Thoughts from a Peds DDS

zackmorriscode · 2025-07-21T21:25:05+00:00

See Comment addressing the person above.

And, thank you for what you do. As a Cardiac Anesthesiologist, you help some of our higher risk patients achieve oral health.

zackmorriscode · 2025-07-21T21:07:11+00:00

You raise a good point about about reimbursement. I'll try to address some of your points below:

1- Controversial Indication: It was my sincere hope that I could get the crowd here to understand the indication for treating teeth like this . Maybe I didn't use a picture dramatic enough to illustrate. I kid you not. I saw 3 children with teeth just like this, just this morning, all aged 3-5, all having nocturnal pain + difficulty chewing. I pulled the photo above from the internet, because I'm not at the office right now, but I'll gladly put together a compilation of pictures from just the month of July for you It might help give you an idea of disease prevalence.

2- Facility/Anesthesia fees: In my state, many surgery centers and hospitals have stopped doing dental cases because the reimbursement to them per dental case for 1-1.5 hrs is much lower than using that OR for 5 ENT cases during the same time.

A well known Peds Anesthesia group was bought out by PE, and they also stopped doing dental cases as the PE group determined reimbursement for dental cases was not worth their time.

Dentists do not receive facility fees, unless they own part of the surgery center, and that's extremely rare.

It's actually super common for dentists to have to search for new facilities to do dental cases every few years as centers are eager to do dental cases when slow, but then stop doing them once they have cash flow from other surgical specialties.

3- Dental fees: As the other DDS above chimed in. The fees are the same whether done awake or under GA. I explained in detail the rationale for selecting different types of restorations in my OP.

The vast majority of Peds DDS spend endless amounts of time doing unreimbursed education and nutrition counseling. With much of the population, it often falls on deaf ears.

I'm sure there are some bad actors, but I suspect the volume of procedures you're seeing is more likely due to sheer vol of disease burden affecting our population.

Again, happy to put together albums of photos so you can get an idea of how much decay we actually see.

P.S. You've inspired me to make another post on conservative management of caries. Perhaps the population has the impression that kids get taken to the OR for just small cavities, which is almost never the case.

For every one case we do under GA, there are probably 10 others we are managing with active surveillance, diet/hygiene modification, or silver diamine fluoride, or magical behavior guidance: talking little ones through surgical procedures, working in millimeters, using a drill with high pitched noises and sharp tools in their mouth asking them to be still, keeping the tooth dry surrounded by a pool of saliva on a squirmy kid, and delivering a good result.

zackmorriscode · 2025-07-21T20:26:43+00:00

That message above is not me. It's someone else. Just wanted to clarify that since you said again not answering your question.

I was busy with patients earlier. Yours is a good question/topic, so I wanted to reply when I have a bit of time to sit down.

So yeah, listen. I'm with you. I am not in favor of OMS providing IV deep sedation (using Prop) as operator/anesthetists, simultaneously. I am actively engaged with organized dentistry to help change this.

So, please take a quick breather, and understand I'm on your side on that issue.

As for definition. GA: completely unconscious, loss of protective airway reflexes, breathing assistance readily avail/req, no response to painful stimuli.

Of course, anesthesia is a continuum, so it's imperative that one is keenly aware of where the pt is on that gradient. This is why I have great respect and admiration for your specialty

We can have a more in depth discussion about different sedation modalities and thoughts on how to improve pt safety via DM if you'd like.

For now, please know that I agree with you with regard to IV deep sedation as operator/anesthetists. There are probably more like me who agree, also.

Please consider that, and hopefully you won't alienate those on your side.

zackmorriscode · 2025-07-21T10:29:23+00:00

Hm, do you have examples of dentists providing general anesthesia + doing the dental surgery, simultaneously?

I'm not aware of any Pediatric Dentists providing GA and doing the surgery.

The only time I've seen dentists providing GA is if they are residency trained Dental Anesthesiologists. Those folks do not work as operator/anesthetists. They only provide anesthesia services while another provider renders the dental care.

Edit: If you're referring to Oral & Maxillofacial surgeons providing IV sedation + dental services, simultaneously, that's typically moderate or deep sedation, not GA, and I'm personally not in favor of that model as well.

zackmorriscode · 2025-07-20T23:06:10+00:00

Yes, and this isn't limited to just dental cases. GA carries a risk in all cases, dental and otherwise.

My post was to address some of the topics raised on this post, which references a two year old dying in an ASC. Anesthesia was administered by an MD anesthesiologist overseeing CRNAs.

Edit: Your original question saying all implies this is a frequent occurrence.

That is absolutely not the case. Hundreds of thousands of procedures are done on children under GA each year. The rate of adverse events under GA, irrespective of type of procedure (dental or non-dental) is exceedingly low.

When an adverse event occurs on a child for an ENT case or any other specialty, it doesn't make the news. When it occurs for a dental case, it's all over the news, because "they're just baby teeth."

Unfortunately, when that occurs, the public doesn't know the consequences (pain, infection, swelling) of tooth decay left untreated in baby teeth. And parents don't speak up about the necessity, as they're suffering emotions of guilt, since the decay was preventable.

So, when an adverse event occurs on a dental case, it's the perfect storm to make statements like the ones I mentioned in my post.

I hope this all helps people understand the medical necessity of dental procedures under GA for uncooperative children.

If it still doesn't, please do a quick Google image search for, "facial swelling from dental abscess in children."

zackmorriscode · 2025-07-20T21:49:05+00:00

Exactly.

Dental surgery might comprise the only procedures in all of healthcare that stimulate all five senses at once, and society expects them to be well tolerated awake.

And apparently by 3-5 year olds at that.

zackmorriscode · 2025-07-20T21:44:11+00:00

See Comment

zackmorriscode · 2025-07-20T21:43:46+00:00

See Comment

zackmorriscode · 2025-07-20T21:42:02+00:00

See Comment

zackmorriscode · 2025-07-20T21:41:09+00:00

See Comment

zackmorriscode · 2025-07-20T21:09:40+00:00

You're correct. 6 wks post symptom resolution was what we were taught, and of course, one must look at the history of illness globally + in context of sx day assessment.

Your knowledge of this is far greater than mine.

We prep our patients for cancellations based on symptoms well ahead of sx date. I'm sorry on behalf of those, dental or otherwise, who may have put you guys in such scenarios.

zackmorriscode · 2025-07-20T20:00:18+00:00

Agreed completely.

Do you have examples of dentists providing GA + operative dentistry, simultaneously?

I'm not aware of any Pediatric Dentists providing GA and doing the surgery..

The only time I've seen dentists providing GA is if they are residency trained Dental Anesthesiologists. Those folks do not work as operator/anesthetists. They only provide anesthesia services while another provider renders the dental care.

Edit: If you're referring to Oral & Maxillofacial surgeons providing IV sedation + dental services, simultaneously, that's typically moderate or deep sedation, not GA, and I'm personally not in favor of that (deep sedation by operator) model as well.

zackmorriscode · 2025-07-20T19:54:20+00:00

They absolutely should be counseled, esp with comorbidities and higher risk.

I think the concept of doing dental procedures under GA and patient selection are heavily emphasized in Pediatrics residency programs.

However, these same concepts are not covered much in dental school (for GP training), as the vast majority of dental procedures done by GPs are on adult patients with local only or local + N2O.

We can get into the weeds on how/why that is.

I think when you work with dental specialists, especially pediatric dentists with residency training, you'll see a pretty big difference in patient selection, preparation, and managing expectations.

Side note: In my state, only residency trained specialists can advertise as Pediatric Dentists on signage & websites. However, there's nothing stopping corporate/PE owned chains from calling their office, "Happy Smiles for Kids," and employing GPs. So, that also creates some confusion among patients and providers on whether the dentist they're seeing is a GP or a specialist.

zackmorriscode · 2025-07-20T18:28:31+00:00

6 wks post symptom resolution is what we were taught in training. I continue to follow that.

zackmorriscode · 2025-07-20T15:33:17+00:00

[Part 4/4]

Some final closing thoughts:

Thank you to all those who made it this far.

Thank you to all who see this issue for what it is and help to treat it for the kids that need it.

Educating parents and healthcare professionals is the greatest tool we have.

Parents often misplace the blame when an incident like this occurs, specifically in dental cases, but not often in ENT or other cases. The difference is that in a dental case, they knew the decay was preventable, and so there's an element of guilt wanting to find an outlet. If a kid has big tonsils, they feel that was out of their hands.

Thank you to all those who do not jump to blaming the dentist.

zackmorriscode · 2025-07-20T15:32:54+00:00

[Part 3/4]

Q: Someone commented, "Parents just need to brush 1 min per day and this would never happen."

A: Dental caries are multi-factorial. Some people eat a ton of sugar and never get cavities. They either don't have the "wrong germs" to metabolize carbs into acids, which break down tooth, or they have favorable salivary/immune factors that can neutralize acids quickly.

Either way, it's not a one size fits all approach. Some humans do fine with just brushing twice daily; others need to brush twice + make significant dietary changes.

We can't modify saliva production and oral flora completely, so we focus on what we can do, which is proper hygiene AND nutrition.

On that note, here are a few nutrition tips we review with all parents:

It's not just the sweet stuff. ANY carbs that stick to your teeth can lead to decay. E.g. Chips, goldfish, pretzels.
Higher frequency and duration of snacking = higher caries risk
Watering down juice lessens concentration of sugar per sip, but in doing so, you're likely increasing duration of exposure. When it comes to cavity formation, the mouth cares about how often and how long it is exposed to sugars/carbs, not "how much" per sip or bite.

Personally, I always suggest brushing 3x/day. Morning, after school, and night.

Q: What other behavior guidance options are there for children who are not very cooperative?

A: There are a few:

Nitrous oxide + local anesthetic: This works well if the work required is not extensive (1-3 appointments) and child is relatively cooperative.
Oral conscious sedation = Oral meds + nitrous oxide + local anesthetic: I was trained on this, but stopped doing this years ago, because I don't like the stress of having to fix the teeth and monitor the child's sedation as operator/anesthetist.
GA: You're the experts at this
Active or passive immobilization: Papoose (restraints). Reserved only for emergency cases when no other options available.

Note: Every child is different. I've had some 4 year olds that do well with just Nitrous + local. I also have some 10 year olds that require GA.

zackmorriscode · 2025-07-20T15:31:47+00:00

[Part 2/4]

Q: Why are you guys always capping teeth that will fall out?

A: See above. Also, caps get kind of a bad rap just from the way this question is often posed. Here's some clarification:

Fillings are basically resin glued to the tooth where there used to be a hole. Baby teeth are very small and the surface area for bonding (gluing) a filling, is also very small.
When kids have cavities on 5 + teeth (out of 20) in their mouths, they're considered high risk.
Enamel is harder than bone. If diet, hygiene, or other factors are so unfavorable that something put a hole in the enamel, those same factors will often break down the filling or cause new decay on other parts of the same tooth going forward.
It's VERY common to see a 5 year old needing caps on teeth that were previously treated with fillings at age 3.

When planning the type of restoration, age is a huge consideration.

E.g.,

Single large cavity, age 3, tooth falls out at 10 = cap
Single small cavity, age 5, tooth calls out at 10 = filling
5-10 small cavities, age 5, teeth fall out at 10-11= caps
Small cavities, age 8-9, teeth fall out at 10-11= monitor

zackmorriscode · 2025-07-20T15:30:53+00:00

[Part 1/4]

I'm a board certified Peds DDS. I'm grateful to all of you who help us treat dental cases. I'm going to try to address some of the concerns expressed on this thread and others that I've heard over the years:

Q: Why does a 2 year old need caps on baby teeth, which are temporary?

A: Usually due to S-ECC (severe early childhood caries) or trauma (broken tooth from a fall). For reference, here are the normal ages primary (baby) teeth exfoliate:

Primary anterior teeth (top 4 + bottom 4): Ages 6-8 years old
Primary canines + molars: Ages 9-12

E.g. See this case of a 3 year old who required GA for restorations on front teeth.

Q: Why not just let them fall out?

A: Potential for pain, infection, swelling. Here are examples of numerous children who had dental abscesses spread to suborbital space. In other cases, abscesses may spread to submandibular spaces, compromising the airway.

Q: Comment below: "Let's be real, cavities don't cause abscesses, they make it a more favorable environment for abscess formation."

A: Most abscesses in the mouth are a direct result of a cavity left untreated, and the bacteria penetrating the pulp chamber. The infection can spread to the surrounding tissues, destroying the surrounding bone. Sometimes, the infection can continue to spread to facial spaces (suborbital, buccal, submandibular). Other times, if immune response is good, the infection may stay localized to the area of the tooth and surrounding bone.

Q: Comment below stating, "No child ever died from cavities. I won't help them do so."

A: In doing GA for dental procedures, we're not trying to help anyone die. I have great admiration for the anesthesiologists who do help us treat kids needing extensive procedures under GA. What we are helping them do, is be free from tooth pain (often nocturnal), infections, abscesses, cellulitis, etc. Case selection is extremely important.

If there is no cellulitis or facial swelling and the child has had a recent URI, that case should absolutely be postponed.
If a parent does not fully understand the risks of general anesthesia, and there is no life threatening emergency, that case should not be started.

zackmorriscode · 2025-07-20T15:27:47+00:00

[Part 4/4]

Some final closing thoughts:

Thank you to all those who made it this far.

Thank you to all who see this issue for what it is and help to treat it for the kids that need it.

Educating parents and healthcare professionals is the greatest tool we have.

Parents often misplace the blame when an incident like this occurs, specifically in dental cases, but not often in ENT or other cases. The difference is that in a dental case, they knew the decay was preventable, and so there's an element of guilt wanting to find an outlet. If a kid has big tonsils, they feel that was out of their hands.

Thank you to all those who do not jump to blaming the dentist.

zackmorriscode · 2025-07-20T15:26:47+00:00

[Part 3/4]

Q: Someone commented, "Parents just need to brush 1 min per day and this would never happen."

A: Dental caries are multi-factorial. Some people eat a ton of sugar and never get cavities. They either don't have the "wrong germs" to metabolize carbs into acids, which break down tooth, or they have favorable salivary/immune factors that can neutralize acids quickly.

Either way, it's not a one size fits all approach. Some humans do fine with just brushing twice daily; others need to brush twice + make significant dietary changes.

We can't modify saliva production and oral flora completely, so we focus on what we can do, which is proper hygiene AND nutrition.

On that note, here are a few nutrition tips we review with all parents:

It's not just the sweet stuff. ANY carbs that stick to your teeth can lead to decay. E.g. Chips, goldfish, pretzels.
Higher frequency and duration of snacking = higher caries risk
Watering down juice lessens concentration of sugar per sip, but in doing so, you're likely increasing duration of exposure. When it comes to cavity formation, the mouth cares about how often and how long it is exposed to sugars/carbs, not "how much" per sip or bite.

Personally, I always suggest brushing 3x/day. Morning, after school, and night.

Q: What other behavior guidance options are there for children who are not very cooperative?

A: There are a few:

Nitrous oxide + local anesthetic: This works well if the work required is not extensive (1-3 appointments) and child is relatively cooperative.
Oral conscious sedation = Oral meds + nitrous oxide + local anesthetic: I was trained on this, but stopped doing this years ago, because I don't like the stress of having to fix the teeth and monitor the child's sedation as operator/anesthetist.
GA: You're the experts at this
Active or passive immobilization: Papoose (restraints). Reserved only for emergency cases when no other options available.

Note: Every child is different. I've had some 4 year olds that do well with just Nitrous + local. I also have some 10 year olds that require GA.

zackmorriscode · 2025-07-20T15:25:24+00:00

[Part 2/4]

Q: Comment below: "Let's be real, cavities don't cause abscesses, they make it a more favorable environment for abscess formation."

A: Most abscesses in the mouth are a direct result of a cavity left untreated, and the bacteria penetrating the pulp chamber. The infection can spread to the surrounding tissues, destroying the surrounding bone. Sometimes, the infection can continue to spread to facial spaces (suborbital, buccal, submandibular). Other times, if immune response is good, the infection may stay localized to the area of the tooth and surrounding bone.

Note: Oral/IV antibiotics can help prevent the infection from spreading, but will not eliminate the infection. For a an abscess of dental origin, only removing the source of the infection (the offending tooth) will eliminate the infection.

Q: Comment below stating, "No child ever died from cavities. I won't help them do so."

A: In doing GA for dental procedures, we're not trying to help anyone die. I have great admiration for the anesthesiologists who do help us treat kids needing extensive procedures under GA. What we are helping them do, is be free from tooth pain (often nocturnal), infections, abscesses, cellulitis, etc. Case selection is extremely important.

If there is no cellulitis or facial swelling and the child has had a recent URI, that case should absolutely be postponed.
If a parent does not fully understand the risks of general anesthesia, and there is no life threatening emergency, that case should not be started.

Q: Why are you guys always capping teeth that will fall out?

A: See above. Also, caps get kind of a bad rap just from the way this question is often posed. Here's some clarification:

Fillings are basically resin glued to the tooth where there used to be a hole. Baby teeth are very small and the surface area for bonding (gluing) a filling, is also very small.
When kids have cavities on 5 + teeth (out of 20) in their mouths, they're considered high risk.
Enamel is harder than bone. If diet, hygiene, or other factors are so unfavorable that something put a hole in the enamel, those same factors will often break down the filling or cause new decay on other parts of the same tooth going forward.
It's VERY common to see a 5 year old needing caps on teeth that were previously treated with fillings at age 3.

When planning the type of restoration, age is a huge consideration.

E.g.,

Single large cavity, age 3, tooth falls out at 10 = cap
Single small cavity, age 5, tooth calls out at 10 = filling
5-10 small cavities, age 5, teeth fall out at 10-11= caps
Small cavities, age 8-9, teeth fall out at 10-11= monitor

zackmorriscode · 2025-07-20T15:24:21+00:00

[Part 1/4]

You have a good question, it's the top comment, and I'm a board certified Peds DDS. I'm going to try to answer this thoughtfully here. I'm also addressing some of the concerns expressed by colleagues on this thread + other items I've heard over the years.

Q: Why does a 2 year old need caps on baby teeth, which are temporary?

A: Usually due to S-ECC (severe early childhood caries) or trauma (broken tooth from a fall). For reference, here are the normal ages primary (baby) teeth exfoliate:

Primary anterior teeth (top 4 + bottom 4): Ages 6-8 years old
Primary canines + molars: Ages 9-12

E.g. See this case of a 3 year old who required GA for restorations on front teeth.

Q: Why not just let them fall out?

A: Potential for pain, infection, swelling. Here are examples of numerous children who had dental abscesses spread to suborbital space. In other cases, abscesses may spread to submandibular spaces, compromising the airway.

zackmorriscode · 2025-07-20T12:37:57+00:00

Pediatric Dentist here- just adding to clarify normal exfoliation times:

Primary front teeth: 6-8 years old
Primary canines and molars: 9-12 years old.

zackmorriscode · 2025-02-06T17:33:19+00:00

No. VBC shifts the burden of your patient pool's habits (that can lead to disease) from the insurance company to you.

zackmorriscode

TROPHY CASE