Current UK dental sedation practice and the 'National Institute for Health and Care Excellence' (NICE) guideline 112: sedation in children and young people.

AIM: Describe current dental sedation practice for under 19-year-olds in the UK and compare it with the recommendations of NICE guidance 112. METHOD: Members of the Society for the Advancement of Anaesthesia in Dentistry and members of the Dental Sedation Teachers Group were invited to participate in an online survey. RESULTS: Two hundred and sixty-six dentists and doctors completed the survey. Eighty-two percent were operator and sedationist (operator-sedationist). Ninety-five percent provided written information and 94% obtained written consent. Eighty-four percent kept a written or electronic sedation record. Eighty-six percent complied with life support training expectations. Eighty-six percent had immediate access to resuscitation equipment. Sixty-seven percent of sedationists reported that treatment could not be completed under sedation for <10% of cases during the previous year. When sedation was unsuccessful, 61% said they would schedule general anaesthesia and 54.5% would schedule advanced sedation care. Forty-nine percent believed that a dentist was an appropriate person to provide advanced sedation for 12-18 years. Only 24% thought a dentist should provide advanced sedation for children<12 years, with 75% preferring an anaesthetist. The appropriate setting for advanced sedation was thought to be primary care by 33% and secondary care by 68%. CONCLUSIONS: We found good agreement between the current practice of sedation and the recommendations of the NICE guidance 112.

Comparison between two regional anaesthesia techniques performed by inexperienced operators: the Gow-Gates block versus the Kenneth Reed block.

AIM: The aim was to compare the efficacy of Kenneth Reed and Gow-Gates inferior alveolar nerve blocks when performed by an inexperienced operator. METHODS: A group of 60 patients was randomised into two groups. One group had the Kenneth Reed technique used to administer an inferior alveolar nerve block whilst the other received the Gow-Gates technique. The efficacy of nerve block produced was evaluated both clinically and by electric pulp tester. MRI examination was undertaken to determine the spread of local anaesthetic. RESULTS: There were no significant differences in success rate of anaesthesia between groups. The failure rate for the Gow-Gates technique was 16.6%, whilst the failure rate for the Kenneth Reed technique was 23.3%. Time to onset was less with the Kenneth Reed technique. MRI examination showed the solution was more widely distributed after the Kenneth Reed block had been used. CONCLUSIONS: Our research has demonstrated that the Kenneth Reed technique is equally effective at producing anaesthesia of the inferior alveolar nerve. Compared with conventional techniques there is a lower incidence of positive aspiration and potential for lower morbidity as the local anaesthetic is deposited further from the neurovascular bundle than when deposited near the mandibular foramen as in most conventional Inferior Alveolar Nerve Block techniques.

Intravenous conscious sedation in children for outpatient dentistry.

The use of general anaesthesia for dental treatment in the NHS outside hospitals has changed over time. Although deaths are uncommon during or immediately after general anaesthesia for dental treatment, they are more likely to occur than with other methods of pain and anxiety reduction, such as local anaesthesia and conscious sedation. Inquiries into recent anaesthetic deaths in dental practice have been critical of the standard of care provided in areas such as pre-operative assessment, monitoring, resuscitation and transfer to specialist critical care facilities.

A partially blinded randomised controlled trial of patient-maintained propofol sedation and operator controlled midazolam sedation in third molar extractions.

Patient-maintained sedation using propofol has recently been shown to be effective for dental surgery. We compared this new technique to the established technique of operator administered midazolam. The two groups were compared before, during and after sedation. The two primary outcomes were time until discharge and oxygen saturation. Vital signs, anxiety and psychomotor skills were also compared. State anxiety was reduced to a greater extent in the propofol group (mean difference 10 (SD 4) mm; p = 0.010. Propofol patients recovered quicker (mean difference 7 (SD 1.4) min; p = 0.001). Propofol patients had a smaller reduction in arterial oxygen saturation (mean difference 0.8 (SD 0.3)%; p = 0.030), and a reduced increase in heart rate (mean difference 9 (SD 2) beats.min(-1); p < 0.001). Both techniques were well tolerated and safe. Propofol sedation offered superior anxiolysis, quicker recovery, less amnesia and less depression of simple psychomotor function.

Intravenous conscious sedation in patients under 16 years of age. Fact or fiction?

Recently published guidelines on the use of conscious sedation in dentistry have published varying recommendations on the lower age limit for the use of intravenous conscious sedation. There are a large number of dentists currently providing dental treatment for paediatric patients under intravenous conscious sedation. The 18 cases reported here (age range 11-15 years), were successfully managed with intravenous conscious sedation. The experience in this paper is not sufficient evidence to recommend the wholesale use of intravenous conscious sedation in patients who are under 16 years. The fact that a range of operators can use these techniques on paediatric patients would suggest that further study should be carried out in this population. The guidance should be modified to say there is insufficient evidence to support the use of intravenous conscious sedation in children, rather than arbitrarily selecting a cut off point at age 16 years.

The prevalence, etiology and management of tooth wear in the United Kingdom.

STATEMENT OF PROBLEM: Recent epidemiologic evidence suggests that tooth wear is now a significant problem in both children and adults. There is growing evidence that a major cause of severe wear in patients is regurgitation erosion due to a variety of factors including gastroesophageal reflux disease. PURPOSE: The purpose of this article is to discuss the prevalence of tooth wear in the United Kingdom. Emphasis in management should be on accurate diagnosis, and in some patients, long-term monitoring before embarking on any irreversible, interventive treatment. Even when treatment is necessary, a period of monitoring is helpful to assess the rate of progress of the wear, the effectiveness of preventive measures, and therefore the extent of the treatment necessary.

Sedation in practice. 4: The use of sedation for the medically compromised patient.

This, the fourth paper in a series of uses of sedation in general dental practice, reviews the use of sedative techniques for patients who have medical conditions which will affect their ability to co-operate with dental treatment or which may be aggravated by the stress of treatment. Advice is given on a range of other conditions which may present as incidental findings when the patient's medical history is being taken.

Postgraduate education in sedation--a new development.

Although demand for sedation courses has continued to increase, the traditionally theoretical format has tended to leave participants without the necessary clinical skills to practice sedation techniques with confidence. This article describes a new model of sedation course, introduced at Newcastle Dental Hospital and School, which has managed to overcome this problem.

Sedation in dental practice. 3: The role of sedation in the management of problems with local anaesthesia.

This article describes how sedation can help to overcome some of the problems associated with the use of local anaesthesia for dentistry. It also reviews those problems where sedation is not the appropriate choice, and gives guidance on distinguishing the appropriate from the inappropriate, along with suggestions for how such cases might be managed.

Epileptic fits under intravenous midazolam sedation.

A case is presented of a patient who suffered from recurrent epileptic fits while being treated under intravenous sedation with midazolam. Those using sedation are advised to beware of the patient who gives a history of fits being provoked in the dental environment.

Sedation in dentistry. Part 2: Management of the gagging patient.

Sedation should be considered as a useful part of the general dental practitioner's armamentarium and as an important alternative to general anaesthesia in selected cases. In this, one of a series of articles on the uses of sedation in various circumstances, the management of the gagging patient is discussed. The many factors involved in the aetiology of the hyperactive gag response are reviewed and measures for dealing with it suggested.

Sedation in dentistry. Part 1: assessment of patients.

This is the first in a series of articles on the uses of sedation in general dental practice. This paper reviews current recommendations for the practice of sedation, and the importance of patient assessment as a part of treatment. The dental and psychosocial indications, as well as medical contraindications, for sedation are discussed. Future articles will expand on other areas where sedation may be a useful tool in the general dental practitioner's armamentarium. It is hoped that these articles will encourage all practitioners to consider a wider use of sedative techniques in dentistry.

The prevalence of toothwear in 1007 dental patients.

The dental profession is becoming increasingly concerned about unacceptable levels of toothwear and there is an impression that the condition is becoming more prevalent. There is, as yet, little epidemiological evidence to illuminate the question and so this study is therefore intended to provide baseline data on the prevalence of toothwear in a sample of the dental attending population of South East England. A degree of toothwear is normal and progresses throughout life. Toothwear which is acceptable in an older age group would not be so with younger patients. It is therefore necessary to designate threshold values of acceptable levels of toothwear for different age groups to reach realistic conclusions about the prevalence of unacceptable levels of toothwear. Of the 1007 patients examined only nine had completely unworn dentitions. More than 93,500 tooth surfaces were examined and of these 5.1% had wear which exceeded the threshold values. Despite increasing the threshold values for the older age groups from those proposed in an earlier study by Smith & Knight (1984), these patients still had higher levels of unacceptable toothwear. There was a slight tendency for men to have more wear than women, but there was no clinically significant relationship between the number of missing posterior teeth and wear of the anterior teeth.

Chronic alcoholism: an important condition in the dentist-patient relationship.

OBJECTIVES: This paper aims to give the dental practitioner an insight into the impact of chronic alcoholism on sufferers. METHODS: A review of the psychiatric and dental literature covering the aetiology, prevalence and complications is presented. CONCLUSIONS: Chronic alcoholism has a number of serious medical and social problems which may affect the provision of dental treatment. It is important for the dental practitioner to be aware of the impact of this condition on patients as he or she may be in an ideal position to stop the alcoholic before a medical consultation has been sought.