Recently on this site it was discussed how guidelines have come out from the American Academy of Pediatric Dentistry (AAPD) and American Academy of Pediatrics (AAP) recommending when deep sedation or general anesthesia is given to children in dental offices there should be two trained individuals present. One individual should provide the dentistry and the other individual is responsible to administer the sedation or anesthesia and to observe the patient for any adverse events. This goes against the single provider model that has been advocated by the American Association of Oral and Maxillofacial Surgeons (AAOMS) and is typically utilized for wisdom teeth removal in the United States of America, where the oral surgeon performs both the dentistry and the administration of sedation or anesthesia. Some have criticized the AAOMS position of a single provider model for its focus on profit and not safety. A new study titled “Are Office-Based Oral and Maxillofacial Surgical Procedures Profitable? A Benefit–Cost Analysis” written by Jason P. Jones and Edward Ellis III appearing in the Journal of Oral and Maxillofacial Surgery (in press, pp. 1-10, 2019) gives support to the argument that there is a strong profit motive by oral surgeons to do both the the dentistry and the administration of sedation or anesthesia for extraction of teeth.
In the article by Jones and Ellis the authors analyzed the costs and reimbursement rates of 6 common office based oral and maxillofacial surgical procedures including simple extraction, surgical extraction, preprosthetic surgery, incision and drainage, pathological procedures, and implant placement. The costs were calculated based on cost of materials at an office practice at the University of Texas Health Science Center at San Antonio along with salaries, fringe benefits, and overhead for oral and maxillofacials surgeons and their assistants based on information from the American Dental Association. Furthermore, all procedures were set to 30 minutes for cost simplification. The authors explored reimbursement for the 6 oral and maxillofacial surgical procedures by looking at fee schedules from the insurance providers for Medicaid, Humana Dental, and Delta Dental.
The authors found that the cost of a single routine extraction is $325 using local anesthesia alone and $412 if sedation is also used. Insurance is expected to reimburse between $64 to $94 for a single routine extraction using local anesthesia alone and between $190 to $343 for a single routine extraction if sedation is also used. This results in a profit of -$261 to -$230 for a single routine extraction using local anesthesia alone and a profit of -$222 to -$69 for a single routine extraction if sedation is also used. The authors also found that the cost of a single surgical extraction is $340 using local anesthesia alone and $427 if sedation is also used. Insurance is expected to reimburse between $98 to $187 for a single surgical extraction using local anesthesia alone and between $224 to $435 for a surgical extraction if sedation is also used. This results in a profit of -$242 to -$153 for a single surgical extraction using local anesthesia alone and a profit of -$203 to +$8 for a single surgical extraction if sedation is also used. A negative profit number indicates a loss for the oral surgeon to perform the procedure. When calculating the cost of using intravenous sedation the authors included the use of a second assistant certified and competent in Basic Life Support for Healthcare Providers. The authors provide some arguments that reimbursement by insurance for procedures has decreased for oral and maxillofacial surgeons in recent years.
In order to turn a profit multiple teeth would need to be extracted. The authors say that at least six teeth would need to be routinely extracted in one visit under local anesthesia alone to create profit if a patient is on Medicaid and at least four teeth would been to be extracted routinely in one visit under local anesthesia alone to create profit if a patient is on either Humana or Delta Dental. The authors also say that at least four teeth would need to be surgically extracted in one visit under local anesthesia alone to create profit if a patient is on Medicaid and at least two teeth would need to be extracted surgically on one visit under local anesthesia alone to create profit if a patient is on either Humana or Delta Dental. Adding sedation to either a single routine extraction or a single surgical extraction would still not be profitable although to a less extent than with local anesthesia alone and therefore more teeth would need to be extracted to become profitable.
The authors say that oral and maxillofacial surgeons must be aware of the cost of procedures they perform to best understand the finance’s of their practice. The authors say
“…the presumed most viable option for the practicing oral-maxillofacial surgeon is to increase the volume of cases to both adequately treat the population and maintain a certain collection goal.”
Based on the study by Jones and Ellis one could attempt to make the argument that oral and maxillofacial surgeons have financial incentives to perform wisdom teeth extractions on all four wisdom teeth if possible and also to perform both the extractions and administer the sedation. However, having an oral surgeon perform extractions on multiple teeth and not having a second independent person present may not be in the best interest of the patient to ensure optimal safety. While the article by Jones and Ellis was published in the Journal of Oral and Maxillofacial Surgery online on June 4, 2019, it was covered by DrBicuspid on July 3, 2019. A female anesthesiologist in California was quick to react to the article and criticize AAOMS on twitter as shown below.
This same female anesthesiologist in California has written in the past on her blog aPennedPoint an article titled “Safe pediatric dental anesthesia: Is there any hope?” (Dec. 14, 2017) that sharply criticizes the use of sedation and anesthesia in dental offices. In this article she says that physicians are not allowed to do a procedure and also provide sedation or general anesthesia at the same time. Thus she feels that patient safety is suffering in dentistry as a result of not abiding by this same standard. In the article a discussion is made of how the California Dental Association and the California Association of Oral and Maxillofacial Surgeons have argued that no data support that it is safer to use an independent anesthesia professional. This data has not been collected due to not having any national or state database of complications and adverse events and not having any randomized prospective trials. In the article she states
“The oral surgery team model… allows a dental assistant with no medical training to monitor the patient’s vital signs and keep the dentist informed as to whether the patient is alive and breathing – or not. The problem is that dental assistants, through no fault of their own, don’t have the medical or nursing background to recognize early enough when a patient isn’t breathing adequately. They lack the medical or nursing training to perform the tasks of advanced cardiac life support.”
In the article by the female anesthesiologist in California discussion is made of two deaths that occurred in the last few years by teenagers having wisdom teeth extracted. She appears to be adamant that wisdom teeth surgery should be performed in a hospital and under the care of an independent anesthesiologist for optimal safety. Similar arguments have been made in the past on this site, see for example Anesthesia in the Oral and Maxillofacial Surgeons Office.
Theresa Pablos, “Study finds common oral surgeries aren’t profitable,” DrBicuspid, July 3, 2019, https://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=324729