Summary of Evidence

For certain patients and/or procedures, the use of general anesthesia in dentistry is an established service. A Minnesota state statute Minn. Stats. §62A.308 Hospitalization and Anesthesia for Dental Procedures requires health plans to cover anesthesia and hospital charges for dental care provided to a covered person who: (1) is a child under age five; or (2) is severely disabled; or (3) has a medical condition and who requires hospitalization or general anesthesia for dental care treatment. Available published evidence, including professional society guidelines and clinical reviews, recommends general anesthesia for certain indications during dental procedures, thus identifying key patient and procedural selection criteria that consider the risks and benefits of the service. General anesthesia is identified as an advanced behavior guidance technique at the end of an overall behavior guidance continuum, which should only be used after other methods of basic and advanced behavior guidance have failed. The criteria within this policy promote compliance with the state mandate and align with published clinical evidence.

Rationale

Minnesota Mandate

Minn. Stats. §62A.308 Hospitalization and Anesthesia for Dental Procedures applies to health plans as defined in section 62A.011 that provides coverage to a Minnesota resident. Minn. Stat. §62A.308, subd. 1 and 2 state the following:

Subd. 1. Scope of coverage.

This section applies to a health plan as defined in section 62A.011 that provides coverage to a Minnesota resident.

Subd. 2. Required coverages.

(a) A health plan included in subdivision 1 must cover anesthesia and hospital charges for dental care provided to a covered person who: (1) is a child under age five; or (2) is severely disabled; or (3) has a medical condition and who requires hospitalization or general anesthesia for dental care treatment. A health carrier may require prior authorization of hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.

(b) A health plan included in subdivision 1 must also provide coverage for general anesthesia and treatment rendered by a dentist for a medical condition covered by the health plan, regardless of whether the services are provided in a hospital or a dental office.

Practice Guidelines and Position Statements

In 2024, the American Academy of Pediatric Dentistry (AAPD) published behavior guidance for the pediatric dental patient. The guidance states that when a child’s cognitive abilities or behavior prevents routine delivery of oral health care using communicative guidance techniques, the urgency of dental needs influences a prioritized plan of treatment. In some cases, treatment deferral may be considered as an alternative to treating the patient under sedation or general anesthesia. However, rapidly advancing disease, trauma, pain, or infection usually dictates prompt treatment. While most children can be managed effectively using techniques of basic behavior guidance (e.g., tell-show-do, ask-tell-ask, voice control, nonverbal communication, positive reinforcement, distraction, memory restructuring, desensitization to dental setting and procedures, enhanced control, parental presence/absence, sensory-adapted dental environment, animal-assisted therapy, picture exchange communication system, mind-body therapies, and nitrous oxide/oxygen inhalation), some children occasionally present with behavioral considerations that require more advanced behavior techniques. These children often cannot cooperate due to lack of psychological or emotional maturity and/or a mental, physical, or medical condition. The advanced behavior guidance techniques commonly used include protective stabilization, sedation, and general anesthesia. The use of general anesthesia or sedation for dental rehabilitation may improve quality of life in children. According to the AAPD guidance, the decision to use general anesthesia must take into consideration:

• Alternative modalities;
• The age of the patient;
• Risk benefit analysis;
• Treatment deferral;
• Dental needs of the patient;
• The effect on the quality of dental care;
• The patient’s emotional development;
• The patient’s medical status; and
• Barriers to care.

The goals of general anesthesia are to:

• Provide safe, efficient, and effective dental care;
• Eliminate anxiety;
• Eliminate untoward movement and reaction to dental treatment;
• Aid in treatment of the mentally-, physically-, or medically-compromised patient; and
• Minimize the patient’s pain response.

General anesthesia is indicated for patients:

• Who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability;
• For whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy;
• Who are extremely uncooperative, fearful, or anxious;
• Who are pre-communicative or non-communicative;
• Requiring significant surgical procedures that can be combined with dental procedures to reduce the number of anesthetic exposures;
• For whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and
• Requiring immediate, comprehensive oral/dental care (e.g., due to dental trauma, severe infection/cellulitis, acute pain).

Contraindications for the use of general anesthesia are identified as:

• A healthy, cooperative patient with minimal dental needs.
• A very young patient with minimal dental needs that can be addressed with therapeutic interventions (e.g., ITR, fluoride varnish, SDF) and/or treatment deferral;
• Patient/practitioner convenience; and
• Predisposing medical conditions which would make general anesthesia inadvisable.

In 2012, the AAPD Pediatric Oral Health Research & Policy Center published a technical report on general anesthesia as an essential health benefit. The report states that general anesthesia may be medically necessary for treating a small subset of pediatric dental patients. Indications for general anesthesia are provided and said to be “based on specific criteria, taking into account the risks/ benefits/ effectiveness/ anticipated outcomes and alternatives to other behavior management techniques.” According to the report, general anesthesia is indicated for:

• Patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical or medical disability;
• Patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy;
• Patients who are moderately to extremely uncooperative;
• Patients who are verbally uncommunicative because of psychosocial, medical, or cultural situations;
• Patients who require significant restorative and/or surgical procedures;
• Patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk;
• Patients who require immediate, comprehensive oral/dental care (e.g., dental abscess threatening patency of the airway or other anatomical structures);
• Patients who have demonstrated the inability to respond to other available behavior guidance techniques.

In the technical report, the AAPD also recommends that federal (ERISA) regulations require health plans to cover general anesthesia and hospital-related costs when any of the following indications are present:

• Patients, including infants, exhibiting physical, intellectual, or medically compromising conditions, for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a humane and successful result and which, under GA, can be expected to produce a superior result;
• Patients demonstrating dental treatment needs for which local anesthesia is indicated, but is ineffective because of acute infection, anatomic variation or allergy;
• An extremely uncooperative, fearful, anxious or uncommunicative patient with dental needs of such magnitude or clinically apparent and functionally threatening to the well-being of the individual that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth or other increased oral or dental morbidity or mortality;
• Patients who have sustained extensive oral-facial and/or dental trauma, for which treatment under local anesthesia would be ineffective or compromised.

The 2016 American Dental Association (ADA) guideline on the use of sedation and general anesthesia by dentists states that the ADA is committed to the safe and effective use of local anesthesia, sedation, and general anesthesia by appropriately educated and trained dentists. While the guideline addresses several topics with regard to delivering general anesthesia (i.e., educational requirements, patient evaluation, pre-operative preparation, personnel and equipment requirements, monitoring and documentation, recovery and discharge, emergency management, and management of pediatric patients and those with special needs), it does not address indications. The ADA refers to the American Academy of Pediatric Dentistry (AAPD) for clinical guidance on sedation and general anesthesia in children.

In 2022, the American Society of Anesthesiologists (ASA) published a statement on sedation and anesthesia administration in dental office-based settings. The ASA is a recognized leader in advancing patient safety and in the safe provision of sedation and anesthesia care. The statement includes the following recommendations:

• The individual providing sedation and/or anesthesia care in the dental office-based setting should:
  • Successfully complete approved formal education, whether incorporated in the core curriculum or as post-graduate education, consistent and equivalent with the level of sedation and anesthesia required for credentialing and privileging in non-office-based facilities where similar procedures are routinely performed.
  • Successfully complete approved education and training in airway maintenance and management of complications from sedation and anesthesia care that include, but are not limited to airway compromise, hemodynamic instability and rescue from deeper than the intended level of sedation.
• National organizations, accrediting entities and others should work with state licensing bodies to develop consistent requirements and standards for dental office-based settings and individuals providing sedation and/or anesthesia care in such settings.
• The individual providing sedation and/or anesthesia care should successfully complete training in age-appropriate resuscitative and related emergency measures. In settings where pediatric patients are administered sedation and/or anesthesia, Pediatric Advanced Life Support (PALS) education and training should be maintained. Basic Life Support for Healthcare Providers (BLS) and Advanced Cardiac Life Support (ACLS) education and training should likewise be documented and maintained within the dental office-based setting where non-pediatric patients undergo treatment.
• Pediatric patients and those unlikely to be able to cooperate with procedures under moderate sedation may require deep sedation and/or general anesthesia. They are at particular risk for respiratory or other complications and have a greater risk of sustaining life-threatening events.  Therefore, ASA recommends that all training and protocols should have specific measures for this patient population, including the same standard of care and monitoring for moderate sedation as for deep sedation and general anesthesia, i.e. a distinct and separate qualified anesthesia provider not otherwise involved in the procedure, as stated above.
• Pediatric patients and adults with major medical problems (ASA Physical Status III and above) are at higher risk of adverse events. For these high-risk patients and younger pediatric patients, ASA recommends evaluation by a primary care physician or physician anesthesiologist prior to scheduling a procedure.
• Prolonged and extensive procedures with longer periods of sedation and anesthesia care are of concern in the office-based setting and qualified anesthesia providers, in consultation with patients and parents, should consider more suitable facilities for the procedure.
• State regulators, with input from anesthesiologists, should consider the development of state-based patient selection criteria (e.g. minimum age, co-morbidities).

For patients with special needs, the Special Care Dentistry Association (SCDA) published a consensus statement in 2009 on sedation, anesthesia, and alternative techniques. General anesthesia is identified as one of several methods to help patients with special needs receive dental care. The statement refers to the literature review published by Dougherty (2009) for risks and indications for general anesthesia during dental procedures in patients with special needs (described below).

Clinical Literature

Clinical literature on indications for dental anesthesia has been published for many years. A literature review by Vargas Román et al (2003) described the following indications for general anesthesia during dental treatment for patients who cannot be treated in a normal dental office setting:

• Patients who are medically compromised (e.g., congenital heart disease (CHD), blood dyscrasia, allergy to local anesthetics, severe liver and kidney failure, uncontrollable epilepsy, etc.);
• Patients who are unable to cooperate, understand, or tolerate treatment as a consequence of physical or mental impairment, or because of a particularly young age (infants);
• Patients requiring extensive dental treatments that cannot be carried out in the dental office, and which must be completed in a single surgical session;
• Patients with important craniofacial abnormalities requiring extensive dental treatments;
• Patients with major orofacial traumatisms or maxillary fractures;
• Patients who must travel long distances to receive dental treatment, and for whom single-session management is advisable.

In a review of general anesthesia for dentistry, Hutchinson (2014) provided the following definitive indications for general anesthesia:

• Where the dentistry is likely to be extensive, and unsuitable for an awake patient with difficult surgical extractions;
• For small children who may not tolerate dental surgery under local anesthesia;
• Allergy to local anesthetics (rare);
• Patients with mental disabilities that make it difficult for them to cooperate with surgery;
• Where there is acute inflammation so that the local anesthetic may not be effective because of local change in pH;
• Patients with medical conditions making awake dental surgery difficult, such as extreme gag reflexes, or inability to maintain adequate mouth opening.

In a review on anesthesia for pediatric dentistry, Adewale (2012) addresses medical management of pain and anxiety associated with pediatric dentistry, including general anesthesia. Indications for general anesthesia during dental procedures in children are identified as:

• The use of local anesthesia is either contraindicated, or inappropriate due to the presence of acute orofacial infection;
• There has been previous failure of local anesthesia or sedation;
• The patient is unable to cooperate with the proposed treatment due to immaturity, disability, or language difficulties;
• The patient suffers from a psychological disorder such as severe anxiety;
• Extensive treatment is required.

In 2009, Dougherty published a literature review on general anesthesia for the treatment of dental patients with special needs. The original purpose of the article was to provide a basis for guidelines; however, the evidence in this area was found to be insufficient. Therefore, a discussion of indications for general anesthesia in this population was provided. While most of the reviewed literature included minimal discussion of indications, the following indications were identified by source:

• Many articles: Inability of the patients to cooperate for treatment;
• Malamed (2003): Extreme anxiety and fear, young age, traumatic procedures, mental disability, physical disability, senility, and disorientation;
• Pohl et al (1996): Inability to cooperate for routine dental treatment, treatment of injuries, and/or extensive odontogenic infections;
• Nunn et al (1995): Extensive treatment needs, behavior management problems, medically compromised children, extreme youth, patients with handicaps, anxiety and long distance from home to a dentist.

The review also cites the pediatric indications provided in the AAPD guideline (described above). It is noted that much of the literature recommends dental treatment under general anesthesia only after other behavioral interventions have been attempted and found unsatisfactory or unsuccessful. No clear evidence was found as to what constitutes appropriate procedures to be performed or optimal frequency of dental treatment under general anesthesia.

Reference List

1. Adewale L. Anaesthesia for paediatric dentistry. Continuing Education in Anaesthesia, Critical Care & Pain. 2012;12(6):288-294. Last accessed October 2024. Available at: https://www.bjaed.org/article/S1743-1816(17)30125-7/fulltext.
2. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024. Epub ahead of print. Last accessed October 2024. Available at: https://www.aapd.org/globalassets/media/policies_guidelines/bp_behavguide.pdf.
3. American Academy of Pediatric Dentistry. Technical Report 2-2012: An essential health benefit: General anesthesia for treatment of early childhood caries. Pediatric Oral Health Research & Policy Center. 2012. Last accessed October 2024. Available at: http://www.aapd.org/assets/1/7/POHRPCTechBrief2.pdf.
4. American Dental Association. Guidelines for the use of sedation and general anesthesia by dentists. 2016. Last accessed October 2024. Available at: https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_sedation_use_guidelines.pdf.
5. American Society of Anesthesiologists. Statement on sedation & anesthesia administration in dental office-based settings. 2022. Last accessed October 2024. Available at: https://www.asahq.org/standards-and-practice-parameters/statement-on-sedation--anesthesia-administration-in-dental-officebased-settings.
6. Dougherty N. The dental patient with special needs: a review of indications for treatment under general anesthesia. Spec Care Dentist. 2009;29(1):17-20. DOI: 10.1111/j.1754-4505.2008.00057.x.
7. Glassman P, Caputo A, Dougherty N, et al. Special Care Dentistry Association consensus statement on sedation, anesthesia, and alternative techniques for people with special needs. Spec Care Dentist. 2009;29(1):2-8. DOI: 10.1111/j.1754-4505.2008.00055.x.
8. Hutchinson S. General anaesthesia for dentistry. Anaesthesia & Intensive Care Medicine. 2014;15(8):366-369. DOI: 10.1016/j.mpaic.2014.04.014.
9. Minn Stats. §62A.308 Hospitalization and Anesthesia for Dental Procedures.
10. Vargas Román Mdel P, Rodríguez Bermudo S, Machuca Portillo G. Dental treatment under general anesthesia: a useful procedure in the third millennium? (I). Med Oral. 2003;8(2):129-135. Last accessed October 2024. Available at: https://pubmed.ncbi.nlm.nih.gov/12618673/.