Friday, March 15, 2019

The Wars of the Smiles

Who can place a patient under general anesthesia in a dentist's office? Should such services even take place in a dental office?  A quiet war has been raging over these very questions at the Mississippi Board of Dental Examiners for nearly a year.

On one side are a group of dental practices operating under variations of the "Smiles" trade name.  They are usually owned by or affiliated with out of state corporations.  The Smiles use dental anesthesiologists to administer general anesthesia and monitor the patient while another dentist operates. General anesthesia is used to place the patient in an unconscious state.   The Smiles usually focus on children.  Opposing the Smiles are the pediatric dentists of Mississippi.  They argue it is safer to use such anesthesia in a hospital and that the operating dentist should be qualified to administer general anesthesia as well if such sedation is used in an office.   

The battle turns over the interpretation of the Dental Board's "Regulation 29".   The Dental Board requires dentists to obtain an anethesia permit for various levels of anesthesia.*  Regulation 29, Section 4(c) states:

General Anesthesia.   No licensed dentist shall use general anesthesia in his/her office on an outpatient basis for dental patients, unless such dentist possesses a permit of authorization issued by the Board.  The issuance of a permit for general anesthesia shall include the privileges of administering parenteral conscious sedation and enteral conscious sedation in accordance with the provisions of this section.
The Board doesn't just pass out such permits to any dentist who asks for them but instead has criteria that must be met before the dentist gets the privilege of knocking out patients.  The dentist must complete training in a post-graduate program for administering general anesthesia.  The facilities where general anesthesia will be used must be properly equipped and have supporting staff who can assist the dentist in administering anesthesia.  However, a permit is not needed if the care is given at a hospital where anesthesia is provided by an anesthesiologist or a nurse anesthetist.

Such regulations seem simple enough.  Complete several years of post-graduate training, get the necessary equipment, have trained staff on hand for the administering of general anesthesia, and pass the necessary inspections if a dentist wants to use general anesthesia in her office. However, the Board posted a "Frequently Asked Questions" section on its website that stated a different policy on Reg 29:

The interpretation of Reg 29 in the FAQ section caused no small amount of heartburn among Mississippi pediatric dentists. Several pediatric dentists accused the Smiles of using dental anesthesiologists to administer general anesthesia for restorative dentistry** while the operating dentist lacks a general anesthesia permit. Mississippi does not recognize the specialty.  However, Dental Anesthesiologists obtain the degree after completing three years of post-graduate training.

A Tupelo pediatric dentist, Dr. Ken Johnson, submitted a complaint to the Dental Board in October 2017 about a dental anesthesiologist practicing in Tupelo.  Dr. Johnson argued Reg 29 required the operating dentist to have a general anesthesia permit and couldn't outsource that crucial chore to a specialist in his office if he didn't have such a permit.   Dr. Johnson checked on the status of complaint in January 2018.  The Deputy Executive Director told him the Board rejected his complaint and said operating dentists didn't need the permit if an anesthesiologist was present.  He submitted another complaint.

His complaint states:

However, I do have major issues with how the Board has allowed these corporate dental clinics to operate and market themselves in a way that suggests that they are specialists, when in fact, they are general dentists with no specialty training to work exclusively on children.

Aside from their misleading marketing tactics, in Fall 2017, it was brought to my attention by multiple professional sources that general anesthesia services were available at Happy Smiles here in Tupelo . Some of my colleagues confirmed the same to be true for Happy Smiles in Horn Lake . Reportedly, general anesthesia is available at this location on certain days of the week.

This was alarming for me, because none of the pediatric dentists I know use general anesthesia in their offices. We are trained to treat children under general anesthesia at either ambulatory surgery centers or hospitals. We are medical staff members to have these privileges.....
 He accused Happy Smiles of using out-of-state  dental anesthesiologists to float from office to office:

The facts are as follows: The founder of Happy Smiles is from Mississippi but lives in Arizona. The dental anesthesiologists in Mississippi working for Happy Smiles are employed by Desert State Dental Anesthesia in Arizona. Each of them have listed up to nine satellite offices they work out of such as Kool Smiles, Happy Smiles, Mississippi Smiles, etc. covering the entire state. December 2017, a child died following a dental visit to a Kool Smiles location in Arizona. His death is believed to have been in correlation with general anesthesia.

According to the Board License search, none of the Tupelo Happy Smiles dentists have general anesthesia permits. Also, no Tupelo Oral Surgeon has been asked to inspect the Happy Smiles offices for compliance. Upon such inspection, one would find that the administering dental anesthesiologist is not on staff at North Mississippi Medical Center. Therefore, he would not have the privileges to admit a patient in an emergency situation....
The controversy didn't end with Dr. Johnson, as Dr. Trice Sumner of Tupelo submitted a letter questioning the Board's enforcement of Reg 29 in a May 2018 letter.  Dr. Sumner is the President of the Mississippi Chapter of the Academy of Pediatric Dentistry.

The Board took up Reg 29 at the July Board meeting.  Board President Dr. Frank Conway of Bay St. Louis opened the meeting by stating the Board could get rid of the controversial FAQ and make no change to Reg 29 or form a committee of people who have sedation experience.   Such a committee could recommend changes that should be made to Reg 29.

Dr. Sumner called out the "increased use of general anesthesia in dental offices across the state."  She said Reg 29 requires every operating dentist to have a general anesthesia permit if such anesthesia is used.   She said if the Board wants to recognize Dental Anesthesiologists as a specialty practice, then it should get the Legislature to pass a bill allowing it to do so.  The Tupelo dentist said dental anesthesiologists are not recognized nationally nor by Mississippi.  She said no pediatric dentists use general anesthesia in an office setting.

She asked the Board how the regulation was changed in the FAQ.  Dr. Sumner said the Academy's questions fell on deaf ears as "we were met with silence."   She asked the Board to enforce Reg 29 as written.  Dr. Conway challenged her and asked if the interpretation included oral surgeons.  She replied Reg 29 has nothing to do with oral surgeons but with restorative dentistry.   The Board President then questioned whether patients could afford an extra "$10,000" to have the services performed at a hospital.  Dr. Sumner replied she had a contracted rate of $2,000 with the hospital she uses.

One anesthesiologist appeared at the Board meeting and made her opinions known to the Board in no uncertain terms.  Dr. Heddy Matthias said she had administered general anesthesia to over 10,000 pediatric dental patients over her long career.  She pointedly asked the Board who could provide anesthesia services or assist the patient in recovery if something happened to the person providing the anesthesia.  Such a concern has been raised repeatedly during the discussion about regulation 29.  She said a dentist was reckless if  there was only one person in the office trained to provide general anesthesia to the patient.   She also expressed concern over whether such practices had recovery rooms for such patients.  She said such facilities must have an RN present to monitor the patient (Her letter is posted below.).

The Board voted unanimously to remove the FAQ's from the Dental Board's website that dealt with Reg 29.  He said the regulation addresses the operating dentist.  The Board also voted to send a letter to all dentists informing them of the Board's interpretation of Reg 29 and removal of the FAQ.

* The various permits required are
1) Enteral Conscious Sedation
2) Parenteral Conscious Sedation
3) General Anesthesia: Completely knocked out.

** Restorative dentistry is the restoration of teeth with metal or nonmetal materials such as fillings and crowns.  

Next Post: The Smiles Strike Back.


Anonymous said...

This post could be used as anesthesia

Anonymous said...

As a parent, that is very scary. 60 minutes (I think it was 60 minutes anyway) recently did a story on Kool Smiles/Happy Smiles. It covered accusations of taking advantage of children with Medicaid by recommending dental procedures that wer not needed.

Anonymous said...

I’m a purist, I want to be treated by the most appropriate, best; board certified physicians or dentist my money and insurance will allow. If advanced or specialized services are required, I want to be assured my health care provider has the highest level of competence that nation board certification assures. My children’s health care needs are taken care of by board certified pediatricians (MD) and a board certified pediatric dentist. If anesthesia is ever required for anything, I want a board certified anesthesiologist (MD) administering my drugs and making sure I wake up in-tact and healthy. I’m sad to think if I were poor, or uneducated and didn’t understand the serious implications of lower level providing sophisticated medical services or procedures, that I might be influenced by the advertising campaigns of these corporate dental mills. Everyone deserves appropriate and good health care. As I understand it, these operations use general dentists for services that should be administered by pediatric dentists, and they fully sedate children in their offices using fly-in dentists that have some kind of anesthesia training...Good Grief! Why aren’t the Dental Board or Attorney General looking out for the innocent public?

Bill Dees said...

God, this post was boring. Do you have skin in this game?

Anonymous said...

Be aware that Kool Smiles recently changed their name to Sunnybrook Dentistry to avoid the bad publicity of their $23.9 M settlement with the feds for Medicaid fraud and abuse. The feds caught them performing unnecessary procedures, causing harm to children with brutal tactics to perform procedures, failure to refer to appropriate specialists. This was done to avoid "losing" the Medicaid money. They are under no special surveillance in MS by Medicaid authorities, despite their corporate history.

Anonymous said...

Not boring if you have children or give a damn about others...

Anonymous said...

General Anesthesia should not be used in office settings for any type of healthcare provider.

Anonymous said...

About 5 years ago a beautiful little 3 year old died an a “Chain Type” dentist after being put to sleep for a procedure. She was on Medicaid and the procedure was later deemed to be unnecessary. Should only br don’t in a hospital setting.

Anonymous said...

What I find interesting is Medicaid does not require an H and P to make sure a child is healthy enough to be put under GA by a fucking DENTIST in a strip mall. This is Medicaid forcing children to have unsafe treatment plain and simple.

Anonymous said...

Corporate dental mills target vulnerable parents and Medicaid recipients.
Market that they are taking are of the underserved, but are really providing questionable care to poor kids.
Why doesn’t the Dental Biard stop them?

Anonymous said...

These ‘Smiles’ businesses are damgerous for kids but are #gettingrichoffMedicaid

Anonymous said...

As a prominent Madison County resident I am concerned because my only tooth is hurting now.

Anonymous said...

The pediatric dentists and anesthesiologists are trying to limit competition. Typical anti-competitive tactics by the ruling class in health care. More health care providers should be figuring out ways to treat patients in more convenient and less expensive settings.

Anonymous said...

I talked with a dentist who works for Kool Smiles. He has quotas of number of dollars billed each month. If he doesn't meet them, he gets called in, signs an "improvement agreement." If he doesn't improve (generate more dollars), he can get fired.

Anonymous said...

Which anesthesiologist are trying to limit competition? Are you referring to the general dentist anesthesiologists who are receiving 8 times the reimbursement of MD anesthesiologist to do the same procedure?

Albert Schweitzer said...

About 30 years ago there was a great need for anesthesiologists. The suggestion was made that dentists should be recruited into anesthesia residencies. Both the American Society of Anesthesiologists and the American Board of Anesthesia flatly rejected that proposal.
Their position was that the administration of anesthesia should be done by a medical doctor (i.e. anesthesiologist) or by a CRNA under the supervision of an anesthesiologist.
Since then we have slid somewhat; both by some dentists pushing the limits of "sedation" and by CRNAs working directly for the dentists.
No system is perfect and all will have failures.
But the failure (i.e. death and wounding) rates have slid too.
If you or your child are sitting in the dentist's chair, Caveat Emptor.

Anonymous said...

I’m sure Drew Snyder stopped all of the Medicaid abuse. Wait, he’s still counting paper clips.

Anonymous said...

It is evident by these comments that Kreepy Smiles doesn’t have the interests of Mississippians in mind. We need to have a board in charge of these carpetbaggers that decide in the interests of our citizens.

Anonymous said...

Color me stupid...I did not know patients are put totally to sleep (under) in a dentist's office.

Anonymous said...

5:56 Recently when I had my wisdom teeth removed, I was 'tickled' to have it! (older adult)

Anonymous said...

The pediatric dentists, oral surgeons, and MD anesthesiologists who testified in front of the Dental Board wanted one and only one thing--safe anesthesia. This includes a qualified anesthesia provider, a qualified assistant to the anesthesiologist (a nurse--RN), qualified nurses in the recovery room, and policies and procedures/inspections that insures that the procedure in the dental office looks exactly like the procedure in an ambulatory surgical center or hospital. That is all! IT'S ABOUT SAFETY, NOT COMPETITION!

Anonymous said...

Is the sedation used for a colonoscopy considered general anesthetic? Do oral surgeons have the proper training to put patients to sleep?

Anonymous said...

The Dental Board meetings are a "three-ring circus." The Dental Board has no specialists on the Board. Not a single one. They are all general dentists, and, except for one shining star dentist, Mark Donald, DDS, they don't understand the issue of anesthesia/sedation safety. But worse than that, they don't know what they don't know, and they don't want to know. Dr. Conaway has been extremely sexist towards female experts, cutting them off, dissing them, yelling at them, etc. These are women who know much more than he does.

The Dental Board has refused for over 2 years to enforce its own Regulations, allowing general anesthesia in various Krazy Smiles offices, without proper inspections, anesthesia permits, etc. by a group of anesthetists who had a pediatric death in 2017.

The Governor needs to reconstitute the Board and put some damn pediatric dentists, oral surgeons and periodontists on the Board.

Dr. Conaway's behavior has been obstructionistic and suspect. His job is to lead the group to protect the public. He's done none of that. No one can figure out his behavior. Does he have some type of financial skin in the game?

After 8 months of requests to form a panel of EXPERTS to re-write sedation/anesthesia guidelines, he finally gave in. However, he purposefully left all nearly ALL the experts who had testified and appointed most members who'd NEVER been to any meetings or shown any interest in the subject. He had to be forced to put an MD anesthesiologist on the panel.

WHY? Conaway--RESIGN! Governor Bryant--fire his butt! Medicaid--wake up and look at the bills they're sending to you.

Kingfish said...

It is my understanding that Oral Surgeons have several years of post graduate training. Feel free to correct me.

Anonymous said...

Does Dr ConWay have any financial interests in these Smiles operations?

Anonymous said...

"Is the sedation used for a colonoscopy considered general anesthetic? "

IIRC, no. Patients were extremely sedated but not unconscious. However, my experience in the colonoscopy suite was awhile ago, and times and rules may have changed.

Anonymous said...

As has already been indicated these franchises all too often prey on Medicaid recipients and have overly aggressive treatment plans. I know way too many people who sought second opinions at regular and pediatric dentists and received completely different options. One family member was told that five teeth needed to capped to the tune of $5000 plus. They sought a second opinion and were told all the teeth were baby teeth and would be falling out soon anyway. They took a wait and see approach and ended up doing one extraction. This kind of systematic fraud is what is killing our healthcare system.

Anonymous said...

Follow the Benjamin$.

Anonymous said...

The reason that Krazy Smiles, etc. have hauled the anesthetists from out of state to their offices is because the general dentist can't get hospital/ASC privileges and they don't want to lose the money by referring to a pediatric dentist that does have privileges.


Anonymous said...

"Several years of post-graduate training"? Well, that's surely a relief. Half the people at the veterinarian's office have several years of training too. But, do you want them putting your dog under and performing operations.

And, to others: The person performing your colonoscopy is an M.D.

Anonymous said...

Colonoscopy is performed with “moderate sedation” (fentanyl / versed) under direction of MD or “monitored anesthesia care” (fentanyl, versed, propofol, ketamine, etc). with a CRNA acting under an Anesthesiologist.

There are very strict regulations about where this can be performed, dedicated RN monitoring, dedicated recovery area with RN recovery staff, strict recovery and safety parameters...not to mention credentialing that the MD has to go through on a continual basis.

Additionally, the physician must maintain hospital credentials in the event of an emergency. See also the State Board is Health Regs that requires ASCs to also have an emergent hospital relationship.

99% of colonoscopies are NOT done with general anesthesia.

Does the dental board even know what “general anesthesia is? (think isoflourane, sevoflourane, and other inhaled anesthetics). If this is being performed in a dental office, then someone should call their attorney.

Even the thought of sedation performed at an outpatient dental office without very strict regulations is downright frightening.

Anonymous said...

There are no (and have never been) any state or federal laws or rules that require a Nurse Anesthetist to work with or “under” an anesthesiologist. Nurse Anesthetists provide approximately 75% of all the Anesthetics in America per year, and the vast majority of anesthesia dental anesthetics (when an anesthesia provider is used). Although able, it is rather uncommon to see an anesthesiologist working in a dental office. Judges ruled in the 1920’s that anesthesia is actually the practice of 3 fields: Medicine, Nursing and Dentistry, Subsequently, Oral Surgeons do receive approximately 3 months of anesthesia training during their residency, while anesthesiologists and nurse anesthetists receive 3 years plus their undergraduate training. Nurse anesthesthetists receive another 2 years of experience working in an intensive care unit and anesthesiologists gain 1 additional year of internship. In regards to laws and rules regarding nurse anesthetist (CRNA) practice, there is only one federal law and one state law (MS) that both say essentially the same thing: when a CRNA is practicing anesthesia, they must work with either a physician (MD or DO) or a dentist. Since surgeons, dentists and anesthesiologists all satisfy that requirement, that enables the CRNA to practice their specialty. Approximately 20 states have removed that law to date. The source of most of the confusion lies within the Medicare/Medicaid billing rules. Those rules permit an anesthesiologist (but no other MD, DO or dentist) to bill for up to 4 simultaneous anesthetics that have been provided by (and also billed) by a CRNA. This billing rule is known as “Medical Direction.” Anesthesiologists also have another CMS billing model known as “Medical Supervision” which pays at a lesser rate, however has less requirements for the anesthesiologist to meet in regards to the CRNAs he/she works with and the anesthetics that those CRNAs provide. These are somewhat confusing concepts, however they have nothing to do with CRNA practice or billing. Furthermore, contemporary medical practice states that the person providing the procedure and the person providing the anesthesia must be two seperate people. As is currently practiced in every other medical profession besides dentistry, its clear that the dentist should provide the dentistry and an anesthesia specialist should provide the anesthesia.

Anonymous said...

Something stinks in dental board meetings in Mississippi

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