The application of IV conscious sedation in dental practice: its recognition assessment and management

To explain the efficacy of using a trained dental sedationist over and above a general anaesthetist, or attempting to become operator-sedationists in their own practices.

Expected standards

In the GDC’s 2001 guidance document for dentists, Maintaining Standards, it outlines expectations regarding

professional and personal conduct. Under the heading, Duty and Expectations, it reads:

‘4.8: Dentists have a duty to provide and patients 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. The

provision of pain and anxiety control carries responsibilities and a dentist who undertakes treatment on a patient without ensuring that conditions are met is liable to a charge of serious professional misconduct.’

This proviso is often overlooked because it’s frequently not on the menu of the treatment-planning practitioner.

Basically if you don’t have a beer in the fridge, you don’t think to offer it to your guests. Under the Behavioural Management heading of the same document, it states:

‘4.9: In assessing the needs of an individual patient,

due regard should be given to all aspects of behavioural

management before deciding to prescribe or to proceed

with treatment.’

In this article, I will attempt to encourage practitioners to take a more thoughtful and sympathetic view of the

nervous/phobic patient and encourage the much wider and safer use of IV sedation in a setting outside of hospital

admission.

There is a clear guideline by the DoH, though I’m given to believe that sedation as a treatment option seems to have been excluded under the new contract. In part, this is explained by the paranoiac attitude towards sedation outside of the hospital environment, by bad publicity, and by not addressing the huge benefits IV sedation brings when in the hands of a specialist dental sedationist or

experienced operator-sedationist.

So, while there are clear guidelines on sedation, there is

little emphasis on it during under- and postgraduate training. We often attend CPD courses where the speaker shows us long, complicated treatments involving long, costly

procedures. I’m always wondering what the poor patients had to endure, since no mention is made of how these procedures were carried out.

The benefits of regularly including sedation on your

treatment-plan option menu is enormous because once reassured, patients will accept all sorts of treatment plans they might otherwise have failed to carry through. Your practice can then indulge in:

• More minor oral surgery

• More implants and associated surgeries

• More molar endodontics

• More cosmetic makeovers

And, for this, you need make no financial investment nor undertake long courses in sedation.

By understanding what is to follow, you can recommend sedation confidently and carry it out safely by calling in a

dental sedationist who, like myself, will ensure you follow all the guidelines of the GDC and undertake treatment safely and without contention.

Relative analgesia

A brief note here about relative analgesia (so as not to ignore its protagonists). RA has a very definite place in dentistry, but I am glossing over it here for the following reasons:

• RA is not suitable for lengthy or deep procedures generally

• The mask often encumbers access to the operator and

his assistant

• Health and safety regulations mean that expensive and

difficult rules need to be observed within the general practice environment necessitating a capital outlay which is large in comparison for that required for IV

• Equipment, though now in very portable form, is still

cumbersome compared to a syringe and a few ampoules.

So, let’s now look at the practicalities of dealing with the

anxious or phobic patient…

Recognition

For many patients who are having elective dentistry, such as implants or makeovers, the question of phobia per se does not arise, but anxiety about lengthy procedures may still be

underlying the patient’s decision to proceed.

This tends rather more to be the case with male rather than female patients, and it is a good idea to try to elicit from the elective patients their actual degree of ‘fear’ of treatment.

Most importantly, reassure your patients that ‘it’s OK to be afraid of the dentist’. Patients sometimes believe that their own fear is unique and irrational. It’s very important to explain that fear of dentistry is neither irrational nor unique. Your patients need this reassurance from you and it

quickly dispels any embarrassment they may be experiencing.

So what do so many practitioners find they do with these patients? Well, they might as well take the cash out of their pockets and burn it because they send them down the road to the local anaesthetic clinic!

All the patient needs is a bag of sympathy and a lot of

caring reassurance, with an explanation of sedation, its effects and its limitations. This is something dentists often fail to do well. We see the signs of nervousness every day – the fiddling, the clenched fists, the too-talkative or the silent patient, the patient who sits rigid in the chair, the persistent throat-clearing or the frequent trips to the toilet. But what do we do? We ignore the signs because often we are so used to seeing them that we become indifferent.

It is absolutely essential to elicit a good dental/social history from a patient so make sure you ask the right questions.

For example:

• How long ago were you last at the dentist?

• Why did you never get your broken teeth repaired?

• Are you genuinely frightened or have you just been lazy?

• Do you want to be ‘knocked out’ for your treatment?

Why, we might ask ourselves, would such a smart,

articulate person have such a wrecked mouth?

Why have they suddenly decided to get something done about it?

Has a family member, a new relationship or a new job

pressurised them into the dental chair? Many of these patients, irrespective of personal presentation or circumstance, give a common history, usually of childhood dental trauma or a visit to the school dentist.

Their memories have been exaggerated by time and fear – they frequently describe the ‘dark room and corridor’ leading to the dentist’s chair.

Assessment

Having just illustrated the signs and symptoms of the

anxious/phobic patient, most of you will have the

experience to have ‘assessed’ your patients before they’ve even sat in the chair. We expect nervousness as a matter of routine in our daily work and can easily fail to spot the petrified patient.

We’re used to the daily throwaway phrases we so often hear made in jest – ‘not happy to see you’ or ‘I’ll be happier when I’m walking in the opposite direction’.

In fact, part of the stress of being a dentist is hearing these constant comments of what is, essentially, rejection.

In your initial contact with the patient, consider the following:

• Does the patient enter the room clutching onto a relative or friend?

• Are they sobbing or crying?

• Are they silent, stoic, barely able to speak?

It may be that you’ve seen this so often that you’re going to go straight into your ‘I’m going to talk you out of this’ mode.

If you make a correct assessment and recognition you don’t need to pile the stress of having to attempt this onto yourself! This is the point you’re going to be considering this patient as a candidate for IV sedation.

So, you need to discuss some specific points with your patient, including:

• Needle phobia

• Dental drill noises phobia

• Claustrophobia

• Gagging reflex

• Difficult operative access

• Is the treatment required even possible under IV sedation or is it best done under GA?

Gagging and needles

IV sedation is excellent for dealing with the gagging reflex. Such patients require very careful and sensitive management. The needle phobe can be most easily helped by initiating treatment with an intranasal dose of sedating agent or premedication with Temazepam, but both these instances are best dealt with elsewhere. However, these are patients you might otherwise have seen as impossible to take on and, in so doing, lose a wealth of challenging dentistry and considerable income as well as future recommendation merely because sedation wasn’t on your menu or out of your considered remit.

The following points need to be considered when assessing patients for IV conscious sedation:

• Medical history and ASA classification

• Dental history

• Social history.

Good patient assessment is critical for IV sedation. A detailed medical history is all that is necessary to determine the suitability of going forward with sedation or not.

Not many disorders preclude the use of IV sedation.

When in doubt however, leave it out! Refer to a doctor or preferably arrange to treat in hospital. But don’t let doubt

outweigh correct assessment for suitability. The patient’s social circumstances must also be taken into account. Make sure you ask:

• Can they get time off work?

• Can someone escort them to the practice and look after them at home on the day of the sedation?

• Is transport available?

Medical history

There is relative misunderstanding about medical histories and their preclusions among GDPs. Quite the contrary in fact – any conditions are actually alleviated by giving sedation, notably epilepsy, hypertension, angina and ischaemic heart disease. Surprisingly, and within reasonable parameters, none of the above actually exclude IV sedation with Midazolam (Hypnovel).

But it is not the purpose of this article to discuss here in detail variable or specific medical histories – merely to

highlight the relative safety of IV conscious sedation outside of the specialist environment when it is appropriate so to do and when in competent hands. There are few absolute contraindications for conscious sedation other than when a patient is quite obvious compromised by systemic disease (above P2 on the ASA classification scale).

But special precautions need to be taken in the following three groups:

• Children under 16

• The elderly

• Physically handicapped.

Children tend to react unpredictably or paradoxically with IV Midazolam. The author always recommends that such patients be treated in hospital or specialist units and never in general practice. Where a burly, six-feet-plus 14-year-old with size 10 shoes presents, then obviously an exception can be made, provided the patient’s medical history condones it.

Elderly patients, who are neither frail nor infirm and whose medical history is not at all in doubt, have in my experience, made perfectly good subjects for sedation – but again, assessments need to made on a good appraisal.

Wheelchair-bound patients and other physically or mentally handicapped patients can be sedated in general practice, usually using intranasal techniques as an induction.

Again if one consults with the patient’s GP, carers and a

dental sedationist, it can save families a lot of waiting and inconvenience if their family member can be treated palliatively at their local family dentist or – as is often the case – they need a periodic visit to a hygienist.

Summarising your clinical confidence in IV sedation: ‘The risk of a medical emergency under IV sedation should be no greater than that for a patient who is not receiving IV sedation provided a correct pre-operative assessment of the patient has been made.’

But there are easily categorised contraindications and such patients should not be considered for conscious IV in general practice:

• Liver, kidney and lung disease

• Pregnancy

• Lactation

• Children under 16

• Elderly and inform

• Severely physically disabled.

Complaints

Due to the amnesic effect of Midazolam, patients tend to

exercise selective hearing when it is explained to them.

For most patients, retrograde amnesia of their dental

treatment is an enormous attraction and is a great selling-point for Midazolam, but it’s always necessary to explain that such memories would be sporadic, broken and totally dissociated from any feelings of fear.

On follow-up, some patients claim they remember something or another, including snatches of conversation between operators and staff. Total amnesia cannot be guaranteed, and your patients should not have an expectation of such.

It is quite easy for a dentist to become easily intimidated by a nervous/phobic patient and particularly when very ‘irritable’ patients are under the influence of Midazolam they may exhibit erratic or disturbed behaviour. But this is generally related to their subconscious perceptions rather than the actual treatment.

Sedated patients will perceive pain, though, if analgesia/anaesthesia is inadequate. So often the operator will ask me to give more sedative, but in most cases it’s more local that’s required. The operator is often quick to blame the sedationist for failed LA!

It is the experienced eye of a dental sedationist that can quickly spot such aberrances, and good communication between operator sedationist nurse and patient is essential to success. It is very often difficult for an experienced

practitioner to accept instruction from a called-in third party!

Expectations

Dentists may expect IV patients to remain perfectly still and silent during treatment. They also may think that all IV patients will have total anterograde amnesia. None of

these things are necessarily true. Experience has shown me that dentists’ expectations are often somewhat higher than that of the patient. This is due to inexperience and misunderstanding.

Many patients can be emotional verbose or restless during IV and, in fact, the main cause is usually insufficient LA or deep psychological stresses. The patient usually expects the same result as a GA, so pre-sedation discussion by sedationist is essential.

The bottom line is that during IV sedation, the patient must demonstrably remain in verbal contact. This is the fundamental directive of the GDC and the definition of conscious sedation in dentistry.

So dentists are sometimes more apprehensive of IV sedation than the patients who actually need it.

Dental professionals may fear:

• Hassle

• Stress

• GDC requirements

• The need to employ extra staff, provide recovery facilities and find funds for equipment.

None of the above need be issues for the referring

practitioner since a trained sedationist exists to alleviate all these apparent hurdles to offering sedation in their practices.

Chief among these is recovery facilities. Such facilities are not always mandatory since in the instance of treating one patient only, they are easily supervised by the sedationist in a chair in a staffroom, a waiting-room or an office. Furthermore, there is a reversing agent for Midazolam, Anexate (Flumazenil) which can be used to hasten recovery from sedation where pragmatism may dictate, though this is not generally part of routine procedure.

Initial examination

During the initial visit for examination, it’s important to employ certain examination methods in order to put a phobic patient’s nerves at rest.

They include:

• Avoiding using the probe

• Only using the mouth mirror

• Encouraging the patient to hold the nurse’s hand

• Using radiographs as the main diagnostic tool

• Taking extra care with the gagging-reflex patient

• Not disclosing clinical details of the treatment.

Body language

There are so many problems with political correctness and chaperoning these days that they can sometimes keep us at a perceptible emotional distance from our patients.

In the case of the nervous or phobic patient, it is very

important to try to overcome this particular barrier. These patients desperately seek reassurance, empathy and sympathy and we must give it to them. Consequently, always see such patients – male or female – under closely chaperoned conditions. This applies not just to the actual appointment for sedation but at all appointments. As a dental professional, you should maintain good eye contact with a reassuring smile, while your dental nurse should take on a close supervisory and chaperoning role and be involved with the whole procedure. A reassuring hand placed on the forearm (this works equally effectively on both sexes) is good body language, too.

Finally, try to avoid leaning over the top of the patient. It can be unsettling to the phobic patient in the chair as this is a position of power and intimidation and should not be a position for communicating anything of worth – including fees! – to your patients.

It has taken your nervous patients as much courage as they can muster just to get into the practice and let you examine their teeth so treat these patients with a psychological

understanding and a lot of tender loving cre which will lead to them ultimately attending for treatment under sedation.

Responsibilities

This seems to be the area that most confuses GDPs. The responsibility for the patient’s welfare and safety lies ultimately with the referring dentist; that is, the dentist in whose practice the sedation will take place and who is ultimately the

operator.

It is the responsibility of the sedationist to protect the

position of the referring dentist by liaising with him/her before the sedation begins. They must:

• Check the training level of supporting staff in basic life support

• Check that the practice is equipped for medical emergencies (the author is always accompanied by his own oxygen

cylinder, emergency drugs kit and automatic electronic

defibrillator)

• Check again the medical history of the patient

• Review and obtain the patient’s clear, signed consent on the day of treatment

• Ensure the patient has received clear pre- and post- written instructions before treatment commences.

Conclusion

IV conscious sedation in general practice can indeed be as

easily offered by your practice as any other service you

provide. Clearly, the practical difference is that specialist knowledge and training is required to ensure the safety of your patients and the smooth running of your practice without unnecessary disruption.

Engaging a dental sedationist is almost certainly the most prudent way to do this if you are unable to find the time to attend practical courses in IV.

Having said that, even if you’ve already attended IV

conscious sedation courses, then you may find – as we all do – that infrequency of use means quickly forgetting what was learned and once again the application of IV sedation in your general practice falls into disuse.