LOG IN

Sedation in Dentistry: Undergraduate Training

Published: May, 1999

Guidelines for Teachers

Foreword

“Dental students should have a sound knowledge of the basic medical sciences relevant to the treatment of patients under sedation and general anaesthesia. They should be able to assess the suitability of various methods of anxiety and pain control including behavioural techniques. They should be capable of selecting suitable cases for pharmacological sedation, and recognise those patients requiring specialist care. They should have had practical experience in the administration of inhalation and intravenous sedation, and of operating on sedated patients. Dental students should graduate with a full recognition of their limited experience in the use of these techniques and of the necessity for postgraduate study and instruction.”

(The First Five Years: The Undergraduate Dental Curriculum: GDC March 1996, Para 122)

“Dentists have a duty to provide and patients have a right to expect adequate pain and anxiety control. Pharmacological methods of pain and anxiety control include local anaesthesia and conscious sedation techniques.”

(Maintaining Standards: GDC May 1999)

The Dental Sedation Teacher Group has produced this document in order to give guidelines to those who are responsible for providing undergraduate training in this subject. Work started on the contents last year when a sub-committee was set up to produce a working document. Members of the sub-committee were Dr Nigel Robb, Dr David Craig, Dr Derek Debuse and Dr Lesley Longman. A draft document was considered in detail by the DSTG committee in November 1998. The document was then sent to all delegates attending a meeting of DSTG at Guy’s Hospital, London on the 18th May 1999. Comments from those attending the meeting were incorporated into the final document.

The DSTG hopes that the following information is helpful and encouraging to teachers of sedation and to those who are responsible for the undergraduate curriculum.

The members of the DSTG Committee are prepared to enter into correspondence with interested parties. Please address any enquiries to the Secretary Dr DC Debuse, Department of Sedation and Special Care Dentistry, Guy’s Hospital, London SE1 9RT

Core Curriculum

A) ATTITUDES

To acquire:

  • a caring attitude to patients needing conscious sedation
  • an appreciation of the concept of multidisciplinary care and teamwork
  • an ability to liaise with personnel from other disciplines and a willingness to seek advice, consult literature and refer patients
  • an ability to remain calm, decisive and purposeful whilst handling difficulties or complications
  • an appreciation of the usefulness and importance of good clinical notes
  • the habit of keeping up to date with the published literature on sedation
  • an appreciation of the potential of the specialty
  • an appreciation of the requirement for postgraduate training prior to commencing
  • independent training sedation practice

B) KNOWLEDGE

To acquire a knowledge and understanding of:

  • history of pain and anxiety control in dentistry
  • causes, signs and symptoms of dental anxiety/phobia
  • spectrum of patient management techniques including the distinction between
  • conscious sedation and general anaesthesia
  • behavioural/non-pharmacological management techniques (e.g.. counseling, hypnosis, systematic desensitization, flooding)
  • patient assessment techniques and criteria (e.g.. American Society of Anesthesiologists classification of physical fitness) including specific problems relating to young and elderly patients
  • cardiovascular and respiratory physiology and anatomy relevant to sedation
  • importance of medical disease and drug therapy in patients undergoing sedation
  • management of patients with special needs
  • indications and contraindications to the use of sedation and general anaesthesia
  • applied pharmacology of current conscious sedation agents, including important drug interactions and potential hazards of polypharmacy
  • pharmacological sedation techniques (e.g. benzodiazepines, inhaled nitrous oxide/oxygen)
  • principles of monitoring basic physiological variables (eg. heart rate, respiratory rate and depth, blood pressure, arterial oxygen saturation)
  • equipment required for the administration of inhalation and intravenous sedation and for monitoring, including the principles of pulse oximetry
  • importance of effective airway protection/management principles of caring for a sedated patient
  • importance of effective local analgesia
  • difficulties and dangers of over- and under-sedation
  • principles of safe recovery and discharge following sedation
  • role of antagonist drugs (eg. flumazenil)
  • drugs and methods used for the relief of acute and chronic pain, including interactions with sedative agents
  • medicolegal aspects of the provision of conscious sedation (eg. GDC regulations, consent, patient instructions)
  • impact of the dental procedure on the provision of sedation
  • management of minor mishaps / accidents (eg. extravascular injections, bruising)
  • role of the Dental Nurse / ‘second appropriate person’
  • recognition and management of complications of sedation
  • occupational exposure limits to nitrous oxide including methods of monitoring

 

C) SKILLS

i) Assessment and treatment planning:
To be able to:

  • take a full medical, dental and social history
  • assess need and suitability for sedation
  • devise an appropriate treatment plan
  • obtain valid consent
  • evaluate effectiveness of sedation/treatment
  • recognise opportunities for providing care without sedation
  • write accurate, clear and concise clinical notes

 

ii) Intravenous sedation:
  To be able to:

  • assess suitability of vein(s)
  • perform intravenous cannulation
  • recognise signs and symptoms of extravascular injection
  • titrate intravenous drug and recognise sedation end-point
  • insert a mouth prop
  • administer supplemental oxygen via nasal cannulae
  • remove intravenous cannula and dispose safely
  • assess fitness for discharge

 

iii) Inhalational sedation (RA):
  To be able to:

perform an RA machine check sequence

connect breathing system and select appropriate nasal mask

adjust RA machine (gas mixture and flow, including observation of reservoir bag)

titrate nitrous oxide concentration and recognise the sedation end-point

ensure correct functioning of anti-pollution measures (scavenging)

assess fitness for discharge

 

iv) Monitoring:
To be able to:

measure blood pressure using sphygmomanometer and stethoscope

perform clinical monitoring of respiration (rate and depth), pulse (rate and rhythm) and level of consciousness. Interpret and respond appropriately to change

use a pulse oximeter, interpret readings and respond to change. Recognise

equipment artefacts and malfunctions

v) Management of sedation-related complications:
 To be able to:

recognise and respond to over-sedation, respiratory depression, airway obstruction

demonstrate use of airway adjuncts (ventilating bag, pocket mask, airways)

perform oral/pharyngeal suction

connect and adjust oxygen supply

[NB: It is assumed that Basic Life Support skills are up to date and rehearsed regularly]

 

 

Aims

AIMS

  1. To provide an introduction to the attitude, knowledge and skills required for
    the practice of conscious sedation in dentistry as defined in the core
    curriculum.
  2. To enable the undergraduate to acquire a sound foundation in these skills
    through clinical practice.

OBJECTIVES

  1. The acquisition and understanding of core knowledge relevant to the
    practice of conscious sedation in dentistry.
  2. To have clinical experience in the:
    1. assessment and treatment planning of patients who require
      conscious sedation
    2. administration of sedation
    3. dental care for sedated patients
    4. appropriate discharge of patients who have received conscious
      sedation
  3. To promote an awareness and understanding of the importance of:
    1. sedation in the management of pain and anxiety
    2. communication skills in the management of patients requiring
      conscious sedation
  4. To appreciate the limitations of the undergraduate experience and understand
    the benefit of continuing professional education.
  5. To promote a critical and caring approach to the management of anxious
    patients.

 

 

Assessment

A. Attitudes
The candidates performance in such areas as attendance, punctuality and communication with patients should provide sufficient evidence.

B. Knowledge
In addition to passing the requisite examinations in anatomy, physiology and pharmacology, the undergraduate should demonstrate knowledge of the clinically relevant basic sciences prior to a clinical attachment on a sedation unit. Such assessment might be made via an MCQ paper. The range of knowledge required is defined in the Core Curriculum.

Knowledge of sedation techniques, and the role of sedation in dentistry may be assessed by MCQ grading, and presentation of a clinical case report.

Teachers, examiners and students should be reminded that sedation is within the
remit of the final BDS examination.

C. Skills
The ability to site an intravenous cannula, check and set up a Relative Analgesia machine, record the patient’s blood pressure using a sphygmomanometer and stethoscope, and to use and interpret pulse oximeter readings can all be assessed using OSCE stations.
The ability to manage a sedation patient may be assessed by observation of a case being treated. The grading of such a case should be based more on an assessment of how the patient is managed, rather than whether or not dental treatment is completed as planned. An example of an assessment sheet for such a clinical examination can be found in Documentation.

Clinical sessions
The undergraduates should have their clinical sessions graded. The clinical grading should reflect the three areas of underpinning knowledge, skills and attitudes. The grading should be based on appropriate criteria that reflect both the undergraduate’s attitude to patients and the skill with which sedation and clinical dentistry are carried out. Such criteria may vary between Dental Schools. A suggested system of clinical grading is included in Documentation.

Summary
At the end of their attachment in sedation each undergraduate should have assessments for:

a)      Professional attitude
b)      Knowledge   MCQ paper
Continuous assessment
c)      Skills Clinical grading reflecting both sedation and dental skills

 

The OSCE stations should be integrated within an appropriate professional examination.
Written questions should be submitted to the banks of final questions and discussions of sedation topics should be within the remit of the viva voce and clinical components of the final examinations.

 

Experience

A) PATIENT ASSESSMENT AND TREATMENT PLANNING   back to top

1)  Recommended minimum number of cases: 5

2)  Experience
Attendance at new patient assessment/treatment planning clinics. Although desirable, it may not always be possible for students to undertake the assessment (even if supervised) but they can gain valuable experience of simple physiological measurement e.g.. blood pressure, pulse rate, arterial oxygen saturation. Patients of different ages, degrees of fitness and disability should be seen. The importance of obtaining an in-depth social history should be stressed. Health and anxiety questionnaires can be helpful (see Documentation). It is also desirable for students to see a small number of recall/check-up cases. Each student may be asked to prepare a short case report.

B) INTRAVENOUS SEDATION   back to top

1)  Recommended minimum number of satisfactorily managed cases: 5

2)  Case mix/treatment
There is probably greater value in a student treating a variety of patients rather than the same patient over and over again. In order to demonstrate the variability of intravenous sedation, it is also useful for some patients to have second or third visits with the same student. In practice, however, patient preference, treatment planning and clinical timetabling constraints will probably dictate patient selection. It is important that each student gains experience of a range of dental procedures.]

It may be helpful to categorise patients according to their medical history, anticipated degree of difficulty in providing intravenous sedation and complexity of the dental treatment. This helps to avoid allocating a difficult patient to a novice student which is not only frustrating but often produces complaints from patients (see Documentation).

3) Pairing/operator sedationist
Students should have the opportunity to observe treatment carried out under intravenous sedation before being directly involved.

When treating their own patients, students should ideally be assisted by a trained and experienced dental nurse but having students working in pairs is also satisfactory. In this case one student carries out both the sedation and the dental treatment whilst the other student acts as the dental nurse. The student who is acting as the dental nurse thus gains from his/her partner’s experience. Where a student is assisting, a suitably trained and experienced dental nurse should also be available. (Allowing one student to administer the intravenous sedation whilst the other carries out dental treatment does not promote either competence or confidence in working as an operator-sedationist).

Notwithstanding the above, under certain circumstances having one student provide sedation for another student or member of staff may be acceptable or even advantageous. This arrangement should, however, be limited to the early stage of sedation training and should not become established as the norm.

4) Checklist
A pre-procedural ‘checklist’ which details the various staff, equipment and patient requirements should be completed for each patient (see Documentation).

5) Venepuncture
A cannula should be used wherever possible. Venepuncture should be closely supervised by a member of staff or dental nurse trained to carry out cannulation. Students should not be permitted an unlimited number of attempts to insert the cannula. Topical local anaesthetic may make the procedure more acceptable to the patient.

6) Titration
Midazolam (Hypnovel) in 10mg/5ml concentration is administered in small increments which are titrated against the patient’s response (the Data Sheet for Hypnovel provides an example of a safe sedation regime). Local analgesia is usually administered once a satisfactory level of sedation has been achieved.

7) Monitoring
The importance of clinical monitoring by the operator and the dental nurse should be emphasized but pulse oximetry must be regarded as standard practice The pulse oximeter should be in position and switched on before sedation is administered in order to establish baseline readings. The SaO2 low limit’ alarm must be set no lower than 90% (some pulse oximeters default to 85% although they can be reset once powered up).

8) Dental treatment
Dentistry should be kept simple, particularly in the early stages of the sedation course. This enables the student to attend to both dental and sedation aspects rather than have to concentrate on a demanding dental procedure. Fillings, non- surgical periodontal and simple oral surgery procedures probably provide the most suitable teaching material. Whatever the procedure, students need to be actively encouraged to make efficient use of the time available. They also need to be aware that there is a ‘treatment window’ provided by intravenous sedation. Allowing this time interval to pass without carrying out treatment is frustrating for both patient and student.

9) Supervision
Supervision needs to be one-to-one during the administration of midazolam, the early stages of treatment and at
discharge. By staggering the procedure start- times, one member of staff can safely supervise up to two cases. Slightly
greater flexibility may be possible when students are more experienced i.e.., towards the end of their clinical course but
then only if the patient is fit and both sedation and dental treatment known to be uncomplicated.
These recommendations relate to a minimum acceptable standard of supervision and assume that each student (or pair of
students) is also supported by a trained and experienced dental nurse as described in (3) above. Asking teaching staff to
supervise too many cases concurrently is stressful and may compromise the standard of patient care. Clinic layout is
important when one person supervises more than one sedation cases.

10) Staff
Dental sedation technique should be taught by suitably trained and experienced dentists rather than members of other
specialties. This is particularly important in establishing the principles of working as an operator/sedationist. However,
advice from other specialties can be helpful, particularly when sedation teaching is integrated into a ‘Pain and Anxiety
Management’ course encompassing local anaesthesia, sedation and general anaesthesia.
Since there are, as yet, few formal qualifications in dental sedation it is impossible to define ‘suitably trained*. However,
many hospital, community and general practice dentists have relevant skills and as in other disciplines, there is an
advantage in having teachers with different backgrounds.
Dental nurses must have received sedation training and should preferably hold the Certificate in Dental Sedation Nursing
of the National Examining Board for Dental Nurses. In some dental schools nurses have received training in intravenous
cannulation which enables them to assist in student teaching (under staff supervision).

11) Recovery and discharge
Students should be allowed to assess fitness for discharge and give post-op instructions to the patient and escort but this
must be closely supervised by a member of staff. (See Documentation). Formal discharge criteria should be agreed and
made available to students in order to encourage sound clinical judgement. The use of flumazenil should be
demonstrated.

12) Clinical records
Written consent is mandatory and must be obtained by a qualified dentist.
Students should be encouraged to record details of the sedation in a standardised
but concise manner e.g.. for midazolam: cannulation site, dose, batch number,
expiry date, time etc. A self-inking stamp or ‘Sedation Record’ is useful for this
(see Documentation).

C) INHALATIONAL SEDATION (RELATIVE ANALGESIA)   back to top

1) Recommended minimum number of satisfactorily managed cases: 5

2) Case mix/treatment
As with intravenous sedation, a variety of patients and dental procedures offers the best experience. Students should gain experience of treating both adults and children.

3) Pairing/operator sedationist
Students should work in pairs with one student providing both RA and the dental treatment whilst the other student acts as the nurse. Indications for having a different person operating and sedating are rare.

4) Checklist
A pre-procedural ‘checklist’ should be completed for each patient. Students should follow printed instructions when testing the RA machine, breathing and scavenging systems (see Documentation).

5) Titration
RA should be administered by titrated increments using a machine designed for dental nitrous oxide/oxygen sedation. Local analgesia is usually administered when a satisfactory level of sedation has been achieved.

6) Monitoring
Clinical monitoring and observation of the reservoir bag provides adequate
monitoring. A pulse oximeter is not normally indicated.

7) Dental treatment
Dentistry should be kept simple e.g.. fillings, non-surgical periodontal and simple oral surgery procedures. As with intravenous sedation, students need to be encouraged to make efficient use of time. However, because the nitrous oxide/oxygen mixture is administered continuously, there is no ‘treatment window’ and so the length of the treatment session is more flexible.

8) Supervision
Supervision needs to be one-to-one during induction of RA, the early stages of treatment and at discharge. By staggering the start times, one member of staff may be able to supervise more than one student but the ratio of staff to students should not exceed I : 3. As with intravenous sedation, clinic layout is important. Teaching and nursing staff must be appropriately trained and experienced (see ‘Intravenous Sedation’).

9) Recovery and discharge
Students should be allowed to assess fitness for discharge and give post-op instructions to the patient and escort but this must be closely supervised by a member of staff. (See Documentation). Formal discharge criteria should be agreed and made available to students in order to encourage sound clinical judgement.

10) Clinical records
Written consent is mandatory and must be obtained by a qualified dentist. Students should be encouraged to record details of the sedation in a standardized but concise manner e.g.. fresh gas flow rate, concentration of nitrous oxide, quality of sedation etc. A self-inking stamp may be useful.

D) ORAL SEDATION AND OTHER TECHNIQUES   back to top

Students should be offered the opportunity to observe the management of patients receiving treatment with oral sedation and new drugs or established drugs administered by different routes. They should be firmly discouraged from using advanced techniques without appropriate postgraduate training and experience.

 

 

Samples

Teachers Clinical Record

Name: Group:
Date IV RA NO
SED
OP ASS Patient Grade
Clinical
Dent   Sed
Prof Comments

(OP = OPERATOR
ASS = ASSISTANT)

Guidance for Assessment of Students

Purpose:

To provide continuous assessment of student’s ability, to identify excellent students and those who are having problems so that appropriate advice and help can be offered.

Practical Ability

5.     Outstandingly good, shows initiative and usually requires no staff assistance.

4.     Most able. Above average ability. Only very occasional staff assistance required.

3.    Competent. Requires some help from staff.

2.    Weak. difficulty in completing work without assistance from staff.

1.    Staff have major misgivings about the practical ability of this student.

Patient management, attitude, and professionalism

5.    Excellence in every aspect of the care and management of patients.

4.    Very good with patients and a responsible attitude.

3.    Satisfactory. Deals well with patients.

2.    Unsatisfactory with regard to patient management.

1.    Poor attitude or very inadequate patient management.

 

Record of Sedation Experience

NAME GROUP
Date: Patient: Type of sedation:
Operator / Assistant
Clinical Notes:
Date: Patient: Type of sedation:
Operator / Assistant
Clinical Notes:
Date: Patient: Type of sedation:
Operator / Assistant
Clinical Notes:

Patient Categories

Simple: Suitable for NEW students and House Officers
Medical: ASA I / II
Dental: Simple cons, perio, forceps extractions, anterior endodontics
Sedation PROVEN uncomplicated RA or IV midazolam
Behavioural Mild dental anxiety ONLY

 

Medium: Suitable for EXPERIENCED students, HOs or postgrads
Medical: ASA I / II
Dental: Simple cons, perio, MOS; anterior or premolar endodontics
Sedation PROVEN / ANTICIPATED uncomplicated RA or IV midzolam
Behavioural Moderate dental anxiety ONLY

 

Difficult: Suitable for teaching staff ONLY
Medical: ASA III / IV
Dental: Complicated cons, perio surgery, MOS; molar endodontics
Sedation Oral, RA, IV midazolam/propofol, difficult veins, indications for supplemental oxygen
Behavioural Dental phobic, needle phobic, Special Care patients

 

Patient Instructions

DENTAL SEDATION

You will be given SEDATION for your dental treatment. In your own interest please follow these instructions to protect yourself and avoid accidents.

ON THE DAY OF TREATMENT

DO bring with you a responsible adult who is able to wait to escort you home (preferably by car) and then stay with you for the rest of the day.

DON’T go without food but have only light meals and non-alcoholic drinks.

DO take your routine medicines at the usual times.

AFTER TREATMENT

DO stay resting quietly at home.

DON’T drive.

DON’T use machinery (eg. cookers, washing machines, power tools).

DON’T sign important documents.

DON’T drink alcohol

ANY QUERIES? TELEPHONE

Stamp for Clinical Notes

MIDAZOLAM
BN EXP
DOSE (mg) TIME
SITE BP

Pre-assessment Questionnaire

Name:

Date:

For each question, please circle the most appropriate answer.

Do you remember your first visit to the dentist as a child? YES/NO
As a child, did you go to the dentist willingly? Willingly / Grudgingly / Not at all
Did your parents, brothers and sisters go to the dentist happily ? YES / NO / Don’t Know
Do (or did) your parents have their own teeth? One / Both / Neither / Don’t Know
How long to you expect to keep your teeth? Until 40 / Until 60 / All Your Life
Would is concern you to wear dentures (false teeth) A Lot / A Little / Not At All
When did you last visit the dentist? Within the year / Over a year ago / Over 5 years
Have you ever had sedation or general anaesthetic for your dental treatment? Sedation / General Anaesthetic / Neither

 

Are you concerned about any of these aspects of dental treatment?

1. Coming for an appointment?
2. Having an instrument in your mouth?
3. Having a tooth drilled?
4. Having your teeth scaled?
5. Having a filling?
6. Having a tooth taken out?
7. Having an injection in your mouth?
8. Having an injection in your arm?

 

Patient Assessment

1. Find out the problem:
Why seeking sedation?
2. Medical history:
Folder questionnaire
Drugs
Alcohol instake / smoking
3. Dental history:
Past history (including past sedation or GA)
Recent history
Main dental problem (pain etc)
4. Social history:
Escort problems? Children? Shift worker?
5. Examination:
Chart lesion and missing teeth only
PROVISIONAL treatment plan
6. Describe and discuss alternative sedation methods:
TLC / Oral / IV / RA / GA
7. Explain that:
Students (undergraduate and postgraduate) may be providing treatment
8. Get consent
9. Give instructions:
Verbally – stress: – “no escort – no sedation”
In writing
10. Request radiographs
11. Book appointment

 

Pre-procedural Checklist

Patient’s Name: 

Staff Check:
Experienced/qualified DN present?
Anther dentist / DN within easy reach?
Operator and assistant know emergency procedure?
Equipment Check:
Site of emergency equipment known?
Oxygen
Suction-dental unit
Suction-mobile / back-up
Positive pressure ventilation bat
Sphygmomanometer & stethoscope
Pulse oximeter
Automatic monitor (BP / ECG)
Emergency drugs (flumazenil)
Sedation Equipment
Dental Equipment:
Handpieces, light, chair
Patient Check:
Patient, parent, guardian know what is planned?
Written consent has been obtained?
Medical and dental history checked?
Routine medication checked?
Last meal or drink checked?
Fasting patient?
   If yes – has glucose been given?
Patient has consumed alcohol?
   If yes – advice to postpone?
Escort present?
BP recorded?
Operator’s Name
DN’s Name

Procedural Record

Intravenous Drug Expiry Date Batch Number Time of Increments

Initial Final
Total Dose Administered
Venous Access Site
Cannula
Monitoring Record
Time Drugs/Oxygen
Procedure
Oxygen
Saturation
Pulse Blood
Pressure
Comments
Operative procedure & conditions
Recovery and Discharge
Recovery with escort / dental nurse
Recovery and Discharge
Written post-sedation instructions to escort & patient
Cannula removed
Clinician’s approval to discharge
Names of discharging – clinician
- nurse
Time of discharge
Signature of clinician

 

MDM RA machine checklist

AIMS

1. To check contents of all gas cylinders
2. To check correct functioning of controls and flowmeters
3. To check the automatic cut-out of nitrous oxide flow
4. To check reservoir bag for leaks.

METHOD

Start with all cylinders off

Gas Check
1. Open “FULL” oxygen cylinder
Check pressure gauge rises
2. Open “FULL” nitrous oxide cylinder
Check pressure gauge rises

 

Bleed System
3. Open flow control with mixer control set 30% oxygen
4. Switch off both cylinders (nitrous oxide first)
5. Check that both flowmeters fall to zero

 

Gas Check
6. Open both “IN USE” cylinders
Check that both pressure gauges rise

 

Flowmeter and Controls Check
7. Set mixer control 100% oxygen
8. Open flow control. Set flowmeter at 6 litres/minute oxygen
9. Set mixer control at 50%
10. Check that both flowmeters indicate 3 litres/min.

 

Automatic Cut-out Check
11. Turn off the oxygen cylinder – WAIT
12. Check that BOTH flowmeters fall to ZERO

 

Reservoir Bag Check
13. Turn the oxygen cylinder back on
14. Turn off flow control. Set mixer dial at 100% oxygen
15. Occlude common gas outlet
16. Press oxygen flush to inflate reservoir bag and check for leaks

Machine ready for use

Disclaimer: The DSTG can accept no responsibility for any acts or omissions resulting from this site. © Copyright 2017 DSTG

Password Reset

Please enter your e-mail address. You will receive a new password via e-mail.