Policy on Hospitalization and Operating Room Access for Oral Care of Infants, Children, Adolescents, and Individuals with Special Health Care Needs

Purpose

The American Academy of Pediatric Dentistry (AAPD) advocates hospitalization and equal access to operating room facilities, when indicated, for oral care of infants, children, adolescents, and individuals with special health care needs. The AAPD recognizes that barriers to hospital oral care for patients who require treatment in that setting need to be addressed. 

Methods

This policy was developed by the Dental Care Committee, adopted in 1989² , and last revised by the Council of Clinical Affairs in 2020³ . A PubMed®/MEDLINE search was performed using the terms: access for dental/oral care in hospitals, operating room access for dental/oral care, and access to hospital dentistry; fields: all; limits: within the last 10 years, humans, English. Additionally, websites for the American Medical Association (AMA), American Dental Association (ADA), AAPD, Commission on Dental Accreditation (CODA), and Centers for Disease Control and Prevention were reviewed. 

Background

Pediatric dentists treat patients who present special challenges related to their age, behavior, medical status, developmental disabilities, or special needs. Caries, periodontal diseases, and other oral conditions, if left untreated, can lead to pain, infection, and loss of function.^4-6 These undesirable outcomes can adversely affect learning, communication, nutrition, and other activities necessary for normal growth and development.^6,7 Many medical (e.g., hematological, oncological, cardiac⁸ ) conditions are exacerbated by the presence of oral diseases. To address these challenges and to provide the treatment needs safely and effectively, pediatric dentists have developed and employed a variety of management techniques, including accessing anesthesia services and/or the provision of oral health care in a hospital setting with or without general anesthesia.⁹

 Hospital dentistry is an integral part of the curriculum of all accredited advanced pediatric dental training programs.¹⁰ Therefore, pediatric dentists are, by virtue of training and experience, qualified to recognize the indications for such an approach and to render such care.^10,11 Urgent treatment needs⁹ , complex medical conditions⁹ , and young age¹² may call for treatment to be provided in a hospital that provides resources and/or ancillary services unavailable in the dental setting. The AAPD and the ADA urge both private and government insurance carriers to include hospitalization benefits for dental treatment so the resources of a hospital are available to patients whose condition – in the judgment of the dentist – warrants treatment in the operating room.¹³ When oral health care is not accessible, the health implications, effects on quality of life, and societal costs are enormous.¹⁴ Parents of children with early childhood caries who underwent complete oral rehabilitation under general anesthesia reported a significant improvement in quality of life, including in areas such as sleeping, eating, and pain.^15,16

Within the hospital environment, some pediatric dentists have experienced reluctance to scheduling operating room time for dental cases, postponement/delay of non-emergent oral care for patients, and economic credentialing (i.e., the use of economic criteria unrelated to quality of care or professional competency).¹⁷ Operating room access for dental procedures decreased over the last decade even though third-party coverage may be mandated.^13,18 The severe acute respiratory syndrome coronavirus 2 pandemic further decreased access as hospitals suspended elective procedures, leading to immense backlogs of dental cases.¹³ Some patients may not be able to access the advanced behavioral, physical, medical, and/or psychological support they require to undergo dental procedures if treatment is limited to a traditional dental setting.^19-21 Inability to access the means to deliver medically-necessary dental treatment to patients promptly, safely, effectively, and humanely is a reason of professional and ethical duress for many pediatric dentists.²²

Economic credentialing to determine qualifications for granting/renewing an individual’s clinical staff membership or privileges has been denounced by the AMA.²³ Rather, decisions regarding hospital staff privileges should be based upon the training, experience, and competence of candidates, considering the availability of facilities and the overall healthcare needs of the community, the facility, and especially the patients.²⁴ Privileges should not be based on numbers of patients admitted to the facility or the patient’s economic or insurance status.²⁴

Policy statement

The AAPD’s strategic objectives include oral health advocacy and addressing barriers to care.1 Therefore, AAPD works with all concerned medical and dental colleagues and organizations to remove barriers to hospital and operating room access for oral care for patients best treated in those settings and for their dental providers. The AAPD affirms that hospitals or outpatient surgical settings are the optimal treatment facilities for some patients with urgent treatment needs or medically-complex conditions and that they should not discriminate against pediatric dental patients requiring care under general anesthesia. Access to these facilities and the timely provision of care are essential to the health and safety of many pediatric dental patients. The dental patient, as with any other patient, should have the right to be seen in a safe and timely manner.