scope of practice general dentist vs. oral surgeon

[InductionAgent]

I'm an anesthesiology resident. I was talking with an acquaintance of mine who is a general dentist. He mentioned a potential interest in consulting an anesthesiologist for sedation for some of his office procedures. He says that he does some wisdom tooth extractions and other procedures sometimes performed by oral surgeons, although he refers the bigger cases to an oral surgeon.

I attempted to search both the Texas dental board website as well as the ADA and could not find any precise definition of the scope of practice of a general dentist vs. oral surgeon. (I also searched this forum.) Is there any precise definition or is it somewhat a matter of comfort level and experience? Before providing anesthesia for any dental procedures in the future, it would be reassuring to know exactly what procedures the dentist's licensure completely authorizes him/her to perform.

Thanks for any replies.

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[SuperC]

A general dentist is licensed to practice all areas of dentistry, including but limited to, extractions, implants, ect. However, if a GP does an extraction he/she is held to the same standard of care that an oral surgeon would provide. Meaning that is he/she were to be sued, she would be compared to the expertise of an OMFS rather than that of a GP.
-C

 

[drhobie7]

A general dentist can take out any set of wisdom teeth so long as he/she performs to the standard of an oral and maxillofacial surgeon. With easy cases this is easy, with hard cases this is much harder. Exodontia can be deceptively difficult. This is especially true of third molars. Here are some things I'd be considering if I was an anesthesiologist looking at doing these cases:

1. There is no protected airway.
2. Saline, saliva, and blood are constantly threatening the airway.
3. A patent airway is dependent upon the dentist and his assistant. They are the ones that prevent blood, saliva, saline, gauze, and teeth from being aspirated.
4. You will be taking the biggest risk in every procedure, not the dentist. The worst thing the dentist can do is damage the lingual nerve...every other tissue will heal. The greatest cause of morbidity and mortality in the dental office is airway problems.
5. You will be responsible for recovering the patients...or overseeing employees who recover them. This becomes important in a fast paced clinic.

Of course there's the plus side:
1. These are healthy 18 year old kids.
2. Short procedures. (if the dentist can take out 3rds fast)
3. Profitable? Oral surgeons typically charge $400 for GA.

If I were in your shoes I'd be most concerned about the general dentist's surgical skills, as this does have a large impact in the success of your anesthetic.

 

[NileBDS]

...
3. Profitable? Oral surgeons typically charge $400 for GA.
...

IV ?

 

[InductionAgent]

A general dentist can take out any set of wisdom teeth so long as he/she performs to the standard of an oral and maxillofacial surgeon. With easy cases this is easy, with hard cases this is much harder. Exodontia can be deceptively difficult. This is especially true of third molars. Here are some things I'd be considering if I was an anesthesiologist looking at doing these cases:

1. There is no protected airway.
2. Saline, saliva, and blood are constantly threatening the airway.
3. A patent airway is dependent upon the dentist and his assistant. They are the ones that prevent blood, saliva, saline, gauze, and teeth from being aspirated.
4. You will be taking the biggest risk in every procedure, not the dentist. The worst thing the dentist can do is damage the lingual nerve...every other tissue will heal. The greatest cause of morbidity and mortality in the dental office is airway problems.
5. You will be responsible for recovering the patients...or overseeing employees who recover them. This becomes important in a fast paced clinic.

Of course there's the plus side:
1. These are healthy 18 year old kids.
2. Short procedures. (if the dentist can take out 3rds fast)
3. Profitable? Oral surgeons typically charge $400 for GA.

If I were in your shoes I'd be most concerned about the general dentist's surgical skills, as this does have a large impact in the success of your anesthetic.

Thanks for the reply. I concur about the concerns with the airway, although I would certainly have the equipment on hand to intubate, and would consider dong certain procedures under general endotracheal anesthesia from the start. That would be a major advantage of my being there in the first place.

The recovery issue is certainly another relevant consideration that would have to be addressed.

From what I gather from the first two replies, there is no legal or licensure restriction preventing a general dentist from essentially practicing oral surgery; however in the event of a bad outcome, he/she might be more vulnerable to negative repercussions.

 

[toofshucker]

Thanks for the reply. I concur about the concerns with the airway, although I would certainly have the equipment on hand to intubate, and would consider dong certain procedures under general endotracheal anesthesia from the start. That would be a major advantage of my being there in the first place.

The recovery issue is certainly another relevant consideration that would have to be addressed.

From what I gather from the first two replies, there is no legal or licensure restriction preventing a general dentist from essentially practicing oral surgery; however in the event of a bad outcome, he/she might be more vulnerable to negative repercussions.

Your assessment is right on. I work for a dentist (gp) that employs an anesthesiologist on a weekly basis. He does it to protect himself. He can focus on what he is good at (dentistry) while you focus on what you are good at. He let's the anesth charge what he wants and makes the patient pay that. I think it is a much, much, much smarter idea to employ an anesth instead of doing it yourself. For me, it is not worth it. Too much risk. I will let you do your job while I do mine.

 

[shabu2]

There are SO many other procedures and capabilities of an OMFS than a general dentist. The amount of training to become an OMFS is not even remotely comparable. Do a search of www.aaoms.org for some of the procedures done.

 

[armorshell]

There are SO many other procedures and capabilities of an OMFS than a general dentist. The amount of training to become an OMFS is not even remotely comparable. Do a search of www.aaoms.org for some of the procedures done.

Shabs, I think this guy is just trying to make sure his GP friend is operating within the scope of general practice, which is seems like he is.

 

[Turnerjo13]

in order for the dentist to be totally protected does the anesthesiologist need to be an anesthesiologist that has an MD? Could they be a nurse anesthesiologist or some equivalent? The reason I ask is because I have a friend that is doing a masters in anesthesiology and we talked about possibly working together in the future.

 

[armorshell]

in order for the dentist to be totally protected does the anesthesiologist need to be an anesthesiologist that has an MD? Could they be a nurse anesthesiologist or some equivalent? The reason I ask is because I have a friend that is doing a masters in anesthesiology and we talked about possibly working together in the future.

I know you can have a dental anesthesiologist or a dentist "certified" in delivering IV conscious, I don't see why you wouldn't be able to have a CRNA.

 

[InductionAgent]

in order for the dentist to be totally protected does the anesthesiologist need to be an anesthesiologist that has an MD? Could they be a nurse anesthesiologist or some equivalent? The reason I ask is because I have a friend that is doing a masters in anesthesiology and we talked about possibly working together in the future.

One important clarification is where along the spectrum of anesthesia you are talking about. See the following ASA publication for a description of the difference between anxiolysis, conscious sedation, deep sedation, and general anesthesia.

http://www.asahq.org/publicationsAndServices/standards/20.pdf

You would have the greatest degree of protection in consulting a nurse anesthetist instead of a physician anesthesiologist if you are in one of the "opt-out" states in which CRNAs are not required by law to be supervised by a physician.

Even if you are not in an "opt-out" state, consulting a CRNA would certainly put you in a better position than having conscious or deep sedation administered by a dental hygenist under your supervision.

If your patients would routinely be undergoing general anesthesia, a stronger argument could be made for preferentially consulting a physician anesthesiologist instead of a CRNA if you are not in an "opt-out" state.

 

[Dr.Millisevert]

I know you can have a dental anesthesiologist or a dentist "certified" in delivering IV conscious, I don't see why you wouldn't be able to have a CRNA.

Yes, you can have a CRNA do these cases. However, if you are working in a state that requires CRNA supervision.. (a Dentist can supervise CRNAs)... and because of this.. you will be more likely to also be listed in any legal case that has problems with anesth, because you as the dentist are the "supervising surgeon". You don't have this problem in those states if you instead just employ an MD/DO anesth. So, again.. yes you can... but if the objective in the first place is to reduce your legal responsibility and you are having the patient pay these costs in the first place. Why not protect everyone to the greatest level by simply hiring a physician anesth instead.

Thoughts?

 

[armorshell]

Yes, you can have a CRNA do these cases. However, if you are working in a state that requires CRNA supervision.. (a Dentist can supervise CRNAs)... and because of this.. you will be more likely to also be listed in any legal case that has problems with anesth, because you as the dentist are the "supervising surgeon". You don't have this problem in those states if you instead just employ an MD/DO anesth. So, again.. yes you can... but if the objective in the first place is to reduce your legal responsibility and you are having the patient pay these costs in the first place. Why not protect everyone to the greatest level by simply hiring a physician anesth instead.

Thoughts?

Makes sense to me.

 

[Turnerjo13]

thanks for the info. I will need to research further to find out what my states laws are.

 

[drhobie7]

Thanks for the reply. I concur about the concerns with the airway, although I would certainly have the equipment on hand to intubate, and would consider dong certain procedures under general endotracheal anesthesia from the start. That would be a major advantage of my being there in the first place.

The recovery issue is certainly another relevant consideration that would have to be addressed.

From what I gather from the first two replies, there is no legal or licensure restriction preventing a general dentist from essentially practicing oral surgery; however in the event of a bad outcome, he/she might be more vulnerable to negative repercussions.

Do you have a portable machine for delivering volatile anesthetics? I don't think you'd ever need to put in an ETT for a procedure in a dental office. That just seems weird to me...dunno. I can't imaging walking into an operatory and seeing a patient with an ETT in place! Perhaps an LMA for certain things.

I think it's a great idea for you to do this, especially for anxious patients. There are a lot of people out there who don't see the dentist because they're afraid. Their only option is the oral conscious sedation or "sleep dentistry", which is not as safe or effective as administration of anesthetics via IV route.

If you try this and like it you could also go to pediatric dental offices. Some of them would be interested in doing IV GAs. Just be careful. Some may also push you to see too many patients.

 

[Yah-E]

From what I gather from the first two replies, there is no legal or licensure restriction preventing a general dentist from essentially practicing oral surgery

This only implies to extractions and placing implants, I can't think of any other simple OMFS procedures that a GP would practice from OMFS scope? Just FYI, OMFS's scope is MUCH border than just "T & T" (teeth and titanium). I understand, in general, when people say "oral surgery", they only think of "T&T" since they are the most performed OMFS procedures.

Unless the general dentist had proper training through an OMFS heavy General Practice Residency (GPR), then maybe (s)he could perform simple I&Ds and biopsies.

I don't believe sinus lifts should ever be done by a general dentist. I don't think a GP is that crazy, then again, there are always exceptions.

I guess a lot of dentists now do Botox also....

 

[Turnerjo13]

incisional Biopsies are with in the scope of general dentistry. some excisional biopsies are also with in the realm depending on how large they are.
I watched a presentation from a gp who is doing some amazing work with sinus lifts. he was using cone beam imaging to help him out.

 

[InductionAgent]

Do you have a portable machine for delivering volatile anesthetics? I don't think you'd ever need to put in an ETT for a procedure in a dental office. That just seems weird to me...dunno. I can't imaging walking into an operatory and seeing a patient with an ETT in place! Perhaps an LMA for certain things.

I think it's a great idea for you to do this, especially for anxious patients. There are a lot of people out there who don't see the dentist because they're afraid. Their only option is the oral conscious sedation or "sleep dentistry", which is not as safe or effective as administration of anesthetics via IV route.

If you try this and like it you could also go to pediatric dental offices. Some of them would be interested in doing IV GAs. Just be careful. Some may also push you to see too many patients.

There are some smaller and portable anesthesia machines with ventilators and vaporizers. We have one in our angio suite.

Regardless of IV or inhalational anesthesia, the main issue regarding ETT vs LMA is airway security. Not all patients are great candidates for LMA, such as the obese and reflux-prone. Also, I would think that an LMA which is large and needs to be midline could interfere with a number of procedures (e.g. on incisors) whereas an oral ETT can be placed to one side to get it out of the way. And there's always the nasal ETT for maximal oral access for the dentist.

The first intubation I did as a medical student was on a patient who was undergoing a complete dental extraction done by a dental GP. (It certainly took away any pressure not to chip teeth, at least from a cosmetic standpoint.) As you've mentioned, airway catastrophes in patients that perhaps should have been intubated given the bloodiness of the procedure and the degree of anesthesia induced have been responsible for many of the mishaps that have occurred in dental offices. While it may seem odd to see an intubated patient in that setting, it might actually be the wisest choice in some instances.

 

[InductionAgent]

Yes, you can have a CRNA do these cases. However, if you are working in a state that requires CRNA supervision.. (a Dentist can supervise CRNAs)... and because of this.. you will be more likely to also be listed in any legal case that has problems with anesth, because you as the dentist are the "supervising surgeon". You don't have this problem in those states if you instead just employ an MD/DO anesth. So, again.. yes you can... but if the objective in the first place is to reduce your legal responsibility and you are having the patient pay these costs in the first place. Why not protect everyone to the greatest level by simply hiring a physician anesth instead.

Thoughts?

I'm certainly in favor of your position in favor of a physician anesthesia provider, but of course I'm biased. If you'll indulge my ego for a bit, the advantage comes from the fact that you would not be "employing" or "hiring" an anesthesiologist, but rather consulting one. If I were your employee, you would be responsible for my actions by way of the "captain of the ship" doctrine. As your consultant, liability for my actions falls upon my own shoulders.

 

[drhobie7]

incisional Biopsies are with in the scope of general dentistry. some excisional biopsies are also with in the realm depending on how large they are.
I watched a presentation from a gp who is doing some amazing work with sinus lifts. he was using cone beam imaging to help him out.

Biopsies are definitely within the scope of GP....but choose wisely.

I know of a few GPs who do sinus lifts. If you do a procedure you should be able to manage the potential complications. Can these GPs manage these complications? I really am not sure.

 

[InductionAgent]

Biopsies are definitely within the scope of GP....but choose wisely.

I know of a few GPs who do sinus lifts. If you do a procedure you should be able to manage the potential complications. Can these GPs manage these complications? I really am not sure.

This points out one big advantage that MD oral surgeons have. They can do outpatient procedures in hospitals with the option of sending patients home or admitting as the situation evolves.

If a GP dentist has a good relationship with an oral surgeon who is willing to admit and manage the GP's rare complicated cases, then perhaps it could work out. It sounds like there are certainly a lot of gray areas, and an anesthesiologist working with a GP could be in some awkward positions ethically and medicolegally if he suspects the GP is practicing beyond the scope of his training and proceeds with the case.

On the other hand, the GP is probably going to do the case anyway, and without an anesthesiologist there, the patient could potentially be at greater risk.

 

[Dr.Millisevert]

I'm certainly in favor of your position in favor of a physician anesthesia provider, but of course I'm biased. If you'll indulge my ego for a bit, the advantage comes from the fact that you would not be "employing" or "hiring" an anesthesiologist, but rather consulting one. If I were your employee, you would be responsible for my actions by way of the "captain of the ship" doctrine. As your consultant, liability for my actions falls upon my own shoulders.

Much Agreed!

 

[drhobie7]

If a GP dentist has a good relationship with an oral surgeon who is willing to admit and manage the GP's rare complicated cases, then perhaps it could work out.

Most of the time a GP will have a good relationship with several oral and maxillofacial surgeons and can count on them to take care of their patients when things go awry. However, I'm sure you can imagine if the GP only sends patients with broken third molar root tips or infected sinus lifts to the OMS, it won't be too long before the surgeon stops bailing him out. Nobody likes cleaning up someone else's mess. It's a symbiotic relationship.

 

[InductionAgent]

Thank you for all the replies, doctors. This has been an enlightening discussion. I feel like I have a better idea of what to consider when I work with GPs and OMS in the future.

 

[Bifid Uvula]

This points out one big advantage that MD oral surgeons have. They can do outpatient procedures in hospitals with the option of sending patients home or admitting as the situation evolves.

QUOTE]

You don't need an MD/OMFS for hospital admissions... Single Degree OMFS typically hold the exact same privileges at hospitals. Some hospitals may still require either an Internal Med/Family Practice or Hospitalist to be on board as well, which isn't a bad thing either (saves the OMFS a lot of stupid headaches and BS late-night pages).

Regardless, the OMFS is around to help manage the medically compromised/medically complex dental-surgical needs of patients. Most have an excellent relationship with their referring dentists and are always willing to help them out in their time of need. They will get pissed from time to time as well if they consistently get that broken # 17 root-tip at 4:45 on a Friday afternoon from Dr. X.

Most OMFS will manage the vast majority of their patients on an out-patient basis in their clinic and only reserve hospital admission or hospital OR for the sickest patients... Bad ASA III's and ASA IV's.