Sir, the paper by Shearer et al (BDJ2004, 196: 93–98) was very enlightening and demonstrated some very entrenched views held by many anaesthetists in Scotland. These suggest to me that some of the opinions expressed may be informed more by professional self-interest than simply patient safety since no evidence was offered why the anaesthetists felt that, on the whole, dentists should not carry out conscious sedation.
The shared airway was mentioned but, by definition, conscious sedation should be no more of a problem than where routine dentistry is carried out using local anaesthesia alone. The opinions of anaesthetists, however highly skilled, are still just that and, like those given in the Poswillo Report1, were not strictly evidence-based.
If the consensus opinion of the Scottish anaesthetists were to be taken to its logical conclusion then all dental sedation cases should be transferred to hospital. This clearly, given the present situation in the NHS, would be impossible, greatly increase the cost per case and would probably not bring any tangible health gain. The ability of anaesthetists to carry out effective sedation should be closely examined.
There is anecdotal evidence that some anaesthetists do not titrate the dose of the sedative agent according to the patient response, but would give what is in their opinion a safe standard bolus dose weight; when using midazolam, for example, this could vary from a 2mg to 10mg which clearly might either give insufficient sedation to enable satisfactory operative dentistry to be carried out or, in frail patients, elicit an excessive response with a real risk of loss of consciousness.
There can be no universal standard dose because the levels of anxiety in patients can vary hugely as do their responses to the sedating agent. Indeed dentists have recounted to me instances where the sedation has been routinely administered by an anaesthetist who required that patients fast before treatment and where the depth of sedation exceeded the level where loss of consciousness was unlikely.
This type of sedation is not the sort practised by dentists and certainly would not be approved of by Poswillo1 or by the Department of Health2. The transfer of all dental general anaesthesia (DGA) into hospital settings following the recommendation of the Department of Health Report in 20002 has led to long waiting lists in many areas.
The possible transfer of dental sedation to an acute setting would have devastating effects on waiting times for treatment and create huge problems in patient management. If dental sedation were to be transferred to anaesthetic hospital departments it follows that all sedation (including relative analgesia) would fall within the domain of the anaesthetist.
This would necessitate that the midwives' use of nitrous oxide in the delivery suite could then only be sanctioned if anaesthetic staff were present at all times. This muddled thinking needs to be tempered with some hard evidence that looks carefully at risk.
All clinical interventions carry risk; the task is to look at probabilities and consequences in order to manage risk rationally. The resource implications of anaesthetists having a monopoly of sedation for dentistry is enormous and would effectively outweigh any putative benefit.
The use of sedation in dentistry needs to be positively encouraged to reduce the need for a DGA, particularly in children, and to avoid exacerbating the problem of large swathes of the population being prevented from seeking timely dental care due to extreme anxiety.
Indeed, a study in Scotland in 19903 concluded that the 'Poswillo Report' had not increased the use of inhalation sedation at all while a similar survey in the North West of England reported a similar under-utilisation of inhalation sedation4.
The use of inhalation sedation can reduce the need for a DGA5. This should help reduce the need for repeat DGAs which has been reported at levels ranging from 9.5% in London6, 23% in Leicester7 an estimated at 25% in Glasgow6 and 31.8% in North Wales8.
I would also like to put the record straight regarding postgraduate courses for conscious sedation. There have been several excellent courses held in North Wales over the last few years providing a mix of didactic teaching and 'hands on' experience and using the expertise of the sedation teachers from dental schools across the UK.
In addition there have been several courses for dental nurses working towards their post-basic qualification in conscious sedation in which the pass rate has been exemplary. North Wales is not a rural backwater but is often ahead of the game!
Those of us who practice sedation need to firmly maintain our right to administer sedation safely and to demonstrate our commitment to high standards of practice, training, clinical audit and continuing professional development. If we do not, who knows when a special interest group might decide that regional block anaesthesia should be the next target?
