Commentary

This guidance has been produced for the dental team to help improve patient care, by bringing together the best available relevant information in an easily interpreted form for implementation. The guidance is for all patients receiving conscious sedation to facilitate dental treatment, in a primary care or hospital setting.

Members of the dental team develop a way of doing things, a routine, for managing patients with sedatives based on what they were taught, their own experiences and also perhaps influenced by respected or politically prominent individuals. Along the way one hopes that the routines are also modified by good research evidence.

The Scottish Dental Clinical Effectiveness Programme makes clear that they are presenting clinical “guidance” rather than “guidelines”. The authors explain that this is because there is often a lack of high-quality evidence that would be necessary to inform conventional guidelines. They bring together legislation, policies and guidelines that are not yet readily accessible. They also include systematic reviews, but whether individual clinical trials are also included is unclear. The group does use methods similar to those used to develop high-quality guidelines, ie, they appraise the quality and evidence base of included items.

If this guidance is to be useful, it should detail specific clinical scenarios and offer specific recommendations for clinical management based on good evidence. It should also describe the nature of the evidence and it should be valid. Does this guidance do what it is supposed to do and help provide improved quality of patient care?

Several databases were searched although it is not clear whether there was a language restriction: clinical practice routines vary around the world. Presumably, although not stated, there were inclusion and exclusion criteria for the items to be brought together in this guidance because the product appears to describe UK current practice. The remit nevertheless seems to have been to produce Scottish rather than global guidance.

The guidance is comprehensive and describes preparation for sedation, conscious sedation techniques, conscious sedation for children, conscious sedation for adults and children with special needs, aftercare, records and documentation, clinical governance and training. The guidance concludes with recommendations for future research. Each section has clear statements with assigned levels of evidence and references where appropriate.

Most evidence is level 4 (expert opinion), but this is consistent with seeking to bring together policy documents and legislation. The guidance describes the state of current practice of sedation for dentistry in Scotland and is a useful document in doing this. It is also useful in that it informs the dental team about decision making and the quality of evidence supporting clinical practice. As most evidence is weak, however, the impact on clinical practice to be made by good research evidence is inevitably limited. More likely is that the guidance will provide a summary descriptive document of current practice that will reassure rather than stimulate improvement in the quality of patient care.

The guidance will be very useful for teaching and training. Even when systematic reviews in dentistry from the past are available it has been show that the quality could be improved.1 If future clinical decisions are to be based upon guidance then it is imperative that higher levels of evidence are available to inform them. This guidance is helpful in identifying key areas requiring further high quality research and in particular, randomised controlled trials.