Please click on the tables and figures to enlarge
A synopsis of articles of interest from the last twelve months to inspire further reading
Adult intravenous sedation in general dental practice: indication, effectiveness and patient experiences
Cowell A, Hare K and Campbell C.
Br Dent J 2024.
DOI: 10.1038/s41415-024-7562-x
Abstract
Background
Conscious sedation is an option in primary dental care for anxious patients or those undergoing extensive procedures. The objective of this retrospective service evaluation was to study the range of treatments delivered during sedation with intravenous midazolam, together with patient-reported experience measures.
Method
Data from 100 consecutive patients treated under sedation at a single private dental practice were evaluated retrospectively. All patients were asked questions about their experience of sedation during a post-operative follow up phone call.
Results
Over half of patients were treated under sedation due to anxiety. The mean dose of midazolam was 7.8 mg and the average treatment time was 1 hour 25 minutes. Of note, the average dose for the most extensive procedure (implant immediate full arch loading) was 11.7 mg; however, this equated to an average dose of 4.5 mg per hour. One patient needed supplemental oxygen; flumazenil was never required. Additionally, 91% of patients felt they had enough sedation and 50% could remember the events of treatment.
Conclusion
With the British National Formulary (BNF) recommending a maximum dose of 7.5 mg midazolam, this study demonstrates that this dose can be safely exceeded in dental treatment; therefore, a dose that accounts for the length of the procedure is a more valid approach. Moreover, patients undergoing a variety of dental treatments were satisfied with the amount of intravenous sedation received and age is not an absolute limit for sedating older people.
Reviewer’s evaluation, opinion and points of interest
This study places emphasis on including patient-reported experiences (PREMs) or outcomes in reflecting the effectiveness of a sedation service and to inform treatment choice. Data from 100 consecutive of patients ASA I or II who underwent a range of dental procedures, including dental implant surgery, with midazolam-based conscious sedation over a two-year period was analysed. Patient age range was 21 to 86 years and the mean was 60 years.
A post-operative telephone call was made the day following treatment and three PREMs questions were asked namely: whether the patients remembered the injection in the mouth (43%); whether they remembered events of the treatment (50%) and, finally, if they thought they had had enough sedation (91%).
Interestingly, a higher percentage of female patients remembered some of the events of their treatment (53%) compared to men (43%)
The overall data also showed that anxiety is not the only benchmark for prescribing sedation and that patients undergoing extensive and invasive treatment should also be offered this option. The authors state that as more complex and prolonged treatments are undertaken in primary care, the proportion of sedation cases may increase further.
With regard to dosage, although the BNF stipulates 7.5 mg midazolam per course (3.5 mg for older patients) the authors refer to the NHS South East London Joint Medicines Formulary which specifically permits exceeding the dose in certain cases.
Feedback from patients is essential for the development of a practice service. The authors acknowledge that this is a basic study which can be advanced to include more specific questions regarding recollection and remembering events. It seems curious that 43% of patients remembered the oral injection which is the one procedure most patients would prefer not to be aware of. It may well be that the local anaesthetic was administered relatively early and before the sedation had time to take effect: timing of the injection would be one element which could be looked into further. Also, in long procedures, the surgeon may presume that continuing to operate as a patient is recovering during the finishing stages would not be cause for increased anxiety or distress, but this may be what some patients do remember. It is generally noted that if a patient visibly experiences some discomfort during a treatment phase, the administration of a small amount of midazolam does bring the amnesic effect into play. So, this is another aspect which can be investigated further.
The paper claims to demonstrate that elderly patients can be safely treated with intravenous midazolam sedation and that ‘age is not an absolute limit for sedating older people’. Nevertheless, caution is still to be advised when treating patients in this cohort, even with an experienced sedationist, because there may be age-related co-morbidities, for example a slowly developing but undiagnosed heart condition which could be triggered and progress into a crisis if the patient became temporarily desaturated. Similarly, a borderline diabetic may slip into a coma during a long sedation procedure. Furthermore, elderly patients may react slower to intervention, and take longer to recover.
Finally, the study does not mention whether the patients were advised to fast or not, as this is an ongoing debate, and a comparison with other studies would be beneficial.
FA
The implementation of conscious sedation by dental professionals in Egypt: an analytical cross-sectional study
Elfezary M T, Moteea M E, Samadah M S A and Waly A S.
Sci Rep 2024; 14: 16502
DOI: 10.1038/s41598-024-66834-z
Introduction
Conscious sedation is widely considered one of the techniques most commonly used to manage anxiety in both children and adults during dental procedures. The application of procedural sedation exhibits considerable variation globally. The purpose of the study was to determine the prevalence of conscious sedation in the current situation in the dental healthcare sector in Egypt and to identify the factors influencing it. An online cross-sectional analytical survey, consisting of nine multiple choice questions, was distributed through the contact lists of national dentists and social media platforms. 163 respondents completed the survey.
Regarding the use of conscious sedation, only 25 (15.3%), 95% confidence interval (10–21) utilised it. The percentage of participants who used conscious sedation was higher among dentists practicing paediatric dental specialists (n = 19, 76%). Academic qualification correlates significantly with the practice of conscious sedation (P = 0.002), but this was not reflected in multiple logistic regression. Indeed, while conscious sedation is part of the dental study curriculum in Egypt, its application rate is relatively low compared to other countries. This discrepancy could be attributed to a variety of factors, including resource availability, lack of training, reflecting the need to develop strategies to improve the implementation of conscious sedation in Egyptian dental practices.
Conclusion
The use of conscious sedation techniques to treat patients with dental anxiety is relatively low among dental practitioners in Egypt. Paediatric dentistry provides most of the sedation services in dental settings in Egypt. The primary factors preventing the implementation of conscious sedation are inadequate training and limited accessibility. Most practitioners believe that sedation is definitely needed within their own practice. Improvements in sedation training are imperative if conscious sedation is to emerge as the primary method alternative to general anesthesia in dental practice. There is no clear guidance on conscious sedation issued by the Egyptian Dental Association or any other medical regulating agency for dental practitioners in Egypt, and this information may help health policy makers develop strategies to improve patient dental care.
Reviewer’s evaluation, opinion and points of interest
In Egypt, a study found that 46.5% of individuals reported experiencing dental anxiety thus endorsing the need for a sedation service. However, the limited provision of sedation is restricted by the requirement for qualified anaesthetists to be present. The primary finding is that of the 163 dentists surveyed in this study, only 15.3% (n = 25) use conscious sedation, mainly in paediatric dentistry. The main reasons for this include the lack of availability, training and qualifications to administer this type of sedation, compounded by a ban on nitrous oxide in Egypt, although the authors do not elaborate on this.
Of the 25 dentists who used conscious sedation, 22 utilised it under the supervision of an anaesthetist, one was fully trained presumably with anaesthetic qualifications and concerningly, two who had not received any training. Unfortunately, the paper makes no mention of what sedative agent is being used and in what form.
Referring to developments in the UK, the 2000 ‘A Conscious Decision’ document is mentioned but not the more updated IACSD ‘Standards for Conscious Sedation in the Provision of Dental Care 2020’. Despite the infancy of sedation provision in Egypt, the authors take some comfort from a study which suggests that that only 8.5% of respondents in Jordan and 12.1% of respondents in Wales perform some form of conscious sedation in their practice.
The authors acknowledge that despite its limitations, this study pioneers the investigation of the use of conscious sedation in Egypt. The study’s focus was exclusively on Egyptian dentists, and this research significantly contributes to the understanding of current conscious sedation practices in Egypt and sets the groundwork for future studies to potentially influence policy and practice within the region. It also highlights an evident need for more collaboration between national sedation groups to help advance the cause of sedation in dentistry worldwide.
FA
Risk reduction: using the properties of sedation to mitigate the risks of stress-induced medical emergencies – a case series
Wyncoll K, Charles L and Clough S.
Br Dent J 2024; 237: 267-271.
DOI: 10.1038/s41415-024-7719-7
Abstract
Dental anxiety and phobia are widespread in the population, with various non-pharmacological and pharmacological techniques available to manage it, including conscious sedation. Medically complex, anxious patients may be at a higher risk of a stress- induced medical emergency during dental treatment. This article lays out the forms of sedation that may be used to help mitigate this risk, the detailed risk assessment required and how conscious sedation may be used as a prophylactic tool to prevent medical emergencies in these patients. Referring clinicians must know what options are available to enable this cohort of patients to access care.
Key Points
The paper provides referring clinicians with an awareness of conscious sedation in specialist settings as a treatment option for medically complex and anxious patients and offers an understanding of the different commonly used modalities of conscious sedation and how to appropriately risk assess. It also provides examples of cases in which sedation has been used to prevent potential medical emergencies in medically complex and anxious patients to demonstrate the concept.
Reviewer’s evaluation, opinion and points of interest
This paper suggests that sedation may be provided ‘prophylactically’ to mitigate the risks of a medical emergency occurring during dental treatment for patients with predisposing conditions. The types of emergencies cited which may be triggered by stress are angina / myocardial infarction, epileptic seizures, hypertensive crises, acute asthma attack, hyperventilation and panic attack.
Four cases are presented of anxious patients suffering from some of these conditions and who were treated successfully under either nitrous oxide / oxygen inhalational or midazolam or remimazolam- based IV sedation with no triggering of any medical crises.
The authors state that they have ‘demonstrated that with thorough assessment and careful patient selection, conscious sedation can be used safely and effectively as a prophylactic tool to reduce the risk of medical emergencies occurring during dental appointments.’
It is accepted that medical emergencies in general dental practice are relatively rare and that some are not anxiety-induced, for example, allergic reactions, in extreme cases anaphylaxis or a diabetic crisis. Furthermore, there is little data as to the number of cases of emergencies which could be said were caused specifically by anxiety. There is no doubt that the availability and provision of sedation definitely reduces stress and is beneficial for the mental and physiological well-being of an anxious and phobic patient. So, to offer it ‘prophylactically’ to certain medically compromised patients, with due risk assessment and ideally in a hospital setting, is reasonable.
However, it has also to be appreciated that conscious sedation can have its limitations and that sometimes it is not as effective as expected. If a patient who is suffering from a condition which can be precipitated by stress, becomes distressed during a sedation procedure, perhaps because of resistance to the drug, a crisis could still develop. So, the option of offering general anaesthetic to a severely phobic patient, with due risk assessment, could also be considered.
FA
Management for the patients with severe Parkinson's disease during dental treatments and tooth extractions: A retrospective observational study
Morimoto Y, Hayashi M, Tanaka Y, Mikuzuki L and Nishizaki H.
J Dent Sci 2004; 19: 261-267.
DOI: 10.1016/j.jds.2023.04.015
Abstract
Background / purpose
When Parkinson's disease (PD) progresses, oral and swallowing functions decline and special care is necessary when performing dental treatments. This study aimed to retrospectively investigate the records of patients with PD and analyse dental and general problems to establish countermeasures during dental treatments.
Materials and methods
We retrospectively examined the medical records of patients with PD to obtain data on dental treatments and management methods.
Results
Of the 27 patients, 40% had severe grade IV or higher Hoehn–Yale (HY) scores and the wearing-off phenomenon was observed in those with grade III or higher. Additionally, 19% of the patients were receiving levodopa 500 mg/day or more. Intravenous sedation was administered 21 times (three patients) and general anaesthesia eight times (three patients). Discontinuation of tooth extraction was observed in four patients: two with difficulty in opening the mouth, one with respiratory failure caused by the wearing-off phenomenon, and one with excessively elevated blood pressure due to the interaction between adrenaline in local anaesthesia and the catechol-O-methyltransferase inhibitor. Tooth extraction was performed by adjusting the time of levodopa administration in two patients, under general anaesthesia in one patient, and using adrenaline-free local anaesthetics under intravenous sedation in one patient.
Conclusion
When PD progresses, oral and swallowing functions decline and body motor function deteriorates. Thus, the respiratory and circulatory conditions and the wearing-off phenomenon during dental treatments should be properly managed in patients with severe PD.
Reviewer’s evaluation, opinion and points of interest
In recent years Parkinson’s disease has received much more media attention here in the UK, especially following the success of the popular podcast ‘Movers & Shakers’ (worth a listen).
I was keen to read this work, as there are very few studies involving this patient group and their experiences of sedation or general anaesthesia. Albeit a small sample size, I felt that the work offered some valuable points for consideration in planning care.
In particular, the data set shows that treatment for several of the patients was not without challenge and required varied modalities. Central to this was the recognition of the ‘wearing off’ phenomenon - when Parkinson’s medication is no longer as effective as it used to be and symptoms may return towards the end of a medication dose, or near the beginning of the next dose. In some cases, the clinicians liaised with the medical teams to make adjustments to the medication regimes and carefully planned appointment times, thereby enabling more control over movements / rigidity and to enable the delivery of treatment. This is also reflected in the low doses of midazolam (up to 2.5mg) required to deliver care, along with anticipated dose adjustment in view of the advanced age of this cohort.
In the UK, it is predicted that due to population growth and an increasingly ageing population, the prevalence of Parkinson's disease will rise by 23.2% by 2025. This means that 1 in every 37 people will be diagnosed with Parkinson’s disease at some point in their lifetime; this remains an incredibly valuable area for future research in context of dental sedation.
SC
Dissociative identity disorder in the dental setting: an assessment of the literature and case report
Pindoria A, Radia S, Stagnell S.
Dissociative identity disorder in the dental setting: An assessment of the literature and case report.
Oral Surg 2024; 17: 270–273.
DOI: 10.1111/ors.12892
Abstract
There is an ever-increasing chance that dentists are likely to experience patients who need additional management for psychiatric disorders. Dissociative identity disorder (DID) is characterised by the presence of two or more distinct personality states or identity fragments that control an individual's behaviour, thoughts and emotions. The aim is to offer additional insights into patients with DID and their management within a dental care setting. This will be demonstrated through the use of a case report as a practical illustration. In order to gain insight into the effects of DID on healthcare, particularly within a dental care environment, a comprehensive review of relevant literature has been conducted by searching, evaluating and synthesising existing academic and scholarly literature on DID. Additionally, the case reported is an example of how a 27-year-old patient with DID has been managed in an Intermediate minor oral surgery setting. Patients often have their DID prompted by stress, as was the case with this patient. There are steps which can be taken in the dental setting to help reduce the patient's anxiety, understand their personalities and foresee any possible issues that could arise. In this case, intravenous sedation was used to extract the patient's wisdom teeth and no other personalities presented during the procedure. The examination of existing literature along with a case report highlights the feasibility of effectively treating individuals with DID. This can be achieved through the careful recognition and handling of different personalities, triggers and potential challenges, all of which should be integrated into the treatment strategy.
Reviewer’s evaluation, opinion and points of interest
I enjoyed reading this publication as it gave an excellent overview of dissociative identity disorder (DID), its diagnosis, assessment and treatment. The authors rightly explain that there is little information available specifically in relation to the delivery of dental care, but they are able to offer us some guidance based on their experience within the case report and associated literature search.
The work reminds us that although pharmacological intervention may be required to enable the delivery of dental treatment, non- pharmacological aspects to care are essential in this group. The authors explain that there have been reports of new personalities developing because of perioperative stress, which can worsen DID symptoms. They suggest that by reassuring the patient and taking steps to reduce the general anxiety that is often associated with dental appointments, the likelihood of multiple personalities presenting can be reduced. This includes ensuring that the whole dental team is informed beforehand and making efforts such as asking the patient for their name or the person accompanying them in identifying the specific personality that has presented on a given day, which allows the team to be aware and responsive to the individual's unique needs during the appointment. They also highlight that consent can be problematic, should patients with DID attend with different personality states at each appointment, particularly if they are unable to recall information regarding the planned treatment. Where treatment requires sedation and an escort, they remind us that this may pose a potential complication, depending which personality could manifest and the appropriateness of the escort. They also suggest that electively reversing sedation could potentially cause confusion, agitation or panic in the patient. Ensuring the patient's safety and offering suitable support and reassurance during this transition is vital to minimise the risk of traumatising the patient or triggering the emergence of a different personality. They explain that this is supported by wider reports of personality switching during hospitalisation and after general anaesthesia.
Overall, this is a succinct case report offering significant information as a quick read for any practitioners who encounter patients with DID.
SC
Remimazolam for procedural sedation in older patients: a systematic review and meta-analysis with trial sequential analysis
Lee M, Lee C, Choi G J and Kang H.
J. Pers. Med. 2024; 14: 276.
DOI: 10.3390/jpm14030276
Abstract
This systematic review and meta-analysis with trial sequential analysis (TSA) aimed to evaluate the efficacy and safety of remimazolam compared to other sedatives for procedural sedation in older patients. We registered the protocol of this systematic review and meta-analysis with TSA in the PROSPERO network (CRD42023441209). Two investigators performed a systematic, comprehensive, and independent search of the PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases to identify randomized controlled trials (RCTs) comparing remimazolam with other sedatives in older patients undergoing procedural sedation. Conventional meta-analysis and TSA were also performed. Seven RCTs (1502 patients) were included. Pooled results demonstrated that remimazolam was associated with a low incidence of hypoxemia, hypotension, bradycardia, respiratory depression, and injection pain. Remimazolam also required a long time to cause loss of consciousness. There were no differences in rates of sedation success, dizziness / headache, postoperative nausea and vomiting or recovery time. Older patients receiving procedural sedation with remimazolam had a lower risk of hypoxemia, hypotension, bradycardia, respiratory depression, and injection pain than those receiving other sedatives, suggesting that remimazolam may be more suitable for procedural sedation in older patients.
Reviewer’s evaluation, opinion and points of interest
It is positive to see that there is a growing body of research relating to the use of remimazolam for procedural sedation in medical specialities. Unfortunately, dentistry has some catching up to do.
I was particularly interested in this publication because it focusses on older patients for which there is generally less research available in the context of sedation. As the authors rightly explain, the increase in the older population has brought about significant change to the healthcare providers around the world. The scope of diagnostic and minimally invasive therapeutic procedures is expanding with advances in medical technology which has led to an increase in the need for procedural sedation. This change in the healthcare environment is favourable for older patients who are likely to have a relatively large number of comorbidities and are at a high risk of respiratory and cardiovascular complications. However, for healthcare providers providing sedation during procedures, increasing the age and severity of underlying diseases in older patients remains challenging.
This research was funded by the Basic Science Research Program through the National Research Foundation (NRF) of Korea funded by the Ministry of Education, Science and Technology and the authors declared no conflicts of interests. Having initially identified 172 publications (26 duplicated) they worked comprehensively through a process of elimination to identify 7 key randomised control trials with data pertaining to 1502 patients (767 received remimazolam, 618 received propofol, and 117 received etomidate plus propofol). The evidence grade was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system with the majority being moderate to high quality for most of the outcomes, which is reassuring.
Overall, it was determined that remimazolam was associated with a low incidence of hypoxemia, hypotension, bradycardia, respiratory depression and injection pain, however, there was no difference in sedation success (defined as no rescue sedation with a sedative agent other than the assigned treatment to complete the entire procedure), recovery time or post-operative nausea and vomiting.
The authors acknowledge that their analysis had some limitations: they had intended to cover all procedures, however, within their literature available it was limited to gastroscopy and colonoscopy procedures. Indeed, much of the research on the use of remimazolam is currently limited to these fields. Furthermore, all studies were conducted in China, although they felt that as heterogeneity is a fundamental limitation of meta-analyses, overall the types of procedures and ethnicities of participants in each study were less heterogeneous than those in other meta-analyses, which may increase the reliability of the findings. Importantly, most studies included relatively healthy older patients and excluded those with significant cardiopulmonary instability, clinically significant hepatic or renal impairment, history of sleep apnoea, body mass index >30 kg/m2, or expected difficult airways. Only two studies encompassed patients categorised as ASA III. Therefore, the authors advise that careful weighing up of risks and benefits is essential in this patient group.
The authors suggest that further research, specifically targeting sick older patients is essential to further establish the safety profile of remimazolam. As more and more services are gradually able to access remimazolam, hopefully this valuable work will come with more time.
SC
Effectiveness of preventive intervention programmes aiming to improve oral health in children who have undergone caries-related dental extractions: a rapid review
Kouassi S M, Salomon-Ibarra C C, Hosey M T, Gallagher J E.
Community Dent Health 2024; 41:208-214.
DOI: 10.1922/CDH_00107Kouassi07
Abstract
Objective
To determine the effectiveness of preventive interventions in children who have undergone caries-related dental extractions.
Methods
Rapid review across five databases (CENTRAL, Ovid Medline, Embase, Web of Science and Scopus). Quality was assessed using the Risk of Bias 2 tool.
Results
Five studies were included, all randomised controlled trials involving pre-and / or post-extractions activity. Three studies involved oral health education (computer game, motivational interviewing, visual aids), one delivered clinical prevention (fissure sealants), and one an enhanced prevention programme combining additional health education and a clinical intervention (fluoride varnish). Retention was mixed (55% - 80% in the intervention groups). Of the three studies measuring caries, all reported less caries development in the test group. However, only a study involving a dental nurse-delivered structured conversation, informed by motivational interviewing, showed an improvement in oral health. Two studies reporting on plaque and gingival bleeding had conflicting results. A study reporting on subsequent dental attendance did not demonstrate a clear improvement.
Conclusion
Few published studies have explored prevention-based interventions in high caries-risk children requiring dental extractions. Whilst evidence of clinical benefit of preventive interventions in this population is limited, the potential use of contemporary behaviour change techniques appears promising. There is an urgent need for more high-quality longer-term trials using contemporary methodologies.
Reviewer’s evaluation, opinion and points of interest
Preventing children from having multiple general anaesthetics (GAs) for dental treatment has been the subject of debate for as long as I have been practising dentistry. There has been debate on the best way to prepare children before the procedure and when preventative advice and treatments should be delivered. An obvious challenge is changing the pattern of attendance to encourage patients and parents to become regular attendees rather than continuing to be emergency care seekers. The evidence for any of the interventions that have been tried is poor.
The one that showed the most promise is the ‘brief negotiated interview for oral health’ which links the family back into their general dental practitioner for follow up care. There is a clear and obvious need to address these issues, which stubbornly refuse to respond to the initiatives of the profession. A previous study found that in 47% of children requiring extractions under GA there was a history of previous GA for the patient or another child in the family.1 This is an area where further research and development is clearly required.
Reference:
Olley R C, Hosey M T, Renton T, Gallagher J E. Why are children still having preventable extractions under general anaesthetic? A service evaluation of the views of parents of a high caries risk group of Children. Br Dent J 2011; 210: E13
Digital Object Identifier: 10.1038/sj.bdj.2011.313.
NDR
Parental use and acceptance of an accessible, commercially available intraoral camera for teledentistry in their children
Tan W K, Chua D R.
Eur Arch Paediatr Dent. 2024; 25: 237-246.
DOI: 10.1007/s40368-024-00878-7
Abstract
Purpose
Monitor paediatric dental health was emphasised during the COVID-19 pandemic and remains underexplored. This study aims to assess parental acceptance and use of a commercially available intraoral camera (IOC) for effective remote monitoring.
Methods
47 child-parent dyads, where the parent was the main caregiver and the child was treated under general anaesthesia for early childhood caries, were recruited. Caregivers were trained to image their child's teeth on a commercially available IOC. Subsequently, submitted images were reviewed asynchronously by dentists for image quality, presence of dislodged fillings, abscesses, cavitation, and oral hygiene. Post-surgery monitoring was performed using teledentistry at 1 and 2 months and in-person at 4 months. A modified Telehealth Usability Questionnaire (TUQ) was used to record caregiver acceptance for study procedures.
Results
A mean TUQ of 6.09 out of 7 was scored by caregivers. Caregiver- reported issues were limited to problems with technique and child uncooperativeness. The number of clear images during the second teledentistry review was improved compared to the first (p = 0.007). 68% of children liked having images of their teeth taken.
Conclusion
This study supports the feasibility of using an IOC as a clinically appropriate avenue for teledentistry with a high level of caregiver-child acceptance.
Reviewer’s evaluation, opinion and points of interest
This article pilots a novel way of improving the accessibility and acceptability of teledentistry. One of the thoughts behind this study was to assess whether this might be a suitable technique for screening children in more remote areas of the United States of America. If acceptable, it could have worldwide applications, particularly in areas where there is a paucity of specialist practitioners. An obvious additional population could be special care dentistry patients.
In the study, the cost of the intraoral cameras was covered by the clinic. The financial viability of the more widespread roll out would have to be considered. The results were still limited, and there is an obvious need for improvement as the general rate of producing clear and correct images improved between the two review appointments, it was between 63 and 81%.
Given that the greatest contribution to greenhouse gas emissions within dentistry comes from patient and dental team travel, initiatives that can reduce the frequency of attendance at face-to-face appointments without compromising the quality of dental care provided should be explored.
NDR
Efficacy and cost analysis of intravenous conscious sedation for long oral surgery procedures
Hassan H, Shado R, Pereira I N, Mistry M and Craig D.
Br J Oral Maxillofac Surg 2024; 62:523-538.
DOI: 10.1016/j.bjoms.2024.04.006
Abstract
The aim of this study was to determine what is considered a long oral surgery and conduct a cost-effective analysis of sedative agents used for intravenous sedation (IVS) and sedation protocols for such procedures.
Pubmed and Google Scholar databases were used to identify human studies employing IVS for extractions and implant-related surgeries, between 2003 and July 2023. Sedation protocols and procedure lengths were documented. Sedative satisfaction, operator satisfaction, and sedation assessment were also recorded. Cost estimation was based on The British National Formulary (BNF). To assess bias, the Cochrane Risk of Bias tools were employed.
This review identified 29 randomised control trials (RCT), six cohorts, 14 case-series, and one case-control study. The study defined long procedures with an average duration of 31.33 minutes for extractions and 79.37 minutes for implant-related surgeries. Sedative agents identified were midazolam, dexmedetomidine, propofol, and remimazolam. Cost analysis revealed midazolam as the most cost-effective option (<10 pence per procedure per patient) and propofol the most expensive option (approximately £46.39). Bias analysis indicated varying degrees of bias in the included studies. Due to diverse outcome reporting, a comparative network approach was employed and revealed benefits of using dexmedetomidine, propofol, and remimazolam over midazolam.
Midazolam, dexmedetomidine, propofol, and remimazolam demonstrated safety and efficacy as sedative agents for conscious IVS in extended procedures like extractions or implant-related surgeries. While midazolam is the most cost-effective option, dexmedetomidine, propofol, and remimazolam offer subjective and clinical benefits. The relatively higher cost of propofol may impede its widespread use. Dexmedetomidine and remimazolam stand out as closely priced options, necessitating further clinical investigations for comparative efficacy assessment.
Reviewer’s evaluation, opinion and points of interest
Although this is badged as a systematic review, the outcome data (patient and operator satisfaction and sedation quality) were too heterogenous to make any meaningful comparisons. I note that 1,328 papers are unaccounted for in their sift of articles for inclusion in the review (see PRISMA chart as figure 1).
There are a number of errors in the calculations that have been made to compare cost effectiveness of the four sedative agents. The cost of midazolam is significantly underestimated as a high strength formulation (50mg/10mL) has been used for comparison which would be neither practical nor safe for dental conscious sedation. The cost of propofol has been overestimated by a factor of five. Finally, the cost of remimazolam is significantly underestimated, as the cost of each sedative agent has been calculated per mg/mcg administered rather than the cost of each vial opened. These errors significantly undermine the conclusions of the review. The stated aim of the article is to determine ‘what is considered a long oral surgery’ but this question is not addressed in the conclusion.
GG
Implementation of a CBT-based dental anxiety management pathway for patients with learning disabilities
Hughes S, Davies L, Monaghan U and Stennett, M.
Br Dent J 2024; 237: 40-44.
Epub July 2024.
DOI: 10.1038/s41415-024-7557-7
Abstract
Dental anxiety is a common phenomenon in the general population and may be more prevalent in people with learning disabilities. There is growing interest in the use of cognitive behaviour therapy (CBT) approaches, including within dental anxiety management. However, relatively little is known regarding the application of CBT approaches in dental anxiety management for patients with learning disabilities. This paper outlines details of the implementation of a CBT-based dental anxiety pathway for patients with learning disabilities treated in a special care dental service in England. The pathway is modelled on the utilisation of skills from the dental team (dental nurses and dentists) to deliver a combination of talking sessions, desensitisation and positive affirmation in five distinct stages. Early feedback from service users following implementation of this pathway indicates successful acceptance of dental care with a decreased use of sedative adjuncts.
Reviewer’s evaluation, opinion and points of interest
This paper outlines a tailored dental anxiety management pathway (‘AMP’) that incorporates behaviour management and tailored cognitive behaviour therapy (CBT) for individuals with a learning disability, piloted in Hertfordshire Community NHS Trust’s special care dental service. The broad findings seen in clinical practice are summarised and are really encouraging, however as the authors identify, more research is needed.
This CDS’s ‘AMP’ is designed to support patients with learning disabilities in overcoming dental anxiety through a structured, multi-stage process. The pathway combines conventional behavioural techniques, including systematic desensitisation / graded exposure and cognitive strategies, such as thought-challenging and post-event appraisal to support development of more helpful beliefs; both of which challenge trait and state anxieties in a supportive environment. Key to its success is building rapport with patients and their families, starting with a nurse-led telephone consultation to assess likes, dislikes and health history. This rapport continues through nurse-led clinic appointments where patients gradually become familiar with dental procedures and tools, incorporating relaxation techniques and graded exposure to anxiety triggers.
The pathway uses the Modified Dental Anxiety Scale (MDAS) to assess patient anxiety, adapting it to include visual cues (smiley faces) for better communication. In later stages, patients are introduced to the dentist, where minimal dental procedures are provided, building trust and confidence. If necessary, sedation is considered, often with positive outcomes due to prior exposure and preparation. The final stage involves treatment by the same dental team, ensuring continuity and trust. Early results of the clinical pathway show great promise, with many patients who previously required general anaesthesia, now able to tolerate dental procedures with local anaesthesia or sedation, within a reported five sessions. The pathway also appears to help some individuals in reducing general health-related anxiety, such as phlebotomy appointments, enabling broader access to healthcare services.
The authors note that further research is needed to refine the approach and validate its effectiveness, though this encouraging summary of an active care pathway infers observable benefits in a clinical setting for this patient group, working to increase access and reduce inequalities for individuals with learning disabilities.
JH
Interventions to reduce adult state anxiety, dental trait anxiety, and dental phobia: A systematic review and meta-analyses of randomized controlled trials
Steenen S A, Linke F, van Westrhenen R and de Jongh A.
J Anxiety Disord 2024. 105; 102891
Epub June 2024
DOI: 10.1016/j.janxdis.2024.102891
Abstract
This review evaluates randomized controlled trials (RCTs) intervening on adult state anxiety (fear and emotional distress during dental treatment), chronic dental (trait) anxiety or dental phobia (disproportionately high trait anxiety, meeting diagnostic criteria for specific phobia). Seven online databases were systematically searched. 173 RCTs met the inclusion criteria, of which 67 qualified for 14 pooled analyses. To alleviate state anxiety during oral surgery, moderate-certainty evidence supports employing hypnosis (SMD=–0.31, 95 %CI[–0.56,–0.05]), and low- certainty evidence supports prescribing benzodiazepines (SMD=–0.43, [–0.74,–0.12]). Evidence for reducing state anxiety is inconclusive regarding psychotherapy and does not support virtual reality exposure therapy (VRET), virtual reality distraction, music, aromatherapy, video information and acupuncture. To reduce trait anxiety, moderate-certainty evidence supports using Cognitive Behavioural Therapy (CBT; SMD=–0.65, [–1.06, –0.24]). Regarding dental phobia, evidence with low-to-moderate certainty supports employing psychotherapy (SMD=–0.48, [–0.72,–0.24]), and CBT specifically (SMD=–0.43, [–0.68,–0.17]), but not VRET. These results show that dental anxieties are manageable and treatable. Clinicians should ensure that interventions match their purpose: managing acute emotions during treatment or alleviating chronic anxiety and avoidance tendencies. Existing research gaps underscore the necessity for future trials to minimize bias and follow CONSORT reporting guidelines.
Reviewer’s evaluation, opinion and points of interest
This systematic review and meta-analysis examines interventions aimed at reducing adult state anxiety, trait anxiety and dental phobia in the context of dental treatments. The findings offer evidence-based recommendations for clinical practice and highlight some important methodological gaps for future research.
For state anxiety, defined as acute fear or distress during dental treatment (ie ‘in the moment’), moderate-certainty evidence (rated using the GRADE approach) supports hypnosis, while low-certainty evidence suggests benzodiazepines provide comparable benefits. Interventions such as virtual reality exposure (VRET), background music, acupuncture, aromatherapy and preoperative video information were found to lack efficacy. Importantly, the review emphasises the need for validated psychometric measures, such as the State-Trait Anxiety Inventory (STAI) or visual analogue scales (VAS), to accurately assess state anxiety. Studies relying on physiological metrics, such as heart rate or salivary cortisol, were excluded due to limited evidence supporting their relationship with emotional states.
Chronic dental anxiety (of varying levels of trait anxiety), was shown to be effectively reduced with cognitive behavioural therapy (CBT), supported by moderate-certainty evidence. Similarly, dental phobia was best addressed by psychotherapy, particularly CBT, with encouraging effect sizes. Additional evidence supported the efficacy of exposure therapy, relaxation training and stress inoculation approaches. However, variations in the use of psychometric tools, such as the Modified Dental Anxiety Scale (MDAS), created inconsistencies in measurement.
The review underscores the importance of using validated psychometric instruments tailored to specific anxiety constructs. Many studies conflated state and trait anxiety due to inappropriate scales, raising methodological and clinical concerns. The authors advocate for future research to adopt rigorous designs, including standardised psychometric tools, consistent timing of anxiety assessments, and comprehensive reporting of outcomes. Overall, the review highlights some findings already known from prior reviews and also raises some interesting learning on the use of other approaches.
JH