Sedation in Dentistry:
Undergraduate Training
Guidelines for Teachers
May 1999
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
- 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. - To enable the undergraduate to acquire a sound foundation in these skills
through clinical practice.
OBJECTIVES
- The acquisition and understanding of core knowledge relevant to the
practice of conscious sedation in dentistry. - To have clinical experience in the:
- assessment and treatment planning of patients who require
conscious sedation - administration of sedation
- dental care for sedated patients
- appropriate discharge of patients who have received conscious
sedation
- assessment and treatment planning of patients who require
- To promote an awareness and understanding of the importance of:
- sedation in the management of pain and anxiety
- communication skills in the management of patients requiring
conscious sedation
- To appreciate the limitations of the undergraduate experience and understand
the benefit of continuing professional education. - 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 | |
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
|
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 |
|
| Bleed System |
|
| Gas Check |
|
| Flowmeter and Controls Check |
|
| Automatic Cut-out Check |
|
| Reservoir Bag Check |
|
Machine ready for use