Sir, we have read with interest two articles published in the BDJ by M. C. G. Manley et al.1 and by G. McKenna and S. Manton.2 The two papers raise some issues which we feel require further explanation. Provision of adequate anxiety control is both a right for the patient and a duty placed on the dentist. We agree about the efficacy and safety of midazolam to perform dental procedures on those who may otherwise require a general anaesthetic. However, also in recent recommendations3 intranasal midazolam administration in patients under the age of 12 years or in adult patients if followed by intravenous administration, is classified in the category of 'alternative techniques' and should be limited to the hospital.4
We stress the definition of conscious sedation, as accepted by many European dental societies: 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 period of sedation. 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. The use of sedation is still a limited practice among European dentists: in Italy sedation is provided mainly by anaesthesiologists (94%); seldom by dentists (6%).5 Education is carried out on a theoretical basis, while practice on the patient is lacking in the majority of the European dental schools.6 With this European scenario we think that in outpatient dentistry a more prudent approach is mandatory. Our advice is to use drugs with a better pharmacological profile for conscious sedation, ie diazepam instead of midazolam.7
Given these points, it seems odd to be concerned about preoperative fasting in a setting where the loss of consciousness must be avoided. It is our opinion that fasting for conscious dental sedation is not required unless there is a specific indication. Patients should be advised to eat normally on the day of their appointment avoiding alcoholic drinks and large meals.8 The absence of evidence to support our current practice is alarming, but is not substantially different from many other areas in medicine.
References
Manley M C G, Ransford N J, Lewis D A, Thompson S A, Forbes M . Retrospective audit of the efficacy and safety of the combined intranasal/intravenous midazolam sedation technique for the dental treatment of adults with learning disability. Br Dent J 2008; 205: E3.
McKenna G, Manton S. Pre-operative fasting for intravenous conscious sedation used in dental treatment: are conclusions based on relative risk management or evidence? Br Dent J 2008; 205: 173–176.
Gilchrist F, Cairns A M, Leicht J A . The use of intranasal midazolam in the treatment of paediatric dental patients. Anaesthesia 2007; 62: 1262–1265.
Standards for Conscious Sedation in Dentistry: Alternative Techniques. A Report from the Standing Committee on Sedation for Dentistry, 2007.
Zanette G, Robb N, Facco E, Zanette L, Manani G . Sedation in dentistry: current sedation practice in Italy. Eur J Anaesthesiol 2007; 24: 198–200.
Robb N . Training for Pain and Anxiety Control in Dental Schools in Europe. Abstracts from 11th International Federation of Dental Anaesthesiology Societies (IFDAS) Congress: International Dental Congress on Modern Pain Control, 4-7 October 2006, Yokohama, Japan. Anesth Prog 2007; 54: 73–74.
Manani G, Baldinelli L, Cordioli G, Consolati E et al. Premedication with chlordemethyldiazepam and anxiolytic effect of diazepam in implantology. Anesth Prog 1995; 42: 107–112.
Scottish Dental Clinical Effectiveness Programme. Conscious Sedation in Dentistry Dental Clinical Guidance. May 2006. Dundee Dental Education Centre. http://www.scottishdental.org/cep
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Zanette, G., Facco, E. & Manani, G. Sedation in Europe. Br Dent J 205, 523 (2008). https://doi.org/10.1038/sj.bdj.2008.988
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DOI: https://doi.org/10.1038/sj.bdj.2008.988
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