Published: October, 2000
Pain and anxiety management of patients is paramount in dentistry. Conscious Sedation is a fundamental part of the pain and anxiety management of patients in operative dentistry. All patients need and deserve to expect appropriate and individually considered pain and anxiety control for any dental procedure. Properly provided Conscious Sedation is safe, valuable and effective for dental patients.
It is of key importance to maintain a wide margin of safety between Conscious Sedation and the unconscious state of general anaesthesia where verbal communication with the patient or protective reflexes are lost. It is inappropriate to restrict clinical techniques as long as the the patient remains in verbal contact with the sedationist. It is misguided to believe that single drug or multiple drug techniques are inherently safer or appropriate for all cases. Training and experience are essential.
Every practitioner providing Conscious Sedation should gain the theoretical and practical hands on, supervised, clinical training necessary to practise the individual techniques for the safe management of the dental patient.
The following guidelines are intended to assist in the practice of Conscious Sedation. These recommendations are directed to all practitioners providing Conscious Sedation for dentistry wherever the setting. Their purpose is to ensure that Conscious Sedation for dentistry continues to be as effective and safe as possible.
The techniques described in this document are appropriate for use bye an operator sedationist whereby the person providing the dentistry also delivers the Conscious Sedation.
During the last decade there has been a number of reports relating to the provision of general anaesthesia and Conscious Sedation for dentistry from advisory bodies, the Departments of Health and specialist societies. In 1990 the report (“General Anaesthesia, Sedation and Resuscitation in Dentistry” prepared by the Standing Dental Advisory Committee”) heralded considerable change in the provision of these services for dentistry. (appx.1) A report by the Clinical Standards Advisory Group entitled “Dental Genreal Anaesthesia” in 1995 recommended standards for patient care, safety facilities and training for dentists and anaesthetists and supporting staff. (appx.2) During this time the Society for the Advancement of Anaesthesia in Dentistry and the Association of Dental Anaesthetists issued specific guidelines in relation to contemporary clincical practice both in relation to General Anaesthesia and Conscious Sedation. (appx.3&4) There were two reports from the Royal College of Surgeons of England in 1993 and 1996. (appx.5&6) More recently The Dental Sedation Teachers Group have published curriculum guidance for undergraduates and the competent graduate. (appx.7&8)
In 1998 the General Dental Council recognised the views of the specialist societies and the Royal Colleges. It endorsed the need for Conscious Sedation provision rather than the continuing provision of General Anaesthesia as a demand led service. This has reduced the use of General Anaesthesia in primary dental care. (appx.9)
In July 2000 the publication of “A Conscious Decision”, a report by a group chaired by the Chief Medical Officer and Chief Dental Officer of England, finally heralded the removal of General Anaesthesia associated with dentistry from non hospital settings. (appx.10) This report made a number of recommendations concerning Conscious Sedation. The government has accepted the report.
A watershed has been reached where the concept of conscious Sedation for dentistry is no longer considered alongside that of General Anaesthesia.
In July 2000, an expert group representative of all branches of dentistry was convened by the Society for the Advancement of Anaesthesia in Dentistry charged to consider standards for Conscious Sedation in dentistry.
This document aims to identify good clinical practice, which is appropriate to both NHS and private dental care both within and outside hospitals. The following guidance will help attain and maintain high clinical standards, standards which all patients deserve.
Definition of Conscious Sedation
Our definition of Conscious Sedation is:
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 understand and respond to verbal commands.
This definition was originally proposed in the Wylie Report (1978),(appx.11) and has been adopted by the General Dental Council, The Department of Health, The Society for the Advancement of Anaesthesia in Dentistry, The Dental Sedation Teachers Group, The Scottish Office National Dental Advisory Committee (appx.12) and the British Society of Gastroenterology.
The above definition describes the state of Conscious Sedation, and does not attempt to prescribe how this is achieved. Specifically, it is acknowledged that many different techniques, involving the use of one or more drugs and varying routes of administration, will fulfil this definition provided that there is and adequate margin if safety.
Any technique resulting in the loss of consciousness or abolition of protectice reflexes is defined as General Anaesthesia.
There is no place for the practise of General Anaesthesia called Conscious Sedation.
Educational & Training Standards
Education and training in Conscious Sedation needs to ensure that ALL members of the dental team providing treatment under Conscious Sedation have received theoretical, practical and clinical training before undertaking independent practice.
All the topics referred to in this document must be included.
Drugs and Equipment:
Practical Training in the use of drugs and equipment used to provide Conscious Sedation and monitoring during Conscious Sedation is essential for sedationists and sedation assistants before they progress to clinical training.
Training in the management of Conscious Sedation-related complications, in addition to the standard requirement for proficiency in Basic Life Support, is essential for all clinical staff (sedationist/assistant/operating dentist) and is desirable for non-clinical support staff. Basic Life Support must conform to contemporary guidelines issued by the Resuscitation council (UK) (appx.13) and General Dental Council Guidance to Dentists on Professional and Personal Conduct (Maintaining Standards).
Supervised hands-on experience must be acquired by both sedationists and their assistants for EACH Conscious Sedation technique used. This may be provided in a variety of settings.
The method and timespan allowed for acquisition of this supervised practice may vary depending upon local circumstances.
The minimum number of documented supervised ases completed should be no less than those specified by appropriate authorities and updated in line with changing recommendations. For example ‘The Competent Graduate’ [Dental Sedation Teachers Group] gives guidance for undergraduate dental students. (appx.7) Sedation assistants/nurses may follow the requirements of the ‘Log of Practical Experience’ for entry to the National Examination Board for Dental Nurses examination for the Certificate in Dental Sedation Nursing.
Provision of Education and Training
This can be provided in-house in clinical areas where Conscious Sedation is practised and/or in more formal courses. Those arranging such training fro their staff have a duty to ensure that the quality of training and trainers is appropriate and that all theoretical and practical training is documented.
Retention and improvement of knowledge and skill relies upon regular updating by means of refresher courses and/or a programme of continuing assessment or review as a routine practice activity. The interval at which such updating is required will depend upon local circumstances but must be carried out at least once a year. Updating may also be undertaken before recommencing practice after a break of 12 months or more.
All Education and Training programmes must be updated regularly and based on currently accepted standards as promulgated by appropriate authorities. Examples of bodies who publish these are listed as Appendix 1.
Environment for Sedation
The Dental surgery should be large enough to allow adequate access for the dental team all around the patient. As with all dental techniques the dental chair must be capable of being placed in the horizontal position.
Equipment for Inhalation Sedation
Dedicated purpose-designed Relative Analgesia machines for dentistry should be used. Such machines should conform to British Standards (appx.14) and be maintained according to manufacturers’ guidance with regular, documented servicing.
Gas supply lines for Relative Analgesia machines must be connected by non interchangeable colour coded pipelines. On installed pipelines there must be a low pressure warning device and an audible alarm.
Nitrous oxide and oxygen cylinders must be stored safely with regard to current regulations. Cylinders must be secured safely to prevent injury.
There should be adequate scavenging of waste gases where inhalation sedation is used since inadequate scavenging may result in unacceptable risks to health of the dental team. Adequate scavenging of gases should not rely on window opening or air conditioning alone and it should conform to current COSHH standards. (appx.15&16)
Breathing systems should have a separate inspiratory and expiratory limb to allow proper scavenging. Nasal masks should be close fitting providing a good seal without air entrainment valves.
Equipment for Intravenous Sedation
All the appropriate equipment for the administration of intravenous sedation must be available in the surgery including syringes, needles, cannulae, surgical wipes/tapes/dressings, tourniquets and labels.
Purpose-designed, calibrated and appropriately maintained equipment is required for all infusion techniques.
It is mandatory to be able to administer supplemental oxygen or oxygen under intermittent positive pressure ventilation to the patient should the need arise. This must conform with General Dental Council guidelines.
Patient Assessment and Selection
Careful and thorough assessment of the patient ensures that correct decisions are made regarding the planning of subsequent treatment. The full spectrum of patient management techniques should be explored.
An objective assessment and discussion with the patient enable decisions to be made such that the patient receives the most appropriate type of Conscious Sedation, administered in the correct environment by the sedationist best able to provide the service.
Reasons for Requiring Conscious Sedation
The patient should be asked directly to state their anxieties about dental treatment and what precipitated them. A discussion of the proposed treatment choices and the patient’s attitude to them should be investigated.
All dental patients should have a thorough medical, dental and social history taken and recorded for each course of treatment.
After a dental examination a provisional treatment plan can be formulated.
Assessment of the patient’s general fitness including colour, pulse and respiration is important in patient selection. Blood pressure measurement is an essential part of risk assessment for sedation. The American Society of Anesthesiologists (ASA) Physical Status classification should be determined. (appx.18)
There are few absolute contraindications for Conscious Sedation. Relative contraindications are important however and can only be considered in the light of the full knowledge of the case which thorough assessment provides.
Preparation of Patients for Conscious Sedation
Patients who are scheduled to receive Conscious Sedation must receive careful verbal and written instructions as to the effects of the sedation and their responsibilities prior to the sedation appointment.
Before a Conscious Sedation appointment patients should be advised to take only light food. Starvation for Conscious Sedation is undesirable.
Specific written consent must be obtained from all patients who are to receive treatment under sedation.
A responsible adult escort must accompany the patient home friom the dental surgery and assume responsibility for the patient’s post-sedation care. Both patients and escort must understand and accept that this responsibility is delegated to the escort and both must agree to comply with this. It is therefore essential that both patient and escort clearly understand the effects of sedative agents and the consequences of failing to follow all post-sedation instructions.
Wherever possible arrangements should be made for the patient and escort to travel home by private car or taxi rather than public transport. Where this is not possible, the escort must be made aware of the added responsibilities of caring for the patient during the journey home. If, in the opinion of the sedationist, either the patient or the escort appear to be unwilling or unable to comply with these requirements, Conscious Sedation should not be given.
With the exception of adult patients receiving nitrous oxide / oxygen inhalation sedation, an escort is mandatory for conscious sedation. (appx.8) It is desirable that the escort should look after the patient for the rest of the day or has made reliable arrangements for a capable adult to undertake that care. Thus the provision of conscious sedation may be unsuitable for a patient who lives alone or who solely cares for children, elderly and/or dependent relatives.
The Consent Process
Consent is a communication process. The General Dental Council currently requires that where sedation is provided then the patient should also provide written consent. It is important to remember that a signature on a form can be misleading and the mere presence of such a signature does not guarantee that the consent obtained is valid.
“Consent is the voluntary and continuing permission of a patient to receive a particular treatment. It must be based upon adequate knowledge of the purpose, nature and likely effects and risks of that treatment, including the likelihood of its success and any alternative to it.”
The law provides for all persons ages 16 and over to consent to dental treatment. In order to provide valid consent a patient must be able to comprehend the information provided, retain it and assimilate the same information so as to be able to make a decision. Caution must be applied where children under 17 provide consent when they are competent to do so.
Patients who are already sedated are unlikely to be competent to take decisions regarding consent for treatment. It is therefore inappropriate to try to seek consent for dental treatment from a patient who is sedated.
All decisions made by patients in respect of sedation should be voluntary. Patients should not be coerced in any way to accept sedation techniques if they do not wish to do so. Sedation should be presented as an option in anxiety control with other options being pointed out to the patient.
If treatment plans cannot be pre-determined this should be explained to patients with an explanation, in broad terms, of the possible treatment.
Patients should be given an opportunity to ask about all aspects of their treatment with questions answered truthfully.
Records and Documentation
The most accurate, contemporaneous record of the consent process is the clinical record card.
It is recommended that a clinical record for conscious sedation should include the reason for Conscious Sedation and evidence of the consent process. The consent process includes both sedation and the treatment to be provided including:
- Written medical history
- Previous dental history.
- Written instructions have been provided pre- and post-operatively.
- The presence of an accompanying adult.
- The patient has complied with pre-treatment instructions.
- The medical history has been checked and acted upon.
- Records of drugs employed, dosages and times given including site and method of administration.
- Previous Conscious Sedation / General Anaesthetic History.
- Pre-sedation assessment.
- Any individual specific patient requirements.
- Suitable supervision has been arranged.
- There is written documentation of consent for sedation (Consent Form).
- Records of monitoring techniques.
- Full details of dental treatment provided.
- Post sedation assessment.
Recovery from sedation is a steady progression from completion of treatment through to discharge into the care of an escort. The first stage of recovery is normally in the dental chair. Once the patient is recorvered sufficientyl to move to a resting area, they should be carefully guided and supported. This recovery area should be serparate from the main waiting room and contain furniture and firments for the comfort and well being of the patient.
A member of the dental team should supervise the patient during this period. Equipment and drugs for dealing with medical emergencies must be available. The dentist or sedationist must be available to see the patient urgently to deal with any problems that may arise.
The decision to discharge a patient into the care of the escort following any type of sedation must be the responsibility of the dentist or the sedationist. The patient must have a responsible adult as an ascort. The criteria for discharge are that the patient should be able to walk unaided without stumbling or feeling unstable.
In addition to specific instructions given to the patient and escort regarding the sedation, details of the dental treatment provided should be given to patient and and escort including any aftercare arrangement relating to pain control and possible postoperative bleeding. Adequate information including how to contact the dentist if necessary must be given.
Conscious Sedation Techniques
The three standard sedative techniques used in dentistry (inhalation, oral and intravenous) all work for the vast majority of patients. Transumucosal and intranasal techniques require special training and experience. These forms of treatment should be restricted to the experienced sedationist in an appropriate environment. The technique that is chosen must be tailored to provide the most appropriate anxiety relief for the individual patient. There are a few absolute guidelines. As a general rule the simplest technique should be used in all cases.
No one technique will be successful for all patients whether it be the use of a single drug, or the use of multiple agents. In certain situations it is possible to mix techniques; for example for a needle-phobic patient it may be that inhalation sedation is used initially to allow intravenous cannulation.
All drugs must be carefully labelled even when only one drug is drawn up. All syringes in use in the surgery must be labelled, whether containing dental medicaments (e.g. root canal medicaments) or drugs (e.g. intravenous sedatives).
Proper checking and labelling of all drugs is particularly important especially as drugs are often used in different concentrations. There must be adequate safeguards where the same drugs of different concentrations are stored in that no confusion occurs over the choice of drug.
Drugs should be given according to accepted administration/titration protocols.
Monitoring standards must be stringent for all types of Conscious Sedation. Clinical monitoring of colour, pulse and respiration is of particular importance throughout all Conscious Sedation procedures. (appx.3)
Surgery staff assisting with Conscious Sedation procedures must be capable of monitoring the clinical condition of the patient.
For inhalation sedation clinical monitoring of patient without further electro-mechanical devices is adequate.
Monitoring for intravenous sedation must include the proper use of pulse oximetry and blood pressure monitoring.
The only currently recommended technique for inhalation sedation is the use of a titrated dose of nitrous oxide with oxygen.
The standard technique used for intravenous sedation is a titrated dose of a single benzodiazepine. Use of a continuous infusion of propofol has gained some popularity in recent years. Other drugs or combinations of drugs may be required in specially selected circumstances. These forms of treatment should be restricted to the experience sedationist in an appropriate environment.
In both Inhalation Sedation and Intravenous Conscious Sedation, success is due to titrating the dose given to the patient’s needs. Fixed doses or bolus techniques are unacceptable.
Oral / Intranasal / Transmucosal Sedation:
These are techniques where doses of a drug are administered to the patient under the direct supervision of the prescribing dentist with the aim of achieving a satisfactory level of sedation for dental treatment to be carried out. This is different from pre-medication where small doses of drug are given to aid the patient’s journey to the surgery, or to assist in a restful night’s sleep before the appointment. Drugs currently used to produce these types of Conscious Sedation include midazolam and temazepam.
Appropriate procedure need to be followed for agents not licensed for oral, intranasal or transmucosal use. (appx.19&20)
Conscious Sedation for Children
Any person under the age of sixteen may be considered for clinical purposes, to be a ‘child’.
If a child of any age is unwilling or incapable of co-operation they are not suitable candidates for Conscious Sedation. Practitioners must be aware that there circumstances where Conscious Sedation is inappropriate. In these cases referral for general anaesthesia must be considered.
Children have different requirements and responses. Conscious Sedation for children should only be undertaken by teams which have training and experience in the case selection, behavioural management, and administration of sedation for this age group, and in an appropriate environment.
Provided that this requirement is fulfilled, there is no contraindication to the administration of Conscious Sedation to children in the Dental Practice setting.
Nitrous oxide / oxygen Conscious Sedation should be the first choice for paediatric dental patients who are unable to cope with local anaesthesia alone and have a sufficient level of understanding to accept the procedure.
Nitrous oxide inhalation sedation should be offered to children with mild to moderate anxiety to enable them to better accept treatment and to facilitate coping across sequential visits.
Nitrous oxide inhalation sedation sedation can be used to facilitate dental extraction in children and is the method of choice for anxious children who undergo elective orthodontic extractions. (appx.21&22)
Topical anaesthetic should be used prior to local anaesthesia and at the cannulation site.
There is insufficient scientific evidence in the United Kingdom to support the routine use of intravenous sedation in children for dentistry.
Oral / Intranasal / Transmucosal Sedation
These forms of treatment should be restricted to the experienced sedationist in an appropriate environment.
Any Conscious Sedation procedure may be associated with complications. It is vitally important that the incidence is kept to the lowest possible leve.
- The management of complications requires the whole dental team to be:
- aware of the risk of the development of complications.
- appropriately trained and regularly rehearsed in emergency procedures.
fully equipped with appropriate means of airway protection, oxygen delivery and drugs for emergency use. It is essential that the equipment is carefully checked, that the oxygen supply is secure and adequate and that the drugs are in-date with all requisite means for their administration.
It is vitally important for the whole team to be prepared and to rehearse the routine regularly.
Clinical Governance and Audit
It is a requirement of good practice that all professional clinicians work with colleagues to monitor and maintain awareness of the quality and care that they provide for their patients. This is a basic principle of clinical governance and risk management.
Attention must be given to risk awareness, risk control, risk containment and risk transfer.
Evidence of active participation in personal clinical audit in an essential feature of clinical governance.
Society for the Advancement of Anaesthesia in Dentistry
53 Wimpole Street
Tel No: 020 7935 1656
Fax No: 01246 208729
British Dental Association
64 Wimpole Street
Tel No: 020 7935 0875
Fax No: 020 7487 5232
The Royal College of Surgeons of England
35/43 Lincoln’s Inn Fields
Tel No: 020 7312 6605
Fax No: 020 7973 2194
General Dental Council
37 Wimpole Street
Tel No: 020 7887 3800
Fax No: 020 7224 3294
Dental Sedation Teachers Group
c/o Honorary Secretary
Department of Sedation and Special Care Dentistry
Tel No: 020 7955 5000 Ext. 3407
Fax No: 020 7955 2676
National Examining Board for Dental Nurses
110 London Street
Tel No: 01253 778417
Fax No: 01253 777268
Resuscitation Council (UK)
Tavistock House North
Tel No: 020 7388 4678
Fax No: 020 7383 0773
Association of Dental Anaesthetists
c/o Honorary Secretary
Dept of Anaesthesia
Royal Victoria Infirmary
Queen Victoria Road
Tel No: 0191 282 4386
Fax No: 0191 282 5401
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