Secretary’s correspondence
Manni Deol BDS, MJDF, PGCMedEd, PGDipConSed
SAAD Honorary Secretary and Clinical Advisor
manni.deol@saad.org.uk
SAAD continues to receive many questions and queries relating to sedation. Please find below some of the questions received by the Secretary and Clinical Advisor’s office during the last year.
Q: The clinical issue is centred around the occasional very dental phobic patient who is in such a state we cannot even get them to extend their arm to commence the IV process. In these patients we have tried two oral sedative agents
- Temazepam at 30 mgms
Lorazepam at 2-6 mgms
Neither of these have provided a situation where we could undertake IV access. In a SAAD event some years ago we discussed nasal atomised / vaporised midazolam.
With that in mind we undertook some searches and found it being used at North Devon Healthcare. It would appear it was a 5 mgm dose that enabled a sedative state to be established to then enable the patient to be cannulated and the process continue as planned. Could I please have your opinion on this please in these sorts of very extreme phobic patients?
A. In the case you have described the use of intranasal midazolam would be a good idea. I believe it is available from St. Thomas's Hospital Pharmacy. Dr Graham Manley pioneered this technique. Please find a link to one of his papers on this subject: https://pubmed.ncbi.nlm.nih.gov/18545267/
This technique is often used for special care and needle phobic patients. Important note: the patient must be cannulated for safety reasons, once calm enough to allow you to do so. You may also wish to top up with a little IV midazolam. Do this with care and caution allowing enough time for the intranasal midazolam to work, so as not to over-sedate. As with all sedation, you should only be using the techniques in which you have been trained.
Q. I attended the SAAD National Course: the Theoretical Elements webinar as a refresher dental nurse. I have two questions:
1. Is an oxygen cylinder needed in the surgery when carrying out IV sedation or a type of oxygen (we have two in the dental practice upstairs and downstairs waiting room but don’t normally take one into the surgery)
2. If the dentist is not sedation trained, is it ok to only have one sedation nurse in the surgery or are two nurses needed?
A. In relation to question 1, it would be good practice to keep an oxygen cylinder in the surgery where IV sedation is carried out so that it is immediately available if the patient’s oxygen levels start to drop and are not manageable by encouraging the patient to breathe and opening up the airway with a chin lift and head tilt alone. Also in a medical emergency you would want it close by and immediately available.
A. In relation to question 2 if the dentist who is carrying out the dental treatment is not sedation trained, the person administering the sedation (dentist or doctor) must remain in the surgery whilst the patient is being treated. If the dentist treating the patient has administered the sedation they need a sedation trained nurse. A nurse cannot take over responsibility for looking after a sedated patient.
Q. We currently have two oxygen cylinders as previous regulations. Please can you confirm that it is regulation that we require an oxygen concentrator 5 litre machine as this has been brought to our attention.
A. No, this is not necessary or regulation. I have seen these being used routinely on all sedation patients at a particular practice, my concern here is that it may give a false sense of security as the oxygen saturation may remain high on the pulse oximeter even when the patient’s respiratory drive is reducing.
Q. Are there any guidance or expert opinions on whether operating dentists who are pregnant should or should not be treating patients under inhalation sedation? If so, is this for the full term or for specific trimesters?
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.
In reality, 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.
We also advocate close attention to technique (eg minimising mouth breathing) and use of rubber dam where at all possible to help reduce the surgery concentration of nitrous oxide to a minimum.
The regulations we are guided by are below in case you want to seek further advice from the Health and Safety Executive. EH40/2005 Workplace exposure limits, EH40 (Second edition, published 2011) http://www.hse.gov.uk/pUbns/priced/eh40.pdf
The short answer regarding pregnancy and nitrous oxide exposure is that there is no definitive guidance. In the days 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 immediate 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 (eg 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.
Q. I am a GDP providing IV sedation with midazolam. I completed the SAAD scheme and my 20 accredited cases several years ago. I have a 15-year-old female seeking treatment under IVS, she is ASA class 1 with a low BMI which is just within normal range (16.4). Would this be appropriate for treatment in general practice?
A. BMI is an indication to help assessment. If you feel this patient is much smaller than normal for her age ie underweight and under developed, similar to a child, you may feel it’s more appropriate to refer to a secondary care setting for IV sedation or manage with inhalation sedation.
Q. I am planning on acquiring a BP / SpO2 monitor. What machine would you recommend?
A. At SAAD we do not endorse or recommend any particular machine. Personally, I use a Dinamap similar to those used in many NHS hospitals, this has a BP, pulse and O2 monitor all in one. I also send this off to a company for servicing annually. Having said that they are expensive in comparison to separate BP and O2 monitors. I would purchase your machines from a reputable medical supplier rather than Amazon or other internet sites as there are cheaper machines on the market that aren’t accurate or appropriate for anything other than home use.
Q. We have a therapist who has completed an inhalation sedation course and would like to start treating patients with IHS. Nitrous oxide is a prescribed drug isn't it? So the therapist would need to have a prescription from a sedation-trained dentist in order to carry out the treatment? And the sedation dentist would need to also carry out the IHS assessment?
A. Yes, the therapist would need to work under the prescription of a sedation-trained dentist who has carried out the initial dental and sedation assessment of the patient. Please check the therapist’s training has covered the IACSD guidelines recommendations on training ie didactic teaching, practical skills training, 20 observed cases and ILS. Please see pages 23, 36, 38, 68 in particular of the IACSD guidelines which are available here: https://www.saad.org.uk/IACSD%202020.pdf
Q. I am joining a private practice and I am very keen to get a sedation service up and running but none of the nurses are currently sedation trained. I have advised that they will need to attend the training and directed them to the SAAD training which the practice manager is booking. However, they will then need to be observed for 20 cases. I was a STAC approved supervisor in community but suspect I will need to renew this. How do I go about this? My concern is that there is no sedation trained nurse so how do I supervise the cases with the nurses without one? I can't seem to work out a way round it?
A. For setting up a new service I would recommend the SAAD Safe Sedation Practice Scheme (information is available here: https://www.saad.org.uk/sedation-practice/practice-evaluations)
Is it possible for you to find another clinician / practice for the 20 cases for your nurse to be observed? Another alternative may be for you to do the observation and training whilst doing a sedationist-only role ie not an operator-sedationist. In this case, another dentist would do the dentistry whilst working with a dental nurse in addition to you doing the sedation and training the trainee sedation dental nurse, which involves four team members.
Q. We've recently seen a patient under IV sedation for implant surgery and she has expressed that she feels the sedation medication (midazolmam) did nothing to her. Is there any other medication that can be prescribed to avoid this as she does require further surgery?
A. As you may be aware the same patient can behave in a completely different manner with IVS midazolam from one appointment to the next. I would try MDZ again and titrate to the patient’s response. Is it possible the patient was under- sedated at the first visit or possibly the procedure was long and therefore she needed to be topped up? In my experience with long implant cases, I often sedate the patient initially and need to top up with care (don't over sedate) as the procedure progresses.
Q. What is the opinion of an acclimatisation visit under inhalation sedation? Is it possible to be done if a patient has doubts whether they will co-operate? Should we only test the capacity of the patient to tolerate the nasal hood? Would we give nitrous oxide to see how the patient would cope or just O2?
A. In my opinion, an acclimatisation visit is a good idea if you feel that will lead to better co-operation, acceptance and tolerance of treatment. How far you go with the nasal hood and administering N2O/O2 will depend on the individual patient and case.
Q. Is there is an upper age limit of who can be treated under intravenous sedation? We only treat adults, so it is only the upper age limit we needed to know if there is one.
A. There is no upper age limit for treatment under IVS. The usual assessment procedures must be in place, with particular attention to any medical comorbidities. It is advisable to halve the dose and double the time when titrating the drug in older patients, as they do not metabolise the drug as fast as younger patients and will have more available drug in the bloodstream due to a reduction in protein binding to midazolam, leaving more midazolam available to bind on receptor sites.
Q. I wanted to know if i-gels are to be removed from the mandatory emergency kit if a practice provides midazolam sedation? Please also let me know SAAD’s latest teaching on taking BP too as I have been told SAAD now advocates using electrical blood pressure devices rather than a manual sphygmomanometers.
A. I-Gels are still a requirement for practices providing IVS with midazolam, training on these should be updated during the team’s ILS training. Electrical blood pressure devices are recommended as most practitioners are not trained in using a manual sphygmomanometer.
Questions answered by other Trustees
A. In relation to your recent query regarding the combined use of inhaled nitrous oxide / oxygen and intravenous midazolam, I can confirm that this is not viewed as an advanced technique. It is a very safe technique as often lower doses of midazolam are required when given in conjunction with nitrous oxide, and the nitrous oxide can be rapidly adjusted as required. It is particularly useful for special care patients.
I hope the above information will allow you to provide this technique and facilitate dental care using conscious sedation as the least restrictive option for dental treatment, and therefore reduce the need for general anaesthesia for some of your patients.