Please click on the tables and figures to enlarge
A synopsis of articles of interest from the last twelve months to inspire further reading
Functional neurologic disorder as a rare complication of dental local anaesthetics: two contrasting cases
Goss A, Br Dent J 2024: 236; 97-99
Abstract
Adverse reactions to dental local anaesthetics are fortunately rare. However, when they occur, they can be severe and debilitating to the patient. Adverse reactions may be either prolonged anaesthesia, with or without dysaesthesia, or systemic reactions. Although these systemic reactions are commonly thought to be allergies, this is rarely the case. Much more commonly, these adverse systemic reactions are either cardiovascular or from the central nervous system. This paper describes two contrasting cases of functional neurologic disorder which illustrates the consequences and appropriate management. The responsibilities of the dentist who injected the local anaesthetic are outlined.
Key Points
- To provide knowledge that systemic adverse reactions can occur following dental local anaesthetic injection.
- Outlines the responsibilities of the dentist who performed the injection.
- Suggests medical management of these systemic reactions.
- Functional neurologic disorder (FND) is a rare complication of dental local anaesthesia.
Case 1
A 60-year-old, fit and well woman in rural South Australia, had a mandibular block with a combination of lignocaine 2% with 1:80,000 adrenaline followed by an infiltration of articaine 4% with 1:100,000 adrenaline for restoration of a molar in 2020. She suffered immediate burning sensations in the scalp, face, hands and feet but no rash. She collapsed and was taken by ambulance to a peripheral hospital. She had marked hypertension which was promptly controlled with antihypertensive medication. She continued to be confused but had a normal brain computerised tomography (CT) scan and electrocardiogram (ECG). The patient was discharged from hospital on antihypertensives and antineuralgics for the continued peripheral burning sensations. Allergy testing proved negative to all the local anaesthetic agents used and in the absence of any other neurologic condition a diagnosis of FND was made. The patient subsequently recovered and had further routine dental treatment with lignocaine local anaesthetic without problems.
Case 2
The second patient was a fit and well 55-year-old woman in England, with no previous history of psychological disturbance or epilepsy. In June 2020, she presented with toothache in the right mandibular first molar. The area was anaesthetised with prilocaine 3% and felypressin 0.03 international units/ml, later supplemented with 4% articaine with 1:100,000 adrenaline. The tooth was uneventfully removed but ten minutes later, the patient collapsed and had a seizure in the car park. Another dentist from the practice came out to attend to the patient and an ambulance was called. Paramedics stabilised her, but as the COVID-19 pandemic was at its height, decided not to take her to hospital. However, over the next few days, she suffered hypertension, multiple seizures, weakness and loss of consciousness, so was hospitalised. The doctors were unsure as to her condition, but the patient was briefly seen by a neurologist. A diagnosis of FND was made.
Subsequent investigations established that this was not the first such event. In January 2019, an attempt had been made to perform endodontic treatment on the same tooth. 2% lignocaine with 1:80,000 adrenaline, later supplemented by 4% articaine with 1:100,000 adrenaline, had been administered. After an hour, she became hypertensive, confused and with left-side weakness. Emergency services were called but surprisingly, despite having the classic features of a transient ischaemic attack / cerebrovascular accident (CVA), she was not admitted. Ongoing slurring of speech became problematic, and the patient insisted her GP refer her to a neurologist, who dismissed her symptoms and thought that menopause was a more likely factor.
In fact, in 2020, she had informed the treating dentist of the previous severe incident she had experienced but the history had been dismissed. Further down the line, the patient went on to suffer another adverse reaction when undergoing beauty treatment to her face with a cream which was in fact 7% lignocaine ointment. She started to feel paralysis in her tongue, her lips drooped, and she suffered slurred speech.
Tests to establish the cause of her symptoms and identify the allergic trigger were inconclusive and unfortunately five years after the initial event, the patient remains in limbo. The patient even had to resort to have a filling done without the use of anaesthetic which proved to be a traumatic experience. She continues to live with symptoms of FND and remains on 250 mg pregabalin twice daily.
Discussion
The author points out that FND is reported to occur in a range of anaesthetic procedures, both local and general. Among several possible mechanisms, excessive dose or intravascular injection may be a factor. There could also be a psychogenic reaction. However, all of these types of FND are of short duration. These two cases illustrate the spectrum of FND. The first case, which may have been less severe, was swiftly and effectively managed and did settle after a few months. The second case was not identified as severe, despite having the full features of a CVA, followed by multiple seizures with varying degrees of unconsciousness. ‘There seemed an unwillingness to accept that this could be the result of a dental procedure.’
Conclusion
The author concludes that although FND was considered primarily a psychologic disorder in both cases, with repressed stress or trauma being ‘converted' into physical disorder (conversion reaction), it is more likely that there is an alteration in chemical brain functioning which causes the abnormal neuralgic symptoms. This would not show on CT or magnetic resonance image (MRI) scans. Indeed, both patients were psychologically sound, well- functioning people before the adverse reaction.
There was a marked disparity in the handling of the emergency situations confronted by the treating dentists and subsequent management. In the first case, they went to the hospital with the patient, sought prompt expert advice and then the medical staff acted on it. In the second case, the dentist dismissed the initial history of the first event, used the same drugs and when the second, more severe event occurred, did not come out to the ambulance but sent a colleague.
Reviewer’s evaluation, opinion and points of interest
It seems possible that had these patients been undergoing treatment under any form of sedation or GA, the use of a local anaesthetic could have provoked a similar response. Or, if there was not a true allergy to the local anaesthetic, would the sedative suppress the neurologic symptoms? The challenge to the sedationist / anaesthetist would be to identify the cause of the unexpected onset of critical symptoms and decide whether the sedative or anaesthetic drug, or the local anaesthetic was responsible for this crisis. Nevertheless, it is essential that practitioners have an awareness of FND. The paper clearly highlights the need to take seriously any indication of a previous history of an adverse reaction to local anaesthetic.
FA
Inhaled methoxyflurane (Penthrox) administration in dentistry as an alternative to nitrous oxide sedation: a review and feasibility study
Inkster D, Jones D, Barker K, Br Dent J 2024; 236: 124-129
Key Points
- Gives knowledge on the potential for new sedative agents
- Provides knowledge on nitrous oxide contribution to environmental pollution
- Refreshes knowledge on sedation best practice.
Abstract
Methoxyflurane (MOF) as an agent for dental sedation has been used safely in Australasia for decades. The drug is now licensed for relief of pain associated with trauma and is being used during several medical outpatient procedures instead of traditional intravenous agents for sedation in the UK. Our aim was to analyse the safety and feasibility of the introduction of MOF as a drug for dental sedation in the UK community setting and assess its environmental impact. A literature review was conducted for available studies and a research audit of medical histories of patients that received nitrous oxide sedation in the previous year was carried out to assess suitability for MOF administration. The published literature shows MOF to be a safe drug for administration in the dental environment and local patients receiving nitrous oxide sedation are medically suitable for MOF administration. The advantages of considering MOF sedation are its environmental benefit and patient acceptability.
Introduction
The authors inform that Methoxyflurane (MOF) is a halogenated ether which fell into disuse as a general anaesthetic due to reports of nephrotoxicity and renal tubular damage associated with high dosages. However, its utility as an analgesic and anxiolytic has since been re-established. In 1978, Penthrox – a self-administered MOF inhaler – became available for use in pre-hospital trauma and minor surgical procedures, at doses which produce light sedation and analgesia without evidence of associated nephrotoxicity. Common side effects are similar to those associated with nitrous oxide (N2O), including dizziness, headache, tiredness, dry mouth and nausea. In dentistry, MOF has been shown to provide effective analgesia and anxiolysis for extraction of third molars in moderately anxious patients and is used widely in general dental practice in Australia for routine sedation. In a 2018 survey of Australian dentists, 9% of the 382 respondents provided MOF routinely as a sedative and anxiolytic agent. Penthrox was approved for use in the UK and Ireland in 2015. Since then, it has been used extensively by the paramedical service, hospital emergency departments and even by the police force. This paper discusses the potential MOF has as an alternative to N2O in UK dentistry with particular emphasis on its comparatively much reduced impact on the environment.
Usage
MOF is available in 3 ml vials as a metered inhaler under the brand name Penthrox. Analgesic effects are usually evident at six to ten inhalations, with patient control not only of inhalation frequency and depth, but also drug concentration. The sedative effect of the inhaler is similar to that achieved by N2O at 50%. Continuous inhalation of the 3 ml vial will produce analgesic effects for around 30 minutes, with intermittent use providing longer-lasting effects. Patients are able to self-titrate once the initial effect has been produced. Maximum dosage is 6 ml or two vials in one day and the weekly dosage should not exceed 15 ml. Analgesic effects remain once inhalation is stopped but any sedative effects do not persist. Studies have shown faster recovery times than those associated with traditional IV agents.
Although MOF is used widely by dentists in Australia as an alternative to N2O for short procedures, there are currently only two studies comparing MOF with N2O. The Australian and New Zealand College of Anaesthetists guideline on sedation and / or analgesia for diagnostic and interventional medical, dental or surgical procedures contains information on MOF use.
The popularity of MOF sedation in Australia may be partially attributed to the more demanding and expensive training required to gain proficiency in conscious sedation relative to the UK. As a result, in March 2023, only 88 Australian dentists were licensed to provide sedation. The use of MOF is not subject to these requirements.
Occupational exposure
The authors admit that the occupational exposure safe limit of MOF when used as an analgesic has not been assessed independently and that further research is necessary to gauge occupational safety. However, they believe that as most dental environments in the UK have developed excellent ventilation regimes with measured air changes per hour (due to the COVID-19 pandemic), if MOF were to be introduced in UK dentistry, occupational exposure would be minimized.
Applicability of methoxyflurane to dental patients managed in a community setting: a retrospective audit
The paper discusses data collected from NHS Highland from the period January to July 2022 inclusive, of 83 adults treated with N2O, some of whom could have benefited if MOF had been used as an alternative. Patients were aged between 18 and 68 years, 78% were female and 24% were male. All but one of the patients was treated successfully with N2O, with good operating conditions reported in 87%. A total of 13 (15.67%) patients had a contraindication to Penthrox.
However, due to the risks of repeat administration, MOF would only be suited for the provision of isolated sedation treatments on these patients rather than for protracted treatment plans. Similarly, as the maximum dose of MOF is reported to be achieved approximately one hour of sedation, certain treatments may need to be curtailed.
Also, MOF is not available for patients under 18 and therefore children would have to continue to rely on N2O or alternative modes of sedation.
Environmental impact of nitrous oxide and methoxyflurane
N2O is a potent greenhouse gas (GHG) and has an atmospheric lifespan of approximately 122 years. A full-size E-cylinder contains 1,800 litres of N2O. The release of this gas causes equivalent global warming to 1.043 tons of CO2. While MOF is also a GHG, comparatively, it has negligible impact on the environment due to an environmental lifespan of just 54 days. Furthermore, its overall global warming potential is just four times that of CO2. Due to volumes of MOF required for sedation being many orders of magnitude less than that of N2O, MOF is likely associated with substantially reduced GHG emissions.
Conclusion
There are no current guidelines covering the use of MOF in dental sedation in the UK. In a joint position statement in 2021, the Society for the Advancement of Anaesthesia in Dentistry and the Dental Sedation Teachers Group stated ‘MOF has promise as potentially beneficial to certain groups. Its use in dentistry is still at an experimental level and more research is needed into safety and delivery’.
However, given that 9% of Australian dentists regularly prescribe MOF, there should be considerable practical experience and data available to be able to collate the information on the efficacy and suitability of MOF as an agent for sedation in general dentistry. Any study would take into account the slightly broader contraindication profile of MOF compared to N2O and the need for finer scrutiny when assessing the patient’s medical status and to strictly monitor dosages and time intervals between treatments.
As with all sedative provision, if MOF were to become endorsed for dental use in the UK, sedation providers would require additional education and training before clinical use.
This work suggests that when substituted for N2O in appropriate cases, clinical use of MOF could reduce the carbon footprint of pharmaceutical release by a factor of over 2,500. However, ‘the decision to use MOF, as an alternative to N2O, should not be made on grounds of climate impact alone’.
Reviewer’s evaluation, opinion and points of interest
Any new drug which is effective and safe and complements the provision of conscious sedation in dentistry is to be welcomed.
MOF is an early, once discarded drug which has gained a new life. In a seeming contradiction, it is not licensed for use in dental sedation in the UK but can be used without restriction by dentists in Australia where the provision of intravenous sedation is much more strictly controlled and requires additional qualifications.
The maximum dose of MOF, that is 2 vials of 3ml Penthrox, is effective for procedures of about an hour’s duration and therefore would be suitable for most aspects of routine dentistry including emergency extractions. For longer procedures, would introducing midazolam when the effects of MOF start to wear down, help prolong the treatment window without risking serious potentiation of the sedation?
A single dose of MOF could also be offered to patients who are acutely needle-phobic to enable venous access. At the time of writing, the NHS indicative price for the 3ml Penthrox inhaler device was £18.64 so the cost would not make it a viable proposition for use in NHS general dental practice. The substantial environmental burden of N2O cannot be ignored and therefore any substitute which is less damaging deserves our attention.
FA
Advanced sedation in oral surgery as an alternative to General Anaesthetic: A service evaluation
Cullingham P, George G. Oral Surgery 2023; 16: 331-335
Aim
The management of dentoalveolar procedures under general anaesthetic has been a widespread challenge recently. The establishment and implementation of an advanced sedation service within the oral surgery department at Liverpool University Dental Hospital offered a potential alternative to managing those awaiting procedures. A comprehensive service evaluation aimed to demonstrate that patients previously considered for general anaesthetic could be safely and efficiently managed with an advanced sedation service.
Materials and Methods
The service evaluation employed mixed methods; a data collection tool captured procedural demographics retrospectively whilst a patient-reported outcome measure (PROM) was designed to engage patients regarding their experience.
Results
The service evaluation highlighted that 27% of patients previously listed for general anaesthetic were managed with local anaesthetic or conscious sedation alone. The sedation outcomes demonstrated that all patients were co-operative and achieved an optimal level of sedation. No adverse sedation outcomes were recorded. Patient-reported outcomes were positive with 100% rating it as an excellent service.
Conclusions
The use of an advanced sedation service has demonstrated successful outcomes and reduced reliance on theatre resources. The use of polypharmacy; midazolam and propofol, provides a safe, effective and efficient modality to perform complex procedures in an outpatient hospital setting. Advanced sedation techniques can be particularly effective in the management of complex procedures, dental anxiety and in adolescent and medically complex patients. Patient engagement supports the service as an effective option for delivering quality care.
Reviewer’s evaluation, opinion and points of interest
This excellent paper provides a detailed account of the experience of setting up an advanced sedation service as an alternative to general anaesthesia during the COVID-19 pandemic when access to general anaesthetic services was restricted. The cohort of patients treated was quite small (n=15) but the data collection was comprehensive. The service was safe, effective and the experience for both operators and patients was positive. Patients were sedated with a combination of midazolam and propofol. No data on costings compared to GA were included, but the study would nonetheless prove very helpful for anyone considering setting up a similar service.
GG
Multicenter RCT on intensive caries prevention for children undergoing dental general anaesthesia: Intensive caries prevention for children undergoing dental general anesthesia
Alkilzy M, Schmoeckel J, Schwahn C, Basner R, Al-Ani A, Takriti M, Splieth C.
J Dent 2022; 118:104057 https://doi.org/10.1016/j.jdent.2022.104057
Abstract
Objectives
Early childhood caries is a persistent problem often leading to dental treatment under general anesthesia (GA). Thus, this study investigated the effect of two additional individual caries prevention appointments before and after GA.
Materials and Methods
In this multi-center, 2-arm randomized, controlled clinical trial, 408 children (age 2–5 years, mean 4.2 ± 1.04) intended for GA were recruited and randomly assigned to the intervention and control groups with or without two additional intensive oral hygiene appointments before and after the GA. At baseline and at 6-/12-months follow-ups, approximal plaque index (API), gingival sulcus bleeding index (SBI), caries experience (dmft/s) and initial caries were recorded.
Results
Participants in test group and control group (ITT; n = 161 vs. n = 147) as well as drop-outs in test and control groups (n = 40 vs. n = 58) showed no statistical significant difference in baseline characteristics. Test and control groups showed equivalent baseline oral health parameters (API: 78 and 77%, SBI: 22.6 and 23.5%, dmft: 8.5 and 8.2, respectively), which continuously improved during the study. The test group exhibited statistically significant greater improvement (API: 42%, SBI: 7%) than the control (API: 54%, OR: 0.48; P = 0.003; SBI: 12%, OR=0.44; P = 0.005). Due to the robust rehabilitation with predominantly stainless-steel crowns and extractions, caries incidence was minimal and, therefore, without statistical significance (mean increase dt, test: 0.5, control: 0.6; P = 0.68), which was also true for new initial carious lesions (mean increase test: 0.8 vs. control: 0.9; P = 0.55).
Conclusions
Additional preventive sessions for children undergoing treatment under GA improved their oral hygiene parameters significantly.
Clinical significance
Intensive caries prevention appointments for children receiving dental treatment under GA improved their oral hygiene and might reduce their caries risk.
Reviewer’s Evaluation, opinion and points of interest
The use of general anaesthesia has long been known to have variable effect on the dental health of paediatric patients in the months and years after treatment. This article demonstrates that incorporating preventive programmes into the pre and post GA phases of patient management can have significant benefit in terms of reducing the impact of future disease. The message from the paper is that prevention works but that adding additional sessions increased the benefit.
A common reason for drop out in the study was distance travelled for specialist care, emphasising the importance of providing access to care locally for patients.
This paper should be a must read for those involved in the provision of paediatric dental GA services.
NDR
Comparison of parental and practitioner's acceptance for dental treatment under general anaesthesia in paediatric patients
Djalali Talab Y, Geibel M A.
BMC Pediatr 2023; 23: 45 https://doi.org/10.1186/s12887-022-03805-1
Abstract
Background
Practitioner's knowledge and parental perspectives on dental general anaesthesia (GA) have been surveyed separately in the past. But in daily routine both need to collaborate for the benefit of the child. The aim of this paper was to compare parental and practitioner's acceptance of GA with special focus on identifying factors which influence their differences in decision making.
Methods
Questionnaires were conducted among 142 participants in a specialized paediatric dental clinic in Germany from February 2020 to February 2021. 51 German practitioners from private practices and clinics participated. Data collection included: age, gender, experience with GA, fear of GA, risk evaluation and indications for GA.
Results
There were no gender related differences in decision making. Emotional factors are present in parents of younger children. Parents are more likely to express fear and uncertainty regarding GA than dentists. Prior experience with GA significantly decreases fears in GA for parents. Both agree that extent of the treatment and low compliance are a suitable indication for GA. Dentists are more likely to accept GA due to a mental disability than parents. Parents were more likely to accept GA than dentists when multiple extractions were needed (regardless of compliance) or acute pain was present.
Conclusions
A significant divergence in risk evaluation, acceptance and decision-making could be found in parents compared to dentists. Influencing factors are previous experience, younger age of the child, lack of knowledge and indication for GA.
Reviewer’s evaluation, opinion and points of interest
This article, which like the preceding paper was reporting a German study, showed that there were significant differences between parental and professional understandings of the risks around general anaesthesia for paediatric patients. Inexperienced parents and parents of younger children had a higher risk evaluation particularly around questions that targeted an emotional response. In general, the dentists surveyed reported a lower level of risk associated with GA than the parents, indicating that here is a potential education issue to ensure that the dental profession understands the parents of their paediatric patients.
In the population surveyed the majority of dentists and parents were female. There is data from a Chinese study quoted where the population had more male participants that has a different outcome. There is the potential for further research to understand how different populations view the issue of GA in dentistry, particularly as the populations of many nations are becoming more multinational.
NDR
Effectiveness of a smartphone application on dental anxiety in adolescents: A randomized controlled trial
Trícia Murielly Andrade de Souza Mayer, Giovanna Burgos Souto Maior, Nataly Pereira da Costa, Michele Gomes do Nascimento, Viviane Colares
International Journal of Paediatric Dentistry 2023; 33: 409-417
Abstract
Background
Dental anxiety is a common issue among adolescents. Despite the use of smartphones being an important part of their daily lives, only a few digital-based interventions for dental anxiety have been tested in randomized controlled trials (RCT).
Aim
The aim of this study was to evaluate a new smartphone application (App) named FALE, which was designed to demonstrate interest from the dentist to adolescent and to reduce dental anxiety.
Design
This is a RCT in which 184 adolescents aged 10 to 19 years were randomly allocated into the intervention group (IG) or the control group (CG). The intervention was applied in the waiting room before the consultation at a dental clinic. The IG answered the FALE, which contained 14 questions, of which the first and last questions addressed anxiety, whereas the CG answered the question about anxiety twice with an interval between them.
Results
There was a significant difference in the distribution of anxiety rating frequencies before and after the intervention period in both groups. For the IG, there was a reduction in anxiety after the intervention of 16.29%, and, in the CG, a reduction of 2.2% (p < .001).
Conclusion
The FALE App effectively reduced dental anxiety before the appointment.
Conflict of interest statement
The authors declare that they have no conflict of interest.
Reviewer’s evaluation, opinion and points of interest
The authors advocate that new strategies targeting the adolescent age group to overcome dental anxiety are required, with smartphone Apps being well placed to help. Most dental patient- focused Apps are currently concentrated on health education and prevention, with few designed for adolescents or as interventions for dental anxiety.
The FALE App is a new Android smartphone application initially developed in Portuguese. It’s a tool designed to demonstrate an empathic attitude from the dentist thereby reducing adolescent dental anxiety in the waiting room. It has 14 questions on dental anxiety, feelings, coping preferences and requests regarding dental care which are filled in while they wait. This is designed to help facilitate communication between the dentist and the patient.
Once the FALE survey was completed the dental students seeing the patient received a report with the adolescents’ responses, before they called them in. The study showed that the App was effective in reducing dental anxiety in the intervention group before the consultation, when compared to the control group. The authors felt this let the adolescent perceive that the dentist cared about their feelings, and how they would like to be treated. This had a particular impact in the younger age group (10 to 14 years).
Other studies have also shown that empathic approaches such as questionnaires before consultations are also highly correlated with a reduction in patients’ anxiety. Tools such as ‘Message to Dentist’ have also been developed by researchers in Sheffield. It seems to be that the main characteristic of the dentist-patient relationship is not the demonstration of empathy itself, but whether the patient perceives it in the relationship.
It will be interesting to see further developments in this area.
RW
Reference:
University of Sheffield:
https://www.sheffield.ac.uk/dentalschool/research/person-centred-population/child-dental-anxiety/resources (accessed 01/05/24).
Exploring dental treatment decision-making experiences of people living with dementia and family carers
Geddis-Regan, A., Wassall R., Abley, C., Exley, C. Exploring dental treatment decision-making experiences of people living with dementia and family carers. Gerodontology. 2024; 41:83–93.
Abstract
Introduction
People living with dementia can have complex dental care needs. Dentists and patients should make treatment decisions together, yet some people living with dementia may be unable to make their own decisions about their dental care. Dental treatment decision-making and patients' experiences of this process have not been comprehensively researched.
Objective
This study aimed to explore the dental treatment decision-making perspectives and experiences of people living with dementia and their family members.
Methods
Semi-structured interviews were undertaken with eight people living with dementia and 17 family caregivers. A constructivist grounded theory approach was adopted, using a maximum variation sample. Qualitative data collection and analysis occurred concurrently. Data underwent initial open coding followed by more focused coding, supported by reflexive memo writing, which supported data categorisation.
Results
People living with dementia reported wanting to be understood as unique individuals with specific needs. All participants described wanting to be actively involved in dental treatment decisions. However, many felt that they were insufficiently involved in treatment decision-making. This perceived under involvement meant that some people living with dementia and family members felt the treatment outcomes they sought were neither discussed nor considered.
Conclusion
People living with dementia and carers had specific expectations of dental care yet felt passive in decision-making despite their desire to be involved in this process. Dentists should seek to actively establish patients' preferences, regardless of mental capacity and consider these in discussions and decisions about dental treatment.
Reviewer’s evaluation, opinion and points of interest
It is not often that I am moved by a piece of research, but this work really struck a chord. We all know someone who lives with dementia; either as a person diagnosed with the disease or an individual acting as a carer for that person.
From a professional perspective, as the prevalence of dementia continues to increase, our patients, those who support them and dental teams will have to make an increasing number of complex treatment decisions, often involving sedation or general anaesthesia. This qualitative research is well-structured and offers a candid insight into the experiences of individuals and their carers in relation to various aspects of dental care. I have selected some excerpts that I felt would be particularly interesting for the readership.
The authors explain that the potential for distress was a concern for those who felt they might need treatment in the future as the disease progresses:
‘If it was me and my brain was now at that [advanced dementia] stage, today, I would say, when I get to the stage, sedate me. Cause it would be much less distressing for me, being sedated you do what's needed to be done, than somebody trying to reassure me and I’m not understanding it.’ Dorothy (living with dementia)
The authors state that patients and carers were generally more supportive of decisions to provide active or extensive dental care when modalities such as anaesthesia or sedation could be considered. If such approaches were used, carers of people with advanced dementia accepted that, in line with national standards in the UK, the nature of treatment might need to be altered to avoid recurrent longer-term problems:
‘The final outcome should be that (my sister's) health, her gums and the teeth are at a stage that they don’t cause her any more problems. If that would mean full extractions then I would even go that far…’ Gary (Brother of person living with dementia)
Acknowledging that dentists had specific knowledge about dental treatments, family members explained how they were willing to consider recommendations for their relative's care. However, they did want to be involved in decisions about the care that had been recommended:
‘If somebody had said to me, you know, ‘His teeth look really sore. We need to sedate him to have a proper look’, if that had been offered to me, I would have accepted it…the communication about it and the options available never amounted to anything, or we weren’t really informed of anything. So it was just left as an area that wasn’t important.’ Liz (daughter of person living with dementia).
Even when complex dental care was facilitated, including radical dental care or that provided under sedation or general anaesthesia, no family members reported being actively consulted about the views of a people living with dementia. Overall, this highlights a need for further education and improved communication in the care of people living with dementia.
I congratulate the research team for undertaking such valuable work and recommend reading the full article.
SC
Effect of photobiomodulation therapy on pain perception during anesthetic puncture of dental local anesthesia: A systematic review
Caio Melo Mesquita, Millena Barroso Oliveira, Marcelo Dias Moreira de Assis Costa, Walbert Andrade Vieira, Rafael Rodrigues Lima, Sigmar de Mello Rode, Luiz Renato Paranhos. Effect of photobiomodulation therapy on pain perception during anesthetic puncture of dental local anesthesia: A systematic review. Clinics. 2024. 79 1-10.
Abstract
Background
Local anesthetic puncture is often related to the experience of pain. This study aimed to systematically analyze the literature on changes in pain perception during the anesthetic puncture of dental local anesthesia after Photobiomodulation Therapy (PBMT).
Material and methods
An electronic search was performed in eight primary databases (Embase, LILACS, BBO, LIVIVO, MedLine via PubMed, SciELO, Scopus, and Web of Science) and three additional ones (EASY, Google Scholar, and OATD) to partially capture the “gray literature”. The PICO strategy was used to identify randomized clinical trials evaluating the analgesic effect of PBMT in the anesthetic puncture site of dental local anesthesia compared to placebo or control groups, without restrictions on publication language and year. Two reviewers extracted the data and assessed the individual risk of bias of the eligible studies using the Cochrane Collaboration Risk of Bias Tool version 2.0.
Results
The electronic search found 3,485 records, of which eight met the eligibility criteria and were included in the qualitative synthesis. The studies were published from 2011 to 2022. None of the included studies had a low risk of bias. PBMT groups showed no significant difference in pain scores compared to placebo and control groups of most studies.
Conclusion
Based on a low to very low certainty of evidence, PBMT seems to have no effect on pain perception during anesthetic puncture in patients undergoing dental local anesthesia.
Reviewer’s evaluation, opinion and points of interest
I am always intrigued by new gadgets that may be useful in our area of clinical practice, and where we are to direct our limited time and money.
As we know, there are many methods to make the delivery of local anaesthesia more comfortable for patients, including topical local anaesthetic gels, computerised systems, behavioural management techniques, acupuncture combined with conventional treatments and anaesthetic puncture site pre-cooling. More recently, attention has also been drawn to photomodulation therapy (PBMT) - the use of near infrared light over injuries and lesions to purportedly reduce pain and improve healing.
The authors of this systematic review highlight that there are now many studies related to the analgesic effects of PMBT on dental local anaesthetic puncture (more than 3000 published in a decade), however, the literature is divided and of variable quality.
This systematic review offers us a good overview of the subject. It is well-structured and of a high standard, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After accounting for duplication in the initial literature search, 2,268 results remained for the analysis, but further reading of the titles, abstracts and remaining full texts whittled this down to only eight for inclusion.
The total number of eligible participants was 540, with ages ranging from six to 75 years and the majority being male. All studies used diode lasers with wavelengths from 660 nm to 980 nm. The laser application time varied from 20 seconds to three minutes, with some studies delivering this continuously, others pulsing and others not reporting.
Similarly, some studies did not report how close the laser was held to the mucosal surface or to which site in the mouth the local anaesthetic was delivered. The preparation of the puncture surface was highly variable, with some offering no description while others isolated and dried the mucosa or applied topical anaesthetic gel. The studies used a variety of pain assessment tools which can also complicate the drawing of comparisons.
The authors explained that the studies brought risks of bias, particularly in relation to the randomisation process and selection of reported results. Within the eight studies, two were described as ‘high risk of bias’ and six as having ‘some concern’. Therefore it was concluded that the outcomes presented very low to low certainty of evidence; PBMT seems to have no effect on pain perception during the anaesthetic puncture in patients undergoing dental local anaesthesia.
So perhaps we should hold off buying another gizmo for the time being…
SC
Leveraging technology to increase the disseminability of evidence-based treatment of dental fear: An uncontrolled pilot study
Heyman R E, Daly K A, Smith Slep A M, Wolff M S
J Public Health Dent 2024; 84: 36-42
Abstract
Objectives
U.S. and global estimates indicate that over 30% of adults fear receiving dental care, including over 20% who have visited a dentist in the last year, leading to avoidance and degraded oral and systemic health. Although evidence-based cognitive- behavioral treatments for dental fear (CBT-DF) exist, they have little impact on the millions who seek dental care annually because they are not disseminable (6 h of in-chair time, delivered only in person at a few sites). We developed a disseminable CBT-DF stepped-care treatment comprising (Step 1) a mobile-health application and, for those who remain fearful, (Step 2) a 1-h, one-on-one psychological treatment session that allows practice during exposure to the patient’s most-feared stimuli. We hypothesized that the treatment would (a) be rated highly on usability and credibility and (b) result in clinically consequential (i.e., lowering fear into the 0–3 “no/low fear” zone) and statistically significant changes in global dental fear.
Method
Racially/ethnically diverse patients (N = 48) with moderate to severe dental fear were recruited; all completed Step 1, and n = 16 completed Step 2.
Results
As hypothesized, users found the stepped-care treatment highly usable, credible, and helpful. Critically, this stepped-care approach produced reductions in patients’ dental fear that were both clinically consequential (with half no longer fearful) and statistically significant (d = 1.11).
Conclusions
This usable, credible, stepped-care approach to dental fear treatment holds promise for liberating evidence-based CBT-DF from specialty clinics, allowing broad dissemination.
Reviewers evaluation, opinion and points of interest
This is a really interesting and encouraging uncontrolled pilot study conducted in the US, exploring a stepped care model for dental anxiety management using a CBT-based mobile app (step 1), with a follow-up one-to-one one-hour session (step 2) with a qualified mental health provider. The team plan to conduct a randomised controlled trial to add further weight to their findings, though this pilot reveals encouraging results.
The study team are exploring methods to increase the roll-out and dissemination of CBT-based interventions for individuals with dental fear, due to the lack of specialised services and the time involved in providing one-to-one CBT. This type of model would provide an ideal stepped-care platform from the self-help resources outlined in the article on page 28. While the authors of the current research paper refer to each step in their intervention as step 1 (mobile app) and step 2 (one-to-one one-hour therapeutic session of exposure and cognitive disconfirmation approaches), these types of intervention may in time be considered within a much larger stepped-care approach to dental fear: where low-level behaviour management and self-help resources are employed first, with patients stepping up to the next level of intervention depending on need.
The ‘Dental FearLess’ app is fully outlined in the paper, and includes all the ‘active ingredients’ and principles of CBT, including psychoeducation, cognitive interventions, emotional and behavioural strategies, as well as video demonstrations of patients modelling these and providing exposure to feared dental stimuli. The app also incorporates a motivational interviewing (MI) approach in its initial steps, which is an evidence-based psychological intervention to increase patient engagement. Following some psychoeducation, and further cognitive, behavioural and affective strategies to utilise in dental appointments, the app ends with patients completing an action plan for managing their fear at their next appointment.
The researchers used Gatchel’s dental fear scale, which is a one- item self-report scale of overall fear of dental treatment; this was specifically chosen as a global measure of fear, instead of Corah’s commonly used modified dental anxiety scale (MDAS), which assesses specific dental situations. Individuals who remained in the high fear category of Gatchel’s scale after step 1, were invited to participate in step 2 of the approach – which consisted of a ‘highly individualised one-hour one-to-one’ CBT treatment session with a qualified psychological professional. This essentially seemed to consist of combining exposure and behavioural experiments (an active cognitive approach to test the validity of specific beliefs) which the researchers call a ‘disconfirmation exposure trial’.
One third of those recruited completed steps 1 and 2, the majority completed step 1 only, though ‘completion’ is patchy with data reported on the percentage of the app content and material completed, with 12% completing all five modules. Nonetheless, the app was rated for usability and credibility as well as impact on global fear ratings and the authors discuss the findings. Interestingly, due to the COVID-19 pandemic, the step 2 session took place virtually for seven participants, whilst none completed them as planned in-person; whilst only a small sample, no differences were observed between these two subgroups.
I look forward to further papers from this research team and reporting any updates that come to press.
JH
Floating-Harbor syndrome and provision of dental treatment: A case report of the dental considerations
Saeed, K A., Alsayer, F. Floating Harbor Syndrome. Special Care in
Dentistry. 2024;1-5
Abstract
Floating-Harbor syndrome (FHS) is a rare genetic syndrome with limited cases reported in the medical literature. It is an autosomal dominant condition with affected individuals carrying a pathogenic variant of the SRCAP gene. FHS cases show individuals having consistent facial features and differing levels of intellectual disability, which can affect their ability to receive different anaesthetic modalities and have capacity to consent for dental treatment. This case report focuses on the clinical management of a young adult with FHS requiring dental care with different treatment modifications tailored to the patient’s individual needs. Further research and awareness of this syndrome is required to fully understand its consistent oral findings and varying intellectual abilities, to ensure appropriate and timely treatment provision.
Reviewer’s evaluation, opinion and points of interest
In Special Care Dentistry, we often encounter patients with rare syndromes and are faced with developing a treatment plan that will ensure the longevity of their dentition as well as deliver this in a manner that is safe and effective, sometimes with little knowledge of the specific condition.
I am grateful when colleagues take the time to share their experiences in such situations, so that we have a resource to guide our thought processes should we encounter a patient with the same rare disease in another service.
Here the authors have provided a focussed case report on Floating-Harbor syndrome (FHS) and offer valuable discussion about the challenges faced. They explain how inhalation sedation was initially planned, however, due to the facial morphology associated with this condition, application of a nasal hood was unsuccessful and how the patient found it challenging to breathe solely through his nose. They go on to explain how anaesthetic modalities for patients with FHS need to be examined carefully due to the wider features seen including short neck, restricted neck movements, malocclusion and microstomia which can compromise the airway. They also explain that specialist anaesthetic techniques may be required as intubation may be difficult, requiring careful planning with relevant medical teams.
Overall the article is very informative for members of the readership who share this complex patient base.
SC
Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: Randomized Controlled Trial
Schibbye R, Hedman-Lagerlöf E, Kaldo V, Dahllöf G, Shahnavaz S.
J Med Internet Res 2024; 26:e42322 https://doi.org/10.2196/42322
Abstract
Background
Dental phobia (DP) and injection phobia (IP) are common in children and adolescents and are considered some of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. As the availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking.
Objective
This randomized controlled trial tests whether therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP or IP to receive dental treatment.
Methods
We enrolled 33 participants (mean age 11.2, SD 1.9 y) whom a clinical psychologist had diagnosed with DP, IP or both. After inclusion, participants were randomized to either ICBT (17/33, 52%) or a control group of children on a waitlist (16/33, 48%). ICBT was based on exposure therapy and comprised a 12-week at-home program combined with visits to their regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and one parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the outcome variables before treatment start and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview with a clinical psychologist. Our primary outcome measure was the Picture-Guided Behavioral Avoidance Test (PG-BAT), which assesses the ability to approach 17 dental clinical procedures and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self- efficacy and levels of dental and injection anxiety. The children and their parents completed the questionnaires.
Results
All participants underwent the 12-week follow-up. After treatment, 41% (7/17) of the participants in the ICBT group no longer met the diagnostic criteria for DP or IP, whereas all participants in the control group did (P=.004). Repeated-measure ANOVAs showed that ICBT led to greater improvements on the PG-BAT compared with the control group; between-group effect sizes for the Cohen d were 1.6 (P<.001) for the child-rated PG-BAT and 1.0 (P=.009) for the parent-rated PG-BAT. Reductions in our secondary outcomes- dental fear and anxiety (P<.001), negative cognitions (P=.001), and injection fear (P=.011)-as well as improvements in self-efficacy (P<.001), were all significantly greater among children in the ICBT group than in the controls. No participants reported adverse events.
Conclusions
ICBT seems to be an effective treatment for DP and IP in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; this therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents.
Reviewers evaluation, opinion and points of interest
On a similar thread to my other journal scan in this issue on increasing access and availability of CBT for dental fear, this research team in Sweden are exploring something very similar for children: internet-based CBT (ICBT) for children and adolescents with dental or injection phobia. This therapist-guided 12-week ICBT intervention with parental support, was put to the test in this randomised controlled trial (RCT) with really encouraging findings.
The authors outline the central components of the 12-week programme in a helpful table and reference the content’s origins from a previously researched and published manual and pilot project published in 2016 and 2018 respectively. Essentially, the core component of the intervention was exposure with video and audio recordings, a toolkit of dental equipment to be used at home with parental (or ‘coach’) support, and in vivo (in person) exposure session at a dental clinic. Parents who put themselves forward as coach for their child / young person, also received input with information on how best to support, motivate and assist their child / young person in their engagement with online / at home tasks. Each participant was assigned one of the three psychological professionals, experienced in CBT and the dental setting specifically; with communication via email and direct message to guide feedback of completed tasks and grant access to the next module. Telephone contact was used if participants were ‘inactive’ on the online platform for more than ten days. Access to the materials and learning on the ICBT platform were left open and active for 12-months, however, input with the psychologist ended at 12-weeks on completion of the intervention.
The findings are clearly reported and it is really great to see clinical reductions in threshold levels of dental anxiety and needle phobia following the intervention for 41% of the ICBT participants. Compared to hour-long sessions, this intervention was less time- intensive for the trained practitioners involved, which has obvious benefits for increasing the accessibility to such a resource. However, as the authors note, it will be of interest and importance to explore how outcomes compare with traditional face-to-face CBT.
Promisingly, the dental treatment and in vivo exposure provided as part of this study was delivered by dentists or dental assistants in general practice with either no or very little input or association with the research team, or with specific training and education in CBT. The authors imply some feasibility in only briefly instructing the dental practitioner on how to conduct exposure (by the parent coach / intervention materials) when this is being supported within an ICBT programme which has the potential for wider dissemination in practice.
Something to note, which the authors fully acknowledge, is the exclusion of children with any neurodevelopment disorders from the RCT; further work is needed on the application of CBT-based interventions for this patient group who present commonly in specialist paediatric dental services. Nonetheless, it is another great indication of how CBT might be made more widely available in future.
JH
Patient-support techniques for treating patients with learning disabilities
Fenesan S, Hare J, Kerr B. Dent Update 2024; 51: 122-130
Abstract
There are many techniques that can, with simple adjustments, be used for patients with learning disabilities. A number of techniques may be familiar to dentists as those which are applied to anxious or paediatrics patients. There is a lack of focused articles clearly describing specific techniques that can be used for individuals with learning disabilities and how these can be adapted to help enable dental assessment and treatment. This article aims to inform general dental practitioners of patient-support techniques that may be used or adapted for individuals with learning disabilities.
CPD/Clinical Relevance
Dental professionals should be able to make reasonable adjustments to their practice to better support individuals with learning disabilities who access dental care.
Reviewers evaluation, opinion and points of interest
Whilst undertaking her speciality training and working in the Sedation and Special Care Dental department at Guy’s, Stephanie Fenesan set about conducting a literature review exploring supportive interventions, or techniques, that may be drawn upon to improve dental care provision for individuals with a learning disability. Bryan Kerr and I supported this review and, in spite of this (!), I wanted to share her paper in this Digest’s journal scan as a very practical source of information for dental professionals working with people with mild, moderate, severe or profound learning disability, considering how approaches can be adapted, based on practical clinical experience.
The review includes a broad range of ‘patient support techniques’, all of which are non-pharmacological and fall under the broad categories of: communication, reinforcement, modelling, desensitization, distraction / relaxation and adapting the clinical environment (note: clinical-holding is not included).
These categories were chosen following a seminal paper by Mac Giolla Phadraig et al (2020)1 exploring terminology and behaviour- change techniques. Indeed, in the 2022 SAAD Digest, I pointed readers to the Mac Giolla Phadraig et al (2022)2 position paper, on the need to define patient and behaviour support techniques used in dentistry due to the lack of universally agreed definitions and terminology.
And in a sneaky journal scan within a journal scan (!) I now also point you to the very recently published paper from the group (with the addition of many more authors who contributed to the research process) in March this year. This study aimed to develop and sort a comprehensive list of terminologies and descriptions of ‘dental behaviour support’ (DBS) for all patients, agreed within an adapted e-Delphi method (Mac Giolla Phadraig et al 2024).3 There is still more work to do, though this a solid start.
For those readers looking for some practical, evidence-based approaches to improve the provision of dental care and experience of receiving dental treatment for individuals with a learning disability, please do take a look at these jam-packed seven pages in Dental Update.
References
1. Mac Giolla Phadraig C, Asimakopoulou K, Daly B, Fleischmann I, Nunn J. Nonpharmacological techniques to support patients with intellectual developmental disorders to receive dental treatment: A systematic review of behavior change techniques. Spec Care Dentist 2020; 40: 10-25. https://doi.org/10.1111/scd.12434
2. Mac Giolla Phadraig C, Newton T, Daly B, Limeres Posse J, Hosey M T, Yarascavitch C, MacAuley Y, Buchanan H, Nunn J, Freeman R, Stirling C, Healy O, Asimakopoulou K. BeSiDe time to move behavior support in dentistry from an art to a science: A position paper from the BeSiDe (Behavior Support in Dentistry) Group. Spec Care Dentist 2022; 42: 28-3. https://doi.org/10.1111/scd.12634
3. Mac Giolla Phadraig C, Healy O, Fisal A A, Yarascavitch C, van Harten M, Nunn J, Newton T, Sturmey P, Asimakopoulou K, Daly B, Hosey, M T, Kammer P V, Dougall A, Geddis-Regan A, Pradhan A, Setiawan A S, Kerr B, Friedman C S, Cornelius B W, Stirling C, Hamzah S Z, Decloux D, Molina G, Klingberg G, Ayup H, Buchanan H, Anjou H, Maura I, Fernandez I R B, Posse J L, Hare J, Francis J, Norderyd J, Rohani M M, Prabhu N, Ashley F, Marques P F, Chopra S, Pani S C, Krämer S. A Delphi study to agree terminology in behaviour management. Community Dent Oral Epidemiol 2024; https://doi.org/10.1111/cdoe.12953. Online ahead of print.
JH
