Providing Pediatric Dental Anesthesia to Refugee Children

In 2017, there was a historic high of 44.5 million people living in the U.S. who were foreign-born, more than double the number from 1990. Since the creation of the Refugee Act of 1980, more refugee families have settled in the U.S. than in any other country in the world (asamonitor.pub/48hDgD8).

Studies show a high prevalence of oral disease and unmet oral health care needs in refugees. Refugees often experience high levels of dental caries, periodontal disease, oral lesions, and traumatic dental injuries. In fact, one study indicated 49% of refugee children had untreated caries, a prevalence over twice that of children from the U.S. (asamonitor.pub/3Le8Qru).

Factors contributing to this high prevalence of disease include a lack of oral health care infrastructure in their home countries, challenging migration trajectories, difficulty accessing care upon arrival to the U.S., and individual health beliefs and practices. Sometimes cultural practices come into play, as when parents believe that primary teeth are unimportant and tooth decay is inevitable, so they don’t prioritize dental appointments for their children. Poor dental care negatively affects nutritional status and child development, and is also linked to other chronic health conditions such as diabetes and cardiovascular disease.

“There are so many refugee children who need to be treated. Often, they haven’t had any dental care in their home country. The problems are exacerbated when we can’t communicate with them, and the patient needs to be anesthetized so they can be treated,” said Dr. Herlich, who retired from the University of Pittsburgh School of Medicine Department of Anesthesiology and Perioperative Medicine to take on his current role as interim chair at the School of Dental Medicine. He is also the American Society of Anesthesiologists liaison to the American Dental Association, the American Association of Oral and Maxillofacial Surgeons, and the American Dental Society of Anesthesiology.

When providing dental care to a refugee child, as with any patient, typical issues include determining how the service will be reimbursed and deciding where it’s going to take place – in a dental office, dental school, clinic, or hospital OR.

Dr. Herlich outlined other considerations when treating this population, including:

• Language translation: “We use an iPad-type device that translates 60+ languages, but even so, the translation isn’t perfect.”
• Legal guardian availability to discuss care: “Problems arise when patients show up, but they’re not accompanied by a legal guardian. The parents may be working, taking care of other children, or they don’t speak the language. The parent may send the child with an older male sibling, who culturally is the ‘man of the house,’ but who is not the legal guardian. It can be difficult to get them to understand that this is not going to work.”
• Fitness for the procedure and existing diseases: “Refugee housing is not the healthiest of environments, and children may have underlying health issues that may affect how well they do during a procedure.” Common infectious diseases affecting refugee and other newly arriving migrants include latent or active tuberculosis, human immunodeficiency virus type 1 (HIV), hepatitis B, hepatitis C, vaccine-preventable diseases, malaria, and other parasitic infections (asamonitor.pub/3LfJUzX).
• Use of sedation as a means of bypassing the need for communication with the child: “Since you often can’t communicate with the child to any great degree, some doctors might resort to an oral or intramuscular premedication to facilitate the induction of anesthesia. Is this in the best interest of the child?”
• If the previous issues have been addressed and full general anesthesia (GA) is indicated, is an OR available? “More and more hospitals aren’t providing OR time for pediatric dentists to do procedures. It’s an age-old issue – as the health care reimbursement dollar shrinks, OR availability is allocated to the procedures which pay more. When I first started in this business in the 1970s, these patients never had a problem getting OR time. However, insurance companies will find reasons not to pay for the care of these patients, and hospitals are left to absorb a lot of the cost,” said Dr. Herlich.

It is the last issue that is becoming more and more of a concern. In about two-thirds of states, pediatric dentists’ access to hospital ORs has been curtailed or eliminated (asamonitor.pub/487IjGc). Financial pressures have forced hospitals to prioritize surgical services based on profitability and necessity. The COVID pandemic made the situation worse because hospitals reduced OR access for all surgical services to prevent the spread of infection. Staff were furloughed, and ORs were closed and downsized. The resulting backlog has caused competition among all surgical specialties that will last for years.

Further limiting access to the OR are requirements for determination of medical necessity, complicated rules for approval of GA dental treatment, and medical approval by a licensed physician before admission to the hospital (asamonitor.pub/487IjGc). As a result, children in need of hospital care for dental procedures are put on long waiting lists or denied care altogether.

A paper issued by the American Academy of Pediatric Dentistry, Pediatric Oral Health Research and Policy Center offered these solutions (asamonitor.pub/487IjGc):

• Create alternatives to traditional ORs, such as freestanding outpatient surgery centers that are dentist-owned and fully outfitted with dental equipment, including pediatric equipment.
• In-office general anesthesia, wherein a dentist brings a licensed anesthesia provider to a private office to deliver general anesthesia.
• Nurture interprofessional relationships. Today, hospitals are required to go beyond management of illness and develop community interactions that support healthy behaviors and services that prevent illness. Dentists can participate in this planning and on-boarding of directors in critical areas of health such as public health clinics and ambulatory surgery centers, as well as serving as a referral source for hospital emergency departments.
• Engage in legislative and regulatory advocacy by raising these issues with state and local legislators, public health officials, and hospital administrators.

“Anesthesiologists can help make these strategies work by welcoming their dental colleagues to the planning table,” remarked Dr. Herlich. “I urge anesthesiologists to be aware of the plight of the pediatric or general dentist who is struggling to treat refugee patients with the limited resources available. Offer solutions and be prepared to help – don’t just point fingers when something goes wrong. Members of ASA always step up to the plate, and we need to continue to do so. We’ve got to care because if you save one life, you save the world.”