DOI: 10.63507/KFZX1321
A synopsis of articles of interest from the last twelve months to inspire further reading
Climate-conscious sedation: how can we sustainably manage dental anxiety using inhalation sedation?
Jones A, Clark H and Girdler J.
Br Dent J 2024; 237: 87-92
DOI: 10.1038/s41415-024-7573-7
Abstract
Climate change represents an urgent global threat. Without action, rising temperatures resulting from human activity will increasingly affect our health and wellbeing through changing patterns of disease, extreme weather events and availability of resources. Expedient decarbonisation of the UK economy is an ambitious goal to which we must all contribute.
The NHS aims to be the world’s first net-zero health service and reach carbon-neutral status by 2040. Dental services are particularly resource intensive. Some dental anxiety management techniques have a disproportionately high impact on the environment relative to their usage. Inhalation sedation with nitrous oxide is one such example.
Nitrous oxide is a greenhouse gas almost 300 times more potent than carbon dioxide, but its utility to facilitate dental treatment for anxious and vulnerable patients is well-documented. This paper balances the health utility with environmental and social harm of continuing to use nitrous oxide and suggests evidence-based methods we can apply to limit the environmental impact of sedation services.
Reviewer’s evaluation, opinion and points of interest
This paper discusses the responsibility of health clinicians, including dental inhalational sedation practitioners, to protect the environment. Dental services contribute 3% of the NHS's carbon footprint, mainly due to travel, procurement and energy use. Nitrous oxide is a potent greenhouse gas that significantly increases the carbon footprint of procedures. Although nitrous oxide is necessary for treating anxious patients, there is a need for evidence-based methods to reduce its environmental impact. Currently, no alternative gases are available to dentists in the UK for providing conscious sedation and there are no specific guidelines for incorporating sustainable practices into sedation services.
There is no doubt that the management of dental anxiety using inhaled nitrous oxide has a high environmental cost but offers significant health and equality benefits for anxious dental patients. The paper calls for thorough assessment of patient anxiety, better planning and tips for sustainable inhalational sedation practice.
This includes the need for a regular audit of nitrous oxide to identify leaks and system wastage. This seems to be a significant problem where nitrous oxide is supplied from centralised storage. Alarmingly, the authors state that ‘16 NHS hospital trusts had audited their piped nitrous oxide and estimated a loss of 13.7 million litres of gas per annum. This represented 95% of their total collective annual volume’. Other trusts have identified that 70-98% of their nitrous oxide is wasted before reaching patients.
Repairing leaking joints and pipes is essential but the authors also encourage replacing central systems with local cylinders which they say can deliver nitrous oxide up to 74% more efficiently than piped systems.
Catalysing scavenged nitrous oxide, ‘cracking’, which is a process which breaks it down into harmless nitrogen and oxygen, is being trialed in the UK. The catalysing units can be retrofitted to existing gas scavenging systems, so this is an important option to consider in the future, depending on costs and practicality.
In clinical practice, efficiency measures include optimising gas delivery by ensuring that the nasal hood fits well and patients are administered nitrous oxide in a titrated method and for as short a time as necessary. This requires a determination by the sedation team to be proactive, assess the patient’s specific requirements and fine-tune the amount of nitrous oxide according to the procedure being performed. For example, a needlephobic patient would require a higher dose while the local anaesthetic is being administered and a lesser level for the rest of the treatment. We should try to reduce the amount of nitrous oxide delivery as much as possible – would a reduction of, say, 0.5 litre per minute in delivery of the nitrous oxide / oxygen combination or 5% less nitrous oxide, still produce good results, could the level of nitrous oxide be stepped down earlier, as the treatment is nearing conclusion? Administering dental treatment with the use of a rubber dam also helps because it both discourages mouth breathing and enhances the scavenging of exhaled gases. The environmental impact of nitrous oxide necessitates careful consideration. Until a superior alternative is identified, the authors suggest methoxyflurane and sevoflurane may present potential options but also accept that these raise safety concerns in general practice. Therefore, it is imperative that we strive to use nitrous oxide efficiently, ensuring it provides genuine benefit to our patients while minimising its greenhouse gas effects.
FA
The Surgical Dental Anxiety Scale (SDAS)
Grossman S
Br Dent J 2024; 237: 935-937
DOI: 10.1038/s41415-024-7846-1
Abstract
Dental anxiety is a prevalent issue in society and national surveys show it to be rising. As a result, strain on sedation services continues to grow. To accommodate this, there is a need to streamline services to ensure that patients who have a clinical need for sedation are able to receive it.
The Index of Sedation Need (IOSN) has been developed as a means of distinguishing sedation need from demand, enabling appropriate assessment and selection. NHS England recommends its use and the Getting It Right First Time programme has incorporated it into hospital dentistry pathways for sedation. However, many patients have sedation or require it for dental extractions, yet the Modified Dental Anxiety Scale (MDAS) component of the IOSN does not take this into account. While the MDAS is an effective tool for assessing anxiety of general dental treatment, it is not specialty or procedure-specific and may underestimate anxiety relating to dental extractions. Consequently, the suitability of its use has been called into question. This paper explores the need for a procedure-specific dental anxiety scale for use in oral surgery and outlines a proposal for a suitable model: the Surgical Dental Anxiety Scale (SDAS).
Reviewer’s evaluation, opinion and points of interest
The Indicator or Index of Sedation Need (IOSN) was developed by Coulthard et al., in 2011 to differentiate sedation need from demand. It includes three components:
- The Modified Dental Anxiety Scale (MDAS)
- Medical and behavioural indicators
- Dental treatment complexity
It is recommended that all secondary care dentistry services should provide access to conscious sedation to reduce the reliance on general anaesthetic and improve patient care and choice. Referral pathways should be established using the IOSN.
Despite its national recommendation, the tool's validity for defining sedation needs in dental extractions has been questioned. Gerrard's (2016) study at a dental teaching hospital found that only 56% of patients receiving sedation were in line with the IOSN and 50% who did not need sedation according to the IOSN were deemed untreatable without it. Goodwin et al., (2012) found that 45% of patients needed sedation despite the IOSN suggesting otherwise.
The MDAS, described by Humphris in 1995, is a widely used five- item dental anxiety questionnaire in the UK. It has been extensively validated and reliable. Not all dental procedures cause the same level of anxiety. Before the MDAS, the Corah Dental Anxiety Scale (CDAS) was used but did not include local anaesthetic injections, missing patients anxious about only injections. Humphris addressed this by adding an injection-related question to the MDAS.
However, the MDAS does not reference dental extractions, which often cause significant anxiety. This omission could lead to underestimating patients' needs for sedation as part of their IOSN score. Consequently, some patients may not be identified as requiring sedation when it might be necessary. To address this, the paper proposes a Surgical Dental Anxiety Scale (SDAS) specific to those needing extractions involving minor oral surgery.
The SDAS structure mirrors the MDAS, with modifications to address procedure-specific concerns. In the MDAS, questions escalate in anxiety, ending with a local anaesthetic injection, considered highly anxiety-inducing. The SDAS similarly orders questions by increasing anxiety, placing the local anaesthetic question before those on simple and surgical extractions.
To assess anxiety for various extraction complexities, the SDAS includes terms which the author suggests are familiar to patients, like ‘raising a gum flap’ and ‘removing bone with a drill.’ However, unless it is explained to them, the words ‘removing bone’ and ‘drill’ are bound to raise anxiety levels and it is questionable whether patients have full insight into their significance and they may well become unduly alarmed for a procedure which may not be too invasive. Instead of obtaining a true picture, graphic surgical language on a questionnaire will inevitably evoke a pronounced anxious response. Further, even if a surgical approach is not envisaged, a routine extraction can become complex and develop into a challenging procedure, requiring robust use of forceps and elevators, and involve ‘tooth or root sectioning’. Should these potential complications form part of the questionnaire to ensure informed decision-making?
More research is needed to establish the SDAS's reliability and validity and create a consistent sedation score. It is accepted that in certain cases, the SDAS may indicate the need for sedation without a calibrated score. For instance, if a patient feels ‘extremely anxious’ about ‘surgical’ tooth extractions, they likely require sedation. In any case, experience indicates that there is a clear demarcation in the perceptions of dentophobic patients between fillings and extractions, the majority consider the latter as more traumatic irrespective of difficulty and would invariably opt for sedation.
We have to acknowledge that despite thorough testing, no scale can replace clinical acumen and assessment entirely. Sedation might be appropriate despite low scores or when the questionnaire can't be completed due to capacity issues. Clinical judgement and expertise should guide decisions, with tools serving as supportive measures.
This paper aims to encourage discussion regarding the use of the MDAS and alternative, procedure-specific scales in the sedation assessment process. Reliability and validity studies are necessary for the SDAS and, until these are completed, the author admits that its clinical application is not recommended. Upon successful testing, its use may be considered as a specialty-specific dental anxiety scale to assist in the decision-making process for sedation but its overall value may well be limited.
FA
Determinants of paediatric dental anxiety after comprehensive dental treatments under general anaesthesia
Gisour E F, Beigi M, Jahanimoghadam F and Nekouei A H.
Sci Rep 2025; 15:10006
DOI: 10.1038/s41598-025-94979-y
Abstract
Providing dental treatment to young patients can pose challenges in certain circumstances, particularly when they experience anxiety about dental procedures. For this reason, general anesthesia (GA) is preferred as an alternative treatment for performing dental treatments on children. On the other hand, the use of general anesthesia could potentially increase the risk of developing dental anxiety complications. This study was aimed to explore determinants of paediatric dental anxiety after comprehensive dental treatments under general anesthesia (CDT-GA). In this prospective study, 80 healthy children aged 3 to 10 years who required CDT-GA were enrolled in 2023. Demographic information and treatment checklist (duration of GA, the number of fissure sealants, restorations, pulpectomies, pulpotomies, crowns, and extractions) were completed for each child. The standardized MCDAS-f (Modified Child Dental Anxiety Scale; Faces Version) questionnaire was used to measure dental anxiety before GA, 7 days after GA, and 14 days after GA. Data were analyzed by SPSS 26 software, repeated measure analysis, and linear regression. The results of the study showed that dental anxiety significantly decreased 14 days after CDT-GA (P = 0.013) compared to before CDT-GA (P < 0.001). Additionally, anxiety before CDT-GA had a significant direct effect on anxiety levels on days 7 (P < 0.001) and 14 (P < 0.001). Other factors, such as the duration of GA, the number of treatments performed, age and gender, did not have a significant effect on anxiety levels on days 7 and 14. Dental anxiety significantly decreases after CDT-GA, and this reduction is strongly influenced by the level of anxiety before CDT-GA. These findings highlight the importance of addressing preoperative anxiety to minimize postoperative anxiety and improve the overall dental experience for paediatric patients.
General
We are all aware that children's fear of dental procedures is a significant public health concern that complicates treatment. This study was conducted in Iran during which comprehensive dental treatments under general anaesthesia (CDT-GA) were carried out as the preferred option for young children, individuals with disabilities, and those with severe anxiety.
The authors state that research on CDT-GA has identified high rates of psychological complications in children, particularly after prolonged or multiple sessions. Studies have shown a link between the duration of anaesthesia and psychological issues such as post- operative pain, fatigue, lethargy, and increased dental anxiety. These complications can lead to long-term effects, including increased fear and avoidance of dental care, which adversely impacts oral health outcomes.
Research on psychological issues and anxiety after CDT-GA is scarce, with most studies focusing on short-term outcomes of less than a week. Many of these studies address mental health broadly, without detailed analysis of dental anxiety. This study aims to identify factors influencing dental anxiety in children after CDT-GA.
Study setting and clinical procedure
The study population consisted of 87 children, ASA Classification 1, aged 5 to 10 years who were referred for CDT-GA to one of the largest referral hospitals in Iran from June to December 2023. An anaesthetist arranged pre-operative consultations for children one or two days before surgery. The children were instructed on oral hygiene, assigned a specific treatment day under GA. An anaesthetist ensured consistent anaesthetic administration across participants. The paediatric dentist's assistant documented treatment types and GA duration. A student explained confidentiality, follow-up appointments, and questionnaire completion to parents, encouraging involvement and answering questions. All dental treatments were conducted in a single session by a paedodontist. These treatments included fissure sealants, restorative procedures, pulp treatments (pulpotomy and pulpectomy), stainless steel crowns (SSCs) for posterior teeth and the extraction of carious teeth. Local anaesthesia was administered for the extraction procedure, and gel foam was placed into the socket to effectively control bleeding.
Data collection and results
A checklist and anxiety questionnaire were used the day before general anaesthesia. Follow-up assessments were conducted on the 7th and 14th days post-procedure, with phone calls made by the researcher to ensure completion. The checklist included the child's age, gender, treatment modality, number of treated teeth and duration of GA. This study enrolled 87 children, with complete data for 80 participants (45% female, mean age 62 months). On average, 18.3 treatments were provided. Anxiety scores differed significantly before CDT-GA, 7 days after GA and 14 days after CDT- GA. Anxiety scores 7 days post-CDT-GA were lower but not significant compared to before treatment. However, scores at 14 days were significantly lower than both pre-operative and 7 days post-GA. Sex, age, number of treatments and duration of GA did not significantly impact anxiety trends.
Reviewer’s evaluation, opinion and points of interest
This study examines the psychological effects of comprehensive dental treatments under general anaesthesia (CDT-GA) on children, specifically focusing on dental anxiety. Dental anxiety in children is a significant public health issue, and managing it is critical for ensuring that young patients receive necessary dental care. Many children with severe anxiety or access challenges undergo dental procedures under general anaesthesia. However, concerns have been raised regarding the psychological consequences of such treatments, especially post-treatment anxiety. This study explores the psychological outcomes associated with CDT-GA, aiming to understand the factors influencing dental anxiety in children after their procedures.
The research involved 80 children aged 5 to 10 years who were referred for CDT-GA at a large hospital in Iran. The children’s anxiety levels were measured before the procedure, seven days post-treatment, and again fourteen days after the procedure, using the Modified Child Dental Anxiety Scale (MCDAS-f ). The results showed a significant decrease in anxiety levels by day fourteen, suggesting that while anxiety may temporarily increase immediately after treatment, it tends to decrease as children adapt to their experience. This finding is consistent with earlier studies, which have found that children often experience temporary spikes in anxiety after dental treatment, but with time, they adjust and their anxiety levels decrease.
Pre-operative anxiety was identified as the most significant predictor of post-GA anxiety, with children who exhibited higher levels of anxiety before the procedure showing greater anxiety fterwards. This finding highlights the critical role of managing pre-operative anxiety in improving the overall dental experience for young patients. Interestingly, the study found no significant impact of demographic factors such as age or sex, nor did treatment variables like the duration of anaesthesia or the number of treatments, significantly affect anxiety trends. This suggests that addressing pre-treatment anxiety is likely more crucial than other factors in determining the psychological outcomes after treatment. These results align with previous research emphasising the importance of psychological preparation before the treatment to prevent long-term anxiety and fear.
Despite the valuable insights this study provides, it acknowledges some limitations. The study relied on parental reports of anxiety, which may be subject to bias. Additionally, the potential influence of socio-economic and cultural factors on anxiety levels was not fully explored, suggesting that future studies should investigate these variables more deeply. Future research should also include larger, more diverse samples to improve the generalisability of the findings. Another limitation is that the study focused on the effects of a single session of CDT-GA, but many children may require multiple treatments. Therefore, the impact of repeated sessions under anaesthesia on anxiety levels remains unclear. It would be valuable to study how multiple experiences with CDT-GA may influence anxiety over time.
In addition to the immediate post-treatment anxiety, the study could benefit from comparing the effects of CDT-GA with other forms of medical treatment that require general anaesthesia. It would be useful to determine whether the anxiety observed is specifically related to dental procedures or if it is a more general response to general anaesthesia. Furthermore, examining how anxiety is managed in patients who receive conscious sedation for dental treatments could provide additional insights into how different anaesthetic approaches influence children’s psychological responses.
While the research provides important information about the psychological effects of CDT-GA on dental anxiety, it also raises the need for further studies. For example, research could explore the long-term psychological effects of general anaesthesia for dental procedures, as well as the role of socio-cultural factors in shaping children’s anxiety levels. A broader investigation into how repeated sessions under general anaesthesia impact dental anxiety would also be essential, as many young patients require multiple treatments. Moreover, understanding how anxiety is managed in patients undergoing different anaesthetic protocols, such as conscious sedation, could be instrumental in improving clinical practice. In conclusion, this study underscores the importance of addressing dental anxiety in children before they undergo CDT- GA. By managing pre-operative anxiety, dental professionals can significantly improve both the immediate post-treatment experience and long-term dental outcomes for young patients. While the findings suggest that pre-operative anxiety is the key determinant of post-treatment anxiety, future research examining the impact of socio-cultural factors and repeated treatments will be critical in developing a more comprehensive understanding of dental anxiety in children. The insights gained from this research could lead to better strategies for preventing and managing dental anxiety in paediatric patients, ultimately improving access to necessary dental care.
FA & JH
The role of antihistamines in dental sedation: perceptions and practices among dentists: a cross- sectional study
Ahmed K A, Alhadii B, Own N M.
Jordan Journal of Dentistry 2025; 2: 1-7
Abstract
Objectives
This study aims to explore the prevalence, reasons for use, dosage adjustments, and dentists' perceptions regarding antihistamines in dental sedation.
Methods
A cross-sectional survey was conducted among 150 dentists. Participants were asked about their usage of antihistamines for sedation, the most commonly used medications, reasons for their use, and any adjustments made to dosages based on patient factors. Additionally, the study explored their opinions on whether antihistamines could replace benzodiazepines in certain cases.
Results
Of the respondents, 46.7% reported using antihistamines, with diphenhydramine (71.4%) being the most common, followed by hydroxyzine (50.0%) and promethazine (40.0%). The primary reasons for use were preoperative anxiety control (78.6%), salivation reduction (54.3%), and adjunct sedation (42.9%). Regarding dosage adjustments, 44.7% of dentists modified doses based on patient factors. A significant difference in dosage adjustments was observed between private- and hospital-based dentists (p = 0.03). When asked about replacing benzodiazepines, 40.0% agreed, 26.7% were unsure, and 33.3% disagreed.
Conclusions
Antihistamines, particularly diphenhydramine, are commonly used in dental sedation for anxiety control and salivation reduction. However, there is a variability in clinical practices, with some dentists modifying dosages based on patient factors. The possibility of replacing benzodiazepines with antihistamines remains a topic of debate among practitioners. Further research is needed to establish clearer guidelines on the safety and efficacy of antihistamines as sedatives in dental practice.
Reviewer’s evaluation, opinion and points of interest
This research was undertaken across Libya, which has different legislation in relation to sedatives to support the delivery of dental treatment compared to my area of work (England, UK). It was interesting to learn about this, and to find from this research that so many dentists use antihistamines regularly as a sedative agent in selected cases (over half of the sample).
I can draw some parallels from my own clinical experience: the team I work in frequently comes across patients who are prescribed antihistamines, such as promethazine hydrochloride, to help with sleep on a pro re nata basis. Although not particularly discussed in overarching sedation guidance here in the UK, several of such medications are licensed for short-term sedation in the British National Formulary. In my team, we often work with our anaesthetic colleagues and general medical practitioners to consider prescription as an adjunct or pre-medication ahead of a general anaesthetic in patients who are considered tolerant to benzodiazepines yet are anxious in hospital settings, notably many adults with learning disabilities and autism. Aside from this advantage, their anticholinergic properties typically help reduce salivary secretion and they also offer an antiemetic effect, which can be additionally helpful.
Overall, I found this to be a thought-provoking piece of research, which is well written and of particular interest to the readership working in special care dentistry.
SC
Safety and satisfaction analysis of intravenous and inhalational conscious sedation in a geriatric population undergoing oral surgery
Iglesias-Rodeiro E, Ruiz-Sáenz P L, Madrigal Martínez-Pereda C, Barona-Dorado C, Fernández-Cáliz F, Martínez-Rodríguez N.
Healthcare (Basel). 2025; 13: 116.
DOI: 10.3390/healthcare13020116
Abstract
Aim
The objective of this research was to compare two methods of conscious sedation (midazolam vs. sevoflurane) used for performing oral surgical procedures in the older adult population by analyzing dental treatment-related anxiety levels, the quality of sedation, and potential hemodynamic changes during the interventions, as well as post-recovery symptoms and patient satisfaction levels.
Methods
A total of 104 patients underwent oral surgery with intravenous (age: 84.00 ± 8.410; 17 men and 36 women) and inhalation conscious sedation (age: 82.73 ± 8.809; 18 men and 33 women). Anxiety levels were recorded using the Modified Corah Dental Anxiety Scale (MDAS) and the Hamilton Anxiety Rating Scale (HARS). During the intervention, the heart rate, systolic/diastolic blood pressure, oxygen saturation, episodes of hypoxia (<90%SpO2), sedation duration, and Sedation–Agitation Scale (SAS) values were monitored. Upon completion of their treatment, all patients completed three questionnaires which evaluated their recall of the intervention, postoperative symptoms, and recommendation of the sedation method used.
Results
Anxiety levels were slightly higher in the midazolam group (MDAS score: 9.60 ± 5.849; HARS score: 27.19 ± 6.802) compared to the sevoflurane group (MDAS score: 8.37 ± 5.063; HARS score: 24.92 ± 5.199), with no statistical significance (MDAS, p = 0.453/HARS, p = 0.065). No significant differences in the analyzed hemodynamic parameters were observed between the two groups. However, SAS values were significantly higher in the sevoflurane group (p = 0.006), while the sedation duration was longer in the midazolam group (p = 0.000). Post-operative symptoms, particularly gastrointestinal disturbances and dry mouth, were significantly more prevalent in the midazolam group, while there were no differences in neurological symptoms between the two groups. The majority of patients expressed a preference for either of these sedation methods.
Conclusions
Sedation with agents such as midazolam and sevoflurane appears to be quite safe, given the absence of relevant hemodynamic changes. Midazolam has been shown to be effective for a longer duration, as well as to have a lower risk of developing greater digestive problems during the postoperative period. On the contrary, sevoflurane produced a greater sensation of dry mouth. Both sedative agents are perceived by the older adult population as satisfactory, recommending their use.
Reviewer’s evaluation, opinion and points of interest
Older people remain an under-researched group in the context of sedation for dental procedures, therefore this publication is a very welcome addition to the evidence base demonstrating the efficacy and safety of both midazolam and sevoflurane as sedative agents in this group.
I found the choice of sevoflurane as the main inhalation agent very interesting as, by comparison, its use is not very common here in the UK. Techniques involving titrated sevoflurane in oxygen or in a nitrous oxide and oxygen mixture, have not particularly been studied in older people, but more so in children and young people. There is some evidence that such techniques are potentially more effective than a titrated dose of nitrous oxide in oxygen. However, despite this, its use can be particularly resource-intensive as a simple delivery system suitable for use in a dental setting is not easily available. Therefore, from a staffing perspective, the IACSD guidance (2020 version available at the time of writing) advises that a dedicated sedationist is required. As sevoflurane brings additional properties such as amnesia as well as less of an environmental burden than nitrous oxide (due to its shorter atmospheric lifetime and lower global warming potential), whilst reading this study, I did wonder whether it will potentially hold a different place in future clinical care here in the UK, despite the present challenges… let’s wait and see.
Aside from the outcomes as mentioned in the abstract, this publication also made me think about the anxiety questionnaires used in our professional circles and our assessment of sedation quality. Here they used the Hamilton Anxiety Rating Scale, which was one of the earliest rating scales developed to measure anxiety symptoms. It includes 14 items which are rated 0 to 4, spanning both psychological aspects (such as depressed mood) as well as somatic anxiety (physical concerns such as gastrointestinal disturbance). The research team also used the Sedation Agitation Scale, where patients are scored from 1 (unrousable) to 7 (dangerously agitated) and 4 is a calm and co-operative patient. I felt that there may be a place for their application in special care dentistry, since they offer greater detail than some of the more commonplace scales currently used, allowing both the level of complexity of an individual as well as the behavioural risks involved in an episode of sedation to be easily recorded.
SC
Sedation in home care surgical procedures for a patient with dental phobia: a case report
Oliveira V G B, Ghelardi I R, Ichimura K T, Reinato I M S, Jardini M A N,
Lopes S L P C, Mendes M S S.
Spec Care Dentist. 2025; 45:e70006.
DOI: 10.1111/scd.70006
Abstract
An 88-year-old woman received dental evaluation at home after missing out on regular dental checks due to a stroke 3 years ago. Her orofacial complaints included pain in the right side of the face and a desire to use dental prosthetics. Her comorbidities included systemic arterial hypertension and sequels from episodes of a thrombotic stroke and an acute myocardial infarction. Medications used were a beta-blocker, an angiotensin-converting enzyme inhibitor, a statin, and an antiplatelet agent. During the initial evaluation, the patient was alert, using a wheelchair, and was quite anxious and apprehensive, reporting episodes of dental phobia. On intraoral examination, findings consistent with the orofacial pain mentioned by the patient were observed. Sequentially, a treatment plan was developed to address the oral condition. The treatment was initiated with basic periodontal therapy and restorative procedures, performed with non-pharmacological stress reduction management. However, due to the patient's behavior during previous follow-ups, it was decided to perform extractions under sedation with antihistamine and nitrous oxide in the home setting. The procedure was conducted with vital signs monitoring, and the use of antiplatelet drugs was not suspended. Local bleeding control measures were applied, and the postoperative period occurred without complications. Besides promoting accessibility, home dental care provides treatment in a safe environment for the patient, which enhances comfort and reduces patient anxiety. Additionally, using sedation with antihistamine and nitrous oxide achieved an adequate level of relaxation for more effective stress control during the extractions.
Reviewer’s evaluation, opinion and points of interest
I enjoyed reading this paper, as it provided an excellent solution to a common but difficult clinical situation in special care dentistry, irrespective of where we are in the world. The team making this case report are based in Brazil, which offers valuable global insight into the legislation around sedation for dental care, as well as the details of the case itself.
The authors open the case report with a great overview of the challenges in the management of anxious older people with advanced frailty and multimorbidity, and how demands on services will continue to increase with time.
The team used an interesting combination of oral hydroxyzine 30 minutes before the introduction of nitrous oxide gas, to reduce anxiety sufficiently to enable sedation for dental extractions to be carried out successfully. The authors explained that this combination / associative technique is indicated for very anxious patients where nitrous oxide alone may be insufficient to achieve the desired state of relaxation and co-operation. By combining the drugs, they aimed to optimise the desired effects by reducing the dosage, concentration, and side effects of the chosen medications. The patient was treated successfully without any complications, and highlights that such difficult situations can be managed with appropriate planning, knowledge and skill set.
It seems there are lots of places in the world where antihistamines are being used successfully by those providing sedation for dental care… are we missing a trick in the UK?
SC
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Reviewers initials
Intravenous sedation for adults with profound acquired brain injury undergoing dental treatment - a seven-year service evaluation
Doshi M, Kahatab A, Gallagher L, Prasad R, Fitzgerald R.
BDJ Open. 2024; 10:101.
DOI: 10.1038/s41405-024-00289-2.
Abstract
Background
Dental treatment may not be possible for patients with a profound acquired brain injury without pharmacological support. Intravenous (IV) sedation with midazolam is a widely accepted, safe, and effective mode of treatment for people with a disability, but there is limited evidence in this patient cohort.
Aims
This evaluation aimed to review the IV sedation service for patients with profound acquired brain injury within the dental department at the Royal Hospital for Neuro-disability.
Method
This study was a retrospective service evaluation of IV sedation for dental treatment over seven years. Descriptive statistics are presented.
Results
In total, 303 episodes of sedation were undertaken at the Royal Hospital of Neurodisability over seven years. Ninety-two percent were graded with an American Society of Anaesthesiologists (ASA) grade 3, and one-third had a history of stroke. 91% had treatment completed successfully. Complications occurred in 7.9% of cases, but all were minor, with no resulting patient harm (e.g. a transient drop in oxygen saturation).
Conclusion
Dentist-led IV sedation with midazolam is safe and effective for dental treatment for patients with a profound acquired brain injury in a specialised setting with experienced clinicians.
Reviewer’s evaluation, opinion and points of interest
It is rare to gain such an open and detailed insight into the practical aspects of working in a highly specialised unit, as provided here by the Royal Hospital for Neuro-disability, making this article especially valuable and commendable for readers interested in special care dentistry.
The authors emphasise that although there is established evidence around the safety and efficacy of IV midazolam, there is indeed very limited evidence in medically complex groups, particularly those with a profound acquired brain injury.
Within the cases reviewed, most patients, 92.1% (n = 279), were graded as being ASA 3 (Table 1), 14.2% (n = 43) had a tracheostomy in situ, and 85.8% (n = 260) were fed via an enteral tube, with baseline oxygen saturations ranging from 86–100%, with a median of 96%. The authors succinctly explain that there are several adjustments that need to be made to ensure safety in this group. This includes liaison with medical professionals and confirmation of fitness for the intended procedure. When sedating patients with a tracheostomy, an airways-trained medical nurse is present during the sedation appointment. Airway suction via the tracheostomy is often undertaken before treatment for patients with excessive chest secretions to clear the airways, which helps with breathing and oxygen saturation. A specific mask that fits over the tracheostomy is available to deliver supplemental oxygen if required. Patients with acquired brain injury often have significant dysphagia with unprotected airway reflexes; midazolam has muscle relaxant properties that can further complicate the airway. The authors advise that such patients are treated in their wheelchairs and not placed supine, water use during treatment is minimised, good chairside suction is available, and gauze is ideally placed posteriorly to reduce the risk of aspiration of debris.
Despite such high complexity, it is reassuring that the majority of patients (91%) had treatment completed successfully with IV midazolam. However, an important issue raised here is that post-sedation, patients need rest and are unable to participate in any of their other therapies for the remainder of the day, which can impact their rehabilitation programme. The team suggest that remimazolam, may offer a safe and effective alternative to midazolam in this patient cohort with less impact on recovery. Indeed, there is growing evidence for the use of remimazolam in this regard and it will be interesting to see the impact on services
with more time.
SC
Your teeth, you are in control: A process evaluation of the implementation of a cognitive behavioural therapy intervention for reducing child dental anxiety
Kettle J, Porritt J, Baker S R, Rodd H, Cross E and Marshman Z.
Community Dent Oral Epidemiol 2025: 53: 224-234
DOI: 10.1111/cdoe.13025
Abstract
Aim
To explore the views of patients, caregivers and dental professionals on the factors that influence implementation, processes and effectiveness of a guided self-help cognitive behavioural therapy (CBT) intervention, 'Your teeth, you are in control' (YTYAIC), in the CALM trial.
Methods
Semi-structured interviews were conducted as part of this qualitative component of the process evaluation, and data were analysed using a framework approach based on the Consolidated Framework for Implementation Research (CFIR) and the Five Areas Model of CBT.
Results
Thirty-seven participants were recruited. Potential mechanisms of action were identified using the Five Areas Model of CBT. Participants felt the intervention may exert change through targeting unhelpful thoughts and feelings (eg building trust and perceptions of control) and behaviours (eg encouraging effective communication and coping strategies) and facilitating a more positive situational context (eg developing more supportive relationships). Enablers (eg adaptability, design and delivery) and barriers (eg time/resource constraints, cost) to implementation were identified using the CFIR.
Conclusion
This study revealed multiple potential mechanisms of action which could reduce dental anxiety and examined how implementation and contextual factors may influence this change process. The results of the research revealed that the intervention could be implemented in primary dental care and identified the potential barriers which should be addressed to aid successful implementation of the intervention in real world contexts.
Trial registration
This clinical trial has been registered with an international registry and has been allocated an International Standard Randomised Controlled Trial Number (ISRCTN27579420).
Keywords
CFIR; cognitive behavioural therapy intervention; dental anxiety; dental care; paediatric; primary health care; process evaluation; qualitative; randomised controlled trial.
Reviewers evaluation, opinion and points of interest
For those readers who follow this section of the Digest regularly, you will be familiar with my journal scan reviews of the publications relating to the CALM trial; a four-year randomised controlled trial (RCT) roll-out, of the Your Teeth, You’re in Control self-help guide for children and young people with dental anxiety, being treated in primary care settings. This intervention is delivered by a dental professional and is in its final stages across five UK regions. Whilst we eagerly await the results of this multi-centre RCT, the project team have just published this qualitative study, aimed to explore the potential mechanisms of action and how the intervention was implemented in primary care.
The study design and process evaluation was supported by service users and a comprehensive team of public and patient representatives. A total of 37 participants were included; the breakdown of which can be found in the supplementary information, comprising a mix of parents (n=10), children (n=9) aged between 9 and 15 years old, dentists (n=14), practice managers (n=2), a dental nurse (n=1) and a dental therapist (n=1).
The study suggests that the multi-component intervention based on the Five Areas Model of CBT, may help young people by improving how they cope and communicate (targeting behaviour), encouraging supportive relationships (targeting situational influences), and help in normalising anxiety (targeting thoughts and feelings). And whilst the ‘Message to the Dentist’ was a favourable aspect of the intervention and one participants spoke positively about, the authors note the importance of recognising why it worked well and the aspects of delivery that made it effective so intervention deliverers do not reduce or undermine the possible impact of using communication tools such as this.
While the intervention was generally felt as easy to use and seen as better than usual care, financial pressures and time constraints were identified as potential barriers. Really encouragingly however, the dental professionals delivering the intervention felt these were all ‘worth it’.
This process evaluation is really encouraging and provides a fantastic insight into the active elements of this intervention Your Teeth, You’re in Control, with some revealing and detailed qualitative feedback and analysis. For those with an interest in this area, I encourage you to read the full paper. And watch this space for the details of the full RCT to be published in the not-too-distant future!
JH
Efficacy of administering a sugar-free flavor before dental injections on pain perception in children: A split-mouth randomized crossover clinical trial
Ola B T, Razan A A, Majd A S.
Int J Paediatr Dent 2024; 34: 915-924
DOI: 10.1111/ipd.13191
Abstract
Background
Sweet taste administration before dental injections helps to control associated pain in children.
Aim
To evaluate the efficacy of using a sugar-free flavor on pain perception during dental injections.
Design
Children (n = 84) aged 4–9 (mean 6.71 ± 1.55) years who required buccal infiltration bilaterally participated in this split-mouth randomized crossover study. On the test side (flavor visit), infiltration injections were applied after receiving a sugar-free flavor. On the control side (no flavor visit), sterile water was administered. Demographic characteristics, body mass index (BMI), and sweet taste preference (STP) were recorded. Pain perception during injection was measured using heart rate (HR), sound, eyes, and motor (SEM) scale, and Wong–Baker Faces pain scale (WBFPS).
Results
Most children had healthy weight (72.6%) and equal STP (32.1%). In the test side, mean HR during injection, HR differences before and during injection, and SEM scores were significantly lower (p < .001, for all). There was no significant difference in the WBFPS between both visits. Flavor had a significant effect on pain reduction (p = .001 for HR, p = .000 for SEM), whereas age, gender, BMI, STP, and treatment side did not. Treatment sequence had a significant effect on total SEM scores (p = .021); children who received the flavor during their first visit had lower SEM scores.
Conclusion
Using a sugar-free flavor before dental injections helps in reducing associated pain in children.
Conflict of interest statement
The authors declare no potential conflicts of interest with regard to the authorship and/or publication of this article.
Reviewer’s evaluation opinion and points of interest
This is an interesting article for those wishing to improve the patient experience when administering local anaesthesia (LA) to those of any age, not just paediatric patients. After initial piloting, a sugar-free cotton candy LorAnn flavour was used in this split mouth randomised crossover clinical trial. The children had bilaterally carious maxillary primary molars.
A topical anaesthetic was used first at the injection site and then they asked the children to rinse out. They then allowed the children to smell the flavour first before dispensing one drop of flavour on the tongue with a cotton tip. In the control visit, sterile water was applied in a similar way. Finally the local anaesthetic was administered. The pain assessment tools used were: pulse rate / heart rate monitoring using a pulse oximeter; the sound, eyes and motor scale and the Wong-Baker FACES Pain Rating Scale.
This study is the first to show that prior administration of a sugar free flavour as a distraction technique can reduce pain during dental injections in children aged 4-9 years. Previous studies have looked at the effect of sucrose solutions. This technique has efficacy irrespective of the child’s age, gender, body mass index, or sweet taste preference.
It is thought that sugar-free flavour solutions act by simultaneously activating the taste and olfactory senses to control associated pain during LA. This article certainly gives food for thought.
One of the limitations of the study was the lack of a negative control group, where no intervention was made (no flavourless placebo or experimental taste). This would have eliminated any chance of distraction made by the placebo itself.
RW