Sedation standards

Abstract

Last year in Maintaining Standards¹ the General Dental Council (GDC) reinforced the need for adequate training in sedation techniques and stated 'dentists have a duty to provide and patients have a right to expect adequate and appropriate pain and anxiety control. Pharmacological methods include local anaesthesia and conscious sedation techniques.'

Main

If conscious sedation is to remain under the control of dentists we must ensure that standards of competence are clearly defined and appropriate measures put in place to safeguard our patients.

The Dental Sedation Teachers Group²point out that while the undergraduate course is the appropriate place to provide that training there is a potential difficulty in ensuring that the new dental graduate will be competent to manage all patients requiring these techniques. Thus, if conscious sedation is to remain under the control of dentists we must ensure that standards of competence are clearly defined and appropriate measures put in place to safeguard our patients.

Obviously, the two issues are linked. Defining an appropriate level of competence remains under review and the GDC's further deliberations must include recognition of personal limitations, the need for appropriate onward referral and the requirement for continuing professional education. This underpins the concept of safety that we as a profession have a responsibility to embrace if complications or even fatalities are to be avoided.

With regard to the safety of patients in October 2000 a new document, The Standards in Conscious Sedation for Dentistry⁴, was published by an independent working group. The document sets out standards for all practitioners with the aim of ensuring that conscious sedation continues to be as effective and safe as possible. The recommendations in the document relate specifically to the operator sedationist, and use the unambiguous definition of sedation proposed twenty years ago⁵.

This definition has been more recently adopted in updated format by the GDC in May 1999 and reiterated in A Conscious Decision⁶ from the Department of Health earlier this year. It is used as the baseline in the new standards document⁴ and states that conscious sedation is . . . '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 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.' In other words 'the level of sedation must be such that the patient remains conscious, retains protective reflexes and is able to understand and respond to verbal commands.' This is designed to prevent the use of 'deep sedation' frequently practiced in North America and elsewhere in the World and place it clearly in the bracket of general anaesthesia thereby falling within the controls firmly laid down by the GDC^1,3 and the Royal College of Anaesthetists⁷.

The final concern we must address is the need for effective case selection. As general anaesthesia for dental treatment further declines we cannot allow the use of sedation to escalate or be used without good clinical justification. It should not be automatically assumed that if sedation is required on one occasion it will be needed time and time again. Indeed we need to remind ourselves that the Standards and Guidelines for General Anaesthesia in Dentistry⁷ published by the Royal College of Anaesthetists in February 1999 states that 'for a patient in whom dental phobia will be induced or prolonged the aim should be graduated introduction of treatment under local anaesthesia using if necessary an intermediate stage employing conscious sedation techniques'.

It is essential that conscious sedation is retained in dentistry and the adoption of standards as proposed by the Expert Group should be of assistance in realising this goal.