New starters must undertake their knowledge and skills training before undertaking clinical supervised experience.

The SAAD national course provides the required underpinning knowledge and introduction to the clinical skills for dental sedation.

The SAAD national course involves two days of lectures and practical learning that sets the trainee up for their clinical supervised experience. 

If you are not completing your supervised sedation experience as part of a university or postgraduate deanery-run training scheme, or with a STAC* approved supervisor, then you should also consider registering for the (STAC* approved) SAAD Assessed Sedation Nurse (SASN) scheme. 

The SASN scheme follows on from attendance at the SAAD national course. It is possible to register for the SASN scheme up to a month after attending the SAAD course.

*STAC – Sedation Training & Accreditation Committee of the IACSD

The SASN scheme includes approval of your supervisor, verification of your Clinical Logbook, Direct Observation of Procedural Skills (DOPS) forms and the SASN Practice Checklist. The SASN scheme is only available to GDC registered dental nurses. 

For how many cases the trainee needs to complete see FAQ A15 for IV sedation and A16 for inhalation sedation. 

In addition to the above, all members of the sedation team should undertake annual ILS/PILS training.

Dental hygienists and dental therapists who are new to sedation must complete recognised training and supervised clinical experience before undertaking independent practice, in line with the requirements of the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD).

The Society for the Advancement of Anaesthesia in Dentistry (SAAD) provides the SAAD Assessed Sedation Hygienist/Therapist (SASH/T) scheme.

The course provides the required underpinning knowledge and introduction to the clinical skills for dental sedation over two days, one day online,  and one day in person. The lectures and practical teaching are designed to prepare trainees for supervised clinical experience.

The supervised clinical experience provides support for practitioners to achieve the competence required for independent clinical practice.
Following the course, dental hygienists and dental therapists complete an online assessment and then commence their documented supervised clinical cases.

Trainees must complete the required number of supervised inhalation sedation cases with an appropriately experienced supervisor and maintain a log of clinical experience in accordance with IACSD guidance.

For the number of cases required, see FAQ A16 for inhalation sedation.

The SAAD Assessed Sedationist (SAS) scheme facilitates your clinical supervised cases whilst offering support and guidance.

The SAS scheme is accredited by IACSD / Sedation Training Accreditation Committee (STAC), RCSEng and includes approval of your supervisor and verification of your SAS portfolio (Clinical Logbook, Direct Observation of Procedural Skills (DOPS) forms and the SAS Practice Checklist).

Successful practitioners will receive a SAAD certificate confirming ‘SAAD Assessed Sedationist’ status which will enable you to practise independently.

The registration deadline is four weeks after attending the SAAD National Course. There will be a presentation about the scheme on the course weekend.

If you are on a university or deanery-run training scheme you can complete your supervised cases through your training scheme and do not have to register for the SAS scheme unless you particularly wish to do so.

The SAAD Assessed Sedation Nurse (SASN) scheme facilitates your clinical supervised cases whilst offering support and guidance.

The SASN scheme is accredited by IACSD / Sedation Training Accreditation Committee (STAC), RCSEng and includes approval of your supervisor and verification of your SASN portfolio (Clinical Logbook, Direct Observation of Procedural Skills (DOPS) forms and the SAS Practice Checklist).

Successful practitioners will receive a SAAD certificate confirming ‘SAAD Assessed Sedationist Nurse’ status which will enable you to practise independently.

The registration deadline is four weeks after attending the SAAD National Course. There will be a presentation about the scheme on the course weekend. 

The SAAD Assessed Sedation Therapist / Hygienist (SASH/T) scheme facilitates your clinical supervised cases whilst offering support and guidance.

The SASH/T scheme is accredited by IACSD / Sedation Training Accreditation Committee (STAC), RCSEng and includes approval of your supervisor and verification of your SASH/T portfolio (Clinical Logbook, Direct Observation of Procedural Skills (DOPS) forms and the SAS Practice Checklist).

Successful practitioners will receive a SAAD certificate confirming ‘SAAD Assessed Sedation Therapist / Hygienist' status which will enable you to practise independently.

The registration deadline is four weeks after attending the SAAD national course. There will be a presentation about the scheme on the course weekend. 

Completion of our schemes is not compulsory to be able to provide sedation. You can complete your  supervised clincial cases with a STAC* approved supervisor. Please note that STAC and SAAD are separate. 

If you are completing your training through this route you should contact your STAC supervisor for further information. 

*STAC – Sedation Training & Accreditation Committee of the IACSD 

SAAD's new starter course includes the SAAD national course as well as the corresponding scheme to ensure that new starters gain their knowledge and skills training and are facilitated to complete their clinical supervised experience. 

The course is the two-day SAAD national course ONLY. 

If you have a STAC* supervisor you can complete your clinical supervised experience with them. If you attend the SAAD national course as your knowledge and skills training then the evidence of your training will be your certificate(s) from the national course alongside your clinical supervised cases signed off by your STAC approved supervisor. 

*STAC – Sedation Training & Accreditation Committee of the IACSD

A suitable supervisor is someone who has a dental sedation qualification or is an experienced dental sedationist, and is providing dental sedation on a regular basis.

Potential SAAD supervisors must demonstrate their own relevant knowledge, skills and experience before supervising sedation new starters.
SAAD supervisors are required to be complaint with the IACSD guidance. This includes:

• 12 hours of sedation related CPD (excluding life support training) over a 5-year period
• Keeping a logbook of sedation cases to demonstrate compliance 
• Hold certification for appropriate annual life support training (ILS or equivalent)

Supervisors are expected to have completed a minimum of 50* cases of the technique being supervised, over the preceding two-year period or be able to evidence active involvement in sedation supervision or teaching.

*This number must not include any cases completed during the supervisor's own supervised clinical practice. 

It is recommended that you limit supervisors to 3, in order to benefit from consistency in supervision.  For every new supervisor you must complete a supervisor nomination form which can be found here and should be completed and emailed to:

For Dentists SAS@saad.org.uk 

For Dental Nurses SASN@saad.org.uk 

For Dental Hygienists/Technitians SASHT@saad.org.uk

Click here for the supervisor nomination form. 

You will need to complete another supervisor nomination form with the new location details on.

Click here for the supervisor nomination form.

Please complete the new supervisor nomination form and return it to:

For Dentists SAS@saad.org.uk 

For Dental Nurses SASN@saad.org.uk 

For Dental Hygienists/Technitians SASHT@saad.org.uk

Dentists: You need to undertake 20 supervised IV sedations where you have not only administered the sedation drug(s) but also been responsible for the care of the patient from induction to discharge. Note that for at least 10 of those cases you must also have provided the dental treatment.

Nurses: You need to undertake 20 supervised IV sedations where you have assisted with the provision of the sedation 

Dentists: You need to undertake 10 supervised inhalational sedations where you have not only administered the sedation but also been responsible for the care of the patient from induction to discharge. Note that for at least 5 of those cases you must also have provided the dental treatment.

Nurses: You need to undertake 10 supervised inhalation sedations where you have assisted with the provision of the sedation

Hygienists / Therapists: You need to undertake 10 supervised inhalational sedations where you have not only administered the inhalation sedation but also been responsible for the care of the patient from induction to discharge. Note that for at least 5 of those cases you must also have provided the dental treatment. 

You have 12 months from finishing the SAAD National Course to complete the scheme. In exceptional circumstances a request to extend will be considered. See FAQ A18

Yes we do offer deadline extensions for extenuating circumstances.  Click here to access the downloadable extension request form. Please fill this in and return it to 

For Dentists SAS@saad.org.uk 

For Dental Nurses SASN@saad.org.uk 

For Dental Hygienists/Technitians SASHT@saad.org.uk 

Dentists and Hygienists / Therapists: you will have been given access to the documents via an email link after you successfully passed your assessment and returned your signed confirmation statement. 

Nurses: Once your supervisor has been approved you will receive a link to the SASN webpage which can be used to access the portfolio documents. 

Portfolio documents should be collated and saved in PDF format. 

Email: please email your portfolio to:

For Dentists SAS@saad.org.uk 

For Dental Nurses SASN@saad.org.uk 

For Dental Hygienists/Technitians SASHT@saad.org.uk

Post: please DO NOT post your original portfolio to us, please post us a copy of your portfolio in case it fails to arrive at our office.  
SAAD (at HGE Ltd) 
Hay Green Corner
Fishlake 
Doncaster
DN7 5LA 

There is no specific length of time that we advise when submitting a portfolio. The moderation time is highly dependent on the quality of the submission, if changes need to be made or information needs to be added then this will elongate the process. 

During the three submission deadlines a year (March, June and November) we recive more portfolio submissions than usual and therefore it may take longer for your portfolio to be approved. 

Please follow our portfolio guidance as close as possible to ensure your moderation journey is as swift as possible. 

Please email for guidance:

Dentists SAS@saad.org.uk 

Dental Nurses SASN@saad.org.uk 

Dental Hygienists/Therapists SASHT@saad.org.uk

You can complete the scheme for either inhalation sedation (IS) or intravenous sedation (IV) or both IS and IV sedation. 

Yes as long as it is within your 12-month time limit – if you feel you need an extension to ensure you get your cases done, we may be able to accommodate this – depending on the circumstances. 

For an extension request form please see FAQ A18. 

You can see our full course list here: SAAD Course Calendar

Attending the SAAD National Course provides knowledge and skills training, however on its own, it is not sufficient training for you to provide sedation independently. As a new starter, unless you have completed a university or deanery (HEE) run training scheme, in order to comply with the training requirements of the IACSD Guidance (April 2015, 2020), you would also need to complete supervised clinical practice either as part of a STAC accredited training scheme such as the SAAD Assessed Sedationist (SAS) scheme, or with a STAC approved supervisor. 

It is possible to register for the SAS scheme up to four weeks after attending the National Course. The SAAD National Course has provided the knowledge and skills training. 

In order to complete your sedation training, in accordance with the training requirements of the IACSD Guidance (2020), you will need to complete supervised clinical practice with a STAC approved supervisor. 

Further details of how a supervisor can apply for approval from STAC on the RCSEng website. Please refer to the current IACSD Guidance (2020 update) for the most up to date requirements. 

IACSD Guidance (April 2020)

RCSEng website.

The SAAD training scheme does not include provision of clinical supervisors and SAAD is not able to provide a list of suitable supervisors. This is because SAAD can only approve supervisors for a named individual, registered for the SAS scheme, at a named sedation facility.

The SAS scheme is a STAC accredited training scheme. This accreditation allows SAAD to approve supervisors for a named individual, registered for the SAS scheme, at a named sedation facility. The approval is specific and not transferable. In order to supervise you, your principal could apply for STAC approval. There are further details of how a supervisor can apply for approval form STAC on the RCSEng website.

It is possible to register for the SAS scheme up to four weeks after attending the National Course. It is necessary for the details of the nominated supervisor(s) to be submitted at the time of registration and the supervised clinical experience portfolio submitted within twelve months of attending the National Course.

The SAAD National Course provides the knowledge and skills training for both IS and IVS, and the written assessment for the SAS scheme will also cover both techniques. However it is acceptable for the supervised clinical practice to be for one or both techniques (10 IHS cases and/or 20 IVS cases). Your certificate of completion will name the sedation technique for which you have completed supervised clinical practice.

Since your previous experience is with IVS and not IHS, you would be considered as a ‘new starter’ for IHS. As a new starter, in order to comply with the training requirements of the IACSD Guidance (April 2020), you would need to complete a STAC accredited training scheme such as the SAAD Assessed Sedationist (SAS) scheme before you can independently provide IHS for your patients.

There are significant differences between premedication and oral sedation, medicolegally it is important to understand how these differ. Premedication is usually a small dose of drug administered off premises, no additional monitoring is necessary although it is good practice to provide written information to the patient as their judgement will be impaired.

Oral sedation is usually a larger dose of drug administered on the dental premises. The BNF is a useful source of basic information. Oral sedation has the same requirements of the sedation team as a team providing IV sedation in terms of knowledge, skills, training, and monitoring.

This is because oral sedation is not a titrated dose to an individual's needs but a bolus dose where absorption from the GI tract is not wholly predictable and a fine adjustment of the sedative state is not possible. So, a patient may become overdosed unintentionally or underdosed just as easily. 

For oral sedation, the sedationist needs to be specifically trained and provide the administration within their scope of practice defined by their regulator. For dentists and dental nurses that is the GDC. The GDC requires practitioners to be knowledgeable of and follow current guidance for standards. 

The standards for oral sedation used for dentistry are set by the IACSD 2020 document. SAAD recommends reading and understanding this document in full if your team plans to provide oral sedation. Pages 18 and 23 are particularly useful. From this you will see that e-learning alone does not meet the requirements. For clarity a second appropriate person is trained to monitor a sedated patient and assist in the case of sedation complication. This is not defined by role but by training. IACSD 2020 gives further details.

SAAD offers training to IACSD guidance for both dentists and dental nurses. The SAAD dental nurses’ course is ‘equivalent’. Other courses are also available and if you need further information, please contact the Sedation Training Accreditation Committee. Course Accreditation (STAC) — Royal College of Surgeons (rcseng.ac.uk)
SAAD dentist courses are found here. 
SAAD nurses courses are found here. 

If you have any further queries, please do not hesitate to get in touch.

The SAAD National course includes teaching in inhalation sedation so that would be a useful starting point to obtain knowledge and skills in this technique.

You could then complete the SAAD scheme with 10 inhalation sedation cases.

To provide IVS for 12–18-year-olds, it is suggested that you start with the older patients in this age group, 16-18years olds with  uncomplicated medical history and simple dental procedures to gain confidence and then incorporate the treatment of younger children ie 12-16. The IACSD guidance states IV midazolam for 12–16-year-olds is an acceptable technique for those trained to use IV midazolam.

The IACSD guidance (Table 1, column 4) state that ILS or equivalent should be held by all members of the team. If you are taking full responsibility for, and dedicated to, the sedation you do not need a second appropriate person. The endodontist and implantologist will need airways management training and ILS ideally.

The evidence of the SAAD training and clinical experience supervised by a SAAD or STAC approved supervisor, or as part of a university or deanery-run training scheme, demonstrates that sedation training has been completed in accordance with the IACSD Guidance. SAAD issues a certificate on completion of supervised clinical experience but most STAC trainers do not. Nor do the university / deanery training schemes usually issue certificates for completion sedation training.

Any employer can insist that further training is carried out, but they cannot imply that this is a national requirement. 

I would recommend trying a local community health Trust as they tend to provide courses. If not, a google search should bring up cannulation courses in your area but do make sure that it is not a phlebotomy course as this won't provide what you need. 

To assist the sedationist as the second appropriate person, a dental nurse should either have a sedation qualification, or have completed sedation training (such as the SAAD SASN scheme), or have been assisting before April 2015 and be compliant with the transitional arrangements on page 87 of the IACSD Guidance. 

If you were assisting with the provision of sedation before April 2015, and have been assisting since, you would be covered by the transitional arrangements (grandparenting clause) in the IACSD Guidance. The transitional arrangements are outlined on page 88.

 

As it is some time since you completed your sedation course, you would be considered a new starter under the IACSD Guidance (2020). Please see FAQ A2 for details of the training required.

If you have previously completed recognised training (such as the inhalation sedation course delivered by SAAD) and successfully completed your clinical portfolio, it is reasonable to return to practice with appropriate support and governance arrangements.

Given the gap in clinical practice, it is advisable to undertake a period of observations followed by supervised clinical cases with an experienced sedation clinician until both you and your supervisor are confident that you have re-established competence. These cases should be documented in a personal logbook for your records.

You should also ensure you meet the continuing professional development expectations set out by the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD), including a minimum of 12 hours of sedation-related CPD within your current 5-year CPD cycle and immediate life support training relevant to the age groups you will be treating.

Before recommencing sedation practice, it is also advisable to discuss your return to sedation with your professional indemnity organisation to ensure they are aware of your training, recent CPD, and the arrangements in place for supervised re-introduction to clinical practice.

Once you have resumed practice, maintaining competence includes regular clinical use of sedation where possible, ongoing sedation-related CPD, and adherence to current national guidance.

Yes, dental therapists can provide inhalation sedation in primary care / practice provided they have undertaken the appropriate training (including supervised clinical practice), maintain the appropriate competencies and ongoing CPD. The practice should comply with the IACSD Guidance.

IACSD Guidance (2020)

 Unfortunately, it is not within the scope of practice of a dental nurse to administer a sedative agent, even if sedation trained and under the supervision of the seditionist.

 

The IACSD Guidance (2020) states that anyone who is new to dental sedation and wishes to provide dental sedation would need to complete a dental sedation qualification or a STAC* accredited training scheme – both involve knowledge and skills training followed by supervised clinical experience (20 IV cases and / or 10 IS cases).
*STAC – Sedation Training & Accreditation Committee of the IACSD

Those enrolled on a university or deanery run scheme would need to complete a course for the knowledge and skills training (e.g. the SAAD National Course) but could then complete their supervised clinical experience under the auspices of the university or deanery since these courses have their own quality assurance mechanisms and so do not need to be accredited by STAC. The evidence of the SAAD training and clinical experience supervised by a SAAD or STAC approved supervisor, or as part of a university or deanery run training scheme, demonstrates that sedation training has been completed in accordance with the IACSD Guidance.

SAAD issues a certificate on completion of supervised clinical experience, but most STAC trainers do not. Nor do the university / deanery training schemes usually issue certificates for completion of sedation training. In such circumstances, the attendance certificate from the SAAD National Course along with the signed logbook of supervised cases will provide the evidence that sedation training has been completed in accordance with the IACSD Guidance.
IACSD Guidance (2020) Page 23.

 SAAD provides knowledge and skills training in conscious sedation in compliance with current UK Standards (IACSD, 2020). We also offer opportunities for course participants to gain supervised clinical experience through the SAS, SASN and SASH/T schemes. However, it is the responsibility of candidates from the Republic of Ireland (and other countries) to ensure that SAAD's training is acceptable to both the national and local authorities, where the candidate intends to practice. SAAD is unable to enter negotiations on behalf of course participants or to identify appropriate supervisors.

As a STAC approved supervisor, you should direct questions to them at stac@rcseng.ac.uk
If you were approved by SAAD to supervise someone on a SAAD Training Scheme, you should directly supervise them for all their cases (20 IV and / or 10 IS cases). 

The specific standards reference is IACSD guidance 2020 page 23:
For revalidation in a sedation technique, a practitioner must undergo a minimum of 12 hours of continuing professional development every 5 years that are relevant to the techniques practised. This applies to dentists, medical practitioners, recovery nurses, dental care professionals and all members of the team providing conscious sedation. Practitioners not regularly practising a technique must consider either the need for mentoring and/or retraining or discontinuing its use. 

It is highly recommended to have an oxygen cylinder available in the surgery room where intravenous sedation (IVS) is being administered. Supplemental oxygen may be required if the patient struggles to maintain adequate oxygen saturation levels, especially in the case of a medical emergency. Delays in providing oxygen can put the patient at unnecessary risk. 

There are drug denaturing pots or kits available specifically for the disposal of unused midazolam.

Unused midazolam should be denatured in accordance with local controlled drugs (CD) procedures and documented appropriately in the CD register. 

Ideally midazolam should be disposed of in a drug denaturing pot or otherwise emptied onto a tissue and disposed in the clinical waste bin.

Do not leave midazolam in a syringe / open ampoule in the sharps bin as, in theory, this could be recovered and misused.

All disposal must comply with local controlled drugs (CD) procedures and be appropriately recorded.

There is no strict upper age limit for intravenous sedation. The eligibility largely depends on an individual's overall health assessment. Important factors to consider include the ASA (American Society of Anesthesiologists) grade, airway assessment, any existing comorbidities, current medications, and the availability of an escort. For older patients, it is advisable to administer midazolam more slowly and in smaller increments—typically, half the usual dose over double the time.

It would be advisable to have 2 oxygen cylinders, one for medical emergencies and one for sedation purposes. The sedation cylinder may be used as an adjunct during sedation if the patient's oxygen saturation is falling or is not maintained or for any emergency situation. This cylinder should be kept in the surgery where sedations are performed and be readily available.

Having 2 cylinders will always ensure there is at least one full cylinder onsite at all times. 

Things to consider are the layout of the practice, where oxygen is kept, and informing all team members of this.

Before providing sedation at other practices, consider creating a checklist covering: - Practice policies on sedation - Appropriateness of the environment in line with IACSD guidance - Availability of medical emergency drugs and equipment - Secure transport and logging of sedation drugs - Clinical record-keeping at both the practice and your end. Ensure the pre-sedation assessment is conducted in person before the day of sedation and clarify the consent process. While the dentist and nurse do not require specific sedation training, they should be ILS trained. Keep your sedation CPD and competencies up to date in accordance with IACSD guidance. 

During recovery, the patient must be supervised by a trained member of the dental team. It is acceptable for the patient to be in the recovery room with an escort while the trained team member checks on them periodically. It’s advisable to inform the escort of the trained member's location in case of emergency. Each case should be assessed individually; a patient showing more sedation may need closer monitoring than one who is nearly recovered.

Regarding your query about IV sedation with midazolam for an epileptic patient classified as ASA grade 2: this is a safe option. Administering Midazolam is wise, as the stress and anxiety of a dental procedure can trigger seizures. 

Midazolam supplied for intravenous sedation is typically provided in glass ampoules, and the recommended practice when drawing up any medication from a glass ampoule is to use a filter needle or filter straw. This is because opening a glass ampoule can occasionally introduce microscopic glass particles, and the filter helps prevent these from being drawn into the syringe.
 
If a filter needle is temporarily unavailable (for example due to supply issues), it is not uncommon in clinical practice for clinicians to draw up midazolam using a standard drawing-up needle, taking care to open the ampoule cleanly and avoid drawing up any visible particles.

However, the best practice remains to use a filter needle whenever possible, and practices should ensure that these are restocked as soon as feasible.
As always, medications should be drawn up using aseptic technique, labelled appropriately, and administered according to local protocols and current sedation guidance

IV sedation with midazolam is a good technique for patients with cerebral palsy and other movement disorders as it can reduce or eliminate unwanted movement, allowing dental treatment to be carried out safely. If the movement is severe, you will need to discuss manual support / clinical holding with the patient to cannulate. Inhalation sedation with nitrous oxide can also work well.

Exercise caution with the airway. Some, but not all, patients with cerebral palsy have involvement of the muscles used in swallowing. Obviously when doing procedures involving water in a sedated patient, in whom you have induced further muscle relaxation, aspiration / choking can pose a risk and be unpleasant for the patient. Therefore, good aspiration is vital and also using a 45-degree dental chair position. Similarly, the respiratory system can be compromised and baseline saturation at the assessment visit is essential. A good tip is to assess the viscosity of the saliva, clarity of speech (control of oral musculature) and ability to drink water without coughing at the assessment visit.

Having said that, a lot of patients have no problems with their airway and the cerebral palsy is mild. For these patients midazolam IV sedation works well and enables patients to have ‘normal’ dentistry. There is a large spectrum of associated disability with this condition and the patient is likely to know their cerebral palsy well.

Here is link to an article which might be useful: https://www.dental-update.co.uk/content/special-care-dentistry/sedation-for-patients-with-movement-disorders

 The dosage of sedation drugs (IV or inhalation sedation) is not correlated in any way with a patient's height, weight, or BMI. This is why we have to titrate the drugs to the conscious sedation endpoint.
The only time we might measure a patient's height is if there is some doubt that they have developed normally for their age. Abnormal development, not just height, might mean some sedation techniques might be unsuitable in a primary care setting.

This is an interesting question, often discussed. Although the BNF states an adult maximum of 7.5 mg per episode of treatment, midazolam as a conscious sedation agent is titrated to the patient’s response and experience shows that this may be a too-low total dose in some patients. Titration ensures neither under-sedation nor over-sedation and guards against negative outcomes either way. The BNF also says an adult initial 2 – 2.5 mg as an initial dose. Individually this may be too high in some patients. So a titrated dose is paramount but may exceed the BNF guidance. There is also a variation for the young and elderly. The scientific literature supports the above.

SAAD considers that dental sedationists must carry out a thorough clinical assessment of the patient including a full contemporaneous medical history including responses to previous sedatives. This should be signed and dated by the patient to validate full disclosure on the day of the procedure.

The length of the procedure, the peak effect of the sedative drug and its half-life should also be considered. This will all have an impact on the route and drugs used for sedation for an individual patient and the titration regime. It is for this reason that SAAD does not teach an absolute minimum or maximum dose. The amount and titration regime of midazolam given should be a clinical decision made by a sedationist with the appropriate knowledge, skills training, and experience.

In primary care setting for patients under 16 years of age: 

• Inhalation sedation (nitrous oxide/oxygen) is preferred technique
• Single agent midazolam IV sedation may be considered in carefully selected cases
• Patients must be ASA I or II
• No complex dental or medical needs
• Appropriate consent and chaperone procedures must be followed 

Clinicians must ensure they are trained and competent in accordance with IACSD Guidance (2020) for paediatric patients 

Please refer to page 26 of the IACSD Guidance (2020). Essentially,  inhalation sedation or single agent midazolam sedation only, for ASA I/II and no complex dental or medical needs.   

There is no evidence that IV midazolam will trigger a desire to start using drugs again

If flumazenil is used to manage acute respiratory depression / apnoea which could not be resolved by asking the patient to take deep breaths / opening the airway / IPPV then this should be logged as a clinical incident.

Using flumazenil electively to improve the quality of recovery (e.g. making travelling home safer) is not a clinical incident but you should have appropriate criteria for its use and keep records. Dr. Christopher Dickinson published a paper some years ago explaining what is done at Guy's Hospital regarding this.

However, the use of flumazenil to increase throughput of patients or just to speed recovery so staff people can go home on time is unacceptable! 

Thank you for your enquiry. SAAD do not recommend any particular machine but do advise the pulse oximeter is not one of the wireless finger probe battery devices that can be purchased cheaply online. We would advise using a medical equipment supplier.
Personally, I use a Dinamap/Mindray similar to what would be used in hospitals to take BP, pulse and O2. These can be quite expensive so a separate BP machine and separate pulse oximeter maybe preferable.

Key features that are useful:

• • Automated blood pressure readings at set time intervals
  • Audible pulse tone
  • Alarms for pulse, blood pressure and oxygen saturations outside of normal ranges.

Intravenous sedation is contraindicated in this case.

Inhalation sedation is not a suitable alternative, as the continuous oxygen delivered may obtund the hypoxaemic respiratory drive that she is likely dependent on.

Consider a referral to secondary or tertiary care.

The occupational exposure to nitrous oxide should not exceed 100ppm over an 8-hour period. An article published by N Girdler in 1998 quantified this as maximum of 2½ hours a day in the sedation environment to remain within the occupational exposure limit. 

Most patients are receiving nitrous oxide for about 30-45 minutes of their appointment time. So, a limit of 4 - 5 patients a day would be reasonable to stay within the occupational exposure limits as long as your surgery has adequate active scavenging and is well ventilated.  

Close attention to technique (e.g. minimising mouth breathing) and the use of rubber dam to help reduce the surgery concentration of nitrous oxide to a minimum would be useful. 

The regulations we are guided by are below for further advice from the health and safety executive.
EH40/2005 Workplace exposure limits, EH40 (Second edition, published 2011).

If there are any concerns regarding pregnancy and inhalation sedation, there is no definitive guidance. In the past when scavenging was passive rather than active, some research was carried out into the incidence of spontaneous abortion seen in pregnant dental nurses assisting for procedures under nitrous oxide inhalation sedation. High concentrations of nitrous oxide were found to be in the environment and it was concluded that there may be a link. However, the results of this research have since been questioned. 

As we now use active scavenging, well-ventilated surgeries and pay attention to the technique (e.g. minimising mouth breathing) in addition to using rubber dam where at all possible, the chances of nitrous oxide having an effect on fertility or being the cause of spontaneous abortion in a pregnant member of staff in modern surgeries is highly unlikely. 

However, this is a very emotive issue and for any pregnant staff or those trying to conceive, it can be an anxiety-provoking one also. In some services, for the reassurance of the staff concerned, pregnant nurses are not placed with dentists providing inhalation sedation, and pregnant dentists are not required to treat patients under inhalation sedation. This may not be possible for all services. 

It is important to titrate to clinical need each time a patient is seen. For the same patient, the level of nitrous oxide required to facilitate treatment will vary from appointment to appointment. Aside from the actual procedure and thus the pain and needs of the patient and dentist changing between each visit, the level of sedation achieved with any given nitrous oxide: oxygen ratio will change. This is because the depth of the anxiolysis and analgesia is not purely drug dose related - the technique uses semi hypnotic suggestion and perception of pain and anxiety is multifactorial.

For example, anxiolysis will vary according to the patient's baseline anxiety and how stressed / calm they are before they enter the surgery, often the time of day can have an effect, as can the quality of sleep a patient has had, if they have eaten, the degree to which the specific procedure to be undertaken provokes anxiety and discomfort and the interplay between the sedative effect and the sedationist's semi hypnotic suggestion. As a patient gets to know and trust the sedation provider and dental team and feels more comfortable, the end titration dose needed to complete treatment is also likely to reduce.