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Training for Safe Practice in Advanced Sedation Techniques for Adult Patients

Foreword

This document represents a departure from the normal Dental Sedation Teachers’ Group publications. The previous publications, “Sedation in Dentistry. Undergraduate Training – Guidelines for Teachers” and “Conscious Sedation in Dentistry. The Competent Graduate”, related to the training in basic sedation techniques that were well established. Courses were available covering the syllabus covered in the first publication, and some included the range of experience recommended in the second.

There are still problems with the delivery of conscious sedation training in dentistry. One of the major issues is how medical and dental practitioners with a special interest in sedation are to be trained to manage those patients who cannot accept the basic techniques. This document aims to start the debate on what training is required for those who wish to use advanced conscious sedation techniques. Advanced conscious sedation techniques are those techniques that are used to produce conscious sedation, but are considered beyond the scope of the basic sedation courses.

These techniques still fall within the General Dental Council’s definition of sedation that 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 the verbal contact is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dentistry should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.

The level of sedation must be such that the patient remains conscious and is able to understand and respond to verbal commands. “Deep sedation” in which these criteria are not fulfilled must be regarded as general anaesthesia.

In the case of patients who are unable to respond to verbal contact even when fully conscious the normal method of communicating with them must be maintained.

This document was drafted by a small working party of the Dental Sedation Teachers’ Group and approved by the Committee.

The members of the working party were: – Dr Nigel D Robb (Chairman), Dr Derek C Debuse, Dr David C Craig, Dr Chris P Holden and Dr Tom Cripps.

As Chairman I would like to thank all the subcommittee for their hard work and all members of the DSTG Committee for their comments on the various drafts as they were produced.

We hope that this document stimulates positive debate that will lead to an improvement in the quality and safety of the management of the dental treatment for the patients who need these management techniques.

Nigel D Robb

May 2003


Introduction

The use of conscious sedation techniques for dental and medical procedures continues to generate much debate. However, many frequently expressed views are based more on prejudice than evidence.

There have been a number of reports that have sought to provide a regulatory base for the practice of conscious sedation. The most important principle (stated in the current General Dental Council’s (GDC) ‘Maintaining Standards’1 is that dentists should only use those techniques for which they have received appropriate training. Such training must include supervised clinical practice.

The recent report from the Academy of Medical Royal Colleges and their Faculties2 emphasises that each speciality must produce its own guidance for the use of sedative techniques. The dental profession has led the field in this regard having produced extensive guidance on training in the use of basic sedation techniques and the use of sedative techniques in dental practice 3-6.

Basic sedation techniques (see below) appear to allow the vast majority of adult patients to be managed effectively and safely. Although there is little published evidence to support this statement, it is consistent with the experience of those who practice conscious sedation for dentistry and the vast number of patients who have been treated successfully. However, basic techniques are not always successful and it is important that the profession recognises that patients who cannot cope have a right to expect more appropriate methods of pain and anxiety control. The GDC regulations indicate that dentists have a duty to provide such care for patients1.

Any sedation technique that is used must produce the state of conscious sedation, which is described by the GDC1. This is a definition of a target state and not a prescriptive list of methods. The target state may be approached in different ways.

The use of any sedation technique must also be justified as both effective and safe and that as the most appropriate for the patient on that occasion. Implicit in such justification is the reason why the basic techniques were inappropriate. Evidence-based medicine now makes it incumbent on the profession to publish evidence to support the use of non-basic sedation techniques. It is equally important that those who believe that particular sedation techniques are inappropriate should publish the evidence. The extrapolation of results from other areas of medical practice may not always be valid. Great care should be taken with the use of evidence from outside the United Kingdom, as definitions of sedation states may be different. In particular, papers describing “deep sedation” as practised in North America are beyond that which the GDC1 would accept.

The aim of this document is to open the debate on the levels of training which are appropriate for the many post-basic sedation techniques, which are currently in use within dentistry in the UK. Inclusion of a drug or technique of administration should not be regarded as an endorsement by the DSTG.

This document is neither a textbook nor a set of course handouts. It seeks to indicate issues that will need to be addressed by those who are considering providing training. It does not aim to give specific syllabi for various sedation techniques.

We have indicated some of the responsibilities that course providers need to consider, but in the same way that the DSTG does not accredit providers of courses for basic sedation techniques, we have not dictated or sought to validate who should provide advanced courses.

A brief reference list is provided for information (Appendix 1). The papers cited have appeared in refereed journals, and have therefore been the subject of peer review. However, inclusion of a reference should not be taken as an indication that the DSTG endorses the work.

1. Conscious sedation techniques

This document lists the basic and advanced conscious sedation techniques that are currently available in dentistry. The requirements for entry to training in advanced conscious sedation techniques and recommendations on training requirements and assessment are described. The responsibilities of those who organise training are outlined.

a) Basic techniques:

  • Intravenous midazolam
  • Nitrous oxide inhalation sedation

These operator-sedationist techniques are taught in most Dental Schools in accordance with the recommendations contained in “The First Five Years”7 and “Maintaining Standards”1. Details of this training can be found in the DSTG publications “Undergraduate Training”3 and “The Competent Graduate”4. The standards of practice and monitoring for these techniques have been described in “Standards in Conscious Sedation for Dentistry. Report of an Independent Expert Working Group”5 and accepted in “Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures in Adults” commissioned by the Academy of Medical Royal Colleges2.

b) Advanced techniques include:

  • Multiple intravenous drugs
  • Continuous intravenous infusion techniques
  • Oral sedation
  • Transmucoscal sedation
  • Inhalation sedation with volatile agents
  • Mixed route techniques

The above are operator-sedationist techniques with the exception of operator-controlled infusions of intravenous sedatives and inhalation sedation using volatile agents: infusion pumps require careful monitoring and there is currently no dedicated inhalation sedation equipment suitable for the delivery of volatile agents.

The standards of practice and monitoring required for the advanced techniques supplement those required for basic techniques.

2. Entry to Training

Candidates should have completed training in the basic sedation techniques equivalent to that defined in “The Competent Graduate”4.

Postgraduate qualifications in sedation (Diplomas or MScs) may provide evidence of appropriate training and supervised clinical practice.

The organisers of advanced sedation courses must seek evidence that candidates have gained substantial experience of basic sedation techniques. The candidates should have an on-going commitment to the use of sedation as an integral part of their practice. As a guide, candidates would normally be expected to have ongoing experience of using the basic sedation techniques. Such experience would be demonstrated by the provision of 100 cases of the basic sedation techniques per year over a period of three years.

3. Training

a) Sedationists

Courses will vary in the range of advanced conscious sedation techniques taught. In general the courses should be organised to revise the syllabus of the basic training as well as covering the additional pharmacology and clinical techniques.

Supervised clinical practice is an integral part of training in advanced conscious sedation. The General Dental Council requires those administering conscious sedation not only to have knowledge of, but also be experienced in, the clinical technique prior to independent practice6.

Recommendations for the appropriate amount of clinical training required may be found in Table 1.

Table 1. TRAINING AND EXPERIENCE

  Basic training and experience (a) Additional theory Equipment and clinical skills training Clinical experience (number of cases) Life support training Continuous ECG required Operator-sedationist (with Second Appropriate Person) Additional training for Second Appropriate Person
Midazolam + Opioid
 
20
ILS
N
Y
Y
Midazolam + Ketamine
 
20
ILS
N
Y
Y
Midazolam + Propofol
20
ILS
N
N
N/A
 
#
Midazolam
20
ILS
N
Y
Y
 
PCS
Propofol infusion (OCS)
20
ILS
N
N
N/A
 
#
Propofol infusion (PCS)
20
ILS
N
Y
Y
Midazolam
 
10
BLS
N
Y
N
 
Oral
Temazepam
 
10
BLS
N
Y
N
 
Oral
Midazolam + Ketamine Oral
 
20
ILS
N
Y
Y
Midazolam
10
BLS
N
Y
N
 
Transmucosal
Sevoflurane
15
BLS
N
N
N/A
 
#
Sevoflurane + N2O / O2
15
BLS
N
N
N/A
 
#

Mixed Route sedation: Training and experience as defined above for each drug and each route

# = Not operator-sedationist techniques

(a) = As defined in DSTG “Competent Graduate” 4

OCS = Operator controlled sedation

PCS = Patient controlled sedation

BLS = Basic Life Support

ILS = Immediate Life Support

b) “Second appropriate person”

The regulations for the Certificate in Dental Sedation Nursing awarded by the National Examining Board for Dental Nurses defines the training and experience required to assist the operator-sedationist when using basic sedation techniques. Where techniques employ drugs and equipment not covered by these regulations additional training will be required. Such training may be provided by courses designed for the whole dental team.

4. Assessment and recording of experience

Candidates should maintain a logbook of clinical experience and should be assessed prior to independent clinical practice. Such assessments may include a written or MCQ examination and presentation of the logbook. Case studies and a review of the practice environment may also be of value.

An example of a suggested logbook page is included as Appendix 2.

5. Responsibilities of course organisers

Course organisers should be responsible for: -

  • Recruitment of suitable candidates. This will include qualitative and quantitative assessment of their previous sedation experience and current level of Life Support skills
  • Developing and delivering appropriate courses in the selected techniques
  • Organisation of appropriate supervised clinical practice
  • Delivery of additional training for the “second appropriate person” if required
  • Devising and implementing appropriate assessment of candidates
  • Academic audit and development of the courses

6. Summary

The aim of this document is to stimulate debate on how we provide training in advanced sedation techniques.

The principle that health care professionals can only use sedation techniques for which they have received training forms the foundation for the safe delivery of conscious sedation.

This document offers guidance for course organisers and for those who wish to be trained to extend the range of their skills for the management of adult patients under conscious sedation.

This document is not aimed at those practitioners who are appropriately trained for the techniques they are practising. It should not be taken as an attempt to regulate existing practice.

References

1. Maintaining Standards. Guidance to Dentists, Dental Hygienists and Dental Therapists on Professional and Personal Conduct. General Dental Council, London, Amended Nov 2001.

2. Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures in Adults. Academy of Medical Royal Colleges. Nov 2001

3. Sedation in Dentistry. Undergraduate Training. Guidelines for Teachers. Dental Sedation Teachers’ Group. May 1999

4. Conscious Sedation in Dentistry. The Competent Graduate. Dental Sedation Teachers’ Group. August 2000

5. Standards in Conscious Sedation for Dentistry. Report of an Independent Expert Working Group. Published by Society for the Advancement of Anaesthesia in Dentistry, London, October 2000

6. Conscious Sedation. A Referral Guide for Dental Practitioners. Society for the Advancement of Anaesthesia in Dentistry and Dental Sedation Teachers’ Group. September 2001.

7. The First Five Years. A Framework for Undergraduate Dental Education. Second Edition. General Dental Council, London. August 2002.

Appendix 1

List of supporting papers
Oral and transmucosal sedation
Hartgraves, PM and Primosch RE. An evaluation of oral and nasal midazolam for paediatric dental sedation. J Dent Child 1994;61:175-81

Roelofse JA, Louw LR, Roelofse PG. A double blind randomised comparison of oral trimeprazine-methadone and ketamine-midazolam for sedation of paediatric dental patients for oral surgical procedures. Anaesth Prog 1998;45: 3-11.

Inhalation sedation with anaesthetic volatile agents
Parbrook GD, James J, Braid DP. Inhalational sedation with isoflurane: an alternative to nitrous oxide in dentistry. Brit Dent J 1987;163:88-92

Averley PA, Lahoud GYG. Comparison of sevoflurane and nitrous oxide mixture with nitrous oxide alone for inhalation conscious sedation: A randomised controlled trial. Anaesthesia 2002: 57:446-450.

Multiple drug intravenous sedation

Hook PC. Lavery KM. New intravenous sedative combinations in oral surgery: a comparative study of nalbuphine or pentazocine with midazolam. British Journal of Oral & Maxillofacial Surgery. 1988;26(2):95-106.

Roelofse JA, Joubert JJ, Roelofse PG. A double blind randomised comparison of midazolam alone and midazolam with ketamine for sedation of paediatric dental patients. J Oral Maxillofac Surg 1996; 54(7):838-844

Craig DC, Boyle CA, Fleming GJP, Palmer P. A sedation technique for implant and periodontal surgery. J Clin Periodontol 2000;27:955-9

Propofol infusion intravenous sedation

Rodrigo MRC, Jonsson E. Conscious sedation with propofol. Brit Dent J 1989;166:75-80

Girdler NM et al. Patient controlled propofol sedation in phobic patients. Anaesthesia 2000; 55:327-333

Leitch JA, Sutcliffe N, Kenny GNC. Patient-maintained sedation for oral surgery using a target-controlled infusion of propofol – a pilot study. Brit Dent J 2003;194:43-45

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