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Sedation in Dentistry:
The Competent Graduate

August 2000

Introduction
Defining conscious sedation
Defining competence
Qualifying competence
Dental Sedation Teachers Group guidelines
Recommended clinical experience
Assessing competence
Awareness of limitations
Extending the range of competence

1) Introduction

The undergraduate course present a unique opportunity to ensure that all dental graduates are able to provide conscious sedation for patients who find dentistry distressing. The General Dental Council reinforces the need for adequate training in sedation techniques:

"Dentists have a duty to provide and patients have a right to expect adequate and appropriate pain and anxiety control. Pharmacological methods of pain and anxiety control include local anaesthesia and conscious sedation techniques"
(Maintaining Standards, para 4.8: GDC May 1999)

This document suggests a standard of competence which would enable the new graduate to use pharmacological sedation techniques effectively and safely. It builds on the Dental Sedation Teachers Group's guidelines for undergraduate training in sedation published in May 1999.

2) Defining Conscious Sedation

The General Dental council defines conscious sedation as:

'A technique in which the use of a drug or drugs produces a start of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact 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'.
(Maintaining Standards, para 4.11: GDC May 1999)

3) Defining Competence

At graduation, dentists should be aware of the advantages and disadvantages of using conscious sedation techniques and should be capable of providing effective sedation for selected patients undergoing straightforward dental procedures in the primary care setting.

This means that the graduate should:

i) be able to assess a patient's need and suitability for conscious sedation and

ii) possess both the ability and confidence to apply knowledge and skills relating to inhalation sedation (using nitrous oxide and oxygen) and intravenous sedation (using midazolam).

The dental graduate will not be competent to manage all patients requiring conscious sedation. It is, therefore, necessary to qualify the term 'competence'.

4) Qualifying Competence  

i) Suitable cases for the recent graduate:

Adult or child patients who are fit and well (ASA I/II) and who require straightforward restorative dentistry or oral surgery which is likely to fall within the clinical experience of a new graduate.

It is assumed that the graduate will be working as an operator-sedationist in a suitably equipped environment with an appropriately trained dental nurse.

ii) Examples of unsuitable cases include:

	Unfit patients (ASA III-V)
	patients with severe dental phobia
	patients who require extensive or difficult dentistry
	recreational drug users

5) The Dental Sedation Teachers Group Guidelines

The Committee of the Dental Sedation Teachers Group (DSTG) has representatives from all UK dental school and from the principal providers of postgraduate training in sedation.

The group's guidelines for undergraduate teachers of sedation are based on the experience of those dental schools currently providing some form of sedation training.

The guidelines contain a core curriculum, recommendation s relating to the provision of clinical experience and suggestions about the assessment of knowledge and skills. There is also an appendix containing examples of course documentation.

The DSTG guidelines were designed to help teachers establish or improve conscious sedation training. Although certain minimum levels of practical experience were suggested, the guidelines did not seek to quantify the amount of experience which would be required for' independent practice' upon graduation.

6) Recommended Clinical Experience

Whilst it is impossible to guarantee that any level of training and experience will always achieve competence in any area of clinical practice, the following figures represent a sound foundation in conscious sedation techniques. They are similar to those achieved by postgraduate students who undertake clinical attachment programmes in sedation. Common sense suggests that there should be some flexibility.

It is also appropriate for graduates to be aware of the usefulness of small doses of oral benzodiazepines prescribed as premedication prior to a dental visit. However, this should not be confused with conscious sedation produced by the oral administration of benzodiazepines or other drugs.

7) Assessing Competence

The DSTG guidelines refer to the practical assessment of knowledge and clinical skills.

A combination of formative and summative assessment is most appropriate. this might involve clinical logbook, written or MCQ type examinations, clinical skill tests (OSCEs), oral examinations and a final assessment of clinical competence.

Designing a suitable system of assessment is no more difficult for conscious sedation than for any other discipline.

8) Awareness of limitations  

The graduate must recognize his/her limitations and understand the need to refer unsuitable cases.

9) Extending the Range of Competence  

The graduate should be aware of the role of continuing professional education and the need to keep both knowledge and skills up to date.

The use of oral, intranasal, multi-drug, patient controlled and infusion based sedation techniques required specific postgraduate training and experience.