Sir, we are collectively concerned regarding the new Clinical Standards for Dental Anxiety Management1 published by NHS England on 17 January 2023. The biggest change being the ban of multi-drug sedation techniques in community and primary care settings within the NHS. Although these standards do not apply to secondary or private care, there is apprehension that this shift reflects a broader trend.

Despite being published a year ago, there has been no announcement regarding implementation, causing unrest among sedation practitioners nationwide. The Association of Dental Anaesthetists and Sedationists (ADAS) surveyed its members working in NHS primary care sedation practices, with results indicating widespread concern: 73% believed that sedation duration and recovery time would increase, 64% believed there would be an increase in sedation failure and 73% believed it would negatively impact on patient satisfaction.

Advanced sedation technique (AST) using a combination of midazolam and opioids have been long established in anaesthesia and conscious sedation with evidence of safety when used in suitably qualified and experienced hands.2,3 The use of opioids provides systemic analgesia for complex and often painful dental procedures and has a synergistic effect, reducing the dose of midazolam required. The IACSD standards suggest its use in patients for whom midazolam alone does not produce adequate anxiolysis.4 The combined use of nitrous oxide and midazolam has its place in managing patients with a severe gag reflex and those who would benefit from the mild analgesic and anxiolytic effects of nitrous oxide. Multi-drug sedation doesn't necessarily induce deeper sedation.

An AST ban would impact on already stretched secondary care with increased referral volume and a concomitant burden of oral diseases worsening dental anxiety and poorer outcomes. More patients on GA waiting lists would further increase NHS burden and disadvantaging those who cannot be seen elsewhere. NHS treatment options under GA are limited to simple restorations and extractions, thus leaving many without viable alternatives. The rationale behind these proposed changes remains unclear. Is it driven by patient safety concerns, or is it a short-sighted cost-saving measure? Without published data on the mortality and morbidity of multi-drug sedation in primary care, the decision lacks transparency.

We fear that patient care would be negatively and irreversibly impacted if this guideline is implemented without due consideration to the available evidence and having alternative resources put in place. We call for a multi-agency stakeholder engagement and discussion to ensure informed decision-making that prioritises patient care and NHS interests.