Conscious Sedation in Dentistry

Prof. James Roelofse (Head: Anaesthesiology and Sedation – University of the Western Cape Visiting Professor in Anaesthesiology – University College London, London, UK )

The provision of adequate pain and anxiety control is an integral part of the practice of dentistry. The General Dental Council in England , and I believe all Dental Councils, have indicated that this is both a right for the patient, and a duty placed on the dentist. All patients deserve appropriate pain and anxiety control for any dental procedure – a range of pharmacological and non-pharmacological options are available.

The area of conscious sedation for dentistry has attracted a lot of attention worldwide. Since 1998 there has been a sea change in the provision of conscious sedation in the United Kingdom . This has resulted in an increased emphasis on the safe and effective provision of conscious sedation.

All international professional societies, including SADA, accept that conscious sedation can be delivered in a dental practice, in a community dental service clinic, or in a hospital setting. The American Society of Anesthesiologists published Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. These Guidelines, and I quote, are designed, “to be applicable to procedures performed in a variety of settings ( i.e. hospitals, clinics, physician, dental, and other offices) by practitioners who are not specialists in anesthesiology” SADA Guidelines on Conscious Sedation in Dentistry state clearly that, “conscious sedation is appropriate for patients receiving treatment in the dental practitioner’s rooms”. This is consistent with all international guidelines on conscious sedation.

Professional dental societies worldwide can feel proud about their contribution towards the safety of conscious sedation. Numerous guidelines are available to support this. The purpose of these guidelines is to allow practitioners to provide their patients with the benefits of conscious sedation while minimizing the associated risks.

In 2001 Dental Societies worldwide, with guidelines on conscious sedation in dentistry, received a huge complement from the UK Academy of Medical Royal Colleges and their Faculties – this was a report of a working party established by the Royal College of Anaesthetists on Safe Sedation Practice – “given that the majority of users, other than dentistry, never attend formal courses of instruction, this is not surprising” – pointing to the evidence that guidelines are not always followed. The UK Academy of Medical Royal Colleges come to a very interesting conclusion – I will say more about this later – “the key point is that safety will be optimized only if practitioners – and this was addressed to all practitioners, specialists and non-specialists – use defined methods of sedation for which they have received formal training”

This brings me to the issue of sedation providers. Who can administer conscious sedation for dentistry – we need to look at the national and international picture. I have been asked to give a lecture at the World Congress of Anaesthesiologists in 2008 on, “Who should administer conscious sedation” If we look at the world picture, then we see that the majority of conscious sedation cases for dentistry are being done by non – anaesthesiologists, who have been trained to administer conscious sedation for dental cases – with a remarkable safety record. This is a tribute to the Dental Societies who have guidelines in place, and insist that those practitioners who do conscious sedation in dentistry – as in the SADA Guidelines, must “undertake formal and ongoing education and training” – more about this later. In 2005 an questionnaire was sent out to 116 University hospitals in the USA and Canada to find out who are involved in providing sedation services – results show that 59% of the sedation cases were done by a physician/nurse combination – anaesthesiologists were involved in 26% of the cases.

There are no international guidelines on conscious sedation in dentistry that say non – anaesthesiologists cannot do conscious sedation in dentistry. In fact, numerous societies have taken responsibility and assiduously promulgated guidelines for sedation by non – anaesthesiologists. Furthermore, the existence of these guidelines is, at least in part, tacit approval for non – anaesthesiologists to provide conscious sedation. The International Federation of Dental Anesthesiology Societies is a leading player in the world in making conscious sedation in dentistry safe. They are also involved in giving direction in teaching pain and anxiety control. This organization has 16 member states of which South Africa is a member. The author is a member of the board.

In the UK the DSTG (Dental Sedation Teachers Group), of which the author is a member, plays an important role in leading the direction as far as training in conscious sedation is concerned.

I peer-reviewed the National Dental Guidelines on Conscious Sedation in Dentistry in 2006 of the Scottish Dental Clinical Effectiveness Program. The guidance was produced by a group of professionals with a particular interest and experience in dental sedation. The guidance is an evolution of the report by a subgroup of the Standard Dental Advisory Committee in the UK, and extends the advice for dentistry by the Scottish Intercollegiate Guideline Network – nowhere in this guidance is there any reference that non – anaesthesiologists cannot administer conscious sedation in dentistry – the guidance is however clear that any practitioner, and this includes everybody, doing conscious sedation for dentistry must be trained!

We need not debate the issue of safety of conscious sedation for dentistry in the surgery here – there are numerous publications on this issue. The fact that it is now supported at international level also shows that conscious sedation has become a safe treatment modality.
The author, and a maxillofacial and oral surgeon, will shortly publish on a comparison of the safety and efficacy of conscious sedation and general anaesthesia in 600 patients – conscious sedation was done in the dental surgery. It is enough to say at this stage that all cases undergoing conscious sedation in the dental surgery were safely done – there were no adverse events, nor any escalation in care. The incidence of side effects was minimal with conscious sedation – patient satisfaction was significantly better with conscious sedation.

This brings us to the issue of training. I believe that qualifications and training should be the foundation of safe practice, whilst the selection of patients and the environment are dependent upon the experience of the sedationist. Continuing professional development is vital in creating a link with guidance and guidelines.

SADA should be complimented on the issue of training for conscious sedation in dentistry in South Africa . Their Guidelines drafted in 2001, and updated in 2007, state clearly what is expected, “education and training in the theory, methods and techniques of conscious sedation can be provided in academic institutions where conscious sedation is practiced and taught ——– even for skilled sedationists and their assistants, refresher courses should be attended at least annually”

With this in mind the University of Stellenbosch , and now the University of the Western Cape started an University-accredited Postgraduate Diploma in Conscious sedation for practitioners. This course provides exactly what the SADA guidelines say, “education and training in theory, methods and techniques of conscious sedation” All the practitioners must pass an ACLS/APLS course as part of the diploma, indicating that they know how to resuscitate if this becomes necessary. This diploma has attracted international students from the rest of Africa, the UK and Canada .
We also present a Masters program in Conscious sedation – this gives students a wonderful opportunity to do research in this field. In the past 4 years five students received their reward with research on a variety of safety and efficacy issues. Many publications will follow in the years to come.

The author is also the program director of the Postgraduate Diploma in Conscious Sedation and Pain Management presented by University College London, London . More than 100 practitioners from all parts of the world have done this certificate over the past 3 years. This course is available for medical and dental practitioners and include theoretical and practical training.

In 2006 we extended our training program into East Africa for anaesthesiologists and non-anaesthesiologists.

The author has been nominated as chairman of a committee that must develop conscious sedation in East Africa . This is a tripartite arrangement between the World Health Organization/UNICEF and an East African University . This will also involve training non – anaesthesiologists to do conscious sedation in rural areas.

The above shows clearly that non – anesthesiologists have become an important group of service providers in conscious sedation for dentistry – in fact they have become policy makers.

On a last note – we have been involved in conscious sedation for dentistry at the Faculty of Dentistry, currently the University of the Western Cape , for the past 15 years. Our sedation providers are mostly non – anaesthesiologists who did our diploma program. We have had no mortalities, no escalation in care, no serious adverse events, doing both children and adults.
We are tremendously proud about this achievement because we have been able to provide a sedation service for those who cannot afford private healthcare.

Let me conclude – we don’t need more guidelines, we need practitioners that follow existing guidelines. Thus the real requirement is for improvement in both the awareness and implementation of information that is already widely available.
As academic people with no vested interests, but the safety of our patients, we need a partnership with SADA, as is the case in all international societies on conscious sedation for dentistry.
Let us not forget – conscious sedation does not belong to a diverse group of people that include paediatricians, anaesthesiologists, emergency medicine physicians, radiologists, endoscopists, dentists, nurses and hospital administrators.
Conscious sedation belongs to our patients. We will never compromise their safety!

James Roelofse
Professor and Head of Anaesthesiology and Sedation
University of the Western Cape

Visiting Professor in Anaesthesiology
University College London,
London , UK

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