September 14, 2011

Dr. Brian T. Kennedy, Chair

Council on Dental Education and Licensure

American Dental Association

211 East Chicago Avenue

Chicago, IL 60611

 

Dear Doctor Kennedy:

The American Association of Oral and Maxillofacial Surgeons appreciates the opportunity to review the Application for Recognition of Anesthesiology as a Dental Specialty submitted by the American Society of Dentist Anesthesiologists.  We understand that the application has been disseminated for review to the communities of interest with a request that comments be submitted by September 16, and that all comments will be considered by the Council on Dental Education and Licensure (CDEL) with a report to the 2012 ADA House of Delegates.

The AAOMS recognizes the important role of anesthesia in dentistry, and dentistry’s outstanding contributions to the discovery and development of safe, effective, therapeutic alternatives for pain and anxiety control.  This dedication has resulted in a history of extremely safe ambulatory anesthesia administration.  Given this significant record of safety, it is critical that the dental profession carefully examine and consider the possible implications of this application for a dental specialty in anesthesiology for dental practitioners, our patients and our colleagues in other healthcare professions, as well as industry and government.

The AAOMS has carefully reviewed the application and its appendices. It is our considered opinion that the information provided by the ASDA does not adequately support all CDEL requirements necessary for recognition as a dental specialty. In particular, we believe the application falls short in a number of areas, most specifically in regards to Requirements 2, 3, 4 and 5. In addition we wish to point out that although the ASDA application defines the proposed specialty training programs, there is no definition provided for the new specialty.

Concerning Requirement 2, we do not agree that dental anesthesiology is a distinct and well-defined field that requires unique knowledge and skill beyond those commonly possessed by dental school graduates. It is our opinion that the dental profession currently trains its students and residents to their level of service and, if their scope of practice changes to include more complex procedures, a variety of opportunities exist for obtaining additional training without changing the current system. The ADA Guidelines for Teaching Sedation and General Anesthesia to Dentists and Dental Students was adopted by the 2007 House of Delegates for predoctoral, postgraduate and continuing education in anesthesia.  If necessary, education and training enhancements to these Guidelines may be initiated by CODA accredited training programs and through the state dental board licensing process. 

Additionally, we do not agree that the proposed anesthesia specialty is separate and distinct from any currently recognized specialty or combination of recognized specialties as noted in Requirement 3. Anesthesia is and has always been an integral part of dentistry and its related specialties. Since they obtained accreditation of their programs in 2007, dental anesthesiologists practice their scope according to their needs. In Requirement 4, which discusses dental fear and phobia, the ASDA application cites small studies conducted in specific geographic regions of the United States, including Seattle and Pittsburgh. These studies do not include sufficient data from other states and larger geographical regions. We believe the application’s use of such limited data to project national demand and needs is inappropriate. Such generalizations cannot be extrapolated from small, geographically limited samples to project a national demand for dental anesthesiology needs.

Predoctoral dental education requires training in the administration of anesthesia appropriate to the needs of the general practitioner. Dental graduates possess the knowledge and skills necessary to manage all but the most complex patients. These practitioners are trained within their specialty curriculum to address anesthesia management unique to their needs.

Despite the contention in the application that there is a vast unmet demand for dental anesthesia services, dentists do not appear to be entering this field  in large numbers; and many of those who do enter the field do not practice dental anesthesiology full time. As outlined in Appendix 18, nearly 30% of dentist anesthesiologists devote less than 50% of their time to practicing the proposed specialty. If there is such a demand and need for dental anesthesia services, we question why these 273 members are not practicing anesthesiology full time. Again, these statistics do not support the need for establishing a specialty.

We did not see evidence of the ASDA having conducted a patient service needs/workforce study as a means of solidifying the argument that there is a need for a specialty in dental anesthesiology.  The creation of a specialist in dental anesthesiology who will work concurrently as an independent consultant with the operating general dentist or specialist when providing anesthesia services will not only increase the cost of dental services, it will further impede access to care.   Dentists wishing to obtain anesthesia services for complex dental procedures have the option of utilizing surgi-centers and hospitals where equipment and qualified staff are routinely employed for appropriate anesthesia administration, physiologic monitoring, emergency management and recovery. It is unlikely that a dental office using the services of an itinerant dentist anesthesiologist would have such qualified staffing and equipment available. It would, therefore, become the responsibility of the profession of dentistry to assure that all facilities where anesthesia services are provided adhere to certain standards of care. 

The current safety, effectiveness and efficiency of anesthesia administered in dental offices may be endangered if dentist anesthesiologists were to become itinerant providers, carrying their equipment from office to office, and providing services in unfamiliar environments with different support staff at each location. Under these circumstances, the risk of complication rates, even for well-trained itinerant dentist anesthesiologists, would be higher than is tolerable in a field in which quality has improved significantly over the past decades. This could leave the dental profession open to questions from government agencies, the insurance industry and other third party payers about the safety and efficacy of anesthesia administration in dental offices.

It seems clear from recent events that in the coming years there will be a concerted effort to reduce dependence on elaborate healthcare facilities and the unneeded expansion of specialists. In this environment, efforts to create a new specialty for which there is no demonstrable need will be viewed with great skepticism.

There is little evidence in the ASDA application that general dentists and recognized dental specialists cannot manage pain adequately within their domain of expertise. To sanction another group of specialty practitioners in an arena already served by nurse anesthetists and medical anesthesiologists would be a disservice to dental patients and dental professionals.  Absent national data demonstrating need, this application may be perceived as an attempt to do what is in the best interests of a small group of individuals, rather than what is in the best interest of our patients and the profession.

The AAOMS realizes that anesthesia services may be needed in some private dental offices, ambulatory surgery centers and hospitals; however, the application implies that this may become the norm in dentistry at a time when healthcare and the economy will most likely refuse payment for an additional fee for dental services. If these anesthesia services are required, they can be effectively provided by a variety of existing anesthesia providers, including physician anesthesiologists, nurse anesthetists and trained dentists and dental specialists. Given the number and variety of anesthesia providers, we do not believe this will require the establishment of a specialty in dental anesthesiology.

The American Association of Oral and Maxillofacial Surgeons respectfully opposes the creation of a dental specialty in anesthesiology as proposed by the American Society of Dentist Anesthesiologists in their Application for Recognition of Anesthesiology as a Dental Specialty. It is the AAOMS’s belief that current evidence does not support the assertion that there is a need and demand for such a specialty coming from the dental profession, the public or the healthcare industry, and that pursuit of such a specialty may counter current efforts to control costs and increase access to care for our patients.

 

Thank you for your consideration,

Larry J. Moore, DDS, MS President, AAOMS	Arthur C. Jee, DMD President-elect, AAOMS
Miro A. Pavelka, DDS, MSD Vice President, AAOMS	Edwin W. Slade, Jr., DMD, JD Treasurer, AAOMS
Ira D. Cheifetz, DMD Immediate Past President, AAOMS
Lawrence J. Busino, DDS District I Trustee, AAOMS	Louis K. Rafetto, DMD District II Trustee, AAOMS
Eric T. Geist, DDS District III Trustee, AAOMS	William J. Nelson, DDS District IV Trustee, AAOMS
Douglas W. Fain, DDS, MD District V Trustee, AAOMS	Henry C. Windell, DMD District VI Trustee, AAOMS

 

cc: Mark E. Wong, DDS, President, American Board of Oral and Maxillofacial Surgery

I would appreciate anyone's insight into the REAL reason behind the AAOMS's  opposition to DA specialty recognition.  To my understanding, there's no competition between DA's and OS's.  OMFS's provide sedation for their own patients and rarely travel office to office to provide anesthesia services.  I can only come up with a few possible reasons for their recalcitrance.  It seems that unless these esoteric sticking points are addressed, they will try to make this ongoing battle.

Excellent question. I do, however, have utmost confidence in our leadership at ASDA to have carefully considered AAMOS's anticipated stance on the specialty application.

I would bet the ASDA leadership and other members who have worked so diligently on this most recent application have carefully considered what AAMOS's position would likely be and the ASDA would have carefully weighed the possible means of trying to work successfully with AAOMS members/leadership to resolve our "differences".

Not all cards in the game need be shown to all so early on in the process. Have faith in the diligent experienced, politically savvy members of ASDA to have anticipated such obstacles and considered means of successfully dealing with said obstacles.

Feedback welcome.

Scott, a great question.

There are probably a multitude of reasons that exist for the opposition of the specialty, but it probably would stand to reason to look at organized oral surgery's perspective. Classically and historically, oral surgery has been the leader in promoting anesthesia in dentistry. It is without question that if someone mentions "wisdom teeth," they will also mention "going to sleep" for the procedure. It is to oral surgery's credit that they have incorporated anesthesia as an integral part of their discipline and it has a firm foundation in that regard. It may seem obvious to us and a no-brainer to ask "what about all of the other dental patients," To acknowledge a specialty in anesthesia for dentistry means that you concede that it is not "your thing" anymore and someone else may be recognized as experts.

Organized oral surgery has been waging many battles as of late. Facial plastics has a long standing feud between them and a highly competitive physician marketplace. Recent published reports regarding the necessity of prophylactic third molar removal has called into question what is essentially the "bread and butter" of most oral surgery practices. And a few years past, organized oral surgery saw the placement of implants trickle down to periodontists, endodontists, and general practitioners -- a surgery that was considered perhaps the sole domain of the oral surgeon. So that may hint at the protectionist position you see in the aforementioned letter.

The scope of the dentist anesthesiologist is probably not really well known to either the everyday oral surgeon or even dentistry in general. You are absolutely correct in that the last thing DA's would do is attempt to try to establish themselves in every oral surgery practice to put everyone to sleep for every procedure involving anesthesia. That may be true for our medical colleagues, but in dentistry, we are unique in that we both perform the anesthesia and the surgery at the same time. The oral surgeons and dentist anesthesiologists have been doing that for a long time and being very safe about that aspect too. We accept this, we promote this, and most importantly, we want to PROTECT this modality for dentistry. This may be the crux of the problem - this misunderstanding that establishment of a specialty would mirror that of medical anesthesiology. Not so.

Interestingly enough, try replacing every instance of "dental anesthesiology" with "dental radiology" in that letter. Would the arguments still be valid? Does every dental school graduate possess all of the knowledge on radiology to call themselves a specialist in dental radiology? How about the idea of "itinerant" dental radiologists? Do you think that it would be better for the patient to have a pair of doctors looking at some film rather than one doctor alone? Does the establishment of dental radiologists mean that every general practitioner or dental hygienist cannot read and diagnose their own films before a radiologist signs off on it? We also have a great number of medical radiologists that vastly outnumber the dental radiologists. Why not send them our complex tomograms or cone-beam films to interpret and diagnose? Yet we have a bona-fide specialty in Oral & Maxillofacial Radiology for 10+ years that has not negatively impacted the dental profession. Instead, we have a greater in-depth knowledge of the discipline, a resource for issues with radiology, and emerging leaders in the field to replace those who have left the profession.

That issue also highlights another pressing concern -- we are at a crossroads in education. When the federal government (NIDR) funded positions for dentists to complete medical anesthesiology residencies in the early 1970's, obtain a PhD in related fields, and eventually enter educational institutions, we saw an emergence of the leaders in dental anesthesiology we see today. Who wrote the texts in local anesthesia and medical emergencies? Who are the editors and contributors to pharmacology texts exclusive to dentistry? Who remains as subject matter experts and spokespeople for anesthesiology in dentistry? These folks are sadly entering retirement or probably thinking about retirement soon. For over 20 years without specialty recognition, the pipeline for new educators and emerging leaders is drying up. From the few formal and informal dental anesthesia departments or sections within dental schools, we are running the real risk of not having adequate educators and leaders for the profession itself.

Its true that this is probably only the tip of the iceberg and there are many things that also contribute to the opposition. It really doesn't come down to either criteria or "need and demand" arguments, but probably the resistance comes from long held misconceptions, the misperceptions of losing a pillar of your discipline, and a lack of understanding that clouds sound, rational decision making. Our big job now is to educate our colleagues in that anesthesiology would be a benefit to the profession and not a hinderance as some would lead them to believe. Consistency and transparency are key, so that's why you'll find our application and published Parameters of Care right here on this website. Moreover, an acknowledgement that one is a competent and proficient at anesthesia for one's discipline is a motivating aspect for many, just as we are looking for acknowledgment and legitimization of our scope of practice.

Sorry for the treatise, just had a strong cup of coffee.

-Jimmy

Thanks for the timely replies. I'm in complete agreement with the notion that OS's reign as the defacto experts of anesthesia in the profession would be in jeopardy with anesthesia specialists on the scene. But I would also posit that a big concern on their part is that as DA's become more commonplace, any negative incident involving anesthesia in an OS's office, that gets broad press coverage, may cause state governments to say,"hey, you've got highly trained anesthesiologists in your profession. Use them. We're not feelin that single operator/anesthetist thing anymore." In essence, a directive, not a choice. My suspicion is that they fear that their ability to practice as they have been will come to an end. States mandated that anyone registering a car had to have liability insurance (probably not a bad idea). So, as anyone who reads their position paper against DA specialty recognition will find their stated reasons comical, I also understand why they may not want to put their heart-felt reasons in writing. Just a thought.

I think that with the soon to be abundance of medical anesthesiologists and nurse anesthetists (in some states already) entering the dental field, OS should feel threatened regardless- if indeed that is the reason behind their opposition of DA specialty.

My fear would be the other extreme...the UK reaction to adverse events in anesthesia in dental offices. If we don't establish an awareness that anesthesiology is part and parcel the practice of dentistry, outsiders will see it only as the practice of medicine. As such, making the leap that dentists shouldn't be practicing medicine wouldn't be too far of a conclusion to make, and then outlaw anesthesiology in dentistry altogether.

The Poswillow Recommendations are a grim reminder of what could happen if we don't take steps to inform, educate, and protect:

www.dh.gov.uk/en/Publicationsandsta...DH_4074702

-Jimmy

http://www.aaoms.org/annual_meeting/2011/docs/jee_address.pdf