Pediatric dentistry/Dental Anesthesiology dual training?

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InformMe123

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My understanding is that pediatric dentists frequently use dental anesthesiologists, so wouldn't certification in both pediatric dentistry and dental anesthesiology be a winning combo? Any pros and cons for doing both? Seems like a rare thing so was wondering why not

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While not common amongst pediatric dentists as a group, pediatric residency training is not unusual for dental anesthesiologist to pursue. They do pair well together clinically as you no longer have to refer out to a hospital and you're far more comfortable taking those patients that would've been very difficult to treat with oral sedation into deep sedation/GA.

But from the few dual trained providers I've actually talked to it seems to be less lucrative to do both the anesthesia and the dental work simultaneously as you see less patients. Where as a pediatric dentist can have an anesthetist in one of his ops sleeping/emerging patients he/she can simultaneously be doing hygiene checks and minor procedures in another room. If you're managing the anesthesia and the dentistry you can't split yourself like that and will only see GA patients that day.
 
For starters, I am a dual trained pediatric dentist/dentist anesthesiologist. I completed peds training first and anesthesia second. Personally, this is the way I would recommend completing this training sequence. I believe it would be difficult to jump back into GA/deep sedation after taking a two year break from anesthesia. A talented anesthesiologist has more then knowledge and airway skills, he/she simply reacts (almost like it is programmed) to the clinic situation as it presents itself. Now can it be done completing anesthesia first and then peds? Sure, but if it was me I would want to be with an experienced anesthesiologist/anesthesia provider while I got back to my previous (immediately finishing anesthesia residency) comfort level prior to going out solo.

While I agree with sublimazing, that your ability to see as many patients operating as both anesthesiologist and pediatric dentist is less then separate providers providing this care it can still be done. I for one see 5 to 6 intubated GA patients where I am acting as both providers. However, I work in several large clinics with several other doctors (never practice alone). Thus, most of the exams are completed by the other doctors. I generally finish my last case around 2 pm and either go home or just do exams until we close.

One of the biggest benefits to being dual trained is that I do not have to rely upon someone else's availability. I also have the luxury of severely decreasing or even comping (giving away) the anesthesia care since I am completing all of the dentistry. However, the biggest benefit is that anesthesia is simply fun and has completely changed how I practice and my satisfaction at work. I highly recommend anesthesia training. It will change your life.

I am currently in the process of starting/building my own peds and special needs clinic and it is my goal to have as many providers with general anesthesia training as possible. The more people we have the more efficient and fun it will be.

Let me know if you have any other questions. Heck, if you do complete both training programs please remember me. I would love to speak with you and see if I had room for another provider.

-Zach

PS While not super common to be dual trained, it does seem to be occurring more and more frequently.
 
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For starters, I am a dual trained pediatric dentist/dentist anesthesiologist. I completed peds training first and anesthesia second. Personally, this is the way I would recommend completing this training sequence. I believe it would be difficult to jump back into GA/deep sedation after taking a two year break from anesthesia. A talented anesthesiologist has more then knowledge and airway skills, he/she simply reacts (almost like it is programmed) to the clinic situation as it presents itself. Now can it be done completing anesthesia first and then peds? Sure, but if it was me I would want to be with an experienced anesthesiologist/anesthesia provider while I got back to my previous (immediately finishing anesthesia residency) comfort level prior to going out solo.

While I agree with sublimazing, that your ability to see as many patients operating as both anesthesiologist and pediatric dentist is less then separate providers providing this care it can still be done. I for one see 5 to 6 intubated GA patients where I am acting as both providers. However, I work in several large clinics with several other doctors (never practice alone). Thus, most of the exams are completed by the other doctors. I generally finish my last case around 2 pm and either go home or just do exams until we close.

One of the biggest benefits to being dual trained is that I do not have to rely upon someone else's availability. I also have the luxury of severely decreasing or even comping (giving away) the anesthesia care since I am completing all of the dentistry. However, the biggest benefit is that anesthesia is simply fun and has completely changed how I practice and my satisfaction at work. I highly recommend anesthesia training. It will change your life.

I am currently in the process of starting/building my own peds and special needs clinic and it is my goal to have as many providers with general anesthesia training as possible. The more people we have the more efficient and fun it will be.

Let me know if you have any other questions. Heck, if you do complete both training programs please remember me. I would love to speak with you and see if I had room for another provider.

-Zach

PS While not super common to be dual trained, it does seem to be occurring more and more frequently.


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I think its poor patient management to be BOTH the pediatric dentist and the anesthesiologist. I am not sure why anyone would think its perfectly adequate to monitor an INTUBATED patient while performing full mouth dental rehab. Aside from OMFS, which in the future will surely not be allowed to practice this way, nobody else does their own surgery and provides the general anesthesia.

PS, I'm on staff at a major medical center providing pediatric dental care to both healthy and special needs patients under GA in the OR. Just my two cents.
 
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I think its poor patient management to be BOTH the pediatric dentist and the anesthesiologist. I am not sure why anyone would think its perfectly adequate to monitor an INTUBATED patient while performing full mouth dental rehab. Aside from OMFS, which in the future will surely not be allowed to practice this way, nobody else does their own surgery and provides the general anesthesia.

PS, I'm on staff at a major medical center providing pediatric dental care to both healthy and special needs patients under GA in the OR. Just my two cents.

You're entitled to your opinion, but do you have any evidence to show the operator/anesthetist model is less safe? And do you have a solution to the 1000s of patients that need in-office sedation for dental work everyday? There are not enough anesthesia providers in the US to be present for the amount of sedations performed in OMFS and PEDS practices on a daily basis, not to mention the costs that would be involved if there were enough separate providers to go around.

It would be great if every patient who needed sedation for a dental procedure had an MD present to perform that anesthesia while a dentist or dental specialist performed the surgical component, but that's not realistic (or frankly necessary). You cannot always provide the absolute best IMAGINABLE care...if that were true, each ICU patient would have a team of physicians assigned only to that patient.

Finally, to address your statement that OMFS are the only providers doing their own sedation and procedure. While this may be mostly true, you have to consider that OMFS is a very unique pathway. There is no field that combines the education/training of two doctorate level health specialties like OMFS (both 4yr and 6yr) and there is no field that performs more office appropriate surgical procedures than OMFS. There is no specialty that receives the anesthesia training that OMFS does (besides anesthesiologists), and OMFS get by far THE MOST training with controlling the sedated AIRWAY. And lastly, anesthesia was invented by a dentist because it is a necessary component to the field.
 
You're entitled to your opinion, but do you have any evidence to show the operator/anesthetist model is less safe? And do you have a solution to the 1000s of patients that need in-office sedation for dental work everyday? There are not enough anesthesia providers in the US to be present for the amount of sedations performed in OMFS and PEDS practices on a daily basis, not to mention the costs that would be involved if there were enough separate providers to go around.

It would be great if every patient who needed sedation for a dental procedure had an MD present to perform that anesthesia while a dentist or dental specialist performed the surgical component, but that's not realistic (or frankly necessary). You cannot always provide the absolute best IMAGINABLE care...if that were true, each ICU patient would have a team of physicians assigned only to that patient.

Finally, to address your statement that OMFS are the only providers doing their own sedation and procedure. While this may be mostly true, you have to consider that OMFS is a very unique pathway. There is no field that combines the education/training of two doctorate level health specialties like OMFS (both 4yr and 6yr) and there is no field that performs more office appropriate surgical procedures than OMFS. There is no specialty that receives the anesthesia training that OMFS does (besides anesthesiologists), and OMFS get by far THE MOST training with controlling the sedated AIRWAY. And lastly, anesthesia was invented by a dentist because it is a necessary component to the field.

Of course its my opinion. How many deaths are there in OMFS offices each year? I'm positive that number exceeds the number of deaths in offices where the anesthesia and surgery are not performed by the same operator.

You want to argue access to care as the reason for needing one provider to do two jobs... I can teach a monkey to do a stainless steel crown or take out a tooth. Should we employ monkeys to provide these services because of access to care. Get a clue dude.

As a pediatric dentist, how can I safely observe the patient's vitals, measure the appropriate medications, administer those medications, manage the airway and still provide EFFICIENT dentistry? You can't. Its a difficult enough task to restore 16 teeth on a child, let alone focus on the anesthesia as well.

OMFS is not unique. Let's be real about this. You completed a surgical residency just like thousands of other surgeons out there today. Your typical OMFS rotated for 5-6 months on the anesthesia service, not 4 years. I'm not arguing that OMFS is the most well trained to handle a sedated patient, but that's not saying much, because in reality, you're the only specialty doing it.

Finally, if you are so well trained and you can provide the same level of care, then why doesn't the hospital allow you to act as both the anesthesiologist and the surgeon for your cases? Same goes for the guy who wants to be a hero and play the pediatric dentist/anesthesiologist. As far as access to care goes (your biggest concern) this seems a like a no-brainer. We can just do away with anesthesia and provide every surgeon/pediatric dentist with 5-6 months of anesthesia training and call it a day. Hospitals would save a ton of money.
 
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Of course its my opinion. How many deaths are there in OMFS offices each year? I'm positive that number exceeds the number of deaths in offices where the anesthesia and surgery are not performed by the same operator.

Reference please?

I'm not sweating because one pedo dentist likes to play a hero and has any clue what I do and how I'm trained. He/She is not going to change it.
 
Reference please?

I'm not sweating because one pedo dentist likes to play a hero and has any clue what I do and how I'm trained. He/She is not going to change it.

I don't have a reference that's why I asked the question. Isn't this information readily available?
 
Of course its my opinion. How many deaths are there in OMFS offices each year? I'm positive that number exceeds the number of deaths in offices where the anesthesia and surgery are not performed by the same operator.

You want to argue access to care as the reason for needing one provider to do two jobs... I can teach a monkey to do a stainless steel crown or take out a tooth. Should we employ monkeys to provide these services because of access to care. Get a clue dude.

As a pediatric dentist, how can I safely observe the patient's vitals, measure the appropriate medications, administer those medications, manage the airway and still provide EFFICIENT dentistry? You can't. Its a difficult enough task to restore 16 teeth on a child, let alone focus on the anesthesia as well.

OMFS is not unique. Let's be real about this. You completed a surgical residency just like thousands of other surgeons out there today. Your typical OMFS rotated for 5-6 months on the anesthesia service, not 4 years. I'm not arguing that OMFS is the most well trained to handle a sedated patient, but that's not saying much, because in reality, you're the only specialty doing it.

Finally, if you are so well trained and you can provide the same level of care, then why doesn't the hospital allow you to act as both the anesthesiologist and the surgeon for your cases? Same goes for the guy who wants to be a hero and play the pediatric dentist/anesthesiologist. As far as access to care goes (your biggest concern) this seems a like a no-brainer. We can just do away with anesthesia and provide every surgeon/pediatric dentist with 5-6 months of anesthesia training and call it a day. Hospitals would save a ton of money.

You say that you are positive that the amount of deaths in OMFS offices is greater when OMFS is the provider/anesthetist...please show us the literature/evidence to support these claims.

Your next point about training a monkey is completely asinine, and I don't understand what you're saying at all. The access to care issue isn't with the operative dentistry portion, it's the anesthesia portion. There are not enough anesthesia providers in the country to provide anesthesia for all the patients who receive sedation everyday. I really don't understand why training a monkey to do the operative portion has ANY relevance to the barrier to care I described with anesthesia providers. Please get a clue. And I by no means think that access to care should be increased at any cost (i.e. training a monkey), but access needs to be as high as possible without compromising safety. All of healthcare is a compromise as we live in the real world where money, time, and resources are a real limiting factor in nearly all aspects of care.

In terms of monitoring vitals, administering medications, and managing an airway safely...OMFS does this everyday. The literature available shows that this method of anesthesia is extremely safe, and readily accessible. And it should be mentioned that even when there is A SEPARATE anesthesia provider the operative dentist is still monitoring vitals, airway, and anesthesia...if they aren't doing this then they are failing as a surgeon.

And in terms of being EFFICIENT...You believe that doing GA cases in the hospital is efficient? The costs and time it takes to run a case in the OR far far exceed those done outpatient.

OMFS is certainly unique...debating this is foolish. I elucidated many points as to why it is unique. Combined medical/dental training, the second most anesthesia training of any doctorate level provider, and the most in-office procedures requiring sedation. And it isn't just 5 months of anesthesia, OMFS does countless sedations throughout their 4-6 years in addition to their OR anesthesia rotation. And you didn't understand my point about the airway. OMFS is the most trained of any provider (Anesthesiologists, Emergency Room, or any other physician) in managing a sedated airway because they do both the anesthesia provider training as well as countless airway procedures including emergent airway access procedures.

The hospital doesn't allow OMFS to act as anesthesia attendings because there are physicians who are better trained at providing anesthesia. Legally, however, an OMFS has the same anesthesia privileges as any anesthesia provider.

Finally, you state that we should provide every surgeon/pediatric dentist with anesthesia training to do away with the hospital...I never insinuated that the hospital doesn't have its place. Complex patients, or complex procedures often require a separate provider to administer/monitor the anesthesia. No one wants to do away with hospitals. But having well trained providers who can perform their own anesthesia and operate allow our system to remain both efficient and safe at the same time.

You have shared your unsubstantiated opinion, and you're entitled to it...but the bottom line is that the current system has worked and will continue to work for years and years. There is no pending laws that may remove the ability of well trained dentists and specialists from providing their own anesthesia. Sorry you are dissatisfied with this system, but you don't have to ever deal with it if you don't want to...and I think someone who is as weary as you are about the operator/anesthetist model absolutely should never attempt it themselves.
 
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I think its poor patient management to be BOTH the pediatric dentist and the anesthesiologist. I am not sure why anyone would think its perfectly adequate to monitor an INTUBATED patient while performing full mouth dental rehab. Aside from OMFS, which in the future will surely not be allowed to practice this way, nobody else does their own surgery and provides the general anesthesia.

PS, I'm on staff at a major medical center providing pediatric dental care to both healthy and special needs patients under GA in the OR. Just my two cents.


Pulpoutofhere,

Thank you for your opinion. I would agree that my mode of practice is rather unique in pediatric dentistry. I also agree that I find myself looked differently at by both ped docs and many anesthesia providers. However, it is really not very different then your private practice OMFS or many DA's who practice dual operator (anesthesia and surgery). In fact, the DA program in Toronto trains their residents to become dual operators (anesthesia and surgery) and approx 20% of the ASDA (American Society of Dentist Anesthesiologists) practice as both anesthesia provider and surgeon....I also practice with an EMT and an RN along with my dental assistants. Finally, many pediatric dentists provide there own sedation (generally oral moderate sedation) and perform dental tx as a single provider. Now, you will probably argue that those pediatric dentists are just practicing moderate sedation and thus it is safer. However, few points to consider below.

#1. I hear from many pediatric dentists that their best/ideal sedations are when the patient does not move for local anesthesia. However, this level of sedation can be argued to be deep sedation even GA. Thus, how safe are they?

http://www.bcbst.com/mpmanual/American_Society_of_Anesthesiologists_Definitions_.htm

#2. Like pediatric dentists I am practicing to the level of my training while providing anesthesia.

#3. I have provided tx for my patients with an open airway while seeking a sedation level close to moderate. However, I just found this to be rather difficult. Ask yourself is moderate sedation even realistically possible or wanted for 5 yr old? I think one can make a argument that pediatric moderate sedation is an oxymoron. IE do you really expect to gain cooperation from a 5 year old by decreasing their ability to understand. Remember a moderately sedated patient should respond to verbal commands. Furthermore, I think an experienced anesthesia provider will tell you the real times to be on alert are induction (breathing tube placement) and extubation (removal of breathing tube). I am not saying you do not have to be alert during the case, but like flying a plane the real dangerous times are starting and ending.

#4. Have you ever tried a precordial sethoscope? For me this a game changer and will alert you of possible airway issues before any monitor, including EtCO2. This is something you hear and not see.

Now in saying all of that, I do agree with you that in general it is hard to argue that the medical model of anesthesia (separate providers) is not in theory safer then dual operator. However, dual operator (anesthesia and surgery) has been practiced with great success in dentistry in North America. Furthermore, if something goes bad in a private pediatric office with an anesthesiologist is the pediatric dentist going to be any more helpful then an RN or EMT? Finally, in dentistry we are lucky that our patients are generally very healthy. Thus, providing anesthesia is not nearly as risky as providing anesthesia for a medically compromised patient.

Finally, as I mentioned earlier I am in the process of starting my own practice. My partner is a DA and we plan on working together for our GA cases in the future. Allows me to run and see exams or maybe even have mod sedation at same time. More fun to work together and then we are also each other's back up.

Anyway, thank you again for your opinion. I think it is good for the dental students/residents to hear different view points and I hope you find my post informative.

Respectfully,
Zach

PS Sorry about not quoting in my post correctly. To be honest, I just did not have the patience to figure this out.
 
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