Sir, the impact of COVID-19 on patient access to hospital general anaesthesia (GA) for oral surgery is significant. With day case elective GA on hold over the pandemic, patients waiting for dental extractions under this modality (DGA) will be stacking up nationally. The 18-week pathway from referral will be more challenging to achieve now for adult dental extractions under GA than ever before. This is likely to have an impact on the previously reported culture of patient demand for this treatment.1 Sedation will have a big role to play and there is likely to be a resurgence in its use.

We read with interest the recent positive anecdotal reports of patient satisfaction and successful outcomes via the use of oral sedation with diazepam prior to attendance for urgent dental care.2 For a number of years our OMFS department has also utilised oral diazepam prior to attendance for surgical removal of impacted wisdom teeth, with content and more relaxed patients in many cases. In addition, we are advocates for the technique of intranasal midazolam sedation using a MAD-device. We envisage this being an increasingly employed way of keeping needle phobic patients away from GA lists and within the more accessible sedation pathways.

Our own service pre-COVID was on the brink of introducing intravenous conscious sedation services to the department for our referred patients. Its current introduction at our site looks to be a well-timed, convenient development and some patients on waiting lists for GA are being successfully transferred to IV sedation. In 2017 a national survey of OMFS units containing questions about GA and sedation services demonstrated that a quarter of units were not routinely offering or able to offer sedation and that there was a need to review provision of sedation in the UK.1 It highlighted a consensus of a lack of availability of sedation services and showed presence of a strong culture of patient demand-driven adult DGA in the UK.1 Cultures needed addressing from patient demand back to clinical need and the authors asked 'what would it take to shift the cultural norm again?' It looks as though the answer to this question is coming to light - a pandemic, reduced access to DGA waiting lists, the resurgence of sedation and patients opting for the more accessible modality.