Objective:

Pediatric patients who undergo general anesthesia (GA) for dentistry may be treated in different venues. This retrospective study compared patients treated in an ambulatory surgery center (ASC) to those treated in a hospital operating room (H-OR). The 2-venue model was also compared with a historical hospital-only model.

Methods:

Twelve months of data were collected via records review: patient demographics, American Society of Anesthesiology (ASA) classification, and medical comorbidities. Data from patients treated at the H-OR 10 years prior were referenced for comparison.

Results:

Between July 2017 and June 2018, 1148 patients were treated: 635 at the ASC and 513 at the H-OR. The most common age range for both venues was 3 to 8 years. Of all the ASC patients, 78% were ASA I, while 48% of H-OR patients were ASA III (P < .001). The number of patients treated with the 2-venue model represented a 240% annual increase compared with those treated historically using the hospital-only model.

Conclusion:

Because of differences in patient medical comorbidities, both the ASC and H-OR are needed to adequately address the needs of pediatric dental patients who require GA. Treating healthy patients in an ASC also creates increased capacity in the H-OR to better accommodate those with higher medical acuity.

Pediatric patients often require general anesthesia (GA) during dental treatment because of uncooperative behavior that can stem from a lack of psychological or emotional maturity and/or mental, physical, or medical disability.1  The use of GA for dental treatment is considered an acceptable and desirable option for parents and practitioners.2,3 

In North America, dental patients may receive treatment under GA in different surgical venues, including a hospital operating room (H-OR), an ambulatory surgery center (ASC), or a dental office with an anesthesia provider. Although the H-OR is generally considered the gold standard, ASCs and in-office GA offer the advantages of decreased cost, increased access to care, and improved patient and provider convenience. Venues outside the hospital may also provide greater scheduling ease and efficiency, decreasing wait times for nonemergent procedures.48  In addition, many hospitals are reluctant to provide operating room time to dentists because of low reimbursement.9  Studies have shown that ASCs are comparable to H-ORs with respect to quality and safety of dental treatment.5,6  These factors make the ASC and in-office GA appealing options for the provision of pediatric dental care requiring GA.

However, not all patients are candidates for care outside the hospital setting. The selection of surgical venue is primarily determined based on the patient's health, recognizing that certain comorbidities have an increased risk for adverse perioperative events and may require coordination of medical care. As such, patients with significant medical comorbidities and/or special health care needs are typically more appropriate candidates for a H-OR vs an ASC or in-office GA. Other factors may include need for combined care involving other medical or surgical specialties, estimated surgery time, and indication for admission to the hospital following dental surgery.1012 

Seattle Children's Hospital (SCH) is a 407-bed, tertiary care pediatric teaching hospital in Seattle, Washington, where dentists provide treatment in an H-OR with anesthesia provided by pediatric anesthesiologists. SCH is affiliated with the University of Washington (UW) across medical and dental disciplines. Before 2010, all UW and SCH pediatric dental patients requiring GA were treated in the SCH H-OR. Characteristics of patients receiving dental treatment under GA at SCH during 2007-2009 were analyzed in an institutionally approved study and used to support a business proposal for the construction of a dental-specific ASC.12 

In 2010, the UW and SCH opened a dental surgery center, an ASC exclusive to pediatric dentistry, and oral surgery where treatment is provided with GA administered by a privately contracted anesthesiologist. Currently, pediatric patients from UW, SCH, and community dental clinics requiring dental treatment under GA are treated either at the UW ASC or in the SCH H-OR. Because the 2 surgical venues are affiliated with the same organizations, there is a unique opportunity to assess patients seen at these venues.

Based on the 2007-2009 data, it was projected that patients with the following criteria could be treated at the ASC: American Society of Anesthesiologists (ASA) classification I or II, good physical health, and no indication for medical combination surgery. With these criteria, it was estimated that 43% of dental surgery patients could be seen at the ASC venue.

The purpose of this study was to assess patients treated at an ASC vs an H-OR, describing key differences between these 2 groups and to make a comparison with historical data obtained before the opening of the ASC. A secondary aim was to evaluate the projections made in the proposal for construction of a dental ASC.

This institutionally approved study (SCH IRB: 00001965) was a 1-year retrospective cohort study of dental patients treated under GA. Criteria for inclusion were patients 1 to 26 years of age who received treatment under GA by pediatric dentists at either SCH (H-OR) or at the UW Dental Surgery Center (ASC) between June 1, 2017, and May 31, 2018. Patients who were inpatients at the time of their surgery were included. Patients treated by private practice dentists at the H-OR were excluded. Patients in both venues were treated by or under the supervision of a board-certified attending pediatric dentist with residents involved in treatment for some patients.

Data were collected from the patients' electronic medical records in the SCH Clinical Information System (CIS; Cerner Corporation) for H-OR patients and from AxiUm (Exan Enterprises Inc.) for ASC patients. Ambiguities were resolved by discussion and consensus between the authors. Data were entered into REDCap,13,14  with the exception of the following data imported from institutionally generated reports: H-OR: birth date, surgery date, sex, zip code, chart number, inpatient status, ASA classification, interpreter status, combination surgery status; ASC: birth date, surgery date, sex, zip code, chart number.

Medical diagnoses were categorized analogous to those used in an unpublished 2010 SCH dental surgery study.12  For patients with multiple medical diagnoses, all diagnoses were recorded and included in the data analysis. ASA classification was assigned by the treating anesthesiologist on the day of surgery.

Statistical Analysis

Descriptive statistics were calculated. Associations between venue type (H-OR vs ASC) and categorical variables were analyzed using chi-square tests or Fisher exact tests. Associations between venue type and continuous variables were calculated using 2-sample t tests. Multiple comparisons were performed for tests of associations with venue and medical diagnoses using the Hommel method. All statistical tests were completed using Stata/SE 14.2 R version 4.0.5 for Windows (StataCorp LLC). The significance level was predetermined to be P < .05.

Demographics

During the study period, a total of 1148 dental surgeries were completed under GA; of these, 635 were at the ASC and 513 at the H-OR. The most common age range for both venues was 3 to 8 years (62.9% overall; 75.6% ASC vs 47.2% H-OR). The H-OR group included all 43 patients older than 18 years. Excluding all patients over the age of 18, the mean age of H-OR patients was 8.6 years (SD 3.0 years) vs 6.3 years (SD 4.3 years) for ASC patients (P < .001). The H-OR served more patients from out of state than the ASC did (5.1% vs 0.5%). Other demographic factors did not vary significantly between the venues (Table 1).

Table 1.

Demographics of Pediatric Dental Patients by Surgical Venue†

Demographics of Pediatric Dental Patients by Surgical Venue†
Demographics of Pediatric Dental Patients by Surgical Venue†

Medical Diagnoses

ASA classification varied significantly between venues, with ASA I being the only group with higher counts at the ASC (n = 495; 78%) than at the H-OR (n = 21; 4.1%). ASA IV patients were treated exclusively at the H-OR (n = 12; 2.3%), and very few ASA III patients were treated at the ASC (n = 5; 0.8%; Table 1). Table 2 presents the medical diagnoses for patients included in this study. Aside from otherwise healthy patients (39.9%), the most frequent medical diagnoses were autism (16.5%), developmental delay (15.4%), and cardiac disorders (11.1%). Comparisons of the ASC vs H-OR groups found the following: healthy (71.3% vs 1.0%), asthma (39% vs 34%), and attention-deficit hyperactivity disorder (ADHD; 37% vs 34%). The H-OR patients had more frequent medical comorbidities (Table 2).

Table 2.

Medical Diagnoses of Pediatric Dental Patients by Surgical Venue†

Medical Diagnoses of Pediatric Dental Patients by Surgical Venue†
Medical Diagnoses of Pediatric Dental Patients by Surgical Venue†

Some of the 513 patients seen at the H-OR were inpatients (n = 24; 4.6%) and/or were admitted after dental surgery (n = 132; 25.7%). Inpatients at the time of surgery most frequently had an oncologic diagnosis (29.2%), whereas patients admitted postoperatively most frequently had a cardiac disorder (32.6%). No ASC patient was admitted after dental surgery.

Combination Surgeries

A total of 123 patients received combination surgeries (10.7%); most had 1 additional service, but some were combined with 2 or more services (total of 142 combined services). There were 6 (0.9%) combination surgeries at the ASC, all with other dental specialties. At the H-OR, 117 of the 513 cases (22.8%) were combination surgeries: 48 (9.4%) with other dental specialties and 69 (13.5%) with medical or diagnostic services (eg, medical radiology; Table 1).

Historical Data

Data were collected for 958 dental patients treated in the H-OR between July 1, 2007, and June 30, 2009,12  and the most common age range was 3 to 8 years. Excluding all patients older than 18 years, the mean age of treated patients was 7.7 years (SD 4.4 years). The most frequent ASA classification was ASA II (n = 447, 46.7%), and only 2 patients (0.2%) were ASA IV. Combination surgeries were performed on 180 patients (18.8%); most had 1 additional service, but some were combined with 2 or more services (a total of 196 combined services). A total of 66 surgeries (6.9%) included a combination of dental specialties, whereas 114 (11.9%) included medical or diagnostic services (Table 3).

Table 3.

Comparison of Patient Data From 2007-2009 and 2017-2019†

Comparison of Patient Data From 2007-2009 and 2017-2019†
Comparison of Patient Data From 2007-2009 and 2017-2019†

Over 24 months (2007-2009), 958 patients received surgery at the H-OR. The current study included 1148 patients treated in 12 months, a 240% increase in the total annual number of dental patients treated under GA. This study found an increase in patient volumes across all age groups, all ASA classifications, and in the number of combination surgeries (Table 3).

The surgical venue where a patient receives dental treatment under GA is decided by the dentist and the anesthesia provider. This study provides evidence that there is a need for both hospital (H-OR) and surgery center (ASC) venues to safely and efficiently serve a community's pediatric patients. ASA classification was a primary determinant for venue assignment; very few ASA I patients were treated in the H-OR, and very few ASA III patients were treated in the ASC, as consistent with other reports.46,1517  Our data also confirmed that ASA II patients may be candidates for either venue.

Our data showed that more than one-fourth of the H-OR patients were admitted postoperatively. At this specific H-OR, there is limited space for postoperative recovery exceeding 2 hours. Patients who need longer observation are admitted until meeting discharge criteria. A study at this H-OR of 156 patients preplanned for admission following dental surgery found that 97 patients (62%) were admitted, most often for challenges with analgesia, hydration, and nutrition.11 

Our data confirm the need for multiple surgical venues. Data projections from the dental patients treated at the H-OR between 2007 and 2009 estimated that 43% of patients would be candidates for an ASC.12  The present study showed that 55% of the total population was treated at the ASC, with the largest increase being ASA I patients. In fact, nearly all of the ASA I patients were treated at the ASC, which has adequate capacity to treat qualified patients. Furthermore, accommodating ASA I patients at the ASC created increased capacity in the H-OR for those with higher medical acuity.

Despite diverting appropriate patients to the ASC, the H-OR did not see a decrease in the number of patients. Surgical volume at the H-OR is limited by the allocation of block time to the dental service. Between 2007-2009 and 2017-2018, there was no increase in available H-OR time allocated for dentistry, resulting in similar annualized patient volumes (479 patients/y for 2007-2009 vs 513 patients/y for 2017-2018).

Rashewsky7  and others4,6,8,9  demonstrated that GA at an H-OR is more expensive and less time efficient, which makes ASCs appear more appealing. However, our study demonstrates a continued need for dental access to an H-OR, as many medical diagnoses in children are contraindications for GA at an ASC (Table 2). A hospital setting is the most appropriate venue for these types of patients to receive comprehensive dental care, as it has the appropriate safety protocols, equipment, and necessary staffing. Additional patient benefits of the H-OR include all-hours treatment for emergencies, coordination with medical and dental specialties, access to advanced postoperative care if needed, and robust financial and social support systems.

While some dentists are able to provide a service similar to an ASC within their own office or clinic, many professional guidelines discourage treatment of medically complex patients with in-office GA. A multivenue model is beneficial to all parties. It offers a more efficient experience for healthy patients and decreases the number of patients waiting for elective treatment in a H-OR. For providers, it offers options to provide patients with the safe and efficient care. And for the community, it increases access to care for dental patients who require treatment under GA.

Limitations

The number of patients planned for surgery was not examined. Capturing these data along with the time between case planning and surgery dates would more precisely reflect the demand for dental surgery requiring GA. ASA classification is subjective and was assigned on the day of surgery by the anesthesia provider. Comparisons with the 2007-2009 group were limited by data collected from the previous study.12 

This retrospective study demonstrates the distinct differences in patient demographic and medical characteristics between those treated at an ASC vs an H-OR. The data clearly support that both venues are needed to best address the needs of pediatric dental patients requiring GA. In addition, the data demonstrated that the two-venue model increased access to care by 240% compared with the H-OR–only model.

The authors thank the Dr. Bryan J. Williams Endowment for Pediatric Dental Medicine at Seattle Children's Hospital, Seattle, Washington, and the Department of Pediatric Dentistry at the University of Washington School of Dentistry, Seattle, Washington, for financial support of this study. Special thanks to Dr. Nolan Gerlach for information related to the historical data. REDCap support from grants UL1 TR002319, KL2 TR002317, and TL1 TR002318 from NCATS/NIH.

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Conflict of Interest The authors report no conflict of interest.