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: amir.azarpazhooh@dentistry.utoronto.ca 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).

39

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

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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 ethics.review@utoronto.ca or (416) 946-3273. In regards to the survey itself, you can contact me at soheil.mohammadikhojasteh@mail.utoronto.ca. 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: soheil.mohammadikhojasteh@mail.utoronto.ca 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 ethics.review@utoronto.ca or (416) 946-3273. In regards to the survey itself, you can contact me at soheil.mohammadikhojasteh@mail.utoronto.ca. 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: soheil.mohammadikhojasteh@mail.utoronto.ca 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 soheil.mohammadikhojasteh@mail.utoronto.ca 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 soheil.mohammadikhojasteh@mail.utoronto.ca or call me at (416) 979-4900, ext 4637

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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)

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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: soheil.mohammadikhojasteh@mail.utoronto.ca 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 soheil.mohammadikhojasteh@mail.utoronto.ca. 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: soheil.mohammadikhojasteh@mail.utoronto.ca. 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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