I learned that pediatric dental surgery is, in many respects, an ineffective intervention to change population oral health. As a clinician, that was a revelation. The idea that removing disease did not result in a cure seemed like a cultural shift. I now work at a safety-net hospital in Chicago that treats a predominantly Medicaid-enrolled population. Our patients wait for over a year to get into the OR to treat their cavities. Imagine being three years old with tooth decay that extends into the nerve root, then multiply that pain by ten. Then imagine living with that pain for a year because access to a hospital-based operating room is difficult.
Limited access to general anesthesia services can put pressure on existing systems to treat children under moderate sedation. I studied media reports of children who died at the dentist office, and it became apparent to me that there are several systems-level factors that contribute to safety. The state-to-state variation of these factors, such as how minimum clinical training is defined, is troubling. I studied patterns and outcomes when children and adults went to the emergency department for a toothache. Toothache pain is treated differently for non-Hispanic Black adults, who are less likely to receive narcotics compared to white patients. Oral health disparities, particularly when medicine and dentistry intersect, represent health inequality and inequity.
The idea of equity in healthcare has gotten more attention lately from the general public, yet access to dental care is often overlooked. What’s at stake for improving access to care for the pediatric dental general anesthesia population?
I think access to care gains attention from the general public at the point of catastrophe. Deamonte Driver was a boy in Maryland who did not have access to a dental provider, even though he was enrolled in his state’s Medicaid program. Insurance coverage does not translate into access. Deamonte had a cavity which, due to lack of care, developed into a brain abscess. He died after surgical intervention for his brain abscess.
Primary prevention is clearly the best way to prevent children from dying, but this proves to be quite challenging. My recent work, which was supported by a FAER mentored research training grant and my chair, Dr. David Schwartz, studied public health interventions as levers to improve population oral health and reduce utilization of pediatric dental surgical services. I looked at Medicaid policy aimed at increasing access to preventive dental care and also studied community access to fluoridated water. I did not observe changes in surgical utilization in association with either of these interventions.
This has led to my current focus on factors that could be changed at the household level. I have interviewed families who present for their child’s dental surgery under general anesthesia. What these families have shared with me has completely altered my research perspective.
Helen Lee, MD, MPH, is Associate Professor of Anesthesiology and Adjunct in Pediatric Dentistry at the University of Illinois at Chicago.