Access to deep sedation and general anaesthesia services
for dental patients:
A survey of Ontario patients
By:
Soheil Mohammadi Khojasteh
A thesis submitted in conformity with the requirements for the degree of Master of Science
Graduate Department of Dentistry University of Toronto
© Copyright by Soheil Khojasteh 2017
ii
Access to deep sedation and general anaesthesia services for dental patients: A survey of Ontario patients
Soheil Mohammadi Khojasteh
Master of Science
Graduate Department of Dentistry University of Toronto
2017
Abstract
Background: Many patients require deep sedation or general anaesthesia (DS/GA) in order to
undergo dental treatment, due to fear, anxiety, age, disability, medical illness or extensive
treatment.
Objectives: To assess the barriers to access to DS/GA as identified by Ontario dental patients.
Methods: A mail-out survey of Ontario patients who received DS/GA over the past two years
was conducted. Descriptive and bivariate analyses, and logistic regression were performed.
Results: With a response rate of 36%, the most frequently reported barriers to access to
DS/GA were added cost of DS/GA, lack of private and public insurance funding for these
services, long wait times, and lack of dentists available to provide DS/GA.
Conclusions: Access to DS/GA for dental treatment in Ontario is limited by lack of insurance
and government funding for these services, as well as decreased availability of providers of
DS/GA.
iii
Acknowledgements This dissertation is the conclusion of research that has been carried out from 2015 to
2017 in fulfillment of a Masters of Science degree in the Graduate Department of Dentistry,
University of Toronto, Canada. This thesis has been made possible with the help and support
of many people, to whom I would like to express my sincere gratitude.
First and foremost, I would like to thank my research supervisor Dr. Amir
Azarpazhooh. Dr. Azarpazhooh has supported me unconditionally throughout this project and
he was always available at any time of day when I would reach out to him. He has a wealth of
knowledge and I am extremely grateful for how much he has taught me about the scientific
process. This project would not have been possible without Dr. Azarpazhooh’s guidance and
encouragement.
I would also like to sincerely thank the members of my advisory committee: Dr. Carlos
Quiñonez, Dr. Carilynne Yarascavitch, and Dr. Andrew Adams. Your input and advice was
always very appreciated, especially because of the professional and kind manner in which it
was always delivered. Your contribution has been invaluable. In particular, Dr. Adams, I truly
appreciate your willingness to answer my many questions throughout this process. I would
also like to sincerely thank Amir Tehrani, whom I befriended during this project, thanks to Dr.
Azarpazhooh. Amir provided invaluable assistance during this project, and this project would
not have been possible without him.
I would also like to thank my parents, Parvin and Mohammad, who have always
supported me and encouraged me to strive for excellence. Your love, wisdom, and the values
you have instilled in me are inspiring, and I cannot thank you enough for your continued
support to this day. I would also like to thank my brother Sina, sister Sara, brother-in-law
Rouzbeh, and my nephew Aiden. Your support throughout this project has been invaluable.
iv
I would also like to express my gratitude to my fellow dental anaesthesia co-residents,
especially Dr. Alia El-Mowafy, whose friendship has made my time as a graduate student
much more enjoyable. I would like to thank my life-long friend, Dr. Asad Siddiqui, whose
support and camaraderie to this day is invaluable to me.
This research was financially supported by the American Society of Dental
Anaesthesiologists (ASDA), Education and Research Fund. I am grateful to the ASDA for
supporting dental anaesthesia research projects and allowing residents to carry out meaningful
projects.
Finally, I would like to thank my loving fiancé and very soon to be wife, Monica.
Thank you for your love, support, and patience with me throughout the past three years. You
always encourage me to set my goals high and to achieve them. I cannot imagine completing
this project and residency program without your support. Monica, I dedicate this project to
you.
Dr. Soheil Khojasteh – Toronto, Canada, July 2017.
v
Table of Contents
ABSTRACT .............................................................................................................................. II
ACKNOWLEDGEMENTS ................................................................................................... III
TABLE OF CONTENTS ........................................................................................................ V
LIST OF FIGURES .............................................................................................................. VII
LIST OF TABLES ............................................................................................................... VIII
LIST OF APPENDICES ........................................................................................................ IX
CHAPTER 1 .............................................................................................................................. 1
1.0 – INTRODUCTION ................................................................................................................ 1
1.1 - DEFINITIONS OF DEEP SEDATION AND GENERAL ANAESTHESIA ........................................ 1
1.2 - INDICATIONS FOR DS/GA IN DENTISTRY .......................................................................... 2
1.2.1 - DS/GA in the management of dental anxiety, dental fear, and dental phobia ........ 2
1.2.2 - Prevalence of dental anxiety, dental fear, and dental phobia ................................. 4
1.2.3 - Demand of Canadian adult patients for DS/GA for dental procedures .................. 6
1.2.4 - Demand for DS/GA for pediatric dental procedures............................................... 7
1.2.5 - Dental fear and anxiety in rural communities ......................................................... 8
1.2.6 - DS/GA for dentistry for patients with disabilities ................................................... 9
1.3 - PROVIDERS OF DS/GA FOR DENTISTRY IN ONTARIO ...................................................... 10
1.4 - CURRENT SEDATION PRACTICES IN DENTISTRY .............................................................. 11
1.4.1 - Recognition of need for DS/GA by dentists ........................................................... 11
1.4.2 - Access to DS/GA for dental procedures ................................................................ 12
1.5 - POTENTIAL BARRIERS TO ACCESS DS/GA FOR DENTISTRY............................................. 14
1.5.1 - Costs to the patients associated with DS/GA......................................................... 14
1.5.2 - Costs to the dentists associated with DS/GA ......................................................... 15
1.5.3 - Wait times .............................................................................................................. 16
1.5.4 - Perceived risk and acceptability of DS/GA ........................................................... 16
1.6 DENTISTS’ PERCEPTION OF BARRIERS TO ACCESS TO DS/GA ........................................... 18
1.7 PATIENTS’ PERCEPTION OF BARRIERS TO ACCESS TO DS/GA ........................................... 20
CHAPTER 2 ............................................................................................................................ 21
2.1 – METHODOLOGY ............................................................................................................. 21
vi
2.2 - SURVEY INSTRUMENT .................................................................................................... 22
2.3 - SAMPLE SIZE CALCULATION ........................................................................................... 22
2.4 - DATA ANALYSIS ............................................................................................................. 23
CHAPTER 3 – RESEARCH PAPER ................................................................................... 24
ABSTRACT .......................................................................................................................... 25
INTRODUCTION ................................................................................................................ 27
MATERIALS AND METHODS .......................................................................................... 28
RESULTS ............................................................................................................................. 31
DISCUSSION ....................................................................................................................... 34
CHAPTER 4: DISCUSSION ................................................................................................. 54
4.1 - SAMPLE POPULATION ..................................................................................................... 54
4.2 - ACCESS AND UTILIZATION OF DS/GA ............................................................................ 55
4.3 - BARRIERS TO DS/GA ..................................................................................................... 56
4.4 – LIMITATIONS ................................................................................................................. 58
4.5 - STRENGTHS, IMPLICATIONS AND APPLICATION............................................................... 59
APPENDICES ......................................................................................................................... 62
REFERENCES ........................................................................................................................ 80
vii
List of Figures
FIGURE 1: A THEORETICAL FRAMEWORK FOR ACCESS TO DENTAL ANAESTHESIA IN ONTARIO .. 48
FIGURE 2: RESPONSE RATES FOR ONTARIO PATIENTS SURVEYED ............................................... 49
FIGURE 3: COMMON INDICATIONS FOR DEEP SEDATION AND GENERAL ANAESTHESIA ............... 50
FIGURE 4: BARRIERS TO DEEP SEDATION AND GENERAL ANAESTHESIA - BARRIERS RANKED AS
"IMPORTANT" OR "VERY IMPORTANT" ARE PRESENTED ...................................................... 51
FIGURE 5: RANKING OF BARRIERS TO DS/GA: SCORE OF 0 - NOT IMPORTANT AT ALL, 1 -
SOMEWHAT IMPORTANT, 2 - IMPORTANT, 3 - VERY IMPORTANT. MEAN SCORE PRESENTED
FOR EACH BARRIER ............................................................................................................ 52
viii
List of Tables
TABLE 1: PARTICIPANT CHARACTERISTICS ................................................................................ 41
TABLE 2: HEALTH ATTITUDES AND BEHAVIOURS ....................................................................... 42
TABLE 3: UTILIZATION OF DS/GA SERVICES BY THE SAMPLE POPULATION ............................... 43
TABLE 4: GEOGRAPHIC FACTORS & AVAILABILITY OF DS/GA .................................................. 44
TABLE 5: FREQUENCY DISTRIBUTION OF PATIENT SATISFACTION WITH DS/GA ......................... 45
TABLE 6: SUMMARY OF BIVARIATE ANALYSIS* IDENTIFYING SIGNIFICANT VARIABLES (P < .05)
FOR REPORTING BARRIERS AS VERY IMPORTANT OR IMPORTANT........................................ 45
TABLE 7: ADJUSTED FINAL LOGISTIC REGRESSION MODEL PRESENTING SIGNIFICANT PREDICTORS
FOR REPORTING BARRIERS AS VERY IMPORTANT OR IMPORTANT........................................ 47
ix
List of Appendices
APPENDIX 1: INVITATION TO STUDY PARTICIPATION - FACULTY OF DENTISTRY PATIENTS ........ 62
APPENDIX 2: INVITATION TO STUDY PARTICIPATION - PRIVATE PRACTICE PATIENTS .................. 63
APPENDIX 3: INFORMATION FOR CONSENT FOR PARTICIPATION - FACULTY OF DENTISTRY
PATIENTS ............................................................................................................................ 64
APPENDIX 4: INFORMATION FOR CONSENT FOR PARTICIPATION - PRIVATE PRACTICE PATIENTS . 65
APPENDIX 5: SURVEY INSTRUMENT ........................................................................................... 66
APPENDIX 6: REMINDER MAIL OUT TO NON-RESPONDERS .......................................................... 73
APPENDIX 7: THANK YOU CARD ................................................................................................. 74
APPENDIX 8: SCHEDULE OF RECRUITMENT ................................................................................ 76
APPENDIX 9: ADDITIONAL DATA AND TABLES ........................................................................... 77
1
CHAPTER 1
1.0 – Introduction
Dentistry is a unique service in such a way that the preference for anaesthesia and
sedation to facilitate dental procedures varies significantly from one patient to another. While
many patients are able to tolerate dental procedures awake with the use of local anaesthesia,
others require sedation or anaesthesia to facilitate dental treatment. For some patients,
conscious sedation is sufficient. However, there are a significant number of patients who will
require deep sedation or general anaesthesia (DS/GA) for dental procedures.1 The indications
for DS/GA for dentistry are vast, and they include, but are not limited to: anxiety associated
with dental treatment, precooperative age, having cognitive impairment or motor dysfunction,
and requiring traumatic or extensive dental procedures.2 Anaesthesia is both important to the
delivery of dental care, but also has its very foundation in dentistry, as the first public display
of anaesthesia was by a dentist.3 Furthermore, the availability of DS/GA is a necessity in
modern dentistry, in order to allow not just the majority of patients, but all patients to access
dental treatment without pain, anxiety, and suffering.
1.1 - Definitions of deep sedation and general anaesthesia
Deep sedation is defined as a state of controlled, drug-induced, depressed level of
consciousness, with partial loss of protective reflexes and the inability to respond purposefully
to verbal stimuli.4 During this depressed level of consciousness, patients cannot be aroused
easily, but will respond purposefully following painful or repeated stimuli. Patients may also
lose their ability to independently maintain an open airway, and so they may require assistance
maintaining a patent airway.4 General anaesthesia is a controlled, drug-induced loss of
consciousness, in which the patient’s protective reflexes are partially or completely lost, and
2
he/she will not be rousable, even by painful stimuli.4 Providers of DS/GA must undergo
extensive theoretical and clinical training in pharmacology, physiology, and anaesthesia, in
order to safely monitor patients who are under the influence of DS/GA.
1.2 - Indications for DS/GA in dentistry
There are many patients who require DS/GA in order to facilitate dental treatment, and
also numerous patients who can tolerate dental treatment without DS/GA, but who would
significantly benefit from it. Typically, patients who require and benefit from DS/GA for
dental treatment are: severely dental anxious patients and patients with dental phobia, pediatric
patients who are under the age of reason and unable to tolerate awake dentistry, patients who
require invasive dentistry or significant dental treatment, patients with intellectual disabilities,
patients with physical disabilities, patients with a severe gag reflex, medically compromised
patients who require reduction and modulation of physiologic stress, and instances where local
anaesthesia is ineffective or contraindicated. 5–7 If these patients do not have the option and
availability to receive DS/GA for dental care, there are implications of dental avoidance and
infrequent dental treatment.8 Furthermore, if patients who require DS/GA are forced to suffer
through treatment while awake, there are harmful consequences to these patients, such as
emotional stress and physiologic stress.9
1.2.1 - DS/GA in the management of dental anxiety, dental fear, and dental phobia
The terms dental fear and anxiety are often used interchangeably, but there are
important differences between the two. Dental anxiety is an emotional state which precedes
the dental encounter which the patient may fear, while dental fear is the activated response the
patient feels when they encounter a dental situation.10 Patients who have dental anxiety will
generally experience dental fear while at the dentist. Furthermore, dental phobia is a marked
level of dental fear, which creates considerable emotional stress for the patient.10 Phobias are
3
mental disorders diagnosed by psychiatrists or psychologists, and dental phobias intuitively
lead to dental avoidance.10
Many dental anxious patients can be managed by non-pharmacological methods, such
as good chair-side manner, voice control, and distraction techniques.10 However, these
methods are not effective for a subset of these patients. Dental anxiety and fear is one of the
most common reasons patients seek DS/GA services for dentistry, as multiple studies have
found a relationship between dental anxiety and preference for DS/GA.2,7 The reasons behind
the anxiety these patients experience is multifactorial. Patients have reported the smell of the
dental office, the sound of the dental drill, and the attitude of the dentist as some of the reasons
they feel anxious and fearful towards dental treatment.7,11 What is important to note is that
patients who prefer DS/GA for dentistry do not only prefer it for invasive dental procedures,
but also for routine procedures, such as restorative dentistry2,7 Thus, dental anxiety is a real
fear that some patients experience, and so DS/GA is an important service that should be
available to facilitate dental procedures for these patients.
The scientific psychology behind dental fear and anxiety has been analyzed in multiple
studies. One of the more prominent theories lies within the Cognitive Vulnerability Model,
which suggests patients feel vulnerable in the dental chair, as they feel they have no control
over what is about to happen to them.10 According to this model, the reason for the fear is loss
of control, loss of predictability, and the feeling of danger.10 Other theories behind dental
anxiety are multifactorial. For example, past dental pain and fear of needles can both play an
important role in the development of dental anxiety.12–14 However, the etiology of dental
anxiety is likely mostly multifactorial, and unique for each patient.
There is a common trend amongst dental fear and oral health patterns; patients who are
dentally anxious have decreased regular dental visits, and are more likely to present only for
emergency dental treatment.7 Patients of emergency dental clinics and emergency rooms
4
reported higher levels of dental fear15,16, and patients who primarily present for emergency
dental visits are more anxious compared to patients who have regular dental visits.17,18 These
patients are also more likely to prefer sedation for dentistry. However, not all of them are
aware that sedation is possible to facilitate dental procedures.17,18Furthermore, there is a
significant inverse correlation between oral health and dental fear/anxiety. Unfortunately, the
dental anxious patients with poor oral hygiene are much less likely to attend regular dental
visits, and primarily visit the dentist on an emergency basis. 17,19 Therefore, dental fear and
anxiety results in irregular dental visits, more dental emergencies, and the preference of
sedation for dentistry. DS/GA are essential services in dentistry, as they are preferred by
dental anxious patients to facilitate dental treatment and will lead to increased access to oral
healthcare in these patients.2,15
1.2.2 - Prevalence of dental anxiety, dental fear, and dental phobia
Many studies have been done to investigate the prevalence of dental anxiety and dental
fear in North America. In the U.S., 11.2%-11.7% of patients have been found to have high
degree of dental fear, while 17.5%-17.7% have been found to have moderate dental fear.20,21
Furthermore, a review of dental anxiety trends over the past 50 years found that there has been
no significant increase or decrease in dental anxiety, and that it has remained stable.21 This
fact suggests that despite advances in preventive dentistry, dental technology, anaesthesia, and
the overall practice of dentistry, dental anxiety has remained unchanged. It also means that
despite the increase in generalized anxiety disorders in the U.S., dental anxiety has not
changed.21 Therefore dental anxiety rates have remained stable for a long period, and have not
been influenced by changes in the delivery of dental care.
Dental anxiety rates have also been significant in Canada. In a national survey of the
Canadian population, Chanpong et al found that 9.8% of the population is somewhat afraid of
5
going to the dentist, with an additional 5.5% having high dental fear.2 The survey determined
that 7.6% of the respondents had missed or cancelled a dental appointment due to their fear.
This statistic was further analyzed and it was found that 49.2% of the high fear group had
missed or cancelled a dental appointment, compared with only 5.2% of the low fear group
missing or cancelling an appointment. 2 Thus, dental anxiety is prevalent in both the U.S. and
in Canada, and it results in avoidance of dental visits.
Dental anxiety is also very prevalent in the pediatric and adolescent population.
Perhaps the most common reason for DS/GA to facilitate dental treatment in pediatric
dentistry is dental fear.22,23 Studies have shown that up to 10% of pediatric patients suffer from
dental anxiety, and that these patients have significantly more dental caries, previous
extractions and irregular dental visits.24 Teenagers and adolescents also experience significant
dental fear. One study found that 12% of adolescents have high dental fear, and 18% have
moderate dental fear. Many of these patients also reported missing dental appointments due to
their fear.8 With respect to teenagers, studies have shown 6.5%-12.5% are dental anxious
patients, and that dental anxiety increases as children age into their teenage years, from
12.5%-21.1%14,25 These dental anxious teenagers are also more likely to avoid dental visits
and they experience more tooth loss.25
While it was once thought that dental anxiety was declining, its prevalence is now
believed to have reached a steady state.18 It is clear that dental anxiety is prevalent in North
America in both pediatric and adult patients. While it is a small proportion of all dental
patients that are anxious and fearful towards dentistry, it is a significant portion and in many
instances, their fear leads to dental avoidance. This patient population should not be ignored.
Many of these patients are not aware that DS/GA is an option to help facilitate their fear and
anxiety, and it is also believed that the current supply of DS/GA in dentistry is not sufficient to
meet the demand for these services.18
6
1.2.3 - Demand of Canadian adult patients for DS/GA for dental procedures
In a national survey of the Canadian population, Chanpong et al found that 12.4% of
Canadians are definitely interested in DS/GA for dental procedures, and 42.3% are interested
in DS/GA depending on cost.2 Furthermore, one third of the patients in the “high dental fear
group” in this study were definitely interested in DS/GA, while over half of these patients are
interested in DS/GA depending on cost.2 Chanpong et al also studied the preferred rates of
DS/GA for specific dental procedures by presenting hypothetical scenarios to survey
participants to see which percentage of participants would prefer DS/GA for specific
procedures. They also studied the current prevalence of DS/GA services for these procedures,
and proportion of increase in the preferences of DS/GA for each procedure.2 The results of the
study are presented in the table below:
Dental Procedure Prevalence of
DS/GA Preference of
DS/GA Proportion of
Increase
Routine Cleaning 1.9% 7.2% 3.8x
Restorative Dentistry/Crown Preparation
6.5% 18% 2.8x
Root Canal Therapy 5.7% 54.7% 9.6x
Periodontal Surgery 4.2% 68.2% 15.9x
Exodontia 21.5% 46.5% 2.2x
These results show that it is evident there is significant demand in the Canadian
population for DS/GA for various dental procedures. Based on previous studies, it seems that
this demand is not being met by dental providers, and many patients are either avoiding dental
treatment or suffering through procedures for which they would like to be sedated.2 It would
be ideal for dental providers to match the demand that is present for DS/GA with adequate
supply, and it has also been suggested that increased accessibility of DS/GA for dental
procedures would benefit patients.15
7
1.2.4 - Demand for DS/GA for pediatric dental procedures
Early Childhood Caries (ECC), a very common disease, is the most common reason
pediatric patients need to undergo dental surgery.26,27 In Canada, pediatric patients from a low
socio-economic status, rural communities, and Aboriginal communities have the highest rates
of ECC.26,28,29 Since ECC is a common disease entity that requires dental treatment, dentists
should be proficient in pediatric dentistry, including behaviour management techniques.
However, since many pediatric patients are below the age of reason and may not understand
why they require dental treatment, non-pharmacologic behaviour management strategies can
fail. Use of DS/GA is especially useful in this patient population, since a negative dental
experience in a dental anxious child can intensify that patient’s anxiety, and cause him to
avoid dental treatment in the future.24 Hence, it is important for dentists to be able to recognize
when pediatric patients require DS/GA, as pediatric patients generally cannot directly
communicate their anxiety and fear towards dentistry. According to the American Association
of Pediatric Dentistry (AAPD), the indications for DS/GA are as follows: uncooperative age
appropriate behaviour, extensive dental treatment needs, patients with special needs, patients
with acute situational anxiety, patients with immature cognitive function, patients with
disabilities, or patients with medical conditions that warrant DS/GA in order to achieve dental
treatment in a safe and humane manner.30
In Canada, pediatric dental surgery under general anaesthesia is the most common day
surgery procedure done in hospital operating rooms.26,29 In 2012, 19 000 children under the
age of six underwent general anaesthesia in a hospital outpatient setting for dental
rehabilitation, which corresponds to 31% of all day surgery procedure in children aged one to
five.26 It is also important to note that these numbers do not take into account patients on wait
lists, and also dental procedures under DS/GA done out of hospital. Thus, a very significant
8
proportion of pediatric day surgery OR time is for dental procedures, which places an
unnecessary burden on the healthcare system.31
The attitudes of parents towards DS/GA are changing as well. Today, parents rank
DS/GA for dentistry only second to the “tell-show-do” method.32 DS/GA is now preferable by
parents to any kind of restraint of the child, active or passive, and this is promising, as these
techniques can enhance dental anxiety.32 What is unfortunate is that many pediatric patients
will need subsequent DS/GA to treat recurrent decay and new dental disease33,34 Although
most of these patients will require only one additional GA, some patients actually require
multiple GAs for dental procedures.34 This emphasizes the need for increased efforts in the
prevention of ECC.
There seems to be a continuing need for DS/GA services for pediatric dental
procedures, due to the high prevalence of ECC and the need for adequate behaviour
management in this patient population. The providers of DS/GA for dentistry need to address
this need, to decrease the high number of in-hospital sedations that are done for dentistry, as
many of these cases can be done out of hospital.35
1.2.5 - Dental fear and anxiety in rural communities
Patients in rural communities not only have more unmet dental needs, but they also
have higher levels of dental fear and anxiety12,36,37 In one study, it was found that there is an
inverse relationship between the level of dental anxiety and the level of general education.12
The fact that patients from rural communities have less access to dental care, as well as higher
levels of dental anxiety contributes to the fact that these patients also suffer higher rates of
dental disease.37 Compared to patients in urban communities, these patients generally do not
have dental insurance, do not have regular dental visits, and are more likely to present for
emergency dental treatment.37
9
1.2.6 - DS/GA for dentistry for patients with disabilities
Patients with unique needs, such as individuals with intellectual or physical
disabilities, have the same right to dental treatment as patients without disabilities, and their
dental care should not be compromised. Unfortunately, these patients often do not have
adequate access to dental treatment, as some dentists may not feel comfortable treating these
patients for various reasons.38,39 An Ontario study found that the main barriers of access to
dental treatment for patients with disabilities are inability to cooperate with dental treatment
(18.9%), dental fear/ fear of dentist (17.5%), cost (16.4%), and barriers of transportation to
dental office/hospital (10.7%).40 In Ontario, individuals with disabilities have access to the
Ontario Disability Support Program (ODSP), which covers dental treatment, however its
services are limited, which is why “cost” is still one of the barriers to treatment.40
Studies in the U.S. suggest that only 44.8% of patients with disabilities reported “no
fear” towards dental visits, and that nearly 30% of this patient population identified
themselves as dental anxious patients, with half of those patients saying they were “terrified”
of going to the dentist.6 These patients have a significant preference for sedation services, as
when they were offered DS/GA for dental procedures, 40% of the patients less than 30 years
old, 24% of the patients aged 31-59, and 8% of the patients greater than 60 years old were
interested.6 Other studies have indicated that 20% of patients with disabilities require DS/GA
for dental procedures, as sedation is the only route which is effective in managing these
patients’ behaviour and cooperation.41
DS/GA is an essential service with regards to dental procedures for individuals with
disabilities. It is especially effective in this patient population for the management of dental
fear and anxiety, cognitive disabilities, uncooperative behaviour, difficulty with mouth
opening for prolonged periods, and multiple comorbidities.42,43 There is also an increase in the
demand for DS/GA as the level of disability increases.43 Parents and support workers of these
10
individuals are generally very satisfied when DS/GA is used to facilitate optimal dental
treatment.44
It is clear that many patients with disabilities would benefit from DS/GA services to
facilitate dental treatment, as this patient population has many common indications for these
services. Dentists and providers of DS/GA need to be familiar with the demand of this patient
population, in order to ensure these patients have adequate access to dental treatment, and do
not have to experience unrealistic wait times for hospital based dentistry.45
1.3 - Providers of DS/GA for dentistry in Ontario
Although DS/GA is an important discipline of dentistry, only specially trained dentists
are able to provide DS/GA in order to protect patient safety. The Royal College of Dental
Surgeons of Ontario (RCDSO) mandates that only the following three groups of individuals
are able to provide DS/GA for dental procedures: Dentists who have completed a post
graduate residency program of at least 24 months in dental anaesthesia, dentists who have
completed a residency program in oral & maxillofacial surgery with sufficient training in
anaesthesia, and medical anaesthesiologists with hospital privileges.4
If a general dentist or specialist without anaesthesia training wishes to utilize DS/GA,
they have the option of: working with a dental anaesthesiologist, an oral & maxillofacial
surgeon or a medical anaesthesiologist; or referring patients to an anaesthesia trained
specialist.4 There are typically three different settings where DS/GA is offered for dental
procedures: 1) Hospital operating rooms (ORs), 2) dental offices that are specially accredited
and equipped with anaesthesia equipment, and 3) private surgicentres. In Ontario, hospital
dental clinics are not readily available to most dentists, as very few dentists have hospital
privileges.46 Hospital privileges for dentists have been reported to be declining in Ontario.45
Furthermore, not all hospitals offer dental services, and in many instances, those that do, only
11
offer their ORs part time for dentistry.46 Generally, medical anaesthesiologists are the DS/GA
providers for dentistry in a hospital setting, and dental anaesthesiologists tend to work in
private outpatient clinics.
1.4 - Current sedation practices in dentistry
The patterns of use of sedation in dentistry vary depending on the demographic area. In
North America, most dentists utilize some form of sedation.47 For example, in Ontario, 60.2%
of dentists use sedation in their practice.48 In the U.S., the most common sedation modality in
dentistry was nitrous oxide (77%), followed by oral sedation (40%), parenteral moderate
sedation (22%), deep sedation (13%) and general anaesthesia (10%).47 Most general dentists
and dental specialists utilize DS/GA to some degree through medical or dental
anesthesiologists, however, the three dental specialties that utilize DS/GA most commonly in
their practices are dental anaesthesiologists, oral & maxillofacial surgeons, and pediatric
dentists.47 The latter group does not provide DS/GA, but must bring in a DS/GA provider.
According to the AAPD, 63% of pediatric dentists perform conscious sedation, and
80% utilize DS/GA services provided by an anaesthesiologist.49 The majority of these
pediatric dentists that offer DS/GA for their patients have less than five days of OR privileges
per month.49 Twenty seven percent of AAPD pediatric dentist members work with a dental
anaesthesiologist to offer DS/GA to their patients in an ambulatory clinic setting, while 65%
of members would be interested in working with a dental anaesthesiologist if one were
available.50 Thus, pediatric dentists are interested in offering more DS/GA services to their
patients, through dental anaesthesiologists, in ambulatory out of hospital settings.
1.4.1 - Recognition of need for DS/GA by dentists
The ability of the dentist to recognize which patients require or would benefit from
DS/GA is a strong component of patients’ access to DS/GA. Many patients may not even be
12
aware that DS/GA is a service offered for dentistry, and so dentists need to recognize which
patients should have this service offered to them.18 Unfortunately, studies have shown that
dentists greatly underestimate the number of patients who require DS/GA48,51 What is
challenging is that each dentist’s perception of DS/GA is influenced by their past experiences
with sedation or anaesthesia, and their personal beliefs and attitudes towards sedation49,52
Furthermore, the dentist’s education on sedation and anaesthesia topics, as well as his/her own
sedation training is a strong component of his/her beliefs about sedation for dentistry.49,52
Studies have shown that dental students are not satisfied with the amount of sedation
education they receive in dental school.53 The great majority of dentists also feel they do not
have enough training and the skillset to effectively manage patients who are dentally anxious,
and 91% of dental professionals stated that they feel anxious themselves when treating dental
anxious patients.54 It has been suggested to increase sedation and anaesthesia education in
dental school, in hopes of reducing this underestimation of DS/GA need by dentists.52,53 While
lack of sedation and anaesthesia education is likely one of the factors responsible for the
underestimation of DS/GA by dentists, the other factors behind this underestimation are not
known, and future research should aim to determine these factors. Initiatives can then be
implemented to ensure dentists are more effective in recognizing which patients would benefit
from DS/GA, so those patients can have adequate access to sedation services, and in turn more
access to oral healthcare in general.
1.4.2 - Access to DS/GA for dental procedures
Ontario patients’ access to DS/GA services for dental procedures has not been studied,
however, it is suggested that the access is not adequate.45 This seems to be especially
prominent in rural populations, patients with special needs, and pediatric patients.45 In general,
there are fewer providers of DS/GA in rural communities, and these patients have less access
13
to sedation services for dental procedures.31 There are also less hospital based dental ORs, as
there are fewer healthcare providers (both medical anaesthesiologists and dentists) in these
regions.55,56 One of the patient populations who experience significant barriers to access to
DS/GA, and who need it significantly, are patients with special needs.57 These patients have
reported wait times of 12 months to receive in hospital DS/GA for dentistry.57 Longer wait
times have also been reported, as some frustrated family members of this patient population
have voiced concerns to local newspapers regarding wait times of 1-2 years to receive dental
care in a hospital setting under GA.58
Another patient group that utilizes DS/GA for dentistry extensively, and so who
requires sufficient access to these services, is the pediatric population. Unfortunately, long
wait times have been reported in this patient population as well. Parents have reported wait
times of up to 1 year for their child to receive DS/GA for dentistry.59 It is due to long wait
times that the 2007 Wait Times Guarantee project identified DS/GA for pediatric dentistry as
one of six areas of pediatric healthcare that need to have wait times shortened.60 The Pediatric
Oral Health Research and Policy Centre has also identified DS/GA for pediatric dentistry as a
necessary service, as it improves access to dental care.61 Thus, it appears that access to oral
health is hindered in a significant portion of the pediatric population, due to long wait times to
access DS/GA for dental care. A possible solution can be to implement more community-
based surgicentres that offer DS/GA for dentistry, as reports have suggested that these centres
are less costly to the healthcare system, and more accessible to patients, and can improve wait
times for access to DS/GA services for dentistry.62
Adams et al constructed a theoretical framework for access to DS/GA for dentistry on
Ontario.45 Along with demographic information on the utilization of DS/GA, this framework
can be used to identify which Ontario patients have limited access to sedation services, and
14
how their access can be improved. The framework is an essential component of determining
the potential barriers that may exist to access DS/GA for dentistry.45
1.5 - Potential barriers to access DS/GA for dentistry
There are many potential barriers to DS/GA for dentistry, and different studies have
outlined some of these barriers. Some of these barriers include: the additional costs to
patients,2,49,63 lack of insurance coverage of DS/GA49,63 lack of coverage from social
assistance programs40,49,64 costs to the dentist,48,49 dentists feeling they do not need DS/GA
services in their practice,48,49,51perception of risks associated with DS/GA,48,49 lack of patient
acceptance of DS/GA,32,48,49 long wait times for DS/GA appointments,26,58,65,66 not having a
DS/GA provider available,35 not knowing DS/GA is available for dentistry,67 difficulty
identifying which patients require DS/GA,48,51 feeling conscious sedation is adequate and
DS/GA is unnecessary,49 lack of DS/GA related continuing education,48,49,53,68 feeling DS/GA
do not remunerate well considering the risk,48 and lack of hospital privileges.46
The most significant perceived barriers that have been studied in more detail are the
costs of DS/GA to the patient, costs to the dentist, wait times associated with DS/GA, and
perceived risk and acceptability of DS/GA.
1.5.1 - Costs to the patients associated with DS/GA
There are clearly additional costs to patients if they have DS/GA services for dental
procedures, and some insurance policies do not cover these costs, or only cover a small
portion of these costs.45 If patients do not have insurance coverage to pay for the significant
costs of sedation, it may make DS/GA unfeasible or impossible. In Chanpong et al’s study of
the need and demand for DS/GA in dentistry, they found that in the Canadian population,
12.4% patients were definitely interested in DS/GA, with an additional 42.3% interested
depending on cost.2 In patients who have high dental fear, 31.1% were definitely interested in
15
DS/GA, with an additional 54.1% interested depending on cost.2 If finances are the reason
these highly dental phobic patients cannot access DS/GA, it will likely affect their access to
oral healthcare and result in decreased regular dental care. It should be noted that there are
additional indirect costs to patients as well, such as taking time off work for DS/GA dental
appointments, arranging for an escort to accompany them home from the appointment, and
travel costs.45
1.5.2 - Costs to the dentists associated with DS/GA
There are numerous direct and indirect costs to dentists if they choose to offer DS/GA
in their practices. The direct costs include hiring additional staff, such as registered nurses,
purchasing pharmaceutical agents for delivering DS/GA, having the required monitors and
anaesthetic equipment, and having the adequate permit and insurance.4 In order to provide
DS/GA in their office, dentists are required to pay a facility inspection and permit fee of $750,
and then pay subsequent fees for inspections on a periodic basis.69 Furthermore, providers of
DS/GA are required to pay an annual fee of $150-$600 for the sedation permit.70
The indirect costs associated with offering DS/GA are that dentists are not able to
provide recall examinations and hygiene checks while providing dental care to a patient under
DS/GA. This is the case if the dentist is working in his office, as he will not be able to leave
the chair-side of the anesthetized patient, and it is also the case if the dentist is at a hospital
caring for patients under DS/GA, away from the hygienists in his office.45 Due to these direct
and indirect costs, some dentists feel the remuneration of offering DS/GA in their practice is
not adequate,49 and this may be one of the barriers that prevent access to DS/GA for some
patients.
16
1.5.3 - Wait times
Studies have shown that long wait times could be one of the barriers associated with
DS/GA for dentistry60,65 This is especially true in the pediatric population, as only
approximately one half of Canadian children are able to get dental treatment under DS/GA in
a timely fashion. Due to this fact, the Wait Times Alliance Report Card has given dental care
under DS/GA the lowest grade of “D”.71 Not only do these long wait times affect the oral
healthcare of children, but long wait times for dental GA lead to longer wait times for other
pediatric surgeries, and so other areas of pediatric healthcare may be compromised as well.72
Canadian studies have shown that community-based dental surgicentres would be beneficial
for treating healthy children, as there services are less costly to the government and they
would reduce wait times for dental rehabilitation under DS/GA.62
The pediatric population is not the only patient group that is potentially affected by
long wait times for dental DS/GA. Adult patients with special needs have also been reported
to experience unacceptable wait times to receive DS/GA in hospital for dental treatment57,73
Although the wait times in community based dental surgicentres have not been formally
studied, it is suggested that they help reduce the burden on hospitals, and they will reduce the
wait times for dental DS/GA.62 Thus, implementation of more dental surgicentres should be a
topic of discussion in Canada’s health policy and health economics meetings.
1.5.4 - Perceived risk and acceptability of DS/GA
Dentists play one of the most important roles in access of patients to DS/GA services,
as oftentimes they make a clinical judgment on which patient(s) would benefit from DS/GA.
Furthermore, dentists’ attitudes towards DS/GA play an important part in their decision
making of who should receive sedation and anaesthesia for dental procedures.67 Dentists’ own
experiences with sedation and general anaesthesia and their knowledge, or lack of knowledge
17
of anaesthesia, contribute to their attitudes towards DS/GA.67 Some dentists are also
concerned about possible litigation that may arise from offering DS/GA in their practice.53
Furthermore, the perception of risk associated with anaesthesia may be a significant
barrier to DS/GA.32 A dentist who feels anaesthesia is “too risky” may convey information to
a patient and persuade them to try to tolerate dental treatment without DS/GA, although that
patient may benefit from sedation. Risk perception of anaesthesia is also an important barrier
in pediatric dentistry.49 Children who require DS/GA for dentistry but attempt to have
conscious dental care may become dental phobic and severely dental anxious patients who
will avoid dental visits in the future. These patients will generally only present for emergency
appointments and will require DS/GA for dental treatment in the future.7,15
Parents’ perception of risk associated with DS/GA has also been noted to be
significant. Although some studies have found that parents have a favorable view of DS/GA
for dentistry,32 there is still some evidence that suggests parents do not view general
anaesthesia as a highly accepted technique to facilitate dental treatment.74 Studies have
reported up to 15% of parents are not in favor of sedation and general anaesthesia to facilitate
dental treatment for their children, however, it should be noted that this attitude was most
commonly seen in very anxious parents.75 The possible unfavourable views of DS/GA are
likely due to parents’ perceived risk associated with sedation and anaesthesia.74 It is important
to recognize that DS/GA was still viewed as more favorable to restraints and hand over mouth
techniques in almost all studies,32,75 but the perceived risk of DS/GA by parents can be a
potential barrier to access to these services for pediatric patients.
Thus, the perception of risk associated with anaesthesia is an important barrier to the
access of DS/GA for dental care. Studies have actually shown that the acceptability of
anaesthesia by patients and dentists is related to their perception of the risk associated with
anaesthesia.32 What is important to recognize is that dental anaesthesia carries a very
18
favourable safety profile. An Ontario study of the anaesthesia related mortality prevalence in
outpatient dental settings revealed a risk profile of 1.4 in 1,000,000 mortality rate.76
1.6 Dentists’ perception of barriers to access to DS/GA
A recent study by Adams et al constructed a theoretical framework for the access of
DS/GA services for dentistry, and identified Ontario dentists’ perceptions of the main barriers
to access these services.45 They also studied the utilization patterns of DS/GA across Ontario,
to see if there is a relationship between access and utilization of DS/GA. Interestingly, they
found an inverse relationship between utilization and access of DS/GA, with the lowest
utilization rates in the urban areas of the Greater Toronto Area (GTA), and the highest rates in
rural Northern Ontario.45 The various perceived barriers to access to DS/GA were classified
by dentists who utilize general anaesthesia services and those who do not.
Dentists who utilize DS/GA in their practice, defined as either having provided or
referred a patient for DS/GA in the past year, reported the following barriers to be the most
significant: costs to patients (66.2%), inadequate coverage from social assistance programs
(56.8%), lack of third party insurance coverage (47.9%), lack of patient or parent acceptance
(24.8%), and too time consuming to incorporate DS/GA into practice (23.8%).45 In contrast,
dentists who do not utilize DS/GA in their practice reported the following barriers to be the
most significant: no need in my patient base (68.3%), conscious sedation is adequate and
DS/GA is unnecessary (45.3%), costs to the patient (28%), unnecessary risk associated with
DS/GA (18.1%), and inadequate coverage from social assistance programs (16.5%).45
Cost to the patient and to the dentist therefore is the most commonly reported barrier to
DS/GA as reported by dentists. The attitudes of dentists who do not utilize DS/GA are a
significant barrier to access to DS/GA for dental patients.45 25.5% of dentists never utilize
DS/GA, which means that a significant patient population who may benefit from sedation
19
services does not have these services offered to them.45 Although the nature of the attitudes of
dentists towards DS/GA are multifactorial, part of the problem may be related to lack of
knowledge about DS/GA, which is a result of lack of education. It has been suggested that
lack of DS/GA related continuing-education (CE) courses can pose a barrier to access.68 With
sufficient access to DS/GA related CE courses, dentists would be able to better understand the
risks and benefits, indications, and safety profile of general anaesthesia, which would aid them
in patient screening and selection for these services.45 The majority of Ontario dentists also
believe more access to anaesthesia related CE would allow them to better care for their
patients.45 Unfortunately, the need for DS/GA has been shown to be underestimated by
dentists48,51This is despite the fact the demand for DS/GA for dentistry is increasing, and so it
indicates that dentists’ attitudes towards DS/GA are a significant barrier to patients’ ability to
access these services.49,50,77–79 Perhaps this should trigger dental schools and dental
associations to offer more education with regards to sedation and anaesthesia, to ensure
dentists are well informed about these services.
Wait times and travel distance were not one of the dentists’ perceived barriers to
access by either group of utilizers and non-utilizers of DS/GA. However, Ontario research has
shown that long travel distances and wait times are a significant issue for some patients,
especially individuals with disabilities.40 Furthermore, patients of offices that use an itinerant
anaesthesiologist are 2.5 times more likely to experience wait times greater than three months,
compared to dental anaesthesiologist and oral & maxillofacial surgeon offices.45 This may
indicate that dental anaesthesiologists and oral & maxillofacial surgeons are able to screen
which patients require DS/GA and treat them in a timely manner, compared to offices that
only offer DS/GA on a part-time basis.45 However, patients are more likely to travel a distance
greater than 50 km to these specialist offices that offer full time DS/GA, as these offices are
limited in number.45 Nevertheless, these results indicate the importance of community-based
20
offices that regularly offer DS/GA, in order to ensure adequate access to oral healthcare for
patients who require sedation and anaesthesia.
Finally, one of the most important barriers to access of DS/GA in dentistry, as
perceived by dentists, was cost and finances.45 Cost has also been identified by Canadian
patients as a barrier to DS/GA.2 Since cost is perhaps the most significant barrier to DS/GA in
dentistry, private and public insurance companies should begin to recognize DS/GA as an
essential dental service.45 Furthermore, it has been shown that community-based surgicentres
are less costly to the government and can improve access, and decrease wait times for dental
DS/GA.62 However, although these surgicentres will benefit the healthcare system from a
financial standpoint, patients will have added costs, as anaesthesia and facility fees are not
publicly funded in community dental offices.45 This emphasizes the previous notion that
insurance parties, both private and public, should begin to dedicate more funding for DS/GA
for dental procedures. If these ideas are implemented and costs to patients are reduced, one of
the major barriers of DS/GA access, and in turn barriers of access to oral healthcare, will be
reduced or eliminated.
1.7 Patients’ perception of barriers to access to DS/GA
The barriers of DS/GA for dentistry, as perceived by patients, have not been formally
studied. Adams et al’s theoretical framework for access to dental anaesthesia in Ontario45 can
be adapted to identify potential barriers. Survey method could then be used to collect
information on which barriers patients feel are most important. Comparison of the previously
reported dentists’ perception with the information on patients’ perception would be important
in identifying areas of improvement in the access of DS/GA. This information could have
implications in the access to oral healthcare for many patient groups, such as pediatrics, dental
anxious patients, and individuals with disabilities.
21
CHAPTER 2
2.1 – Methodology
The study used a cross-sectional mail-out survey, which was approved by the
University of Toronto Health Sciences Research Ethics Board (Protocol No.32841). The
sampling frame consisted of the total sample of patients in the patient registry of the
University of Toronto, Faculty of Dentistry, who received DS/GA for dental procedures at the
ambulatory Surgicentre from January 2014 to January 2016. This list was extracted using
Axium software clinic management system version 4.41.12 (Exan Group, Coquitlam,
Canada.) This sampling frame accounted for 602 patients. Additionally, 400 patients from the
private practice of 20 Ontario dental anaesthesiologists were included.
Participants who were patients at the Faculty of Dentistry were mailed a package,
which included the introduction and aims of the survey, the questionnaire, as well as a prepaid
return postage envelope. Following the recommendations of Dillman, Smyth, and Christian,80
the package was mailed to non-responders two more times (2 reminders), with each reminder
sent two weeks following the previous mail-out. Two weeks after the third wave of mail-outs,
phone calls were made to all non-responders to remind them to participate. Those participants
who requested another questionnaire were sent a new package. Finally, all participants were
sent a “Thank You” postcard two weeks after the phone call reminders, thanking them for
participating in the study, and also reminding non-responders to participate.
The university-based convenience sample was supplemented by an external
convenience sample (n=400) of the patients of 20 practicing dentist anaesthesiologists. These
practitioners were all Canadian Academy of Dental Anaesthesia members and practice in
Ontario. Each of the 20 members distributed the surveys to 20 in-office patients. These dentist
anaesthesiologists were instructed to avoid explanation of questions and reviewing
participants’ responses. The external participants were asked to complete the questionnaire at
22
home and return it using the prepaid return postage envelope. No gift or remuneration was
provided to study participants.
2.2 - Survey instrument
The theoretical framework for access to DS/GA in Ontario45 (Figure 1), which is based on
previously validated frameworks of access to healthcare,81–83 was used to construct the survey
tool. The survey tool was pilot tested amongst 10 patients at the University of Toronto,
Faculty of Dentistry’s Surgicentre clinic, in order to evaluate the face validity of the design,
respondent burden, time needed to complete the survey, and level of understanding of the
survey. After revisions, the survey tool was finalized based on two domains:
Domain 1 included questions based on which factors participants perceive to be the most
significant barriers to accessing DS/GA, as well as factors that may truly inhibit access to
DS/GA.45 These included wait times, driving distance and travel times to the appointment,
having to take work-days off for the appointment, and satisfaction with DS/GA.
Domain 2 included questions based on the participants’ characteristics such as age, sex,
location/region, education, marriage status, immigration status, employment status, income,
and health attitudes and behaviours.
2.3 - Sample size calculation
The sample size (n) calculation was based on the population size (N), proportion of
population expected to choose 1 of 2 responses (P=0.5 to allow for maximum variance), the
assumed sampling error (C=0.05), and the Z-statistic of 1.96 (for a 95% confidence interval –
CI).84 Assuming that approximately 75% of the Ontario population accesses dental care,85 an
Ontario population of 13.6 million (N), and that 1% of patients in Ontario have had DS/GA
23
for dental procedures (excluding exodontia), the sample size of 384 was calculated: n = [
(N)(P)(1-P) ] / [ (N-1)(C/Z)2 + (P)(1-P) ]
The sample target was increased to 602 University patients and complemented with a
400 person sample of private practice patients for a total sample of 1,002 patients, to ensure
adequate number of responses for analysis of the data.
2.4 - Data analysis
Data from the mail-out surveys was entered into Epi Info software (Centre for Disease
Control and Prevention, Atlanta, GA.) The final database was exported to Microsoft Excel
(Microsoft Corp, Redmond, WA) and then to the Statistical Package for Social Sciences
software 22.0 (IBM Corp, Armonk, NY) for statistical analyses. The results were summarized
by using descriptive analysis, using frequencies (counts and percentages). For each question,
responses that were left blank were not included in the descriptive analysis. Rank analysis was
conducted to determine the barriers that patients feel are the most significant to accessing
dental anaesthesia.
Bivariate analysis was used to evaluate individual significant variables for reporting
barriers as “very important” or “important” by using X2 tests, with P < 0.05 indicating
statistical significance. The significant variables were further explored using binary logistic
regression, where all significant variables were entered into the model. Logistic regression of
the bivariate findings was computed to determine potential correlation between variables and
the relative importance, and to identify significant predictors of reporting barriers as
important, with P < 0.05 indicating statistical significance.
24
CHAPTER 3 – RESEARCH PAPER
ACCESS TO DEEP SEDATION AND GENERAL
ANAESTHESIA SERVICES FOR DENTAL PATIENTS: A
SURVEY OF ONTARIO PATIENTS
Soheil Khojasteh DDS, Amir Tehrani, Andrew C Adams DDS, MSc, Dip. ADBA, Carilynne Yarascavitch DDS, MSc, Dip. ADBA, Carlos
Quiñonez DMD, MSc, PhD, FRCD(C), Amir Azarpazhooh DDS, MSc, PhD, FRCD(C),
Faculty of Dentistry, University of Toronto
Corresponding author:
Dr. Amir Azarpazhooh, DDS, MSc, FRCD (C) (DPH), Cert. Endo., PhD, FRCD (C) (Endo) Faculty of Dentistry, University of Toronto Email: [email protected] Tel: (416) 579-4908 Ext. 4429 This study was funded by the American Society of Dental Anaesthesiologists Education and Research Foundation
25
ABSTRACT
Background: Patients can require deep sedation or general anaesthesia (DS/GA) in order to
undergo dental treatment. Indications for DS/GA include fear, anxiety, pre-cooperative age,
physical or intellectual disabilities, complex medical status, and extensive dental treatment.
There is significant demand for DS/GA services; however, there is little evidence of the
barriers that prevent patients from accessing DS/GA.
Objectives: This study aims to assess the barriers to access to DS/GA as identified by Ontario
dental patients.
Methods: Data were collected through a mail-out survey sent to patients who received DS/GA
at the University of Toronto, Faculty of Dentistry (n=602), as well as the patients of 20
practicing community-based dental anaesthesiologists (n=400). Participants were asked to
identify their indications for receiving DS/GA for dental care, the procedures they prefer
DS/GA for, and the factors they believe to be significant barriers of access to DS/GA.
Descriptive and regression analysis were performed.
Results: A total of 890 surveys was received (Response Rate = 36%). The majority of the
survey responders were patients from the University of Toronto Faculty of Dentistry (51.4%).
The most common indications for DS/GA were pre-cooperative age (45.8%), fear of dentistry
(42.0%), and dental anxiety (38.9%). The most frequent procedures which patients required
DS/GA for were restorations (52.0%), exodontia (49.5%), crown and bridge (38.2%), and root
canal treatment (26.6%). Participants identified the added cost of DS/GA and the lack of
funding for these services as the most significant barrier to accessing DS/GA for dental
26
treatment. The next most identified barriers were long wait times and lack of dentists available
to provide DS/GA.
Conclusions: Access to DS/GA for dental treatment in Ontario is limited by lack of insurance
and government funding for these services, as well as decreased availability of providers of
DS/GA.
Significance: Public and private funding for DS/GA services can increase community access
to these services and take the burden of delivery of this care off of the provincial healthcare
system. These findings are consistent with data from a previous study by our research team, in
which Ontario dentists identified costs to the patient as a major barrier to access.
27
INTRODUCTION
There is significant demand for deep sedation/general anaesthesia (DS/GA) services in
dentistry. A national survey of the Canadian population has showed that approximately 12%
of patients prefer DS/GA for dental procedures, and a further 42.3% are interested depending
on cost.1 Indications for DS/GA in dentistry include fear, anxiety, pre-cooperative age,
physical or intellectual disabilities, complex medical status, and extensive dental treatment.2–4
Although there are various indications for DS/GA in dentistry, the three most common patient
populations who require sedation for dental procedures are patients who have dental anxiety,
pediatric patients, and patients with disabilities.4 Studies have shown that 11.2%-11.7% of the
U.S. population reported “high dental fear” and approximately 10% of Canadians indicated
similar fear levels. 1,5,6 These dental anxious patients are more likely to avoid regular dental
care and neglect their oral health, and thus, they are more likely to present for emergency
dental appointments.4,7,8 Studies have also shown that there is a significant correlation with
dental anxiety and demand for sedation.1,4 There is also significant demand for DS/GA for
pediatric patients.9–11 In fact, in Canada, pediatric dental surgery under general anaesthesia is
the most common day surgery procedure done in hospital operating rooms.12,13 This creates
long wait times for dental treatment for many patients. Furthermore, DS/GA is an essential
service for dental patients with intellectual disabilities, as a high proportion of these patients
require sedation due to dental anxiety and poor cooperation.3,14
The patient’s perspective on barriers to access of DS/GA services for dental procedures has
not been studied, although it is suggested that the access is inadequate.15 Previous research by
our team studied the barriers to DS/GA as identified by Ontario dentists, and it showed that
28
access to DS/GA is not uniform.15 The added cost to patients and dentists’ attitude of lack of
perceived demand for DS/GA were identified as the most significant barriers to access to
DS/GA.15 This study aimed to determine the factors that patients who have received DS/GA in
the past two years believe to be the most significant barriers in accessing DS/GA.
MATERIALS AND METHODS
Design: The study used a cross-sectional mail-out survey of a convenience sample of patients
who have received DS/GA care. The protocol and survey were approved by the University of
Toronto Health Sciences Research Ethics Board (Protocol #32841.)
Participants: The sample consisted of the total number of patients in the patient registry of the
University of Toronto, Faculty of Dentistry, who received DS/GA for dental procedures at the
ambulatory Surgicentre from January 2014 to January 2016. This list was extracted using
Axium software clinic management system version 4.41.12 (Exan Group, Coquitlam,
Canada). This sample accounted for 602 patients. Additionally, 400 patients from the private
practice of 20 Ontario dental anaesthesiologists were included, for a total N of 1,002.
Participants who were patients at the Faculty of Dentistry were mailed a package, which
included the introduction and aims of the survey, the questionnaire, as well as a prepaid return
postage envelope. Following the recommendations of Dillman, Smyth, and Christian,16 the
package was mailed to non-responders two more times (2 reminders), with each reminder sent
two weeks following the previous mail-out. Two weeks after the third wave of mail-outs,
phone calls were made to all non-responders to remind them to participate. Those participants
who requested another questionnaire were sent a new package. Finally, all participants were
sent a “Thank You” postcard two weeks after the phone call reminders, thanking them for
participating in the study, and also reminding non-responders to participate. The university-
29
based sample was supplemented by an external sample of the patients of 20 practicing dentist
anaesthesiologists. These practitioners were all Canadian Academy of Dental Anaesthesia
members and practice in Ontario. Each of the 20 members distributed the surveys to the first
20 patients they treated after receiving the survey. These dentist anaesthesiologists were
instructed to avoid explanation of questions and reviewing participants’ responses. The
external participants were asked to complete the questionnaire at home and return it using the
prepaid return postage envelope. No gift or remuneration was provided to study participants.
Survey instrument: The conceptual framework for access to DS/GA in Ontario15 (figure 1),
which is based on other frameworks of access to healthcare,17–19 was used to construct the
survey tool. The survey tool was pilot tested amongst 10 patients at the University of Toronto,
Faculty of Dentistry’s Surgicentre clinic, in order to evaluate the face validity of the design,
respondent burden, time needed to complete the survey, and level of understanding of the
survey. After revisions, the survey tool was finalized based on two domains:
- Domain 1 included questions based on which factors participants perceive to be the
most significant barriers to accessing DS/GA, as well as other factors that may inhibit
access to DS/GA.15 These included wait times, driving distance and travel times to the
appointment, having to take work-days off for the appointment, and satisfaction with
DS/GA.
- Domain 2 included questions based on the participants’ characteristics such as age,
sex, location/region, education, marriage status, immigration status, employment
status, income, and health attitudes and behaviours.
Sample size calculation: The sample size (n) calculation was based on the population size
(N), proportion of population expected to choose 1 of 2 responses (P=0.5 to allow for
30
maximum variance), the assumed sampling error (C=0.05), and the Z-statistic of 1.96 (for a
95% confidence interval – CI).20 Assuming that approximately 75% of the Ontario population
accesses dental care,21 an Ontario population of 13.6 million (N), and that 1% of patients in
Ontario have had DS/GA for dental procedures (excluding exodontia), the sample size of 384
was calculated: n = [ (N)(P)(1-P) ] / [ (N-1)(C/Z)2 + (P)(1-P) ].
Data analysis: Data from the mail-out surveys was entered into Epi Info software (Centre for
Disease Control and Prevention, Atlanta, GA). The final database was exported to Microsoft
Excel (Microsoft Corp, Redmond, WA) and then to the Statistical Package for Social Sciences
software 22.0 (IBM Corp, Armonk, NY) for statistical analyses. The results were summarized
by using descriptive analysis, using frequencies (counts and percentages). For each question,
responses that were left blank were not included in the descriptive analysis. Rank analysis was
conducted to determine the barriers that patients feel are the most significant to accessing
dental anaesthesia.
Bivariate analysis was used to evaluate individual significant variables for reporting barriers
as “very important” or “important” by using X2 tests, with P < 0.05 indicating statistical
significance. The significant variables were further explored using binary logistic regression,
where all significant variables were entered into the model. Logistic regression of the bivariate
findings was computed to determine potential correlation between variables and the relative
importance, and to identify significant predictors of reporting barriers as important, with P <
0.05 indicating statistical significance.
31
RESULTS
Sample characteristics
The survey was sent to a total of 1,002 patients, yet only reached 890 patients due to address
changes. 319 (36%) of the 890 patients completed and returned the mail-out survey. 164
patients were from the University of Toronto, Faculty of Dentistry and 155 were private
practice patients (Figure 2). Highlights of the sample characteristics (Table 1 and Table 2)
include:
- Demographic characteristics: The majority of patients who received DS/GA were
males (51.1%), aged 3-10 (56.3%) and living in the Greater Toronto Area (58.3%).
Most of the survey respondents were married (62.8%), born in Canada (58.6%) and
had a community college education. Most of those born outside of Canada (69.1%)
immigrated to Canada more than 10 years ago.
- Socioeconomic characteristics: Most survey respondents were full time employed
(40.1%) and received income from wages and salaries (54.5%). Almost half of the
respondents had a family income of less than $40,000. The majority of the respondents
used government assistance programs to pay for dental care (41.1%) and had to pay
out of pocket for DS/GA (42.2%).
- Health attitudes and behaviors: The majority of patients had their last visit to the
dentist less than one year ago (62.0%) and rated both their present overall health and
oral health as “excellent/very good”. They value aspects of oral function such as
“having no pain” and “being able to chew and taste” more so than aesthetics.
32
Factors relating to deep sedation/general anaesthesia
The most common indications for DS/GA were pre-cooperative age (45.8%), fear (42.0%),
and anxiety (38.9%) (Figure 3). The majority of patients received DS/GA at the University of
Toronto’s Faculty of Dentistry (51.8%), followed by “specialist’s office” as the second most
common location (30.4%). The procedures that patients needed DS/GA for the most were
restorations, exodontia, crown and bridge, and root canal treatments. Patients also indicated
that they would be most interested in receiving DS/GA for these same four procedures in the
future (Table 3). Most patients were referred by their family dentist, had a driving distance of
<50 km (87.1%), driving time of <1 hour (67.7%) to the sleep dentist office, and an average
wait time of 1 to <3 months (57.1%). The majority of patients had to take one day off from
work or school for the DS/GA appointment (Table 4).
In general, the majority of patients were satisfied with their appointment and access to DS/GA
(Table 5). Moreover, majority of participants believed that DS/GA improved their ability to
undergo dental treatment [significantly (79.7%) or somewhat (15.8%)]. The factors that some
patients were dissatisfied with were the wait time to get an appointment and appointment
factors such as the placement of the IV needle or the amount of shivering experienced after the
appointment.
Barriers of deep sedation/general anaesthesia
The most frequently reported barriers are related to the payment and funding of DS/GA
(Figure 4). The wait times and lack of dentists available to provide DS/GA are the next most
significant barriers to DS/GA. Rank analysis was also performed on the barriers (Figure 5).
This rank analysis yields the same top 5 barriers as the descriptive analysis (Figure 4), which
33
shows consistency and confirms the most important barriers. The most significant barriers of
access to DS/GA for dentistry are related to the cost and funding of DS/GA (mean scores 2.25
- 2.40), the long wait times associated with DS/GA (mean score 2.12), and the lack of
availability of providers for DS/GA services (mean score 2.10).
Predictors of reported important barriers
The significant variables for reporting barriers as “very important” or “important” were
identified through bivariate analysis (Table 6). These significant variables at the bivariate
level were entered into a logistic regression model to identify predictors of reporting important
barriers at the multivariate level (Table 7). Private practice patients were less likely to report
“having to take time off work” as an important barrier (odds ratio [OR] = 0.4; 95% CI 0.2 –
0.9, p <.05). Furthermore, patients aged 0-17 were significantly more likely to report “lack of
insurance coverage” (OR = 2.6; 95% CI 1.2 – 5.4, p <.05), “longer wait times for treatment”
(OR = 4.7; 95% CI 1.6 – 14.3, p <.01) and “added risk associated with sleep dentistry” (OR =
1.8; 95% CI 1.0 – 3.4, p <.05) as important barriers. Patients residing in Northern, Central, and
Eastern Ontario were significantly more likely to report “longer wait times for treatment” (OR
= 5.7; 95% CI 1.2 – 26.5, p <.05) as an important barrier. Patients who pay for DS/GA
through government assistance programs were less likely to report “lack of insurance
coverage” (OR = 0.3; 95% CI 0.1 – 0.6, p <.01) and more likely to report “having to arrange
for ride from the appointment” (OR = 1.9; 95% CI 1.1 – 3.2, p <.05) as important barriers.
Finally, patients who have to drive 50 km or greater to their appointment are more likely to
report “not having access to a vehicle” (OR = 2.8; 95% CI 1.2 – 6.4, p <.05) as an important
barrier, and patients who have to drive one hour or longer to their appointment are more likely
to report “lack of number of providers of DS/GA” (OR = 4.3; 95% CI 1.2 – 15.6, p <.05) as an
important barrier.
34
DISCUSSION
The purpose of this survey was to assess Ontario patients’ perceptions of barriers to DS/GA
for dental treatment. The sample for this study was a convenience sample of patients who
received DS/GA over a period of two years. We did not study patients who require DS/GA but
have not yet accessed, or are not yet able to access this service due to the barriers which exist.
However, our sample still allowed us to examine the barriers to DS/GA. Our response rate of
36% was within the range of 24% - 43% of other surveys of Ontario dental patients.20,22,23
The most frequently identified barriers to access to DS/GA for dental treatment were the cost
and lack of insurance coverage of DS/GA, and the majority of the patients in our study paid
out of pocket for the DS/GA service they received. This finding is consistent with Ontario
dentists’ most frequently identified barrier to access to DS/GA.15 Many insurance programs
still do not cover DS/GA for dental treatment, although it is an essential service for many
patients. Some insurance programs cover DS/GA, but only for specific treatments, such as
exodontia. This is also not ideal, as our research has shown that there are procedures and
treatments other than exodontia for which patients prefer to undergo DS/GA.1
Long wait times and the lack of availability of providers of DS/GA were the next most
frequently identified barriers. The majority of the survey respondents experienced a wait time
of 1 to 3 months, but nearly 40% of the respondents experienced wait times of greater than 3
months, and some respondents even experienced wait times of greater than one year.
Furthermore, two thirds of respondents experienced a driving time of greater than one hour to
get to their appointment. Both the reported long wait times, and the long travel distances in
our study suggest lack of availability of DS/GA providers, which was identified as a
significant barrier.
35
Our logistic regression analysis allowed us to identify predictors of reporting important
barriers, and our results have implications of validity. Patients who reside in Northern,
Central, and Eastern Ontario were nearly six times more likely to report “longer wait times” as
an important barrier, which may suggest inadequate access in areas other than the Greater
Toronto and Hamilton area. Also, parents of pediatric patients are more likely to report longer
wait times and the added risk of DS/GA as barriers. The long wait times may be related to the
fact that pediatric patients are one of the largest utilizers of sedation services in dentistry, and
that anecdotally, not all DS/GA providers in Ontario treat children.24 Furthermore, parents
may be more concerned about the risks of DS/GA for their children due to reports warning
about the use of general anaesthesia in young children.25 Finally, patients who experienced
longer driving times to their appointment were 4.3 times more likely to report “lack of
providers of DS/GA” as an important barrier. These obvious patterns demonstrate that patients
understood the questions in our survey and they strengthen the internal validity of our study.
There are limitations to this study. As previously mentioned, our sample was a convenience
sample, not a random sample. Furthermore, we surveyed patients who have already received
DS/GA in the past, and we did not study patients who require DS/GA, but have not received
treatment. Also, some of the larger groups of DS/GA users, namely patients from Northern
Ontario, rural patients, Indigenous patients, and patients with disabilities, were likely under-
represented in this study.3,13,14,26–28 Patients sedated and anaesthetized by medical
anaesthesiologists were not represented in our study either. Since these patients are likely
receiving care at offices that provide DS/GA services on a part-time basis, they may report
and encounter different barriers than the patients in our study, such as longer wait times.15 We
also chose not to include hospital patients in our study, as the majority of DS/GA that is
36
provided for dentistry is outside of the hospital setting and the access to care framework we
utilized was constructed based on the ambulatory setting.29
Our research is novel, as it is the first study to determine which factors patients believe are
significant barriers to accessing DS/GA for dental treatment. We also used two different
sample groups, which included an external sample of private practice patients, in order to
increase the external validity of our study. Our findings have important implications in the
areas of dental public health, health policy, and healthcare provider education.
The results of this study suggest that the added cost and the lack of insurance funding of
DS/GA are major barriers to accessing DS/GA, which is consistent with results from our
previous research.15 This finding is important to both public and private stakeholders. DS/GA
is an essential service in dentistry, and limitations on the insurance coverage of these services
should be reviewed. Critically, previous studies have shown that the cost of dental surgery
under DS/GA is much less in community-based clinics compared to in hospital operating
rooms.30,31 However, although the cost per patient would likely be reduced in community-
based clinics compare to hospital operating rooms, the overall cost of care may be increased or
unaltered, as more patients would be able to access dental care under DS/GA. Additionally, as
wait times for treatment may be reduced by implementing more community based clinics, we
may see a reduction in the number of patients presenting with pain and infection to hospital
emergency room, which may ultimately reduce public healthcare costs. Since there are a
number of factors involved in the economic impact of these community-based clinics, a health
economic study and cost analysis would be beneficial in determining the effect of these clinics
on public expenditure.
37
Therefore, funding sources which support community-based care may be the most cost
effective. However, increasing the number of community based clinics would likely increase
costs to patients, as anaesthesia and facility fees are not covered by the Ministry of Health and
Long-Term Care in community clinics. This reiterates the importance of increasing funding of
DS/GA and removing restrictions on the coverage of these services by private dental insurance
providers.
Furthermore, our previous research also concluded that dentists’ attitudes towards and lack of
knowledge of DS/GA are major barriers in patients’ access to these services.15 Hence, dentists
need more education regarding the indications, risks and benefits, supply and demand of
DS/GA, as well as the procedures for which patients generally prefer DS/GA. Dental
education of this topic should be improved in professional school settings, and also in
continuing education programs. Improving education of healthcare providers will also
improve patient education regarding DS/GA, and it will likely have meaningful improvements
in access to care.
While increasing insurance funding of DS/GA and improving dentists’ education regarding
DS/GA would lead to more timely referrals and increased access to care, dentists’ efforts
should still primarily be focused on disease prevention, as dental disease is mostly
preventable. Future research should be directed towards analyzing current education patterns
of DS/GA and improving education opportunities of healthcare providers, and ultimately
patients.
38
REFERENCES
1. Chanpong B, Haas DA, Locker D. Need and demand for sedation or general anesthesia in dentistry: a national survey of the Canadian population. Anesth Prog. 2005;52(1):3-11. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=15859442.
2. Dionne R, GORDON S. Assessing The Need for Anesthesia And Sedation in the General Population. J Am Dent Assoc. 1998;129(February 1998):167-173. http://jada.info/content/129/2/167.short. Accessed September 12, 2013.
3. Gordon SM, Dionne R a, Snyder J. Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Spec Care Dentist. 1998;18(2):88-92. http://www.ncbi.nlm.nih.gov/pubmed/9680917.
4. Boyle C a, Newton T, Milgrom P. Who is referred for sedation for dentistry and why? Br Dent J. 2009;206(6):E12; discussion 322-323. doi:10.1038/sj.bdj.2009.251.
5. Gatchel R, BD I, Bowman L, Robertson M, Walke C. The prevalence of dental fear and avoidance: a recent survey study. JADA. 1983;107(4):609-610.
6. Smith TA, Heaton LJ. Fear of dental care. Are we making any progress? JADA. 2003;134(August):1101-1108.
7. Baker R, Farrer S, Perkins VJ, Sanders H. Emergency dental clinic patients in South Devon, their anxiety levels, expressed demand for treatment under sedation and suitability for management under sedation. Prim Dent Care. 2006;13(1):11-18. doi:10.1308/135576106775193932.
8. Allen EM, Girdler NM. Attitudes to conscious sedation in patients attending an emergency dental clinic. Prim Dent Care. 2005;12(1):27-32. doi:10.1308/1355761052894149.
9. Ashley PF, Parry J, Parekh S, Al-Chihabi M, Ryan D. Sedation for dental treatment of children in the primary care sector (UK). Br Dent J. 2010;208(11):E21-E23. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=20543774.
10. Taskinen H, Kankaala T, Rajavaara P, Pesonen P, Laitala M-L, Anttonen V. Self-reported causes for referral to dental treatment under general anaesthesia (DGA): a cross-sectional survey. Eur Arch Paediatr Dent. August 2013. doi:10.1007/s40368-013-0071-2.
11. AAPD. Guideline on Use of Anesthesia Personnel in the Administration of Office-Based
Deep Sedation/general Anesthesia to the Pediatric Dental Patient. Vol 34. 2012. http://www.ncbi.nlm.nih.gov/pubmed/23211905.
12. Canadian Institute for Health Information. Treatment of Preventable Dental Cavities
in Preschoolers: A Focus on Day Surgery Under General Anesthesia.; 2013.
13. Schroth RJ, Quiñonez C, Shwart L, Wagar B. Treating early childhood caries under general anesthesia: A national review of Canadian data. J Can Dent Assoc (Tor).
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2016;82:1-8.
14. Dougall a, Fiske J. Access to special care dentistry, part 1. Access. Br Dent J. 2008;204(11):605-616. doi:10.1038/sj.bdj.2008.457.
15. Adams A, Yarascavitch C, Quinonez C, Azarpazhooh A. Access to deep sedation and general anaesthesia services for dental patients : A survey of Ontario dentists. J Can Dent Assoc. 2017;(In Press).
16. Dillman D, JD S, Christian L. Internet, Mail and Mixed-Mode Surveys. The Tailored
Design Method. Vol Third Edit. Hoboken, New Jersey: John Wiley and Sons; 2009.
17. Aday LA, Andersen RM. Equity of Access to Medical Care: A Conceptual and Empirical Overview. Med Care. 1981;19(12):4-27.
18. Khan AA, Bhardwaj SM. Access to Health Care. A Conceptual Framework and Its Relevance to Health Care Planning. Eval Health Prof. 1994;17(1):60-76.
19. Levesque J, Harris MF, Russell G. Patient-centred access to health care : conceptualising access at the interface of health systems and populations. Int J
Equity Health. 2013;12(1):1. doi:10.1186/1475-9276-12-18.
20. Azarpazhooh A, Dao T, Figueiredo R, Krahn M, Friedman S. A Survey of Patients’ Preferences for the Treatment of Teeth with Apical Periodontitis. J Endod. 2013;39(12):1534-1541. doi:10.1016/j.joen.2013.07.012.
21. Sadeghi L, Manson H, Quinonez CR. Report on access to dental care and oral health inequalities in Ontario. Public Heal Ontario. 2012;(July 2012):21.
22. Koneru A. Access to Dental Care for Persons With Disabilities in Ontario: A Focus on Persons with Developmental Disabilities. 2008.
23. Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Use of mouthguards among 12- to 14-year-old Ontario schoolchildren. J Can Dent Assoc (Tor). 2007;73(6):505 - +. <Go to ISI>://WOS:000248149100009.
24. Hicks CG, Jones JE, Saxen M a, et al. Demand in pediatric dentistry for sedation and general anesthesia by dentist anesthesiologists: a survey of directors of dentist anesthesiologist and pediatric dentistry residencies. Anesth Prog. 2012;59(1):3-11. doi:10.2344/11-17.1.
25. FDA. General Anesthetic and Sedation Drugs: Drug Safety Communication - New Warnings for Young Children and Pregnant Women. US Food Drug Adm. 2016. https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm533195.htm.
26. Lawrence H, Romanetz M, Rutherford L, Cappel L, Binguis D, Rogers JB. Oral Health of Aboriginal Preschool Children in Northern Ontario. Probe (Lond). 2004;38(4):172-190.
27. Wang Y-C, Lin I-H, Huang C-H, Fan S-Z. Dental anesthesia for patients with special needs. Acta Anaesthesiol Taiwan. 2012;50(3):122-125. doi:10.1016/j.aat.2012.08.009.
28. Petrovic B, Markovic D, Peric T. Evaluating the population with intellectual
40
disability unable to comply with routine dental treatment using the International Classification of Functioning, Disability and Health. Disabil Rehabil. 2011;33(19-20):1746-1754. doi:10.3109/09638288.2010.546934.
29. Baird A, Abate R. Hospital Restructuring, Downsizing and Cutbacks - The Impact on
Hospital-Based Dentistry.; 1998.
30. Rashewsky S, Parameswaran A, Sloane C, Ferguson F, Epstein R. Time and cost analysis: pediatric dental rehabilitation with general anesthesia in the office and the hospital settings. Anesth Prog. 2012;59(12):147-153. doi:10.2344/0003-3006-59.4.147.
31. Lalwani K, Kitchin J, Lax P. Office-Based Dental Rehabilitation in Children With Special Healthcare Needs Using a Pediatric Sedation Service Model. J Oral
Maxillofac Surg. 2007;65:427-433. doi:10.1016/j.joms.2005.12.057.
41
Table 1: Participant characteristics
Variables Number (N) Percentage
(%)
De
mo
gr
ap
hic
ch
ar
ac
ter
isti
cs
Age
0-2 8 3.0%
3-10 151 56.3%
11-17 8 3.0%
18-64 85 31.7%
65 + 16 6.0%
Sex Male 158 51.1%
Female 151 48.9%
Region
Greater Toronto Area 183 58.3%
Hamilton & Niagara 42 13.4%
Southwestern Ontario 45 14.3%
Central Ontario 31 9.9%
Eastern Ontario 10 3.2%
Northern Ontario 3 1.0%
Marriage Status (of person
completing survey)
Married/ Living with partner 194 62.8%
Not living with partner 115 37.2%
Education (of person completing
survey)
Elementary School 16 5.5%
High school without graduation 36 12.4%
High school with graduation 66 22.7%
Community College 89 30.6%
University degree 62 21.3%
Graduate School 22 7.6%
Immigration Status
Born in Canada 181 58.6%
Born outside Canada 128 41.4%
Moved to Canada <10 yrs ago 38 30.9%
Moved to Canada >10 yrs ago 85 69.1%
So
cio
ec
on
om
ic c
ha
ra
cte
ris
tics
Employment Status (of person
completing survey)
Full-time employed Unemployed Part-time employed
123 65 46
40.1% 21.2% 15.0%
Self-employed 26 8.5%
Retired 24 7.8%
Students 23 7.5%
Source of Income (of person
completing survey)
Wages & salaries Gov’t assistance/ welfare
158 65
54.5% 22.4%
Self-employment income 33 11.4%
Pension Borrowed money (LOC, friends/family)
24 10
8.3% 3.4%
Family Income
Less than $10,000 34 11.6%
$10,000 - $19,999 51 17.3%
$20,000 - $39,999 64 21.8%
$40,000 - $59,999 42 14.3%
$60,000 - $79,999 33 11.2%
$80,000 - $99,999 29 9.9%
More than $100,000 41 13.9%
Method of
payment
Dental care
Gov’t assistance program Out of pocket Employment insurance Partner/spouse’s employment insurance
130 111 51 24
41.1% 35.1% 16.1% 7.6%
DS/GA part of dental care
Out of pocket Gov’t assistance program Employment insurance Partner/spouse’s employment insurance
133 123 37 22
42.2% 39.0% 11.7% 7.0%
42
Table 2: Health attitudes and behaviours
Number (N) Percentage
(%)
Overall Health At time of sleep dentistry Excellent/Very good Good/Fair Poor
224 83 5
71.8% 26.6% 1.6%
At present time Excellent/Very good Good/Fair Poor
214 74 0
74.3% 25.7% 0.0%
Oral Health At time of sleep dentistry Excellent/ Very good Good/Fair Poor
126 131 55
40.4% 42.0% 17.6%
At present time Excellent/Very good Good/Fair Poor
151 116 16
53.3% 41.0% 5.7%
Importance/Values
of oral health
aspects
Having no pain in mouth Very important/Important
308 99.7%
Being able to chew Very important/Important
309 99.4%
Being able to taste Very important/Important
307 99.1%
Being able to speak clearly Very important/Important
297 96.5%
Appearance of teeth Very important/Important
290 91.7%
Last visit to the
dentist
Less than 1 year ago 196 62.0%
1 year to less than 2 years ago 45 14.2%
2 years to less than3 years ago 25 7.9%
3 years to less than 4 years ago 2 0.6%
4 years to less than 5 years ago 3 0.9%
5 or more years ago 36 11.4%
Never 9 2.8%
How often visit
general dentist
More than once a year for checkup/treatment 137 43.6%
About once a year for checkup/treatment 72 22.9%
Less than once a year for checkup/treatment 22 7.0%
Only for emergency care 49 15.6%
Never 34 10.8%
Affordability of
“sleep dentistry” in
past
Needed sleep dentistry in past but unable to afford 87 28.0%
Needed sleep dentistry in past and able to afford 224 72.0%
43
Table 3: Utilization of DS/GA services by the sample population
All Survey Participants: 319
Number (N) Percentage (%)
Sleep dentistry for self or dependent
Yes 301 94.4%
No 18 5.6%
Location sleep dentistry was received
UofT Faculty of Dentistry 159 51.8%
In a specialist’s office 94 30.4%
In a family dentist’s office 51 16.5%
Hospital 4 1.3%
Other 0 0.0%
Procedures
that DS/GA used (� preferred for future)
DS/GA received in past
Examination 69 (�37) 21.6% (�11.6%)
Radiographs 68 (� 34) 21.3% (� 10.7%)
Hygiene 84 (� 52) 26.3% (� 16.3%)
Restorations 166 (� 98) 52.0% (� 30.7%)
Crowns/Bridges 122 (� 91) 38.2% (� 28.5%)
Root canal treatment 85 (� 99) 26.6% (� 31.0%)
Periodontal surgery 43 (� 90) 13.5% (� 28.2%)
Exodontia 158 (� 112) 49.5% (� 35.1%)
Implant surgery 29 (� 88) 9.1% (� 27.6%)
44
Table 4: Geographic factors & availability of DS/GA
All Survey Participants: 319
Number (N) Percentage (%)
Referred by healthcare
professional for DS/GA
Yes 259 81.7%
No 58 18.3%
Healthcare professional referral to sleep dentist
Dentist 232 92.8%
Family Doctor 14 5.6%
Other healthcare professional 14 1.6%
NOT referred
by healthcare professional for sleep dentistry
Internet search 9 16.7%
Asked family dentist 22 40.7%
Asked family doctor 5 9.3%
Asked family member/friend 12 22.2%
Other (ie advertisement) 6 11.1%
Distance
travelled from home to sleep dentist
<50 km 223 87.1%
50 – 100 km 25 9.8%
>100 km 8 3.1%
Driving time from home to sleep dentist
<1 hour 193 67.7%
1 - <2 hours 83 29.1%
2 - <3 hours 8 2.8%
3 - <4 hours 0 0.0%
4 hours or more 1 0.4%
Wait time to get appointment with sleep dentist
<1 month 12 4.6%
1 - <3 months 149 57.1%
3 - <6 months 58 22.2%
6 - <9 months 35 13.4%
9 - <12 months 4 1.5%
12 months or more 3 1.1%
Work days had to take off because of appt
0 work days 1 0.5%
1 work days 131 64.5%
2 work days 35 17.2%
3 work days 20 9.9%
4 or more work days 16 7.9%
Work days family
member or friend to take off because of appt
0 work days 1 0.6%
1 work days 119 69.6%
2 work days 22 12.9%
3 work days 16 9.4%
4 or more work days 13 7.6%
45
Table 5: Frequency distribution of patient satisfaction with DS/GA
All Survey Participants: 319
Number (N) Percentage (%)
Satisfaction with DS/GA Access (very
satisfied/satisfied)
Distance travelled 282 90.4%
Travel time to office 279 90.3%
Wait time to get appointment 251 81.8%
Satisfaction with DS/GA Appointment (very
satisfied/satisfied)
Anxiety relief from DS/GA 282 98.3%
Anaesthesiologist chair side manner 282 98.3%
IV needle placement 247 92.9%
Amount of pain after appointment 249 93.6%
Amount of nausea/vomiting after appointment
228 97.4%
Speed of recovery after appointment 261 94.9%
Amount of shivering after appointment 227 92.7%
Quality of sleep after appointment 259 97.0%
Quality of speech after appointment 254 95.1%
Being able to go back to work/school 245 95.7%
Overall feeling/behaviour after sleep dentistry
263 94.9%
Overall convenience of sleep dentistry 283 97.6%
Overall satisfaction of sleep dentistry 286 99.0%
Extent which DS/GA improved ability to
undergo dentistry
Not improved at all 6 2.1%
Slightly improved 7 2.4%
Somewhat improved 46 15.8%
Significantly improved 232 79.7%
46
Table 6: Summary of bivariate analysis* identifying significant variables (p < .05) for reporting barriers as very important or important.
*The complete bivariate analysis is attached in Appendix A.
Ad
de
d c
ost
of
sle
ep
de
nti
stry
Insu
ran
ce d
oe
sn't
co
ve
r
sle
ep
de
nti
stry
Lon
ge
r w
ait
tim
es
for
tre
atm
en
t
Lon
ge
r tr
av
el
dis
tan
ce
for
tre
atm
en
t
Ha
vin
g t
o t
ak
e t
ime
off
wo
rk
No
acc
ess
to
a v
eh
icle
Ha
vin
g t
o a
rra
ng
e f
or
rid
e f
rom
ap
po
intm
en
t
No
t k
no
win
g e
no
ug
h
ab
ou
t ri
sks
an
d b
en
efi
ts
of
sle
ep
de
nti
stry
Ad
de
d r
isk
ass
oci
ate
d
wit
h s
lee
p d
en
tist
ry
No
t e
no
ug
h d
en
tist
s
av
ail
ab
le t
o d
o s
lee
p
de
nti
stry
-Income
-Method of
payment for
dentistry
-Method of
payment for
DS/GA
-Work days
taken off
(self)
- Work days
taken off
(family
member)
-Age
-Method of
payment for
DS/GA
-Age
-Faculty vs private
practice
-Region
-Immigration
status
-Employment
status
-Needed DS/GA in
past and could
not afford
-Distance
travelled
-Driving time
-Wait time
-Needed DS/GA
in past and
could not afford
-Distance
travelled
-Driving time
-Age
-Faculty vs
private practice
- Work days
taken off (self)
-Distance
travelled
-Employment
status
-Method of
payment for
DS/GA
-Frequency
dental visits
-Age
-Immigration
status
-Income
-Age
-Faculty vs
private
practice
-Income
-Faculty vs
private
practice
-Distance
travelled
-Driving
time
-Wait time
- Work days
taken off
(self)
47
Table 7: Adjusted final logistic regression model presenting significant predictors for
reporting barriers as very important or important.
Adjusted final model, OR (95% confidence interval), p<0.05
Q1
3.2
In
sura
nce
do
esn
't c
ov
er
sle
ep
de
nti
stry
Q1
3.4
Lo
ng
er
wa
it
tim
es
for
tre
atm
en
t
Q1
3.6
Ha
vin
g t
o t
ak
e
tim
e o
ff w
ork
Q1
3.7
No
acc
ess
to
a
ve
hic
le
Q1
3.8
Ha
vin
g t
o
arr
an
ge
fo
r ri
de
fro
m
ap
po
intm
en
t
Q1
3.1
0 A
dd
ed
ris
k
ass
oci
ate
d w
ith
sle
ep
de
nti
stry
Q1
3.1
1 N
ot
en
ou
gh
de
nti
sts
av
ail
ab
le t
o
do
sle
ep
de
nti
stry
Private practice patients 1
0.37
(0.16-
0.85)
Age 0-17 years 2
2.58
(1.22-
5.43)
4.71
(1.55-
14.28)
1.84
(1.00-
3.40)
Reside in Northern, Central & Eastern Ontario 3
5.69
(1.22-
26.47)
Pay for sedation/GA through
government assistance program(s) 4
0.27
(0.12-
0.61)
1.85
(1.07-
3.22)
Visit the dentist once per year 5
0.60
(0.35-
1.00)
Drive 50 km or greater to sleep dentist 6
2.81
(1.23-
6.43)
Drive 1 hour or longer to sleep dentist 7
4.26
(1.16-
15.64)
Reference categories: (1) Faculty of Dentistry patients, (2) Age 18 years +, (3) Reside in Greater Toronto & Hamilton
Area, (4) Pay for sedation out of pocket, (5) Visit the dentist less than once per year, (6) Drive <50km to appointment,
(7) Drive <1hour to appointment
48
A THEORETICAL FRAMEWORK FOR ACCESS TO DENTAL ANAESTHESIA IN ONTARIO
Health Care Policy & Planning
Regulatory:
• Ontario Government & Ministry of Health and Long Term Care
• RCDSO Standards of Prac ce & Regulated Health Professionals Act
Financing:
• Insurance companies
• Government
• Social assistance programs (OW, ODSP, CINOT, HSO, NIHB)
• Grants/funding
Educa on:
• Con nuing dental educa on
• Undergraduate dental programs
• Graduate dental specialty programs
Organiza on
• CADA, ODA
Characteris cs of Healthcare System
(Personnel & Facili es)
• Number of general den sts and anaesthesia providers
• Distribu on/loca on:
• Dental anaesthesiologists, medical anaesthesiologists, hospital OR facili es
• Organiza on
• Hospital
• Private prac ce or operator/anaesthesia
• I nerant anaesthesia
• Surgicentre
• Preferences or prejudices of referring den st
• Age, educa on, and anaesthesia experience of primary den st
• Perceived need for anaesthesia and acceptance of GA from referring
den st
• Perceived risk/liability amongst general den sts
• Access to con nuing dental educa on
• Referral process
• Availability of DS/GA in primary dental office
• Cost to setup anaesthesia prac ce, obtain permi ng & insurance
• Reimbursement of provider and financial incen ves
Characteris cs of Poten al Users
(Individuals & Communi es – “the popula on at risk”)
• Number of poten al pa ents
• Age
• Sex
• Demographic factors
• Health status
• Burden of oral disease
• Socioeconomic status (income, employment, insurance/benefits)
• Living Environment
• Transport
• Mobility
• Social Supports
• Geographic distribu on and loca on
• Need/Demand in region
• Preferences and prejudices
• Preference amongst parents
• Preference amongst pa ents
• A tudes and values
• Trust and expecta ons from provider
• Psychological variables:
• Fear, phobia, anxiety
• Health knowledge:
• Health literacy and beliefs
• Knowledge of seda on anaesthesia and risks/benefits
• Fear of safety, death, brain damage,
neurodevelopmental damage
Availability
(Poten al Access)
• Geographic and
Socioeconomic Factors
Barriers & Facilitators
• Geographic and
Socioeconomic factors
• Internal Economy
(direct costs of treatment
and travel/
accommoda on)
• External economy
(travel me,
accompaniment, lost
wages)
U liza on
(Realized access)
• Geographic and
Socioeconomic
• Type
• Consult
• Treatment planning
• Treatment
• Site
• Time between referral
and appt.
Consumer Sa sfac on
• Convenience
• Internal/External costs
• Sa sfac on with experience
• Pa ent educa on
• Quality and perceived health
benefit from encounter Present Access
• Degree of access for each
subgroup of pa ent
• Geographic access
• Socioeconomic determinants
Adequate access
Inadequate Access
Improved Future
Access
FEEDBACK
Figure 1: A theoretical framework for access to dental anaesthesia in Ontario
49
Figure 2: Response rates for Ontario patients surveyed
Survey sent to 1,002 patients - 602 faculty patients
- 400 private practice patients
Reminders to non-responders - 2 Mail reminders - Phone call reminder - Thank You cards
-112 Return to sender envelopes
Sample size of 890 patients
Final number of usable surveys = 319
Response rate = 35.8%
50
Figure 3: Common indications for deep sedation and general anaesthesia
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Other reasons
Medical reasons
Physical reasons
Intellectual disability
Severe gag reflex
Treatment length
Treatment invasiveness
General comfort
Being anxious at dentist
Fear of Dentistry
Child is too young
Indications for Having Sleep Dentistry
51
Figure 4: Barriers to deep sedation and general anaesthesia - barriers ranked as
"important" or "very important" are presented
0% 20% 40% 60% 80% 100%
No access to vehicle to get to appt
Having to arrange for ride to appt
Having to take time off work
Longer travel distance for treatment
Not knowing enough about risks &…
Added risks associated with DS/GA
Longer wait time for treatment
Not enough dentists available to do…
Gov't insurance does not cover enough…
Insurance does not cover DS/GA
Added cost of DS/GA
Significant Barriers to DS/GA
52
0
0.5
1
1.5
2
2.5
3
Barrier Mean Score
Figure 5: Ranking of barriers to DS/GA: score of 0 - not important at all, 1 - somewhat
important, 2 - important, 3 - very important. Mean score presented for each barrier
53
Appendix A – Bivariate Analysis of respondents indicating a barrier as very important
or important
54
CHAPTER 4: Discussion
The purpose of this survey was to assess Ontario patients’ perceptions of barriers to
DS/GA for dental treatment. Patients’ utilization of DS/GA for dentistry was also analyzed, as
there is a direct relationship between barriers and access.82,86 The most frequently reported
barriers to access to DS/GA were the added cost of, lack of insurance coverage of, lack of
available providers, and long wait times for treatment.
4.1 - Sample population
The sampling frame for this study was a convenience sample of University based
patients who had received DS/GA for dental treatment for a period of two years, as well as an
external sample of the patients of Ontario dentist anaesthesiologists. Thus, it is not a random
sample of the Ontario population. Although it would have been ideal to survey a random
sample of the population, it was not feasible in this case due to the limited number of patients
who receive DS/GA for dental treatment, which is approximately 1% of all dental patients.87
Since we only studied patients who have previously received DS/GA for dental treatment, we
likely were not able to capture a large portion of patients who are awaiting dental care under
DS/GA. We also did not study patients who require DS/GA but are not able to access this
service due to the many barriers that exist. Furthermore, our sample population likely consists
of the subset of the population that visits the dentist somewhat frequently, as the majority had
their last dental treatment less than one year ago and visit the dentist more than once per year
for checkup and treatment. This suggests that our sample has adequate access to oral
healthcare. However, our convenience and external sample still allowed us to examine the
barriers to DS/GA, but in a more economical and efficient manner.
Our response rate of 36% was within the range of 24% - 43% of other surveys of
Ontario dental patients.84,40,88 Our use of follow-up mail and phone call reminders with non-
55
responders may have helped reduce non-response bias, as follow-up reminders are known to
reduce bias.89 The number of our respondents was 319, which is less than our required sample
size of 384. Although this limitation has the implication of reducing the power of our analyses,
the number of our respondents is still large enough that any reduction in the statistical power
of our analysis is minimal.
4.2 - Access and utilization of DS/GA
Previous research has shown that patients from Northern Ontario, rural communities,
and Aboriginals require DS/GA for treatment of early childhood caries more than patients
from other areas.28,29 It has also been shown that one of the largest patient populations who
require DS/GA for dental treatment are patients with disabilities.6,41–43 Our study surveyed
patients who had received DS/GA at the University of Toronto, Faculty of Dentistry, as well
as the patients of practicing dentist anaesthesiologists. Thus, it is very likely that patients from
Northern Ontario and rural parts of Ontario were not included in this study, as none of the
current dentist anaesthesiologists in Ontario practice in Northern Ontario. This is consistent
with the fact that only 1% of the study population was from Northern Ontario. Furthermore,
patients with disabilities are likely under-represented in our study, as many of these patients
undergo dental treatment in hospital settings, and only one of the practicing dentist
anaesthesiologists who participated in our study has a part time hospital practice. This under-
representation can be seen in the indications for DS/GA portion of our results, as only 10% of
patients identified “intellectual disability” and less than 5% identified “physical reasons” as
indications for DS/GA.
In Ontario, the three groups of DS/GA providers in a dental setting are oral and
maxillofacial surgeons who have completed sufficient anaesthesia training, dentists who have
completed a post graduate residency program of at least 24 months in dental anaesthesia, and
56
medical anaesthesiologists.4 Medical anaesthesiologists are one of the largest groups of
providers of DS/GA, and our study did not include the patients of these providers. Thus, it is
likely that our sample population may have slightly different patient characteristics and
perceived barriers to access to DS/GA. For example, our previous study found that patients
who were referred to offices who utilize an itinerant anaesthesiologist are two and a half times
more likely to experience wait times of greater than three months.45 There are only a handful
of itinerant dentist anaesthesiologists, but all of the more than 500 registered medical
anaesthesiologists who provide out of hospital DS/GA for dental care are itinerant.
Furthermore, the cost of DS/GA is usually higher when a separate itinerant anaesthesiologist
provides DS/GA, as there are additional fees, namely the “provision of facility” fee associated
with the DS/GA care. Hence, patients who received DS/GA from itinerant anaesthesiologists
may have identified longer wait times and higher costs of DS/GA as a more significant barrier.
4.3 - Barriers to DS/GA
The most frequently identified barriers to access to DS/GA for dental treatment were
the cost and lack of insurance coverage of DS/GA. This finding is consistent with Ontario
dentists’ most frequently identified barrier to access to DS/GA.45 The majority of the patients
in our study paid from personal funds for the DS/GA service they received. Our previous
research showed that dentists who utilize DS/GA services in their practice believe that the cost
to the patient and lack of private and public insurance coverage is the most significant barrier
in their patients being able to undergo DS/GA to facilitate dental treatment.45 Many insurance
programs still do not cover DS/GA for dental treatment, although it is an essential service for
many patients. Some insurance programs cover DS/GA, but only for specific treatments, such
as exodontia. This is also not ideal, as our research and previous research has shown that there
57
are other procedures and treatments that patients prefer to undergo DS/GA in addition to
exodontia.2
Long wait times and the lack of availability of providers of DS/GA were the next most
frequently identified barriers. The majority of the survey respondents experienced a wait time
of one to three months, but nearly 40% of the respondents experienced wait times greater than
three months, and some respondents even experienced wait times of greater than one year. Our
finding is consistent with previous research from Ontario, which has shown that long wait
times can be a barrier to accessing dental care, especially for vulnerable populations.40
Furthermore, two thirds of respondents experienced a driving time of greater than one hour to
get to their appointment. Both the reported long wait times and the long travel distances in our
study suggest lack of availability of DS/GA providers, which was identified as a significant
barrier.
The added risk associated with DS/GA was a somewhat frequently reported barrier.
Previous research has shown that parents have a high acceptance of DS/GA, and they prefer
DS/GA to many other methods of behaviour control for their children.32 Three months after
our data collection period, the U.S. Food and Drug Administration released a report warning
young children and pregnant women regarding many medications used in general
anaesthesia.90 The report warned that lengthy use of general anaesthetic medications in
pregnant women and children under three years of age could affect the development of these
children’s brains.90 Although few pregnant women and children less than three years of age
undergo DS/GA for dental treatment, it is possible that parents may have reported the added
risk of DS/GA more frequently as a barrier, had this new report been released prior to our data
collection.
Our logistic regression analysis allowed us to identify predictors of reporting important
barriers, and our results have implications of validity. Patients who reside in Northern,
58
Central, and Eastern Ontario were nearly six times more likely to report “longer wait times” as
an important barrier, which may suggest inadequate access in areas other than the Greater
Toronto and Hamilton area. Also, parents of pediatric patients are more likely to report longer
wait times and the added risk of DS/GA as barriers. The long wait times may be related to the
fact that pediatric patients are one of the largest utilizers of sedation services in dentistry, and
that anecdotally, not all DS/GA providers in Ontario treat children.35 Furthermore, parents are
more concerned about the risks of DS/GA for their children due to the lack of information
available regarding the effects of sedative medications on children’s developing brains.32,90
Finally, patients who experienced longer driving times to their appointment were 4.3 times
more likely to report “lack of providers of DS/GA” as an important barrier. These obvious
patterns show that patients understood the questions in our survey and they strengthen the
internal validity of our study.
4.4 – Limitations
This study does have some limitations. As previously mentioned, our sampling frame
was a convenience sample, not a random sample, which may reduce our external validity.
Furthermore, we surveyed patients who have already received DS/GA in the past, and we did
not study patients who require DS/GA, but have not received treatment. Our validity and
power would have been improved, had we used a random sample of the Ontario population, as
we may have also surveyed patients who are waiting to receive dental care under DS/GA or
who are unable to receive this care, despite needing it. However, considering the fact that
roughly 1% of dental patients receive DS/GA, it would not have been feasible and economical
to carry out such a project.87
Furthermore, some of the larger groups of DS/GA utilizers, namely patients from
Northern Ontario, rural patients, Aboriginals, and patients with disabilities, were likely under-
59
represented in this study.6,29,41,28,42,43 Also, patients sedated and anaesthetized by medical
anaesthesiologists were not represented in our study. Since these patients are likely receiving
care at offices that provide DS/GA services on a part-time basis, they may report and
encounter different barriers than the patients in our study, such as longer wait times.45 We also
chose not to include hospital patients in our study. We made this decision due to the fact that
not all Ontario hospitals have dentistry departments, hospital dental clinics are not available to
most dentists, and hospital privileges for dentists have been reported to be declining.46 Thus, it
is likely that the majority of DS/GA that is provided for dentistry is outside of the hospital
setting.
Another limitation in this study was that pediatric patients in our sampling frame did
not fill out their own surveys. If the patient was a child or did not have adequate mental
capacity, the parent or caregiver of the study participants were instructed to complete the
survey on the participants’ behalf. Although it is not feasible to ask pediatric patients and
some patients with disabilities to complete the survey, we still recognize this limitation.
4.5 - Strengths, implications and application
Our research was novel in the scientific literature, as it is the first study to determine
which factors patients believe are significant barriers to accessing DS/GA for dental treatment.
The study design and data collection was vigorously conducted.80 We also used two different
sample groups, which included an external sample of private practice patients, in order to
increase the external validity of our study. Our findings have important implications in the
areas of dental public health, health policy, and healthcare provider education.
The results of this study suggest that the added cost and the lack of insurance funding
of DS/GA are major barriers to accessing DS/GA. This was consistent with results from our
previous research, which suggested that dentists who utilize DS/GA services in their practice
60
identify the cost to the patient as the most significant barrier to access.45 This information
should be communicated to public and private insurance companies, as well as the Canadian
Life and Health Insurance Association. DS/GA is an essential service in dentistry, and there
should not be limitations on the insurance coverage of these services. Previous studies have
shown that the cost of dental surgery under DS/GA is much less in community-based clinics
compared to in hospital operating rooms.91,92 While the Ministry of Health and Long-Term
Care may find this information useful, increasing the number of community based clinics
would increase costs to patients, as anaesthesia and facility fees are not covered in community
clinics. This reiterates the importance of increasing private insurance funding of DS/GA and
removing restrictions on the coverage of these services. Moreover, although the cost per
patient would likely be reduced in community-based clinics compare to hospital operating
rooms, the overall cost of care may be increased or unaltered, as more patients would be able
to access dental care under DS/GA. Additionally, as wait times for treatment may be reduced
by implementing more community based clinics, we may see a reduction in the number of
patients presenting with pain and infection to hospital emergency room, which may ultimately
reduce public healthcare costs. Since there are a number of factors involved in the economic
impact of these community-based clinics, a health economic study and cost analysis would be
beneficial in determining the effect of these clinics on public expenditure.
Furthermore, our previous research also concluded that dentists’ attitudes towards and
lack of knowledge of DS/GA are major barriers in patients’ access to these services.45 Hence,
dentists need more education regarding the indications, risks and benefits, supply and demand
of DS/GA, as well as the procedures for which patients generally prefer DS/GA. Dental
education of this topic should be improved in professional school settings, and also in
continuing education programs. Improving education of healthcare providers will also
improve patient education regarding DS/GA. There are many patients who are unaware that
61
DS/GA is available to facilitate dental treatment.2 If these patients are dental phobic and avoid
dental care, their avoidance will lead to more invasive, emergency dental treatment.8 Thus,
improving the current education of dentists will likely have meaningful improvements in
access to care.
While increasing insurance funding of DS/GA and improving dentists’ education
regarding DS/GA would lead to more timely referrals and increased access to care, dentists’
efforts should still primarily be focused on disease prevention, as dental disease is mostly
preventable. Future research should be directed towards analyzing current education patterns
of DS/GA and improving education opportunities of healthcare providers, and ultimately
patients.
62
APPENDICES Appendix 1: Invitation to study participation - Faculty of Dentistry patients
Dear ___________,
My name is Dr. Soheil Khojasteh and I am a dentist and a resident of dental anaesthesiology at the University of Toronto, Faculty of Dentistry. I am inviting you to participate in a research project that we are carrying out regarding the accessibility and barriers to sleep dentistry, namely deep sedation or general anaesthesia, for dental treatment. I would appreciate your help for our research by participating in this survey.
You have been selected to complete this survey because you, or a person that you care for
(example: your child, sibling, elder family member), have received sleep dentistry in the past two years. Little is known about access to sleep dentistry for patients in Ontario. Your participation will allow us to assess how accessible sleep dentistry is in Ontario, and identify factors that enable or inhibit access to sleep dentistry. We can then work to improve the availability of sleep dentistry for patients who need it. This survey will take approximately 10 minutes to complete. There are no right or wrong answers. Your participation is voluntary.
Your privacy is important to us. Please be assured of complete confidentiality in completing
this survey. Your responses will not be linked to your name in any way. Although, I am encouraging you to complete this questionnaire, you may withdraw from this study at any time, for any reason. If you chose to not participate in this study, this will in no way affect the care you receive at the University of Toronto Faculty of Dentistry, or at a private dental clinic. This study has been approved by the Research Ethics Board at the University of Toronto. If you have any questions about your rights as a participant, you may contact the ethics office at [email protected] or (416) 946-3273. In regards to the survey itself, you can contact me at [email protected]. Kindly ensure your responses are received as soon as possible. Thank you for your time. It is only with the help of generous people like you that our research can be successful. Sincerely, Soheil Khojasteh, BHSc, DDS MSc Candidate (Dental Anaesthesia) University of Toronto, Faculty of Dentistry Room 129, 124 Edward Street, Toronto, ON, M5G 1G6 Email: [email protected] Phone: (416) 979-4900, ext 4637 Co-Investigators at the Faculty of Dentistry, University of Toronto:
Dr. Amir Azarpazhooh, Assistant Professor, Discipline of Dental Public Health & Endodontics Dr. Carilynne Yarascavitch, Assistant Professor, Discipline of Dental Anaesthesia Dr. Carlos Quiñonez, Associate Professor and Program Director, Discipline of Dental Public Health Dr. Andrew Adams, Clinical Instructor, Discipline of Dental Anaesthesia
63
Appendix 2: Invitation to study participation - private practice patients
Dear patient,
My name is Dr. Soheil Khojasteh and I am a dentist and a resident of dental anaesthesiology at the University of Toronto, Faculty of Dentistry. I am inviting you to participate in a research project that we are carrying out regarding the accessibility and barriers to sleep dentistry, namely deep sedation or general anaesthesia, for dental treatment. I would appreciate your help for our research by participating in this survey.
You have been selected to complete this survey because you, or a person that you care for
(example: your child, sibling, elder family member), have received sleep dentistry in the past two years. Little is known about access to sleep dentistry for patients in Ontario. Your participation will allow us to assess how accessible sleep dentistry is in Ontario, and identify factors that enable or inhibit access to sleep dentistry. We can then work to improve the availability of sleep dentistry for patients who need it. This survey will take approximately 10 minutes to complete. There are no right or wrong answers. Your participation is voluntary.
Your privacy is important to us. Please be assured of complete confidentiality in completing
this survey. Your responses will not be linked to your name in any way. Although, I am encouraging you to complete this questionnaire, you may withdraw from this study at any time, for any reason. If you chose to not participate in this study, this will in no way affect the care you receive at the University of Toronto Faculty of Dentistry, or at a private dental clinic. This study has been approved by the Research Ethics Board at the University of Toronto. If you have any questions about your rights as a participant, you may contact the ethics office at [email protected] or (416) 946-3273. In regards to the survey itself, you can contact me at [email protected]. Kindly ensure your responses are received no later than Friday August 5, 2016. Thank you for your time. It is only with the help of generous people like you that our research can be successful. Sincerely, Soheil Khojasteh, BHSc, DDS MSc Candidate (Dental Anaesthesia) University of Toronto, Faculty of Dentistry Room 129, 124 Edward Street, Toronto, ON, M5G 1G6 Email: [email protected] Phone: (416) 979-4900, ext 4637 Co-Investigators at the Faculty of Dentistry, University of Toronto:
Dr. Amir Azarpazhooh, Assistant Professor, Discipline of Dental Public Health & Endodontics Dr. Carilynne Yarascavitch, Assistant Professor, Discipline of Dental Anaesthesia Dr. Carlos Quiñonez, Associate Professor and Program Director, Discipline of Dental Public Health Dr. Andrew Adams, Clinical Instructor, Discipline of Dental Anaesthesia
64
Appendix 3: Information for consent for participation - Faculty of Dentistry patients
How was I selected to be in this Sample? Who will see my answers? Will my answers be confidential? You are being contacted because you or a person that you care for received sleep dentistry at the University of Toronto, Faculty of Dentistry between January 1, 2014 and December 31, 2015. Your contact information was obtained from the Faculty of Dentistry’s registry of patients, and it will only be used for the purposes of research. During this research project, names and addresses of participants will be securely stored electronically on a secure and encrypted network, on a password-protected computer. The surveys will be kept in a locked cabinet in the department of anaesthesia resident office. All electronic data will be stored on a password-protected computer at the department of anaesthesia and the primary
investigator (Dr. Soheil Khojasteh) will be the only individual with access to these data. Each questionnaire is numbered: the number represents your mailing address. The list that identifies your address is stored separately in a locked cabinet at a different location, and will also be destroyed upon completion of this study. As a result, there is little - if any - possibility of linking a returned survey to the individual who completed it. Contact information is only used for survey distribution and tracking responses. At the end of this study, all of the contact information and all of the surveys will be destroyed and shredded. Your responses are completely confidential. Your name and any personal identifying information will not be stored will not be stored with your answers, and it will also not be used in any reports or publications from this study. The research study you are participating in may be reviewed for quality assurance to make sure that the required laws and guidelines are followed. If chosen, (a) representative(s) of the Human Research Ethics Program (HREP) may access study related-data and/or consent materials as part of the review. All information accessed by the HREP will be upheld to the same level of confidentiality that has been stated by the research team.
What happens if I do not participate? Participation is completely voluntary. It is your right to refuse to answer any questions or participate, and you can withdraw from the study at any time by not completing the survey and not returning it to us, or by contacting us and informing us about your wishes to withdraw from the study. There are no consequences to you if you decline to participate in this study, and the care that you receive at the Faculty of Dentistry will not be affected in any way.
Does my participation provide any benefits to myself? There are no immediate benefits to you.
Are there any risks or harms in participating? There are no risks or harms in participating in this study.
How do you obtain my consent to participate? Completing this questionnaire and returning it to the primary investigator implies your consent to participate in this study.
How is this survey important? Why do my views matter? Will I be able to see the results of this study? Patients’ views on the factors that make it difficult to access sleep dentistry in Ontario have not been studied. Previous research has shown that many patients need sleep dentistry. By understanding the factors that prevent patients from accessing sleep dentistry, we can work to make sleep dentistry more accessible for the patients that need it most. Your participation and answers are extremely important for us to better understand these factors. The enclosed survey is part of a Master’s thesis project. All participants are invited to review the graduate thesis publication in the Harry R Abbott Dentistry Library in 2017.
Who can I contact for more information? Further questions about this study can be answered by myself (the principal investigator) at any time. Kindly email me at [email protected] or call me at (416) 979-4900, ext 4637
65
Appendix 4: Information for consent for participation - private practice patients
How was I selected to be in this Sample? Who will see my answers? Will my answers be confidential? You are being contacted because you or a person that you care for received sleep dentistry within the past two years. During this research project, all surveys will be kept in a locked cabinet in the department of anaesthesia resident office. All electronic data will be stored on a password-protected computer at the department of anaesthesia and I will be the only individual with access to these data. There is no possibility of linking a returned survey to the individual who completed it. At the end of this study, all of the surveys will be destroyed and shredded. Your responses are completely confidential. Your name and any identification information will not be present on the survey, or any other material related to this research project, and it will also not be used in any reports or publications from this study. The research study you are participating in may be reviewed for quality assurance to make sure that the required laws and guidelines are followed. If chosen, (a) representative(s) of the Human Research Ethics Program (HREP) may access study related-data and/or consent materials as part of the review. All information accessed by the HREP will be upheld to the same level of confidentiality that has been stated by the research team.
What happens if I do not participate? Participation is completely voluntary. It is your right to refuse to answer any questions or participate, and you can withdraw from the study at any time by not completing the survey and not returning it to us. However, once you have completed the questionnaire and returned it, your answers are completely anonymous and you may not withdraw, as there is no identifying information on the questionnaires. There are no consequences to you if you decline to participate in this study, and the care that you receive at your dental office will not be affected in any way.
Does my participation provide any benefits to myself? There are no immediate benefits to you.
Are there any risks or harms in participating? There are no risks or harms in participating in this study.
How do you obtain my consent to participate? Completing this questionnaire and returning it to the primary investigator implies your consent to participate in this study.
How is this survey important? Why do my views matter? Will I be able to see the results of this study? Patients’ views on the factors that make it difficult to access sleep dentistry in Ontario have not been studied. Previous research has shown that many patients need sleep dentistry. By understanding the factors that prevent patients from accessing sleep dentistry, we can work to make sleep dentistry more accessible for the patients that need it most. Your participation and answers are extremely important for us to better understand these factors. The enclosed survey is part of a Master’s thesis project. All participants are invited to review the graduate thesis publication in the Harry R Abbott Dentistry Library in 2017.
Who can I contact for more information? Further questions about this study can be answered by myself (the principal investigator) at any time. Kindly email me at [email protected] or call me at (416) 979-4900, ext 4637
66
Appendix 5: Survey instrument
Access to Sleep Dentistry in Ontario
Thank you for taking the time to fill out this survey. It will take roughly 10 minutes of your time. Please answer all of the questions relating to the last experience of sleep dentistry (within the past 2 years) you or a person that you care for had. Please ensure to answer all of the questions in this survey. When completed, please return only the questionnaire in the prepaid postage envelope included with this package.
Definitions: Below are the meanings of some of the words used in this survey that may not be familiar
to you… Sleep Dentistry (Deep Sedation or General Anaesthesia): The state of being “unconscious” or “fully asleep” and lose your senses during dental procedures. Drugs given into veins (intravenous drugs) are used to facilitate sleep dentistry. Person that you care for: A child, sibling, elderly person, or person with disability whom you look after or are responsible to care for. Severe gag reflex: Involuntary choking or coughing when objects are placed in your mouth
Root canal treatment: Filling the nerve and roots of your teeth when they are infected
Implant surgery: Replacement option for missing teeth, where a titanium screw is placed in your jaw bone to serve as a root for a cap/crown. IV (intravenous) needle: Needle that is placed in your hand/arm/foot to allow the sleep doctor to give you medications Shivering: Shaking of your body, such as when you are cold Government assistance program: Support programs in place to help you pay for healthcare and dentistry needs, such as the Ontario Disability Support Program (ODSP), Healthy Smiles Ontario (HSO), Ontario Works (OW), Children In Need of Treatment (CINOT), Non-Insured Health Benefits (NIHB), etc.
Do you agree to participate in this study?
1 Yes 2 No
If you agree to participate in this study, please proceed to the next question. If you decline to
participate in this study, please return the unfilled questionnaire using the pre-stamped envelope
attached, so we do not contact you in the future. Thank you.
The first few questions relate to whether you had sleep dentistry in the past two years
1. Did you or a person that you care for have sleep dentistry within the past two years?
For myself: 1 Yes 2 No � If yes, how old were you: ___ years old
For a person that I care for: 1 Yes 2 No � If yes, how old was he/she: ___ years old
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2. Where did you receive sleep dentistry?
1 University of Toronto Faculty of Dentistry 2 In a specialist’s office 3 In my family dentist’s office 4 Hospital 5 Other: ___________________________
3. Please list all the reasons you (or a person that you care for) received sleep dentistry. Please check all that apply.
☐ Fear of dentistry
☐ Being anxious at dentist
☐ Child is too young to cooperate
☐ Treatment invasiveness/complexity
☐ Treatment length
☐ General comfort
☐ Severe gag reflex
☐ Intellectual disability (example: autism, Down’s Syndrome, etc.)
☐ Medical reasons (example: high blood pressure, chest pain, asthma, epilepsy)
☐ Physical reasons (example: Parkinson’s, Alzheimer’s, arthritis, tremors, dementia)
☐ Other reason (please specify): ____________________________
The next few questions relate to how you found out about sleep dentistry
4. Were you referred by a healthcare professional to receive sleep dentistry?
1 Yes � If Yes, who referred you? 1 Your dentist 2 Your family doctor 3 Other healthcare professional: __________________ 2 No � If No, how did you find a sleep dentist?
1 Internet search 2 Asked my dentist
3 Asked my family doctor 4 Asked a family member or friend 5 Other: _____________________
5. Please check for which dental procedures listed below you had sleep dentistry for in the past, or you would prefer to have sleep dentistry for in the future. Please check all that apply. Received sleep dentistry
in the past Prefer to receive sleep dentistry in the future
Examination/checkup
Radiographs/X-rays Routine cleaning/ hygiene Fillings/restorations
Crowns/caps or bridges Root canal treatment Gum surgery
Removing/pulling teeth, extractions Implant surgery
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The next few questions relate to travel distances and wait times for sleep dentistry
6. What is the name of the city/town you live in? ________________________________ 7. For the last sleep dentistry appointment you or a person that you care for had, please answer the following questions:
Distance in kilometers you travelled from home to get to the sleep dentist office ___________ km
Driving time in hours to get to sleep dentist office from home ___________ hour(s)
Wait time in months to get an appointment to see sleep dentist ___________ month(s)
Work days you had to take off because of the appointment ___________ day(s)
Work days a family member/friend had to take off because of the appointment ___________ day(s)
The next few questions are about your health…
8. In general, how would you rate your overall health and oral health:
9. In general, how important are the following aspects relating to your teeth and mouth:
Overall Health Excellent Very good Good Fair Poor
At time of sleep dentistry appointment
At present time
Oral Health Excellent Very good Good Fair Poor
At time of sleep dentistry appointment
At present time
Very Important Important
Somewhat Important
Not Important at all
Appearance of your teeth
Being able to chew food
Being able to taste food
Being able to speak clearly
Having no pain in your mouth
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The next few questions relate to how satisfied you were with your last sleep dentistry experience
10. Based on your last sleep dentistry appointment, how satisfied were you with the following aspects relating to getting to your appointment?
Very satisfied Satisfied Dissatisfied
Very dissatisfied
Distance you had to travel
Travel time to get to office
Wait time to get appointment
11. Based on your last sleep dentistry appointment, how satisfied were you with the following?
Very Satisfied Satisfied Dissatisfied
Very Dissatisfied
Not Applicable
Anxiety relief from sleep dentistry
Chair side manner of sleep dentist
Placement of IV needle
Amount of pain after appointment
Amount of nausea/vomiting after appointment
Speed of recovery/feeling fully awake after appointment
Amount of shivering after appointment
Quality of sleep after appointment
Quality of speech after appointment
Being able to go back to work/school
Overall feeling/behaviour after sleep dentistry
Overall convenience of sleep dentistry
Overall satisfaction of sleep dentistry
12. To what extent would you say sleep dentistry has improved your ability, or the ability of a person that you care for, to undergo dental treatment? 1 Significantly improved
2 Somewhat improved 3 Slightly improved 4 Not improved at all
70
13. In your opinion, what factors or barriers make it hard to access sleep dentistry?
Other factors: _____________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________
The next few questions relate to how you pay for dental treatment
14. How do you pay for your dental care?
1 Through my employment insurance 2 Through someone else’s employment insurance (like a spouse or a parent) 3 Through government assistance program(s) (ODSP, HSO, OW, CINOT, NIHB) 4 Directly out of my pocket (cash/credit)
15. How do you pay for the sleep dentistry part your dental care?
1 Through my employment insurance 2 Through someone else’s employment insurance (like a spouse or a parent) 3 Through government assistance program(s) (ie ODSP, HSO, OW, CINOT, NIHB) 4 Directly out of my pocket (cash/credit)
16. Have you ever needed sleep dentistry in the past but you could not afford it?
1 Yes 2 No
Very Important Important
Somewhat Important
Not Important at all
Added cost of sleep dentistry
Insurance does not cover sleep dentistry
Government insurance programs do not cover enough cost of sleep dentistry
Longer wait time for treatment
Longer travel distance for treatment
Having to take time off work
Not having access to a vehicle to get to appointment
Having to arrange for a ride from the appointment
Not knowing enough about risks and benefits of sleep dentistry
Added risk associated with sleep dentistry
Not enough dentists available to do sleep dentistry
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17. When was the last time you went to a general dentist?
1 Less than 1 year ago 2 1 year to less than 2 years ago 3 2 years to less than 3 years ago 4 3 years to less than 4 years ago 5 4 years to less than 5 years ago 6 5 or more years ago 7 Never
18. Do you usually see a general dentist?
1 More than once a year for check-ups or treatment 2 About once a year for check-ups or treatment 3 Less than once a year for check-ups or treatment 4 Only for emergency care 5 Never
Finally, some questions about you
19. What is your gender and the gender of the person that you care for (if applicable)?
20. What is your main employment status?
1 Full-time employed 2 Part-time employed 3 Self-employed 4 Retired 5 Unemployed 6 Student
21. What is your main source of income in the past 12 months?
1 Wages and salaries 2 Income from self-employment 3 Government social assistance or welfare 4 Pension 5 Borrowing money (line of credit, from family or friends, etc.) 6 Other: (please specify): _______________________________
22. Are you married or living with a partner?
1 Yes 2 No
Male Female
My gender
Gender of person I care for (if applicable)
72
23. What is the highest level of schooling you and your spouse/partner (if applicable) have
completed? 24. Were you born outside of Canada?
1 Yes � If yes, did you move to Canada more than, or less than 10 years ago? 1 More than 10 years ago 2 Less than 10 years ago
2 No
25. What was your family’s income in the past year?
1 Less than $10 000 2 $10 000 - $19 999 3 $20 000 - $39 999 4 $40 000 - $59 999 5 $60 000 - $79 999 6 $80 000 - $99 999 7 More than $100 000
Thank you for taking the time to participate in this survey!
Please place the filled questionnaire in the enclosed self-addressed and self-stamped
envelope,
seal it, and return it to us.
Elementary
School High school
without graduation
High school with
graduation
Community college/Technical
school
University degree/bachelors
or equivalent
Graduate degree
Myself
My spouse/partner (if applicable)
73
Appendix 6: Reminder mail out to non-responders
Gentle Reminder
ACCESS TO SLEEP DENTISTRY IN ONTARIO
Dear __________________,
As you may recall, I previously sent you a letter requesting your participation in a
research project, which is about sleep dentistry in Ontario.
If you have already responded, I’d like to take this opportunity and thank you for your time and your inputs. If you haven’t had a chance to respond yet, I would be extremely grateful if you kindly respond to the attached questionnaire. Please be assured of complete confidentiality in completing this survey. Your responses will not be linked to your name in any way. Please note that the success of this project partly depends on your participation. Thank you very much for your time. Sincerely, Soheil Khojasteh, BHSc, DDS MSc Candidate (Dental Anaesthesia) University of Toronto, Faculty of Dentistry Room 129, 124 Edward Street, Toronto, ON, M5G 1G6 Email: [email protected] Phone: (416) 979-4900, ext. 4637
74
Appendix 7: Thank you card
Front:
ACCESS TO SLEEP DENTISTRY RESEARCH STUDY
THANK YOU
DATE__________________________ We would like to thank you for being involved in our survey and research study on access to sleep dentistry in Ontario. It is with the help of generous people like you that our research can be successful. If you have any questions regarding the survey and this research study, you can contact me at [email protected]. Also, if you did not receive a survey, or if you misplaced it, please contact me and I will get another one in the mail for you today. Sincerely, Soheil Khojasteh, BHSc, DDS MSc Candidate (Dental Anaesthesia) University of Toronto, Faculty of Dentistry Room 129, 124 Edward Street, Toronto, ON, M5G 1G6 Email: [email protected]. Phone: (416) 979-4900, ext. 4637
75
Back:
124 Edward Street – Room 129, Toronto, ON M5G 1G6
Study participant name
Study participant address
76
Appendix 8: Schedule of recruitment
Week Recruitment
0 Letter of invitation, survey information and importance, survey commences
1
2 Reminder letter and replacement questionnaire sent
3
4 Reminder letter and replacement questionnaire sent
5
6 Phone call reminder to non-responders
7
8 Thank you/Reminder card sent
77
Appendix 9: Additional data and tables
Appendix 9.1: Barriers to DS/GA
All Survey Participants: 319
Number (N) Percentage (%)
Added cost of
DS/GA
Not important at all 20 6.7%
Somewhat important 16 5.4%
Important 86 29.0%
Very important 175 58.9%
Insurance does
not cover DS/GA
Not important at all 32 11.6%
Somewhat important 15 5.5%
Important 73 26.5%
Very important 155 56.4%
Gov’t insurance
does not cover
enough cost of
DS/GA
Not important at all 32 11.1%
Somewhat important 20 7.0%
Important 80 27.9%
Very important 155 54.0%
Longer wait time
for treatment
Not important at all 24 8.2%
Somewhat important 40 13.7%
Important 106 36.2%
Very important 123 42.0%
Longer travel
distance for
treatment
Not important at all 51 17.9%
Somewhat important 50 17.5
Important 96 33.7%
Very important 88 30.9%
Having to take
time off work
Not important at all 62 21.1%
Somewhat important 55 18.7%
Important 88 29.9%
Very important 89 30.3%
Not having access
to vehicle to get to
appointment
Not important at all 96 33.3%
Somewhat important 51 17.7%
Important 68 23.6%
Very important 73 25.3%
Having to arrange
for a ride from
appointment
Not important at all 84 29.2%
Somewhat important 43 14.9%
Important 73 25.3%
Very important 88 30.6%
Not knowing
enough about
risks & benefits of
DS/GA
Not important at all 52 17.6%
Somewhat important 32 10.8%
Important 99 33.6%
Very important 112 38.0%
Added risks
associated with
sleep dentistry
Not important at all 31 10.6%
Somewhat important 48 16.4%
Important 104 35.5%
Very important 110 37.5%
Not enough
dentists available
to do sleep
dentistry
Not important at all 26 9.0%
Somewhat important 36 12.4%
Important 111 38.3%
Very important 117 40.3%
78
Appendix 9.2: Ranking of barriers to DS/GA: score of 0 - not important at all, 1 –
somewhat important, 2 – important, 3 – very important. Mean score presented for each
barrier
Rank Barrier Mean
Score 1 Added cost of DS/GA 2.40
2 Insurance does not cover DS/GA 2.28
3 Gov’t insurance does not cover enough cost of DS/GA 2.25
4 Longer wait time for treatment 2.12
5 Not enough dentists available to do sleep dentistry 2.10
6 Added risks associated with sleep dentistry 2.00
7 Not knowing enough about risks & benefits of DS/GA 1.92
8 Longer travel distance for treatment 1.78
9 Having to take time off work 1.69
10 Having to arrange for a ride from appointment 1.57
11 Not having access to vehicle to get to appointment 1.41
Appendix 9.3: Indications for DS/GA
All Survey Participants: 319
Number (N) Percentage (%)
Indications for having sleep dentistry
Fear of dentistry 134 42.0%
Being anxious at dentist 124 38.9%
Child is too young 146 45.8%
Treatment invasiveness 86 27.0%
Treatment length 81 25.4%
General comfort 94 29.5%
Severe gag reflex 32 10.0%
Intellectual disability 32 10.0%
Medical reasons 8 2.5%
Physical reasons 9 2.8%
Other reason 10 3.1%
79
Appendix 9.4 – Bivariate Analysis of respondents indicating a barrier as very important
or important
80
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