Introduction
Painless dental care is an important indicator of quality care from the perception of pediatric patients. Most children experience anxiety and tension when required to undergo dental treatment (Kuhad, 2019; Reis et al., 2016). Therefore, dentists aim at minimizing pain, anxiety, and panic among pediatric patients to enhance the quality of care by using nitrous oxide inhalation sedation (Oubenyahya & Bouhabba, 2019). The American Academy of Pediatric Dentistry (2018) defines nitrous oxide inhalation as a safe technique to reduce anxiety among children and establish communication between a patient and a medical worker. Considering that anxiety and pain are the key concerns faced by many pediatric children, proper sedation serves as a viable solution to the identified problem (Gazal et al., 2016). In this connection, the importance of the chosen topic is associated with understanding the current sedation practices in pediatric dentistry and revealing any tendencies and opportunities for its further improvement. Ras-Al-Khaimah specialized dental center is one of the 8 specialized dental centers under the Ministry of Health and Prevention (MOHAP) in the United Arab Emirates (UAE) and this center does not have nitrous oxide inhalation sedation.
The vision of the organization is to become an effective and sustainable healthcare system for a happy society. By providing nitrous oxide inhalation sedation, the clinic will deliver effective treatment to pediatric patients facing anxiety. Ultimately, these patients will be happy with the quality of services, thereby aligning with the clinic’s vision.
The mission of the organization is to improve community health by delivering all-inclusive, state-of-the-art, and unbiased healthcare services based on international standards as well as performing its role as a controller and overseer of the healthcare sector through an up-to-date and amalgamated health legislative system. By installing a nitrous oxide sedation system, the clinic will update its services to compete favorably with other health facilities that provide similar services. It will also provide unbiased sedation to patients, which will align with its mission.
Justification for the Business Case at Ras-Al-Khaimah Specialized Dental Center
Dental visits are scary experiences for most pediatric patients, often resulting in fear, which is worsened by the sound and smell of dental offices as well as recounted experiences of dental treatment among children (Bajrić et al., 2016). Consequently, pediatric patients have negative perceptions of dental care, which is an impediment to successful treatment (Galeotti et al., 2016). It also interferes with the quality of dental care. Nitrous oxide sedation helps to calm down children by easing their anxiety during treatment. As a result, pediatric patients develop a positive dental attitude, which is beneficial for treatment compliance and causes patient satisfaction. It also enhances patient cooperation during treatment (Nelson et al., 2017).
The pediatric dental clinic in a specialized RAK dental center does not have nitrous oxide inhalation sedation. Whenever an anxious and uncooperative pediatric patient requires treatment at the facility, the pedodontist is compelled to treat the patient under general anesthesia (GA) even if the treatment is a simple procedure such as filling or extraction involving a single tooth (Al Karaawi, 2019). However, treatment under GA costs the hospital vast resources in terms of blood tests, x-ray, admission, space, medication, and recovery room. Furthermore, it takes a longer time to discharge patients after procedures involving GA (American Dental Association, 2016). Therefore, there is a need to install and operate a nitrous oxide inhalation sedation system to save up on these costs and provide comfort to uncooperative patients. Doing so will align with the purpose and scope of MOHAP’s policy to minimize physical discomfort, anxiety, and negative psychological responses to patients through the provision of sedation, amnesia, and analgesia (UAE Vision 2021, 2018).
SWOT
A SWOT (strengths, weaknesses, opportunities, and threats) analysis of the current situation justifies the use of nitrous oxide sedation at Ras-Al-Khaimah Specialized Dental Center. The following sections elucidate each part of the analysis with respect to the business case.
Strengths
The physical properties of nitrous gas make it appealing to use for sedation. Laughing gas is odorless and its administration is a painless, non-invasive process that makes patients relaxed (Nelson et al., 2017; Kharouba et al., 2020). Currently, four out of the eight specialized dental centers under MOHAP have been using nitrous oxide in their pediatric dental clinics since January 2020. The other four clinics, including the Ras-Al-Khaimah dental clinic, stating using nitrous oxide machines in March 2020 after the MOHAP sourced them at the end of February 2020. The machine has been used on 9 patients since March 2020, achieving great levels of success.
Weaknesses
Nitrous oxide sedation is linked with a few side effects such as shivering, dizziness, headaches, fatigue, nausea, and excessive sweating (Huang & Johnson, 2016; Zafirova et al., 2018). However, the benefits of anesthesia outweigh its risks, particularly when compared with the cost of GA (Knapp et al., 2017). Furthermore, measures such as the signing of informed consent forms before sedation will be put in place. The elective procedure involving nitrous oxide inhalation sedation was stopped because of the Coronavirus epidemic. Currently, only emergency cases are accepted at the clinic and many patients are turned away.
Opportunities
Before using the nitrous oxide, all uncooperative and anxious patients were referred to the Saqar hospital for treatment under GA even if the patient needed fillings only, single tooth trauma, or single tooth extraction. Patients were put on the GA list and expected to wait for their turns. Currently, there is a long waiting list because dental treatment under GA in Saqar hospital is considered an elective process. Furthermore, the hospital gives the elective dental producer-only one day during the week and accepts only two cases during the week. Therefore, some of the patients are referred back to the pediatric dental clinic in a specialized Ras-Al-Khaimah dental center, however, most of them require multiple tooth extractions, pulpectomy, and pulpotomy. For these reasons, there is a need to establish an operational nitrous oxide system at Ras-Al-Khaimah Specialized Dental Center that will serve these patients without causing unnecessary delays by referring them to Saqar hospital.
Another opportunity is that providing nitrous oxide sedation will attract many clients and generate a reliable customer base. Noncompliance with dental treatment is linked to anxiety about the pain that often accompanies dental procedures (Kupzyk & Allen, 2019). Missing dental appointments worsens the condition of problematic teeth, which may require more costly treatments if a tooth cannot be salvaged. For example, the timely filing of cavities may lead to the avoidance of more costly processes such as root canal treatments, extractions, and future implants for the children (Ashley et al., 2015; Almendra & Dos, 2019). Noncompliance with dental treatment worsens patient outcomes and increases the overall costs of care (Baskaradoss, 2016). Therefore, making nitrous oxide sedation readily available could encourage patient compliance with their dental appointments and cut down on this cost.
Threats
The key threat, in this case, is competitors who are already using nitrous oxide inhalation sedation. For example, the major competitor for MOHAP is the Private RAK hospital, Dubai Health Authority (DHA), and private dental clinic like Retag private dental clinic. Patients demand value for their money when it comes to health care services and they are willing to pay a premium for their comfort. If MOHAP’s competitors continue availing nitrous oxide sedation, they are likely to attract all clients to their facilities. Table 1 summarizes the expected outcomes in terms of costs and benefits.
Table 1: Cost of expected costs and benefits.
Key Performance Indicators
The KPI for nitrous oxide inhalation sedation in the ministry of health and prevention are mainly four KPIs. Related to care quality there are two KPIs which are “Equipment checklist” and Consent form. However, related to the patients and staff satisfaction also there are two KPIs. These KPIs are Patient satisfaction and staff satisfaction. For the cost, there are 2 suggested KPI but still not implemented which are “More than one procedure done in one visit” and “Duration of the treatment under sedation within the time of appointment”. After contacting the coordinators of the specialized centers. I got results for one center only for January, February, and March 2020 and the results for the Ras-Al Khaimah specialized dental center for march only. The results for specialized Sharjah dental center for the Equipment checklist was January (94%), February (97%) and March (100%), while for the consent form the results were January (97%), February (100%) and March (100%). However, regarding the patient satisfaction survey, the results were January (83%), February, and (90%) March (91%) while for the staff satisfaction survey the results were 100% for all of the staff. Talking about the Ras-Al Khaimah specialized dental center only 9 patients seen in this pediatric dental clinic and got treatment under inhalation sedation. The result for the Equipment checklist for March (88.9%), while for the consent form the result for March was (88.9%). However, regarding the patient satisfaction survey, the result for March was (100%) while for the staff satisfaction survey the 100% was the result for the march.
Related to the care quality
Related to the Cost
Related to the patient satisfaction/ Staff satisfaction
Potential impacts
Impact of Nitrous Oxide adoption on Care Quality
During a long period, sedation is defined as one of the appropriate pharmacological techniques to facilitate dental care in pediatric patients and enhance quality and safety. To enhance success of dental services for pediatric and anxious patients, Nelson and Xu (2015) introduce nitrous oxide nasal hood that is modified to be used with “an end-tidal carbon dioxide sampling line” (p. 98). Along with simulation training, this mechanism is proved to be effective in improving health care quality and patient safety at the same time. The contributions of nitrous oxide to human health are remarkable among British and American patients as people find this laughing gas working and not harmful in treating mental health disorders and neurodegenerative disorders (D’Angelo et al., 2017). The study proves the enhancement of cognition, motivation, and creativity among patients who use nitrous oxide as one of the lifestyle drugs (D’Angelo et al., 2017). If care quality is improved in different healthcare fields, its effectiveness in pediatric dentistry cannot be neglected and must be thoroughly evaluated.
Comparing nitrous oxide sedation and local anesthetic with general anesthesia, it should be stated that the former is the most preferred option (Adewale, 2012). Inhalation sedation turns out to be a safe method that is applied by many dentists to enhance communication and cooperation with patients and increase tolerance for new appointments. In addition, nitrous oxide may be combined with such drugs as melatonin (3 mg), ketamine (0.25-50 mg), midazolam (0.005-05. mg), or trilofos (70 mg) (Corcuera-Flores et al., 2016). This sedation type is proved to be less harmful in comparison to general anesthesia in terms of its postoperative care and reactions among children aged 3-10 years (Ilasrinivasan & Shyamachalam, 2018). If patients need to undergo such procedures as multiple extraction or pulpectomy, nitrous oxide inhalation in combination with ketamine (preferably) can be applied to pediatric patients. Even though studies show that better quality is attained with GA, it poses a very small risk of death in children with multiple comorbidities (Walia et al., 2018). Therefore, nitrous oxide sedation helps to mitigate this risk (Souto & Robb, 2018).
Nitrous Oxide Implementation Costs
Regarding the experiences of people and their attitudes toward pain associated with dental care, the question of cost is not significant when the necessity to calm down and control anxiety occurs. In the majority of cases, people pay about $200-300 for nitrous oxide for one procedure and $400-600 for general anesthesia for one hour. However, nitrous oxide is commonly used alongside local anesthesia such as Xylocaine, which costs about $0.56 per unit (Drugs.com, 2020a). The maximum initial dose is 2.5 cartridges, which costs $1.4 (Drugs.com, 2020b). Therefore, nitrous oxide plus local anesthesia may cost between $201.4 and $301.4.
Sometimes, insurance plans could cover the costs, but the prices for dental services remain high. The investigations by Burgette and Quiñonez (2018) show that in 2015, treatment of 1000 healthy children having dental caries with 3 years old cost around 19,178 $ under General Anesthesia. However, in the same year, treatment of 1000 3-y-old healthy children with dental caries under conscious sedation cost around 15,016 $. In a separate study by Jameson et al. (2007), the mean cost of treatment of a child through advanced conscious sedation such as nitrous oxide was £245.47, which is equal to $306.19, whereas treatment using dental general anesthesia cost £359.91 ($448.93). This price difference represents a margin of 46%. The benefits of nitrous oxide are evident, and one should admit the length of the recovery period for both options. If general anesthesia may need hours in a recovery room to obtain normal physical qualities, nitrous oxide administration is characterized by rather short recovery periods – from 12 to 26 minutes after a procedure (Lyne et al., 2019). Hospitals obtain certain benefits when the length of recovery is shortened, and more patients could be served instead of observing patients after general anesthesia or making some preparations before the procedure (required for general anesthesia) (Dental Economics, 2009).
Nitrous Oxide adoption and Patient/Staff Satisfaction
Local sedation that has no color or odor is a good offer that pediatric patients, their parents, or other caregivers could receive from dentists. Laughing gas to control anxiety and reduce the level of pain satisfies patients and makes them free, relaxed, and protected. Its anxiolytic and sedative effects are discussed by healthcare experts to prove the effectiveness of the chosen modality (Appukuttan, 2016). Modern dentists continue investigating their opportunities to understand what kind of services are less damaging and more preferable to children (Bonafé-Monzó et al., 2015). Their anxiety and fear could influence their further visits and the inability to support dental care. Caries can be prevented, and if a pediatric patient is satisfied with dental services, there is a good chance to cooperate with families (Pasarón et al., 2015). Therefore, nitrous oxide that is free from needles and other fearful devices are chosen by parents to protect their children. Both patients and dentists find nitrous oxide as a predictable way to achieve necessary sedation during dental treatment and various specific procedures to prevent referrals to general anesthesia. However, it has been noted that dentists were not as enthusiastic about nitrous oxide inhalation sedation as patients and their caregivers (Foley, 2005). Nonetheless, patient satisfaction remains a critical consideration when deciding to use nitrous oxide inhalation sedation.
Conclusion
There is sufficient evidence to demonstrate the benefits of nitrous oxide over GA in dental care. Nitrous oxide sedation takes away anxiety and pain, which enhances patient comfort during treatment. Installing nitrous oxide machines for inhalation sedation is likely to benefit the clinic in terms of cost reduction and achievement of quality patient outcomes. The expected cost declines are attributed to the cost-effectiveness of nitrous oxide compared to GA in simple dental procedures and time savings in the form of reduced waiting times. In contrast, reduced anxiety in pediatric patients will enhance patient satisfaction. The key performance indicators in this business case are related to cost (more than one procedure during one appointment and duration of the treatment under sedation within the appointment time) which are still not implemented, while patient satisfaction (patient and staff satisfaction surveys), and quality of care (equipment checklist and consent form) are implemented KPIs. Overall, painless dental care is crucial to the attainment of pediatric patient satisfaction. Optimum sedation plays a vital role in calming down patients, providing comfort during dental procedures, and maintaining their psychological wellbeing following treatment. This business case demonstrates that nitrous oxide has numerous benefits over GA in terms of cost and patient satisfaction. Therefore, Ras-Al-Khaimah specialized dental center should install and continue using a nitrous oxide sedation machine to reap these benefits, live up to its mission and vision, and provide quality care as required by the UAE MOHAP.
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