is Director of Education and Resident Training and 3Dr. Williams is in the department of dental medicine, both at Children’s Hospital and Regional Medical Center, Seattle, Wash; 4Dr. Mancl is research associate professor, department of dental public health sciences, School of Dentistry, The University of Washington, Seattle, Wash. Correspond with Dr. Stapleton at stapletonmf@hotmail.com Abstract: Purpose: The purpose of this study was to analyze cases in which dentistry was combined with other procedures during a single outpatient general anesthetic (GA) in a children’s hospital. Financial and time savings were evaluated for a subgroup of combined care patients. Methods: Records of 120 patients who received combined dental and one other procedure under GA were reviewed. All were treated as outpatients, and dental procedures were more than just radiographs. Descriptive statistics were calculated for: (1) patient characteristics; (2) procedures; (3) times for procedures; (4) anesthesia; (5) recovery; and (6) total time in hospital. Records of 18 patients with combined dentistry and extraction of third molars were compared to 36 patients receiving the same procedures during separate GAs to evaluate time and costs for combined vs separate procedures. Results: Patients ranged from 2 to 21 years, and 98% had special health care needs. Oral surgery (41%) and otolaryngology (23%) were most frequently combined with dentistry. Estimated mean savings for patients receiving dentistry and third molar extractions in combination were 312 minutes and $2,177. Conclusions: Combining care offers an economical vehicle for providing medical and dental care to patients needing multiple procedures. Awareness of the effi ciency of combined care may lead to more combinations of procedures when possible. (Pediatr Dent 2007;29:397-402) Received July 30, 2006 / Revision Accepted November 3, 2006.