A Referral Guide for Dental Practitioners
This document is a joint initiative by the Dental Sedation Teachers Group (DSTG) and the Society for the Advancement of anaesthesia in Dentistry (SAAD).
The Dental Sedation Teachers Group was formed to provide a forum for all individuals who are interested in the teaching of conscious sedation in dentistry. The membership includes dental and medical practitioners and nurses from academic, hospital and general practice. Its aims are to exchange information on practice and research in the field of conscious sedation and to improve standards of teaching. Its committee includes a representative from each of the dental schools in the UK.
The Society for the Advancement of Anaesthesia in Dentistry was established over 40 years ago. It is an educational trust and a major provider of postgraduate education in conscious sedation for dentists, doctors and dental nurses. With a membership of over 1,200 it is well placed to represent dental sedation practitioners. With three courses a year, a publication (SAAD Digest) and an Annual meeting it is an active Society which is well-represented in all the major groups which have an interest in pain and anxiety control.
Most dental patients are able to accept dental treatment with local analgesia and sympathetic management. Some, however, require additional help from a range of techniques, including conscious sedation.
This document is intended to provide an informative, but easy-to-read, guide to referring patients for conscious sedation.
It is intended for dental practitioners who are unused to sedation techniques and are presented with anxious or phobic patients whose dental treatment is difficult to complete with behaviour management and local analgesia alone.
Conscious sedation is an important part of pain and anxiety control. The application of conscious sedation techniques to dental procedures can greatly reduce the need for general anaesthesia.
Many practitioners offer sedation techniques as part of their day-to-day dentistry. Others may choose to refer patients who require conscious sedation to practitioners who are both happy to accept referrals and who have the necessary expertise and facilities. This document is designed to assist the referring dentist in patient selection, treatment planning and the referral process.
Conscious sedation is defined as:
A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.
The level of sedation must be such that the patient remains conscious, retains protective reflexes, and is able to respond to verbal commands.
Sedation beyond this level of consciousness must be considered to be general anaesthesia and is then subject to different regulations.
Range of Techniques:
Intravenous sedation with midazolam
Inhalation sedation with nitrous oxide and oxygen
Oral sedation with benzodiazepines
The majority of anxious or phobic patients can be treated with these techniques or a combination of them. Others may respond better with alternative techniques such as:
Intravenous sedation with more than one drug
Intravenous sedation with propofol
Transmucosal sedation (nasal, sublingual)
Some reasons for prescribing sedation:
To treat anxious or phobic patients who would otherwise be denied access to dentistry.
To enable an unpleasant procedure to be carried out without distress to the patient.
To avoid general anaesthesia
Selection of patients:
Reasons for anxiety:
Patients who cannot accept an injection in the mouth can often be persuaded to accept venepuncture. If not, inhalation sedation may be acceptable either to provide sedation for the treatment itself or to provide sufficient anxiolysis to enable venepuncture to be performed. Oral sedation may provide a satisfactory alternative.
Fear of “the drill”, sharp instruments and the dental environment can be reduced with conscious sedation.
Pronounced gag reflex
This distressing condition is greatly reduced by inhalation sedation. Alternatively, intravenous sedation may be more effective.
Degree of anxiety
Whilst anxiety scales such as Corah are useful for research, the practitioner needs only assess levels as severe, moderate or mild. Severe anxiety may suggest that intravenous sedation may be more appropriate.
Care must be taken in using intravenous sedation for older patients. Age is not a contraindication however as long as the patient is physically fit.
Intravenous sedation with benzodiazepines is not predictable for children and early teenagers. Inhalation sedation can be used for children of any age. Currently there is insufficient scientific evidence in the United Kingdom to support the routine use of intravenous sedation for children.
A full medical history is required for all patients. This must be recorded and retained with the patient’s records. When sedation is to be considered, special note should be made of the following conditions:
Liver or kidney disease
All drugs that are currently being taken should be recorded., This includes prescribed medication, alternative remedies and recreational drugs. Special note should be made of central nervous system depressants.
There are no absolute contraindications for sedation, apart from allergy to the sedative agent, but relative contraindications may arise from the medical history.
Measurement of blood pressure forms an important part of the assessment of the patient for sedation.
American Society of Anaesthesiology Classification of Physical Status (ASA)
Car must be taken in the choice of technique and where it is to be provided, depending on the severity of the patient’s condition. The ASA classification helps when making this decision.
|I -||Normal, healthy patient|
|II -||A Patient with mild systemic disease|
Well controlled diabetes or epilepsy
|III -||A patient with severe systemic disease limiting activity but not incapacitating|
Epilepsy with frequent fitting
Recent myocardial infarct
|IV -||A patient with incapacitating disease that is a constant threat to life|
|V -||Moribund patient not expected to live more than 24 hours with or without treatment|
Only patients who fall into the ASA categories I and II are suitable for treatment in the general practice or peripheral Community Dental Service situation. ASA IV and V are normally hospitalized or bed-ridden and are generally only seeking emergency dental treatment. ASA III patients are best treated in an environment where more experienced support is available. This should be in a hospital based clinic or a sedation clinic where medical support is available.
Most dental treatment can be performed under conscious sedation, but detailed treatment planning is best left until the level of cooperation under sedation has been determined. Access problems may limit the provision of some procedures. Some dental procedures are sometimes impractical with inhalation sedation due to the presence of mask and tubing.
Discussion with the patient will ascertain whether the aim of treatment is to retain teeth or not. Any recommendations need to be tempered with the possibility that patients’ attitudes may alter once a satisfactory means of providing treatment has been established.
Sedation requires that patients leave the surgery in the company of a responsible adult escort. If the patient is unable to comply with this instruction, sedation cannot be considered. Exceptions may be made occasionally in the case of inhalation sedation with nitrous oxide and oxygen when, at the discretion of the sedationist, the patient may leave unaccompanied if the patient is medically fit and responsible.
Where to refer:
General Dental Practice
Suitably experienced dentists can provide treatment as operator-sedationist in the presence of a suitably trained assistant. The surgery should be equipped with appropriate equipment including devices to assist with monitoring the patient. Appropriate resuscitation equipment and emergency drugs must be present. The requirements for safe sedation are set out in the document “Standards in Conscious Sedation for Dentistry” (Ref 2). Techniques that may be offered include intravenous and oral sedation with benodiazepines and inhalation sedation with nitrous oxide and oxygen. Health Authorities will have lists of practitioners who provide sedation through the NHS. Those providing treatment under private contract are found by word of mouth or by receipt of a circular letter inviting referrals.
Oral Surgery Departments of General Hospitals
Sedation is provided by the operator or an anaesthetist. Treatment may be limited to exodontia.
Community Dental Service
Clinics often provide treatment under sedation for patients who cannot be treated in general practice for a number of reasons. The service varies but is usually limited to disabled patients or patients with complex medical histories. Sedation is provided by operator-sedationists or anaesthetists. Many will have close proximity to a critical care unit.
Many departments of teaching hospitals accept referrals for conscious sedation. The arrangements vary, so contact with the appropriate department should be made to ascertain what service could be offered. Departments of Oral Surgery, Paedodontics, Restorative, Sedation, and Special Care may provide treatment under sedation. Sometimes the treatment is carried out by undergraduate or postgraduate students under supervision.
Responsibilities of referring dentist:
Alternative methods of pain and anxiety control should be considered by discussion with the patient. A description of the different types of conscious sedation and how sedation is achieved will help the patient to understand what is available.
Careful selection of treatment centre
Referring practitioners should satisfy themselves that what is offered to their patients on referral is conscious sedation according to the agreed definition. Such assurance should be gained prior to the referral. This may involve local enquiries or even a visit to the practitioner to inspect facilities.
Conscious sedation techniques for children are limited and for them this assurance takes on an even greater importance.
This should include:
|1.||Reasons and justification for the use of conscious sedation, after consideration of alternative mathods of pain and anxiety control.|
|2.||A full medical history which must be up to date. This can be a copy of notes made.|
|3.||Outline of dental treatment required.|
|4.||Relevant dental history|
|5.||Indication as to whether referral is for single procedure or whether the patient is being referred for all further treatment.|
Careful note taking should include details of discussion with the patient. A copy of the referral letter must be kept.
1. “Maintaining Standards”. General Dental Council. Revised May 1999
This document is regularly updated. The latest version is on the GDC website.
2. Standards in Conscious Sedation for Dentistry. Report of an Independent Working Group. October 2000.
This document is available from the offices of the Society for the Advancement of Anaesthesia in Dentistry.
Dental Sedation Teachers Group, c/o Chairman DSTG, Department of Sedation and Special Care Dentistry, Floor 26, GKT Dental Institute, Guy’s Hospital, London SE1 9RT
Society for the Advancement of Anaesthesia in Dentistry, 53 Wimpole Street, London, W1G 8YH. Registered Charity No. 210485