Malaysian Dental Journal

Vol 2/2016

MALAYSIAN DENTAL JOURNAL

Care Settings in Conscious Sedation for Dentistry: What is Required? - A Literature Review

a b c Siti Zaleha Hamzah , Samalie Koburunga , Chris Dickinson a. Specialist in Special Needs Dentistry. Department of Special Needs Dentistry, Hospital, Jalan Semenyih, 43000 Kajang, b. Senior Specialist Clinical Teacher (King’s College London Dental Institute). Department of Sedation and Special Care Dentistry, King’s College London Dental Institute, Floor 26, Tower Wing, Guy’s Hospital, Great Maze Pond, London SE1 9RT a. Consultant (Guy’s & St Thomas’ NHS Foundation Trust), Honorary Senior Lecturer (King’s College London Dental Institute). Department of Sedation and Special Care Dentistry, King’s College London Dental Institute, Floor 26, Tower Wing, Guy’s Hospital, Great Maze Pond, London SE1 9RT

ABSTRACT The aim of this literature review is to review the current care setting for conscious sedation for dentistry in the primary and secondary care sectors in the United Kingdom (UK) and to recommend a plan for setting up a service for the provision of conscious sedation in based on the UK models. An electronic search using various databases and web-based search engines were conducted during the period from January to March 2016. Various combinations of keywords were used to help the literature search including dental care settings, conscious sedation, equipment for conscious sedation, referral pathway for sedation and training in sedation. The findings have shown that, although there are specific requirements for the facilities practising sedation, the majority of the requirements are common to all dental practices, such as health and safety, infection control, emergency drugs etc. The good integration between primary and secondary care in providing conscious sedation relies on the compliance with the referral pathway. It is recommended that the practice of conscious sedation

Malaysian Dental Journal

Vol 2/2016 in the dental setting in Malaysia begins at the Special Needs Dentistry (SND) Unit, Kajang

Hospital because the unit has been partly equipped for conscious sedation and the specialist in charge has received appropriate training in Conscious Sedation for Dentistry at King’s College

London Dental Institute. Ensuring safety, effectiveness and appropriateness of the sedation techniques used are the major aims when delivering care to fit individual needs. It is highly recommended to look into the country in which the service has been well established such as

United Kingdom as a reference for future development of the conscious sedation service in

Malaysia.

Keywords: Dental care settings, conscious sedation, equipment for conscious sedation, referral pathway for sedation and training in sedation.

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Introduction

The main objective of using the conscious sedation technique is to ensure patients’ comfort while receiving dental treatment. This must be addressed appropriately according to individual requirements. The National Dental Advisory Committee,

General Dental Council, Standing Dental Advisory Committee and the Dental Sedation

Teachers Group have accepted the following definition for Conscious Sedation:

“A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.”1, 2

Conscious sedation for dentistry in England began with the administration of ether for dental extractions by a dentist, James Robinson in 1846. In the 1900s, it was reported that nitrous oxide was used for inhalation sedation for dentistry. It was then followed by the use of intravenous barbiturates, hexobarbitone, in UK dental practice in the 1930s. However, information regarding the care settings of sedation in the yester years is lacking. Nevertheless, in the year 2000, after the publication of “A Conscious

Decision”3 which led to the cessation of general anaesthesia in dentistry in primary care settings, more reports and guidelines have been published and have taken care settings including environment and facilities, equipment, record keeping, training, referrals and techniques for conscious sedation into consideration.

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This literature review will address various topics about the requirements for setting up a conscious sedation unit in dentistry especially in the UK and how this will assist a country such as Malaysia to develop the service which currently is not widely available.

Aims

This review aims to address the key issues and recommendations with regards to:

i. The current care setting for conscious sedation for dentistry in primary

and secondary care in the UK.

ii. The plan for setting up the dental care settings in Malaysia for conscious

sedation based on the settings in the UK.

Methodology

The literature review began with an electronic search using database and web-based search engines. It was undertaken during the period from January to March 2016. The initial search was conducted through a library electronic database which included

Pubmed, Ovid Medline, Science Direct Journals Elsevier and SCOPUS Elsevier for relevant articles. The additional search was performed via web-based search engines such as Google Scholar, Google, reports and documents from the National Health

Service (NHS), Public Health Department, British Dental Association and Ministry Of

Health Malaysia websites. Some of the literature was obtained from the bibliography of relevant papers. Various combinations of keywords were used to help the literature search including dental care settings, conscious sedation, equipment for conscious

Malaysian Dental Journal

Vol 2/2016 sedation, referral pathway for sedation and training in sedation. Articles and documents which are published in English and Bahasa Melayu (author’s first language) are included. Since the number of papers related to this topic is limited, there is no time scale for the published articles specified.

Findings

Structure and Organisation of Dental Care Setting Under the National Health

Service (NHS)

Since the 1st April 2013, the oral health care delivery system under the National

Health Service (NHS) in United Kingdom has undergone major changes. The NHS

Commissioning Board commissions the dental services (primary and secondary care) directly, therefore, the integration between primary and secondary services is more efficient and provides better outcomes for patients and clinicians 4. With regards to conscious sedation for dentistry, it may not be significantly affected but certainly may improve the patient care and referral pathway from primary care to community and secondary care settings. Sedation services under the NHS can be provided 5:

1. in primary dental care services

2. in secondary care

3. by independent contractors under Personal Dental Service (PDS)

agreements (which could be limited to the provision of treatments under

sedation)

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4. by independent contractors under General Dental Service (GDS)

contracts. (provided that sedation is an agreed ‘additional service’).

The Primary Care Setting

The primary care service in the UK is commissioned according to the following routes:

GDS contracts, PDS contracts which include Community Dental Services (CDS) and non-mandatory services such as orthodontics and sedation. The CDS is the service led by a specialist such as Special Care (SCD) and Paediatric Dentistry 4, 6 .

As a consequence of a report entitled ‘A Conscious Decision’ in 2000, the demand to carry out conscious sedation for dentistry especially in primary care settings has increased. This report emphasised that “general anaesthesia for dental treatment should only be used where there is no other appropriate method of pain and /or anxiety management available for a patient”, thus limiting such management to be done in a hospital setting where access to critical care facilities is available 5.

Therefore, to fulfil such demand, commissioning of sedation service in primary care has been set to encompass assessment of needs, reviewing service provision, deciding priorities, designing services, management of demand, referrals and individual needs assessments, management of performance and seeking public and patient views. A publication by Foley in 2002 reported that the provision of sedation in primary care varies across different practices. The majority of the participants felt that sedation is required in their practice but more than 50% of them were not able to offer the service due to inappropriate training 7. It has also been reported that sedation is provided across the life course and social spectrum in support of NHS primary dental care. However,

Malaysian Dental Journal

Vol 2/2016 there is an existence of geographical inequalities in accessing primary dental care sedation service 8.

Apart from that, although there are specific requirements for the facilities practising sedation, the majority of the requirements are common to all dental practices, such as health and safety, infection control, emergency drugs etc. The Dental Reference

Service (DRS) checklist of the NHS Business Services Authority can be used to inspect practices in relation to sedation services 5.

The Secondary Care Setting

Many dental specialist services provided by the Secondary Care Service in the UK are limited. Some are only available at dental hospitals and mainly provided by academics holding honorary NHS contracts 9. Others may be accessed at all general hospitals and some might be provided only by a single consultant in a particular specialty. Private secondary care dental service is also an alternative.

As far as sedation is concerned, a recent survey by Coulthard et.al. 10 has indicated that 68.7% of the UK dentists/doctors who participated in the study believe that advanced sedation techniques are more suitable to be carried out in the secondary care setting. It covers all Tier 2 service which will be described later in detail. While the sedation setting requirements are no different from that in the primary care, the availability of multidisciplinary teams and advanced sedation training received by the specialists are the major advantages in secondary care settings. This makes it more suitable in managing patients with American Society of Anaesthesiologists

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Vol 2/2016 classification of III (ASA III) (unstable) and above whereby the medical problems require special attention.

The Integration of Primary and Secondary Care Settings in Delivering

Conscious Sedation

Although 90% of dental care can be provided by primary care dentists, there is a range of complex cases which are not appropriate for primary care and have to be managed by specialists via referral from General Dental Practitioners or General Medical

Practitioners 11.

Referral Pathway

The NHS, United Kingdom, produced a Referral Criteria and Guidance for Sedation

Services in 2013 12. The guidance has introduced two types of referral pathway which fall under Tier 1 and Tier 2 service. An appropriate referral pathway shall assure that the patients are assessed and triaged accordingly by a qualified dental team such as the

SCD CDS, Hospital Dental Service (HDS) or trained GDS sedationist.

Tier 1 service is the provision of standard techniques of inhalation, oxygen + nitrous oxide (O2 + N2O) and intravenous sedation (IVS) with midazolam which would be the simplest and least interventional measures to relieve anxiety. This includes O2 + N2O sedation for children above 5 years old and adults with a sufficient level of understanding of the treatment. Similarly, adults (16 years and above) with severe dental anxiety and suitable for intravenous midazolam sedation are also categorised under Tier 1 service. However, it should be noted that referral to primary care should

Malaysian Dental Journal

Vol 2/2016 be limited to patients of ASA I and ASA II categories and have a Body Mass Index

BMI of between 18 and 35. ASA III patients and those with a BMI of less than 18 or more than 35 should be referred to the CDS or HDS 12, 13.

Tier 2 service relates to the provision of more advanced sedation techniques which is usually a consultant anaesthetist supported service 12. Alternative or advanced sedation techniques are those outlined in Standards for Conscious Sedation in the

Provision of Dental Care 2015 (conscious sedation other than O2 + N2O inhalation for children below 12 years old; combination of midazolam and opioid/ propofol/ ketamine; propofol either alone or combined with other agents; inhalation sedation

(IHS) using any agent other than N2O; combined routes: IVS+ IHS/ intranasal sedation). Children aged between 3 and 5 with dental anxiety are also referred to Tier

2 service. The same goes for stable ASA III patients.

As a general rule, a patient has to be assessed for suitability prior to being referred for sedation services. Appropriate anxiety assessment should be undertaken according to the age group. NHS referral pathways for sedation for children in primary care, adults in primary care, overall NHS sedation referral pathways and dental sedation referral form can be accessed from the NHS website.

Practice Facilities Requirement

A lot of literature has outlined the specifications of practice facilities in order to carry out conscious sedation to ensure the safety and comfort of patients. While meeting the requirements of a general dental practice is essential, sedationists must ensure that each component in the practice is appropriate and complies with the national guidance for sedation 1, 14.

Malaysian Dental Journal

Vol 2/2016 i. Space Requirement

Generally, it must be clinically fit for purpose and large enough to accommodate all the necessary equipment, wheelchair access and dental care team. It should include appropriate lighting, ventilation and adequate access for emergency services, treatment area and recovery area 1, 2, 14, 15. This is to ensure that patient safety is guaranteed and good care can be provided efficiently. ii. Dental Surgery

Due to limited space available, many practices may not be able to provide an enclosed dental surgery with an en-suite disability friendly toilet as recommended. Nonetheless, it is forgiven as long as the patient’s privacy is assured and the size is reasonable to manage any emergency that happens 1, 2, 14. The operating dental chair should be able to be adjusted in the head-down tilt position in case artificial respiration or intubation is required at any time during the sedation procedure as stated by the British Dental

Association as well as ensuring that all the equipment is in proper function prior to carrying out the sedation 15. iii. Recovery Bay

Another important component is a recovery bay or area which is separated from the waiting area and has direct access from the surgery room. Therefore, the individual privacy of patients and escorts is assured 1, 14. The recovery chair must be capable to be lowered down to manage any emergency event. This may allow a calm and smooth recovery process. In case a dedicated recovery bay is not available, a patient must be allowed to recover in the treatment area and can only be discharged after adequate recovery is achieved with full support and guidance 15.

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The storage area should be specific and suitable for the items to be stored with regards to space, temperature, humidity and ventilation. In addition, it must be in compliance with the current regulations and guidelines 16. A dedicated consultation room is optional though it is a pleasant environment to have one in the practice to maintain patient confidentiality and privacy throughout the process of sedation.

Equipment for Sedation

Equipment for sedation is the major concern in this literature review as it represents the safe sedation techniques to be carried out in a practice be it in primary or secondary care settings. i. Inhalation Sedation (IHS)

It is essential that the equipment for inhalation sedation is dedicated and is specifically designed to administer the gas for dentistry purposes. It must conform to British standards at all times and follow the maintenance guidelines provided by the manufacturer with regular servicing documentation recorded 2, 15. There is a variety of inhalation sedation machines available on the market but similar features and operating systems are applied. The safety feature permits a minimum concentration of 30% oxygen at all time. This unique mechanism would prevent the delivery of hypoxic gas mixtures. This ensures a safe delivery of the gas by the sedationist who is also the dental operator during the procedure16.

Apart from that, the gas is generally supplied to the delivery machine by two colour coded cylinders, black with a white collar and solid blue containing O2 and N2O respectively. In a portable system, the cylinders are mounted below the head of the

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machine and usually available with two O2 and N2O cylinders. One of each is labelled ‘IN

USE‘ and the other is labelled ‘FULL’ designated as reserve. The ‘IN USE‘ should be turned

on during the procedure16. The cylinders must be safely stored according to current regulations

to prevent injury 2. The components of the system are illustrated in Figure 1, 2 and 3.

Figure 1: The Gas Cylinders and Other Components

Flush button

Gas indicator

Patient breathing circuit Reservoir bag

Nitrous oxide tank Oxygen tank

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Figure 2: Nasal Mask

Figure 3: Head of The Machine

Nitrous oxide Oxygen flow flow meter meter

Mixture dial

Flow control knob

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A large storage cylinder or a remote tank which supplies the gas directly to the patient

breathing circuit is recommended whenever a few surgeries are to be utilised for IHS.

In this situation, a colour coded, non-interchangeable pipe line is required.

The gas is delivered via three components consisting of inspiratory tube, a nasal

mask (varies in size and design) and expiratory limb. A good seal of the nasal masks

should be achieved to prevent leaking of the gases. Control of Substance Hazardous to

Health (COSHH) standards must be complied with when considering the scavenging

of the waste gases. The scavenging system must be active and sufficient 2, 16. Craig and

Skelly have recommended a machine checklist prior to its use as malfunction of the

system is totally unacceptable. The checklist is displayed in Table 1.

Table 1: Nitrous Oxide Machine Checklist

Nitrous Oxide Machine Checklist

Cylinders: “FULL” and “IN USE”

Pressure gauges

All connections

Flow and mixture controls

Oxygen flush controls

Reservoir bag

Breathing system and range of mask

Scavenging system

Adopted from Craig and Skelly, 2004

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ii. Intravenous Sedation (IVS)

As opposed to IHS, the equipment and drugs required for IVS are much simpler and

inexpensive. Generally, regardless of the drugs used for the IVS, all the administration

and monitoring devices must be available within the treatment area. The equipment

should be calibrated and maintained regularly for all types of infusion techniques

especially monitoring devices such as pulse oximeter and blood pressure monitor 2, 16.

In addition, it is required that supplemental oxygen is available at all times in case the

need for it arises, concurrent with the skills of delivering intermittent positive pressure

ventilation to patients.

Listed below (Table 2) are the items required for administration of IV midazolam

which is often used as a drug of choice in dentistry for sedation:

Table 2:Materials and Equipment Required for IV Midazolam Administration16, 17

Drugs/ Devices Description

Midazolam Drug used for IV sedation prepared in 5mg/5ml or

10mg/2ml solution in a vial. The former preparation is

more preferable as it is easier to be titrated to prevent

over-dosage and over-sedation.

Flumazenil Antagonist for midazolam presented in 500

micrograms in 5ml

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Vol 2/2016 Syringes (5ml or 10ml) The 5ml syringe is the most useful one as it can be

used for both midazolam and flumazenil. However, if

a patient requires more than 5mg of midazolam to

achieve an optimal sedation, 10 mg syringe is more

appropriate to be used. Ensuring that the syringe hub

is compatible with both the drawing-up needles and

the cannula system is essential to allow smooth

delivery of the sedative agent.

Drawing up needles To draw up the midazolam into the syringe

(21 gauge)

Cannula system The currently used system is the Y-type cannula as it

allows easy access to small veins and is less painful. It

is best to avoid the butterfly needles as it tends to

develop blood clot within 5-10 min after

administration of the sedative agents and has the

potential to cut through the vein with the patient’s

movement. It is important to keep a flexible plastic

cannula in a vein throughout the procedure until

normal recovery is obtained and the patient is ready to

be discharged.

Malaysian Dental Journal

Vol 2/2016 Gauze A piece of clean gauze is usually used to hold the drug

ampoule while breaking it to reduce injury to the

operator’s finger.

Tourniquet A tourniquet may not be used routinely but only when

it is indicated in cases where the access to the vein is

difficult.

Antiseptic wipe It should be used to wipe the skin surface prior to

venepuncture to prevent infection and to get clear

access to the vein.

Stopwatch/ clock This is used to monitor the drug titration rate.

Non-allergenic tape To hold the cannula in place and to hold the dressing

over the venepuncture site after de-cannulation.

Pulse oximeter This device measures arterial O2 saturation (SaO2) and

heart rate which is a mandatory requirement during

IVS of any techniques of infusion. An alarm is

incorporated in the device to indicate low SaO2,

tachycardia and bradycardia. It should be set no lesser

than 90% of SaO2, 140 beats per min (bpm) for

maximum limit of the heart rate and 50 bpm for

minimum limit of the heart rate. Although the

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of abnormality of the reading, clinical monitoring and

justification of the patient’s condition by the dental

team remains crucial for patient safety under sedation.

Blood pressure (BP) BP is measured before sedation starts to get the

monitoring device baseline reading which should be within the

acceptable therapeutic range according to the patient

medical conditions if any. It is also measured during

recovery to ensure the patient is discharged when the

BP returns to normal.

iii. Medical Emergency Kit

A medical emergency kit should be readily available in the treatment area in preparation

for any emergency event which may occur. Although the risk of having medical

emergencies is considered low during IHS and IVS with a single drug, some form of

preparedness is still essential. It is also a requirement regardless whether sedation is

practised or not within the dental premise 18. A basic medical emergency kit should

comprise of the items listed below in Table 3.

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Table 3: Contents of Basic Emergency Kit 17-19

Contents suggested for a basic dental office emergency kit when using nitrous oxide/oxygen inhalational sedation and enteral sedation

Emergency equipment Emergency drugs

Stethoscope Oxygen (at least one portable “E”-sized

cylinder with regulator)

Blood pressure cuffs (adult and large adult Flumazenil (Romazicon and benzodiazepine size) antagonist)

Self- inflating bag-valve device or any Epinepherine (1:1000 = 1mg/ml x 3, or an mechanism for delivering positive pressure EPI-Pen.2)

O2

High volume suction tubing and Younkauer Diphenhydramine (Benadryl, 50mg/ml) suction tips

Clear face masks Albuterol inhaler (Proventil)

Syringe (1ml, 5ml and 10 ml) Glucose (e.g cake frosting, orange juice)

Needles (27 and 20 gauge) Nitroglycerine (spray or paste)

Dilution fluids (sterile water, 0.9% sodium Aspirin chloride)

Alcohol sponges

Gauze

Oral and/or nasal airways

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Placing the contents in one easily identified container is preferable as it is easier to be transported. The dental team should be familiar with the contents, check the expiry dates daily and most importantly must be able to utilise the equipment and perform the life support skills when and if required 18, 20. iv. Maintenance and Service of the Equipment and Devices

Maintaining equipment and devices is an integral part of dentistry whether or not sedation is practised and even more crucial if sedation is carried out regularly. It includes the maintenance of the machines used for the delivery of sedative agents, monitoring equipment and emergency equipment according to manufacturers’ instructions and conform to current British standards. Regular checks would ensure that they are all in proper function for the designated purpose within the stated expiry date.

This has to be recorded and documented by an appointed person in the team 17. v. Storage, Handling and Disposal of Gas Cylinder and Sedative Drugs

Storing gas cylinders for inhalation sedation should follow a systematic manner. Gas cylinders must not be held for a long period of time and the longest kept one should be next to be used. The storage of the cylinders requires certain criteria such as a dry, flat surface, well ventilated room, away from sources of ignition and flammable materials and any sources of external heat which may affect the mechanical integrity of the gases.

Transportation of the cylinders including moving and lifting, must be done appropriately following specific guidelines or manufacturer’s instruction 17.

On the other hand, in 2008, the National Patient Safety Agency recommended that midazolam should only be kept in dental practice in 2ml and 5ml preparation in an ampoule with a standard concentration of 1mg/ml 21. Midazolam and Temazepam are

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classified under schedule 3 by the Misuse of Drugs Regulation 2013. Midazolam can

be stored on an open shelf. Although the transaction of the drugs is not required to be

recorded in a controlled drug register, they should be denatured and rendered

irretrievable before disposal. Purchasing records must be retained for at least two years

in the practice 17.

Documentation and Clinical Records

Maintaining good clinical records and documentation is a legal requirement in every

dental practice. They must be clear, thorough and updated.

Inclusion of the information outlined below is recommended for the clinical records of

patients undergoing sedation 17, 22:

• Medical history assessment and questionnaire incorporating prescribed medications

and drug allergies

• Previous dental history

• Presenting complaints

• Previous sedation history and general anaesthesia

• Reason for referral if relevant

• Indication for sedation

• Pre-sedation assessment

• Pre and post-operative instruction (written and verbal)

• Instructions for escort

• Presence of accompanying responsible adult

Malaysian Dental Journal

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o Venepuncture access

o Monitoring measures: SaO2, BP, heart rate (HR)

o Sedation scale

o Acceptance of sedation and treatment

o Complications if relevant

o Post-sedation assessment, recovery level and time of discharge and de-

cannulation

• Dental treatment

• Treatment plan for the next visit

i. Anxiety Questionnaire

Various anxiety scales available can be utilised according to the clinician’s preference.

The Corah Anxiety Scale and Modified Dental Anxiety Survey (MDAS) are the most

common ones used as the questionnaires are short and easy to understand 23. This is to

verify the levels of anxiety so that an appropriate treatment plan and better dental

management catered to the patient’s needs can be carried out. It is good practice to keep

the questionnaire in the patient’s clinical record.

ii. Informed Consent and Consent Form

Informed consent is a mandatory component that should be taken into account. A

consent form should be clear and explained to the patient and escort with regards to

dental treatment and sedation technique. There must be a section where both the patient

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Having a Standard Operating Procedure (SOP) in a practice for a specific clinical procedure, especially conscious sedation, advocates reliability, consistency, accountability and high standard of treatment approach. This in turn should be in line with the current UK guidelines available in providing conscious sedation for dentistry.

The information relating to specific responsibilities of each team member, safe and effective use of the sedative agent, storage, access to the drug, emergency response as well as appropriate review of the SOP, lead author and contributing individuals to the

SOP should be included in the document 17.

It is also recommended to keep the most current guidelines such as Standards for

Conscious Sedation in the Provision of Dental Care published in 2015 by the

Intercollegiate Advisory Committee for Sedation in Dentistry in the practice. Other useful guidelines could be The Safe Sedation Scheme: The quality assurance programme for implementing National Standards in Conscious Sedation for Dentistry in the UK and Conscious Sedation Advice by the British Dental Association.

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Training and Education in Sedation

Proper training and education in conscious sedation for the dental team involved in carrying out the procedure should aim to achieve the highest standard of skills in various aspects concerning knowledge and critical understanding, intellectual and practical skills as well as personal attitude. The Standards for Conscious Sedation in the Provision of Dental Care report has documented in detail the learning outcomes that should be achieved following the completion of the training for each specific group such as the dentists and the dental nurses.

The provision of the course should be advocated by an accredited and nationally recognised organisation. In addition, the trainers must be experienced sedationists in dentistry for the techniques to be taught. However, the syllabuses outlined in the report may be modified following the local legal authority guidelines and practice 1. i. Sedation Training for Dentists

Upon completion of the training, a competent dental sedationist should be capable of assessing the needs and suitability of the patient for conscious sedation. Apart from that, the ability to apply the knowledge and skills with confidence must be demonstrated specifically in the area of assessment and treatment planning for both inhalational and intravenous midazolam sedation techniques, monitoring, managing sedation-related complications together and a caring attitude towards patients 2, 24.

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Dental nurses who assist in providing conscious sedation should receive appropriate training which conforms to the Certificate of Dental Sedation Nursing as awarded by the National Examining Board for Dental Nurses (NEBDN) 25. The training includes the completion of a log book in the workplace of sedation combined with practical competencies. Ongoing Continuous Professional Development (CPD) education should be attended and recorded. In-house training may be acceptable as long as it covers the topics documented in the NEBDN syllabus. However, this type of training must be appropriately and thoroughly recorded 17 iii. Advanced Life Support (ALS) /Immediate Life Support (ILS) Training in

Hospital

Should there be any emergency that occurs in the dental office, everyone in the dental team must understand the role and responsibility in the basic emergency action plan and receive training in Basic Life Support (BLS) 26. ALS/ILS training may be appropriate for dental sedationists.

The knowledge should be updated via continuous and hands-on training in the management of medical emergencies. Conducting regular emergency drills and those related to sedation at least once a year in dental practice could help in improving the skills and reinforce the responsibilities of each team member during emergency situations 18.

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Planning for Setting up a Conscious Sedation for Dental Service in Malaysia

The practice of conscious sedation in the dental setting in Malaysia is not readily available. Many dental professionals are worried about the safety issues concerning conscious sedation if it were to be performed in the dental setting.

Without special training and proper equipment, sedation is not advisable to be practised by dental professionals. In the primary dental care setting, the facility may not be well equipped with a back-up system and the staff may not be well trained in BLS to deal with any emergency or adverse effect from the sedation. Performing conscious sedation in the hospital dental setting is more preferable as access to emergency care and facilities is better. However, this has to comply with recommended local guidelines and regulations to ensure patient safety and effectiveness of care. Referring to the current publication by The College of Anaesthesiologists, Academy of Medicine

Malaysia entitled ‘Recommendation for Sedation and Analgesia by Non- anaesthesiologists’, if conscious sedation is to be carried out by non-anaesthesiologists which may include dental specialists in a local setting, it must be kept at a minimal to moderate level 27. The paper also defines conscious sedation as a procedure which depresses the central nervous system and/or reflexes by the administration of pharmacological agents via any routes without loss of consciousness and lead to reduction of discomfort, anxiety and, perhaps, pain. This will allow uncomfortable procedures to be performed effectively by the health practitioners. This guideline is the only standard reference available currently for setting up the sedation service for dentistry in Malaysia.

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As the initial step, in the Ministry of Health Malaysia, the sedation setting is planned to be started at the Special Needs Dentistry Unit, Kajang Hospital. It is because dental anxiety may not be the only reason for performing the conscious sedation techniques. It is well documented that those patients with movement disorders, physical and/or mental disability, who are otherwise unlikely to allow safe completion of treatment, may benefit from the use of conscious sedation 5, 15, 28. An unpleasant and complicated procedure such as surgical removal of a tooth is also an indication for this approach to reduce distress to the patient 5, 15, 28. Conscious sedation can also be an alternative approach when general anaesthesia is contraindicated due to safety issues and financial problems.

Although the SND surgery is currently not fully equipped for sedation services, it has been supplied with a basic IHS unit which has been used frequently. This also includes a pulse oximeter and blood pressure monitoring device. As a way forward, more attention should be given in preparing the surgery and the dental team to carry out

IVS with midazolam. First and foremost, following the training received by the specialist in Special Care Dentistry (SCD) in Conscious Sedation for Dentistry from

King’s College, London, in-house training for the dental auxiliary staff at the respective practice has to be conducted. Since there is an absence of a local training module for dental nurses in sedation, the Society of the Advancement of Anaesthesia in Dentistry

(SAAD) programme course for dental nurses will be adopted where appropriate to suit the local needs and environment. The hands on training will be held in the SND unit itself under the supervision of the SND specialist in charge. Other relevant departments, especially the anaesthesiology team in the hospital, will be approached and informed of the plan to carry out conscious sedation procedures in the SND dental clinic as it

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Vol 2/2016 would be completely new to them and some issues and concerns may be brought up by this team.

Apart from the training, the equipment for sedation has to be upgraded. The Oral

Health Division, MOH Malaysia has to be approached for a financial budget in order to purchase and install items such as equipment for the administration of supplemental oxygen, automated blood pressure and pulse oximeter machines, sedative agents, cannulation sets and antagonist drugs. A recovery area has to be made available. A consent form for sedation, information sheet for pre and post sedation care and format for clinical record keeping have to be developed. The successful model of the SND unit will be a pattern for other dental sedation units to follow. This has to be supported with a good safety record to gain the confidence of the higher authorities that the IVS procedure is safe to be practised in dental clinics with proper training and equipment in place. Therefore, more general dental practitioners will become more interested and be able to go for further training to help patients receive dental care in a more friendly and comfortable environment while saving costs by reducing the number of general anaesthesia (GA) sessions in the hospital. This will also resolve issues such as long waiting lists for GA sessions and patient refusal of dental treatment due to dental anxiety. As a result, it is expected that the oral hygiene among adults and patients with special needs will be much improved.

Malaysian Dental Journal

Conclusion Vol 2/2016

This literature review highlights that, in setting up a conscious sedation care service in dental practice, certain requirements have to be met. Ensuring safety, effectiveness and appropriateness of the sedation techniques used are the major concerns when delivering care to suit individual needs. This is made possible by the availability of adequate facilities and equipment, good clinical records and appropriate training received by the dental team in the practice including the sedation clinicians, dental nurses and other non-clinical staff. Keeping the dental team in line with the local guidelines and standard requirements is imperative. While numerous reports, guidelines and articles about conscious sedation in the UK can be accessed easily, similar information from other countries is limited. In fact none is available for developed countries such as Malaysia. Thus, it is highly recommended to look into the country in which the service is well established as a reference for future development of the conscious sedation service in Malaysia. Last but not least, everyone deserves to receive dental care in the most comfortable manner in which it can be achieved by delivering conscious sedation especially to those with dental anxiety.

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Acknowledgement The authors thank the Director General of Health Malaysia for his permission to publish this article.

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