FOR DENTISTS

SAS SCHEME

REGISTER
The deadline for registering for the SAS scheme is four weeks after attending the SAAD National Course.

INFORMATION REQUIRED
When registering you will need to be able to provide the following information:

• Date you will attend the SAAD National Course
• Intended sedation technique(s)
• Age group of patients (adults, children or both)
• Name of proposed clinical supervisor(s)
• GDC/GMC No. of proposed clinical supervisor(s)
• Qualifications of proposed clinical supervisor(s)
• Dental sedation experience of proposed clinical supervisor(s)
• Sedation services offered by proposed clinical supervisor(s) including approx. no. of dental sedation cases in the last 12 months
• Address of the practice(s) where the clinical supervision will take place
• A brief description of sedation facilities.

APPROVAL
The information about the nominated clinical supervisor(s) and the sedation facility where the supervised clinical practice will take place is submitted for approval to the SAAD Training Board.

SAAD NATIONAL COURSE
Attend the SAAD National Course for the knowledge and skills training.

WRITTEN ASSESSMENT
After attending the SAAD National Course, once supervisor (s) have been approved, a link will be provided to complete the online written assessment in your own time. The assessment is 30 ‘single best answer’ questions.

ASSESSSMENT RESULTS
The results will be emailed immediately. This is followed by a confirmation statement to be signed and returned. On receipt of the signed confirmation a link to access the SAS scheme webpage will be emailed.

SAS SCHEME WEBPAGE
From this page it will be possible to download all of the documents required for completion during the supervised clinical experience.

• Document Submission Checklist
• DOPS form
• Logbook
• Practice Self-Evaluation Checklist (for each location)

Also available is guidance on setting up the SAAD Document Repository (SDR)

SUPERVISED CLINICAL EXPERIENCE
20 IVS and/or 10 IS cases should be documented and signed by the approved clinical supervisor. For ten of the IVS and five of the IS cases the sedation trainee should provide both the treatment and the sedation.

ACCESS THE SAAD DOCUMENT REPOSITORY (SDR)
This enables SAS scheme documents to be uploaded, via a secure section of the SAAD website, and submitted for approval. All documents must be submitted within 12 months of attending the SAAD National Course.

APPROVAL AND CERTIFICATION
Successful practitioners will receive a SAAD certificate confirming ‘SAAD Assessed Sedationist’ status which will enable you to practise independently.

For more information and to register see: https://www.saad.org.uk/index.php/new-to-sedation/sas-scheme

 FOR DENTAL NURSES

SASN SCHEME

REGISTER
The deadline for registering for the SASN scheme is four weeks after attending the SAAD National Course.

INFORMATION REQUIRED
When registering you will need to be able to provide the following information:

• Date you attended the SAAD National Course
• Intended sedation technique(s)
• Age group of patients (adults, children or both)
• Name of proposed clinical supervisor(s)
• GDC/GMC No. of proposed clinical supervisor(s)
• Qualifications of proposed clinical supervisor(s)
• Dental sedation experience of proposed clinical supervisor(s)
• Dental sedation services offered by proposed clinical supervisor(s) including approx. no. of dental sedation cases in the last 12 months
• Address of the practice(s) where the clinical supervision will take place
• A brief description of sedation facilities.

APPROVAL
The information about the nominated clinical supervisor(s) and the sedation facility where the supervised clinical practice will take place is submitted for approval to the SAAD Training Board.

SAAD NATIONAL COURSE
Attend the SAAD National Course for the knowledge and skills training

SASN SCHEME WEBPAGE
From this page it will be possible to download all of the documents required for completion during the supervised clinical experience.

• Document submission checklist
• DOPS forms
• Practice profile (for each location)

Also available is guidance on setting up the SAAD Document Repository (SDR)

SUPERVISED CLINICAL EXPERIENCE
20 IVS and/or 10 IHS cases should be documented and signed by the approved clinical supervisor.

ACCESS THE SAAD DOCUMENT REPOSITORY (SDR)
This enables SASN scheme documents to be uploaded, via a secure section of the SAAD website, and submitted for approval.

SUBMIT DOCUMENTS FOR APROVAL
All documents should be submitted to be approved within 12 months of attending the SAAD National Course.

ONLINE WRITTEN ASSESSMENT
After the submitted documents have been approved, a link will be provided to complete the online written assessment in your own time. The assessment is 30 ‘single best answer’ questions.

ASSESSSMENT RESULTS
The results will be emailed immediately. This is followed by a confirmation statement to be signed and returned. On receipt of the signed confirmation a certificate will be posted.

APPROVAL AND CERTIFICATION
Successful practitioners will receive a SAAD certificate and badge confirming ‘SAAD Assessed Sedation Nurse’ status which will enable you to assist with the provision of dental sedation as the second suitable trained person.

For more information and to register see: https://www.saad.org.uk/index.php/new-to-sedation/sasn-scheme 

 FOR DENTAL HYGIENISTS & THERAPISTS

SASH/T SCHEME

REGISTER
The deadline for registering for the SASH/T scheme is a week before the weekend of the SAAD National Course.

INFORMATION REQUIRED
When registering you will need to be able to provide the following information:

• Age group of patients (adults, children or both)
• Name of proposed clinical supervisor(s)
• GDC/GMC No. of proposed clinical supervisor(s)
• Qualifications of proposed clinical supervisor(s)
• Dental sedation experience of proposed clinical supervisor(s)
• Sedation services offered by proposed clinical supervisor(s) including approx. no. of dental sedation cases in the last 12 months
• Address of the practice(s) where the clinical supervision will take place
• A brief description of sedation facilities.

APPROVAL
The information about the nominated clinical supervisor(s) and the sedation facility where the supervised clinical practice will take place is submitted for approval to the SAAD Training Board.

SAAD NATIONAL COURSE
Attend the SAAD National Course for the knowledge and skills training

WRITTEN ASSESSMENT
After attending the SAAD National Course, once supervisor(s) have been approved, a link will be provided to complete the online written assessment in your own time. The assessment is 30 ‘single best answer’ questions.

ASSESSSMENT RESULTS
The results will be emailed immediately. This is followed by a confirmation statement to be signed and returned. On receipt of the signed confirmation a link to access the SASH/T scheme webpage will be emailed.

SASH/T SCHEME WEBPAGE
From this page it will be possible to download all of the documents required for completion during the supervised clinical experience.

• Document Submission Checklist
• DOPS form
• Logbook
• Practice Self-Evaluation Checklist

Also available is guidance on setting up the SAAD Document Repository (SDR)

SUPERVISED CLINICAL EXPERIENCE
Ten IS cases should be documented and signed by the approved clinical supervisor. For five of these cases the sedation trainee should provide both the treatment and the sedation.

ACCESS THE SAAD DOCUMENT REPOSITORY (SDR)
This enables SASH/T scheme documents to be uploaded, via a secure section of the SAAD website, and submitted for approval. All documents must be submitted within twelve months of attending the SAAD National Course.

APPROVAL AND CERTIFICATION
Successful practitioners will receive a SAAD certificate and badge confirming ‘SAAD Assessed Sedation hygienist/therapist’ status which will enable you to practise independently.

For more information and to register see: https://www.saad.org.uk/index.php/new-to-sedation/dental-hygienists-therapists

DOI: 10.63507/WGVY5328

A synopsis of articles of interest from the last twelve months to inspire further reading 

Oral implant rehabilitation under general anesthesia for patients with cognitive and physical disabilities: A 14-year cohort study 

Bogner M-S, Chambas V, Veyrune J-L, Faulks D, Hennequin M.
J Prosth Dent 2025; 134: 1156-1163
DOI: 10.1016/j.prosdent.2024.01.012

Abstract
Statement of problem
Oral rehabilitation with implants is an alternative to the provision of removable dentures in all patients for whom missing teeth require replacement. However, individuals with cognitive, mental health issues, and / or physical disabilities are often excluded from implant-supported prostheses because of the high perceived risk of failure linked to poor oral health, presence of parafunction, or systemic conditions.

Purpose
The purpose of this cohort study was to describe the protocols, outcomes, and survival rates of oral rehabilitation with implant- supported prostheses in patients with cognitive and physical disabilities treated under general anesthesia (GA) in a French unit of Special Care Dentistry.

Material and methods
A retrospective cohort study was conducted on patient files. Data collected included demographics and information about the surgical and prosthetic phases of rehabilitation. Clinical and radiological reports were retrieved to establish the survival, success, and failure rates of implant placement according to the Health Scale for Dental Implants (HDSI) classification.

Results
A total of 298 dental implants had been placed under GA in 57 patients between January 2007 and August 2021. The prevalence of technical and biological postoperative complications was found to be 14% and 13% respectively. Thirty implants were determined to be failures. The estimated survival time in the population studied for loaded implants was 144.7 months [138.0; 151.3]. The cumulative survival rate was estimated to be 86% at 157 months.

Conclusions
Implant-supported prostheses were found to be effective, and oral rehabilitation carried out under the conditions described was determined to be stable.

Reviewer’s evaluation, opinion and points of interest
This paper provides a review of a significant number of Special Care Dentistry patients who had implants placed under general anaesthesia (GA) and then restored using a variety of anxiety management techniques dependent on the ability of the patients to co-operate. Many of these patients would have been refused treatment at a range of different implant services due to poor co-operation, poor oral hygiene and irregular attendance. Despite this, the survival figures found in this study, of 95% at 60 months are comparable with those found in many studies of the general population.

In this study there was no significant difference found in the estimated survival time of implants placed in those with poorer oral hygiene and those with better oral hygiene. There was quite a high level of implant related complications with only 20 patients free of complications. Fourteen patients presented both biological and technical complications, prosthetic complications occurred in 29 patients.

There was a significant exposure to GA, the average number of sessions required for implant placement being 1.5. Thirteen patients required GA for the loading of implants, and seven for the treatment of complications. Given the reluctance to expose patients to repeat GA, adoption of this approach in the UK would be a major culture change.

The authors state ‘Patients with special needs should not be excluded from receiving implant-supported prostheses. However, information about the higher risk of complications compared with the general population should be discussed with patients and carers. Alternative solutions should be discussed in the event of failure.’

Caution does have to be advised when reading this paper as it is a retrospective study based on the data available from the clinical records, and 18 patients had to be excluded from the study, but it does question some of the conventional wisdom around patient selection for implant placement.

NDR

Role of digital technologies in special care dentistry: a scoping review

Kammer P V, Souza B B, Sobral M B, Molina G F, Zar M R, Bolan M.
Spec Care Dentist 2025; 45:e70071.
DOI: 10.1111/scd.70071

Abstract
Aims
This scoping review aims to explore the application of digital dentistry in special care dentistry (SCD), focusing on the types of digital tools used, their clinical applications, reported outcomes, and challenges. The review seeks to synthesize current evidence to provide a foundation for advancing research and practice in this field.

Methods and results
Using the population, concept, and context (PCC) framework, this review included studies addressing digital dentistry applications for individuals requiring special care due to physical, cognitive, developmental, or medical conditions. A systematic search of PubMed, Embase, Scopus, and Web of Science identified 18 eligible studies, including case reports, cohort studies, and systematic reviews. Digital tools such as CAD/CAM systems, intraoral scanners, and 3D imaging technologies were highlighted for their effectiveness in improving diagnostic accuracy, treatment planning, and patient comfort. Key benefits included reduced patient discomfort and enhanced prosthetic precision, while barriers included high costs, limited training, and challenges with digital workflow integration.

Conclusion
Digital dentistry demonstrates significant potential to enhance care quality in SCD by addressing unique patient needs with improved efficiency and precision. However, financial, educational, and technological barriers limit widespread adoption. Future research should focus on long-term outcomes, cost-efficiency, and innovative solutions to promote equitable access and implementation.

Reviewer’s evaluation, opinion and points of interest
This article reviews the use of digital technologies in special care dentistry, and while it points to some of the benefits these new technologies can bring in terms of patient comfort, it also reviews the barriers to use.

Digital impression taking is highlighted particularly for patients with cleft lip and palate and those with Epidermolysis bullosa. Chairside CAD/CAM restorations are highlighted as improving quality of life.

Barriers that are mentioned include the cost of the equipment, the difficulty in retrieving high quality articles from the literature and the lack of inclusion in teaching programmes.

NDR

Assessment of self-medication behaviour in response to dental pain in two populations, France

Le Texier L, Savanovitch C, Nicolas E , Cousson P Y.
Int Dent J 2026; 76: 109418.
DOI: 10.1016/j.identj.2026.109418 

Abstract
Introduction and aims
Self-medication appears to be a common practice for dental pain. However, in France, its prevalence and patterns in dentistry have never been studied. The primary objective was to assess the prevalence and self-medication behaviours in two at-risk populations: patients consulting for acute pulpal or periapical pain and patients with dental anxiety requiring treatment under general anaesthesia. The secondary objective was to examine the influence of socio-behavioural factors on these practices.

Method
Between April 2021 and May 2023, the behaviours of two at-risk populations regarding self-medication were analysed in a cross-sectional observational study. The first population regrouped patients referred to an endodontic postemergency care unit after visiting the emergency service of a dental hospital. These patients were referred due to acute pulpal or periapical pain (Endodontic Group). The second population regrouped patients referred to a special care unit for dental treatment under general anaesthesia due to dental anxiety (Anxiety Group). Self-medication behaviours of the two at-risk populations were analysed with 5 self-administered questionnaires (self-medication, EPICES, IDAF-4C, Pain Catastrophizing Scale, Socio-demographic data). Comparisons between the two population were done using Pearson's chi-square and Student's t tests.

Results
During the study period, 43 patients were included in the endodontic group and 66 in the anxiety group. Socio- demographic and behavioural data differed between the two groups. However, self-medication prevalence was similar (51.2% in the Endodontic Group vs 45.5% in the Anxiety Group), as were self-medication behaviours (types and number of substances used, methods of acquisition, knowledge). No socio-demographic or behavioural factors explained these attitudes.

Conclusion
Self-medication in dentistry is often overlooked or poorly managed. Preventive measures and patient education on the proper use of medication are essential.

Clinical relevance
Standardized co-operation protocols should be developed involving dentists and community pharmacists to optimize the management of patients suffering from dental pain.

Reviewer’s evaluation, opinion and points of interest
This study demonstrates that a significant number of patients who self-medicate on analgesics are unaware of the maximum safe doses of medication and are at risk of overdose. Anxious patients were less knowledgeable about the maximum doses with only 36% knowing the maximum dose of paracetamol and 42% the maximum dose of ibuprofen compared with 43% and 50% of the endodontic patients.

Anxious patients and those having endodontic treatment used a similar number of drugs, however, anxious patients were more likely to use paracetamol and codeine than those awaiting endodontic treatment. In both groups approximately half of the patients chose to self-medicate without any professional advice.

Whilst this study took place in France, there have been other studies indicating that self-medication using both over the counter medications and left over prescription only medications is common worldwide.

The suggestion is that improved protocols for the management of dental pain are needed, as is their communication to the population at large. 

NDR

Prevalence, characteristics, and predictive factors of dentoalveolar and spreading odontogenic infections in children treated under general anaesthesia

Hyppänen A, Mussalo F, Snäll J, Alapulli H, Salmela E.
Int J Paed Dent 2026; 36: 13-18.
DOI: 10.1111/ipd.70020

Abstract
Background
Children receiving dental treatment under general anesthesia (GA) often have odontogenic infections (OIs). Early detection and treatment of patients at risk of OIs can improve oral health and prevent early tooth extractions.

Aim
To investigate the prevalence, characteristics, and predictive factors of OIs in children receiving dental treatment under GA.

Design
This retrospective study included children (< 16 years) receiving GA dental treatment at New Children's Hospital in Helsinki, Finland. The associations between predictor variables and OI were evaluated through logistic regression analyses. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

Results
Of 1089 patients, 352 (32%) had signs of OI. The most common infection findings were fistula (59%) and abscess formation (36%). Primary teeth were involved in 96% of cases. Severe odontogenic infections were rare (3%). The odds of OIs were significantly higher among girls compared to boys (OR =1.346; 95% CI: 1.043–1.737; p=0.022). Patients with previous GA dental treatment, neurodevelopmental disorders, chronic diseases, or intellectual disabilities had fewer OIs.

Conclusion
OIs are common in patients undergoing dental treatment under GA, with nearly one-third having findings of infections. However, severe OIs are rare in children. Girls have OIs more often than boys, which should be taken into consideration by dentists.

Reviewer’s evaluation, opinion and points of interest
This study reviewed the records of 1089 patients who had undergone dental treatment under general anaesthesia (GA) in the year 2022 in a hospital in Finland. The study found that 32% of the patients had clinical signs of odontogenic infection including swelling, abscess formation or presence of a sinus tract. Although the majority of the patients were male, girls were significantly more likely to have OIs than boys. This is an interesting finding given the recent publicity that has been given to the underdiagnosis of women’s symptoms and pain in healthcare. Those whose first language was not one of the native languages of Finland were overrepresented in the study population, perhaps indicating difficulties in accessing healthcare services in their country of origin. Another interesting finding was that those with chronic disease, intellectual disability, or a neurodevelopmental disorder such as autism spectrum disorder or attention deficit hyperactivity disorder (ADHD) had fewer OIs and were more likely to have received previous dental care under GA. The authors sum up the key points of their paper:

Why this paper is important to pediatric dentists

• Nearly a third of children receiving dental treatment under GA have clinically notable odontogenic infections that can cause symptoms in patients. There should be a stronger emphasis on earlier and preventive care to reduce the number of odontogenic infections and thereby early tooth removals and the need for the use of antimicrobial drugs in children.
• The vast majority of odontogenic infections in children requiring GA treatment occur in primary teeth.
• Girls have odontogenic infections more often than boys. Oral health professionals and the child's guardians should be more diligent in evaluating the oral health of girls in particular.

NDR

Compared to intravenous injection of midazolam, does intranasal dexmedetomidine provide adequate sedation for dentoalveolar surgery?

Jingmei Yang, Yanzheng Liu, Zhanfei Liang, and Chaojing Lv
J Oral Maxillofac Surg 84:656-664, 2026.
DOI: 10.1016/j.joms.2026.01.017

Abstract
Background
Conscious sedation is crucial for managing anxiety and ensuring safety during dentoalveolar surgery. The efficacy of intranasal dexmedetomidine (DEX) as a sedative agent in this context remains unclear.

Purpose
The purpose was to measure and compare the level of sedation in subjects receiving either intranasal DEX or intravenous midazolam (MID).

Study design, setting, and sample
A randomized, nonblinded clinical trial was conducted at the People’s Liberation Army 63750 Hospital. Patients scheduled for outpatient dentoalveolar surgery between February and April 2024 were screened. Those requiring vasoactive drugs during operation were excluded.

Predictor variable
The primary intervention was the esthetic agent, and subjects were randomly assigned to receive either intranasal DEX (1.5 μg/kg) or intravenous MID (0.07 mg/kg).

Outcome variable
The primary outcome was the Observer’s Assessment of Alertness/Sedation scale (1 = deep sleep, 5 = fully alert; lower scores indicate deeper sedation). Measurement time points were when sedation was ready, when local anesthetic infiltration started, 5 minutes, 10 minutes, 15 minutes, 20 minutes, and 30 minutes during the intraoperative period, and 30 minutes after the completion of the operation. Secondary outcomes included visual analog scale, hemodynamic parameters, and adverse events.

Covariates
The covariates included demographics (age, sex), perioperative variables (procedure type, medications for heart rate or hemodynamic blood pressure), and operative details (number of teeth, volume of local anesthetic, and surgical time).

Analyses
Data were analyzed using independent samples t tests, χ 2 tests, and repeated measures analysis of variance (ANOVA) for the primary outcome. Statistical significance was set at P < .05.

Results
The sample was composed of 103 subjects with a mean age of 63.98 ± 16.89 (P = .6) and 43 (42%) were male (P = .5). Observer’s Assessment of Alertness/Sedation scores were 2.65 ± 0.481 and 2.30 ± 0.462 for MID and DEX, respectively (P < .001). Visual analog scale scores were 1.72 ± 1.180 and 1.27 ± 1.163 for MID and DEX, respectively (P = .037). Systolic pressure was 124.18 ± 8.4341 and 120.65 ± 9.180 for MID and DEX, respectively (P = .030). Diastolic pressure was 78.30 ± 5.475 and 76.28 ± 4.762 for MID and DEX, respectively (P = .033); heart rate was 74.98 ± 3.296 and 72.95 ± 5.047 for MID and DEX, respectively (P = .010). No significant differences were observed in oxygen saturation (P = .069) or adverse reactions (P = .5)

Reviewer’s evaluation, opinion and points of interest
This study highlights intranasal dexmedetomidine as a promising tool for ‘co-operative sedation’ with the significant advantage of needle-free delivery.

• Co-operative sedation profile: unlike the GABA-mediated effects of midazolam, DEX mimics natural sleep, allowing patients to remain easily rousable and able to follow commands (e.g., mouth opening), which is ideal for dentoalveolar surgery.
• Induction lead-time: a significant practical constraint is the 30-minute wait required after intranasal administration for the drug to reach peak effect. This differs substantially from the rapid titration possible with IV midazolam.
• Omission of discharge data: the study does not report a time to discharge, concluding data collection at 30 minutes post-operatively. Other literature suggests DEX may result in a prolonged recovery period compared to traditional agents.
• Safety and monitoring: DEX offers a superior respiratory profile with no observed oxygen desaturation or respiratory depression, a key advantage in outpatient settings. DEX produced greater transient reductions in blood pressure and heart rate compared to midazolam, but none required any intervention.
• Amnesia: it is worth noting DEX provides significantly less procedural amnesia (56.7%) than midazolam (75%). Midazolam remains the superior choice if the primary clinical goal is total lack of recall.
• Overseas study: this study was conducted in China. DEX would be an advanced sedation technique in the UK. This necessitates specialised training and a dedicated sedationist independent of the operator. The intranasal administration of DEX is an off-label use in the UK.

Overall Impression
Intranasal DEX is an effective, needle-free alternative to intravenous midazolam that provides excellent early sedation and analgesic benefits. The 30-minute induction time, potentially extended recovery times and classification as an advanced technique are significant downsides, but this is a promising technique that warrants further research to explore its application in dental sedation.

GG

The relationship between burnout in dental care professionals and patient safety: a scoping review

Bruj-Milasan G, Plessas A, Anabalon-Cordova P, Hopcraft M,
Johnston A, Yuh C, Newton J T.
Int Dent J, 2026 2; 76: 109525.
DOI: 10.1016/j.identj.2026.109525

Abstract
Objective
To identify within the published literature the relationship between the experience of burnout and patient safety.

Methods
Scoping review conducted in accordance with the JBI methodology for scoping reviews. Searches were conducted in the following databases up to and including December 2024: CINAHL, EMBASE, MEDLINE, PsycINFO, and Scopus.

Findings
Five studies were identified as relevant to the aims of the review, with a total of 2362 dental participants. A variety of measures of burnout were adopted, and there were marked differences in the aspect of patient safety addressed. Burnout was related to the intention to leave the dental profession and, in 1 study, to self-reported errors of practice.

Conclusions
The conclusions drawn from the review are limited by the marked heterogeneity in measures across the 5 studies. Some evidence suggests that burnout is related to the intention to leave the dental profession and with self-reported patient care errors.

Reviewer’s evaluation, opinion and points of interest
This timely scoping review by Geanina Bruj-Milasan and colleagues tackles an important but surprisingly neglected question: does burnout among dental professionals compromise patient safety?

Despite the growing literature on burnout in dentistry, the authors identified only five eligible studies (applying the JBI scoping review methodology) examining links with patient safety outcomes. The evidence base was heterogeneous and limited; however, the findings suggest burnout may be associated both with intention to leave the profession and with self-reported clinical errors. In one US study, dentists with high burnout scores were more than four times as likely to report an error in the previous six months.

This paper moves the conversation beyond individual resilience and towards systems-level concerns. The discussion around workforce pressures, retention, and the potential downstream effects on patient care feels particularly relevant in the current climate. The authors are appropriately cautious about the limitations of the evidence, especially the reliance on cross-sectional designs, self-reported errors, and predominantly US-based samples. Interestingly, three of the five studies focused on dental hygienists rather than the wider dental team, which the authors note, but do not explore… perhaps this reflects where workforce pressures are currently being most visibly studied and it would be great to see more research across the wider dental team.

Overall, this is a thoughtful and useful review that highlights how little we know about the relationship between burnout and patient safety in dentistry. The review is unlikely to change practice immediately, but it makes a strong case for better quality research in this area. It also importantly tackles burnout in a wider context, with consideration than it simply being an occupational wellbeing issue.  The paper also indirectly highlights the importance of psychological safety within dental teams, although the concept itself is not explicitly discussed. Environments where clinicians feel able to raise concerns, acknowledge mistakes and discuss stress openly are increasingly recognised as central to both workforce wellbeing and patient safety an area that remains relatively underexplored within dentistry.

JH

Reference
Edmondson A C, Lei Z. Psychological safety: The history, renaissance, and future of an interpersonal construct. Annu Rev Psychol 2014; 1: 23–43.

Me, we, they: identifying the key stressors affecting the dental team

Mills I, Knights J, Ellwood F, Witton R, Young L, UK Dental Team Mental Health Research and Implementation Group.
Br Dent J 2025; 239: 197-203.
DOI: 10.1038/s41415-025-8645-z.

Abstract
Introduction
The mental health and wellbeing of the dental workforce is essential in providing oral healthcare services which are sustainable, safe and of the highest quality. Yet, there remains a lack of qualitative studies exploring the factors that negatively affect wellbeing in dentistry in the United Kingdom, not least in regard to the views and experiences of the wider dental team.

Aim
The aim of this paper is to identify and explore the factors that contribute to stress and burnout within dental teams as reported through the MINDSET U.K. Survey 2023.

Method
Qualitative data were collected in an online questionnaire which provided an opportunity for respondents to provide a free-text response. Following an inductive approach, thematic analysis was used to synthesise the findings.

Results
In total, 1,507 responses were received, of which 287 included a valid free-text response. The sample included 203 dentists, 69 dental care professionals, 13 practice managers/ receptionists and two respondents who did not select a professional group. Six themes were identified from the data: workload; NHS system; regulatory compliance, patient complaints and litigation; financial pressures; leadership and management; and self-worth.

Conclusion
Current reactive approaches to dealing with the mental health and wellbeing of dental healthcare workers are insufficient. Measures need to be urgently developed and implemented to reduce or mitigate the contributing factors at the macro (system) level. These need to be considered as a priority in order to create the working conditions necessary to allow all members of the dental team to develop, flourish and feel valued

Reviewer’s evaluation, opinion and points of interest
On the same vein as the previous journal scan, I wanted to review another paper (well, two papers!) published last year, just in case they were missed by our Digest readers in the BDJ August 2025 issue (239).

The paper from Ian Mills et al., offers a useful qualitative extension of the UK dental workforce literature, drawing on free-text responses from the MINDSET UK survey to explore key drivers of stress and burnout across the wider dental team. Six themes are identified: workload, NHS system pressures, regulatory burden and complaints, financial strain, leadership and management, and reduced self-worth. The central message is consistent with recent UK work (and the other paper to read: Knights et al.,) which reports that distress is largely structurally produced, rather than located at the level of individual resilience. 

Together, Mills et al., and Knights et al., provide complementary evidence describing both the prevalence and lived mechanisms of distress across the UK dental workforce, converging on a predominantly system-level account of burnout, characterised by high emotional exhaustion, role-specific patterns of strain and workforce-wide impacts extending beyond dentists to the wider dental team.

Across both papers, there is a clear pattern of chronic workload pressure, compounded by recruitment and retention difficulties, target-driven NHS systems and a pervasive fear of complaints, litigation and regulatory escalation. Leadership and organisational culture are repeatedly positioned as either buffering or amplifying stress, with particular emphasis on feeling undervalued and unsupported across professional groups, not just dentists. Emotional exhaustion and disengagement are evident across the full dental team, including dental nurses, reception staff and practice managers.

The qualitative excerpts are particularly striking, with repeated references to entrapment, loss of morale, and moral distress (eg feeling unable to provide adequate care or being ’trapped in the system’). This moves the interpretation beyond burnout as fatigue, towards something closer to identity strain and moral injury (eg ’I go home knowing I have failed my patients’) within constrained systems.

Although not explicitly framed in these terms, several findings map closely onto the concept of psychological safety particularly around fear of speaking up, anxiety about complaints and the perceived punitive nature of regulatory and organisational systems. This aligns with the broader ’me, we, they’ framing (proposed by Tim Newton), where system- level (‘they’) factors are positioned as the dominant drivers of distress.

Of course, for Digest readers, there are also clear implications for anxiety, sedation and special care pathways. These services rely heavily on relational containment, trust-building and emotionally regulated clinical interactions. Where workforce burnout is high, there is a risk that the consistency and quality of these interactions become harder to sustain; particularly for dentally anxious patients, for whom clinician calm, predictability and relational safety are often central to receiving care.

Overall, this paper reinforces the growing consensus in the UK literature (including Knights et al.,) that workforce distress in dentistry is primarily systemically generated and that service design and organisational culture are likely to be as important as individual-level interventions in sustaining safe, effective and relationally responsive care.

It was also encouraging to hear the Chief Dental Officer, Jason Wong, discussing these issues in his recent address at the spring British Society for Special Care Dentistry (BSSCD) conference, where current resources for dental professionals were signposted alongside a clear emphasis on ongoing support for the workforce.

I’d like to reshare these here:
‘BREATHE is a dedicated wellbeing platform for the oral health community, providing a one-stop hub for expert guidance, support, and evidence-based tools to help individuals, teams, and organisations reduce stress, prevent burnout, and improve performance across dental settings’. 

JH

References
British Dental Journal. And BREATH. 2025. Online information available at https://www.breathedentalwellness.org/ (accessed May 2026)

Knights J, Young L M, Humphris G, Newton J T, UK Dental Team Mental Health Research and Implementation Group. Burnout and depression in the UK dental workforce: findings from a cross-sectional survey. Br Dent 2025; 239: 189-196.

Effectiveness of virtual reality glasses versus white noise on dental anxiety in children with attention-deficit hyperactivity disorder: a randomised controlled clinical trial

Aly N A, Abdelrahman A M, Omar T E I, Dowidar K M
Int J Paediatr Dent 2025; 35:529-539.
DOI: 10.1111/ipd.13264

Abstract
This randomised controlled clinical trial evaluated the effectiveness of virtual reality (VR) glasses and white noise compared with basic behaviour management techniques (BMTs) in reducing dental anxiety and improving behaviour in children with attention-deficit hyperactivity disorder (ADHD). Forty-eight children aged 7–10 years with ADHD were allocated into three groups (VR, white noise, control) and underwent three sequential dental visits (examination, preventive care, restorative treatment). Outcomes included self-reported anxiety using the Faces Image Scale (FIS), physiological response via heart rate (HR), and behaviour using Venham’s Behaviour Rating Scale (VBRS).

No significant differences were observed between groups for FIS scores, although anxiety reduced across visits in all groups. The white noise group demonstrated significantly lower heart rates compared to control across visits, indicating reduced physiological anxiety. Behaviour (VBRS) during the restorative visit was significantly improved in both VR and white noise groups compared with control.

The study concludes that VR and white noise are effective adjuncts to BMTs in managing dental anxiety and improving behaviour in children with ADHD, with white noise showing superior physiological calming effects. 

Reviewer’s evaluation, opinion and points of interest
This is a well-designed, pragmatic RCT addressing a clinically relevant and under-researched cohort: children with ADHD in dental settings. Several strengths stand out:

Strengths

• Robust RCT design with CONSORT adherence and clear methodology
• Well-defined ADHD cohort with diagnostic confirmation
• Multi-modal outcome assessment (subjective, behavioural, physiological)
• No attrition, which strengthens internal validity
• Clinically relevant staged treatment model (mirrors real-world paediatric dentistry pathways).

Key findings of interest

• White noise appears superior for physiological anxiety reduction (HR), which is particularly useful where objective calming is needed (e.g. LA administration)
• VR and white noise both improve behaviour during invasive procedures, especially restorative visits
• No difference in self-reported anxiety (FIS) suggests:
  
  • either limited sensitivity of FIS in ADHD populations
  • or strong impact of acclimatisation and repeated exposure
• Reinforces that basic BMTs alone remain effective, especially with staged visits and TSD.

Clinical implications

• White noise is a simple, low-cost, scalable intervention with minimal equipment burden compared to VR
• VR may be more engaging but less practical (bulkiness, communication barriers, access issues)
• Both techniques should be viewed as adjuncts, not replacements, for core behavioural management
• Particularly relevant for:
  
  • avoiding escalation to sedation / GA
  • improving cooperation in restorative care under LA.

Limitations

• Lack of blinding (unavoidable but introduces bias)
• Small sample size (n=48) limits generalisability
• Inclusion limited to positive Frankl children → findings may not apply to more challenging behavioural phenotypes
• White noise was operator-selected (rain sound) rather than patient-preferred
• VR hardware not optimised for paediatric use
• Parental presence may have confounded anxiety outcomes

Reviewer’s evaluation, opinion and points of interest

The lack of reduction in heart rate observed in the virtual reality (VR) group is particularly noteworthy. This may suggest that VR induces engagement or physiological arousal rather than true relaxation, which is an important distinction when selecting an appropriate distraction modality in clinical practice. While VR may successfully capture a child’s attention, it may not provide the same calming physiological effect as other interventions such as white noise.

It is also likely that repeated exposure to the dental environment and the structured, staged nature of the visits played a significant role in reducing anxiety across all groups. This highlights that the intervention alone is not the sole determinant of improved outcomes; rather, acclimatisation and careful appointment planning remain key components of effective behavioural management.

Furthermore, the heterogeneity of ADHD has not been fully explored within this study. Outcomes may differ considerably between children with predominantly inattentive versus hyperactive–impulsive subtypes, as well as in those with comorbidities or more challenging baseline behaviours. This limits the generalisability of the findings to the broader ADHD population.

From a clinical perspective, white noise appears to be the most practical first-line adjunct for managing children with ADHD, given its simplicity, cost-effectiveness and demonstrated physiological benefits. VR remains a useful option but is associated with operational challenges, including equipment limitations and potential interference with communication. Importantly, neither approach replaces the need for high- quality paediatric behavioural management, with techniques such as tell–show–and–do remaining fundamental. Overall, there is a strong case for incorporating non-pharmacological adjuncts into routine care to help reduce reliance on sedation and general anaesthesia pathways.

RW

Please click on the tables and figures to enlarge

The effect of remimazolam on a Parkinson’s patient

S. Madaan*¹ BDS (Lond), MFDS RCS (Ed), General dentist with a special interest in restorative and surgical dentistry, St Johns Dental Practice, Oxford, OX1 2LH.
A. Harris² BDS (Lond), DPDS, General dentist, visiting sedationist and SAAD accredited mentor, London, The Dentist Salisbury, SP1 2LH.
*Correspondence to: Dr Sita Madaan
Email: drsitamadaan@gmail.com
Madaan S, Harris A. The effect of remimazolam on a Parkinson’s patient. SAAD Dig. 2024: 40(II): 124-127 

Case Summary

A 63-year-old lady who is 5 ft 4 in and weighs 66 kg was diagnosed with Parkinson’s disease in 2016. Sedation with remimazolam was used with the aim of alleviating the patient’s fears so that we could remove her poor prognosis teeth and perform socket preservation in the upper left quadrant with the view to placing dental implants in the future. We found that using remimazolam enhanced her involuntary movements due to Parkinson’s disease, with each dose administered.

Patient details
Gender: Female
Age at start of treatment: 62 

Pre-treatment assessment

The patient presented with a left-sided swelling of the buccal space relating to two upper retained roots, not affecting the eye, and a toothache of two weeks. The patient stopped caring about her dental health after she was diagnosed with Parkinson’s disease in 2016 and started to neglect her dentition. She has started to feel self-conscious of her teeth but is extremely nervous of the dentist and has only presented because she had been suffering with pain for two weeks and had developed an abscess relating to some retained roots.

Relevant medical history

The patient is an ASA II. She was diagnosed with Parkinson’s disease in 2016. The patient also suffers from epilepsy and has been diagnosed as having grand mal seizures, although she had experienced a petit mal seizure in the last year. She has also been diagnosed with hypothyroidism. Overall, the patient is mobile, but says she is stiff in the morning and ok with stairs.

Medications

• Co-careldopa 50mg: primarily used to manage the symptoms of Parkinson's disease, however, it does not slow down the disease or prevent it from worsening
• Ropinirole 100mg a day: used to treat the symptoms of Parkinson's disease and restless legs syndrome - it can improve symptoms like shaking (tremors), slowness and stiffness
• Epilim 4mg bd: for epilepsy
• Levothyroxine 100µg od
• The patient also has a codeine allergy.

Previous sedation history

The patient has never been sedated before and has a BMI of 25. Her alcohol intake is 18 units per week with no history of taking benzodiazepines or recreational drugs. Her pre-operative blood pressure was 120/78.

Dental history

Irregular attender, has not attended for over 10 years.

Clinical examination

The patient had some trismus, not relating to dental infection. Several fractured teeth were seen with heavy evidence of parafunction and her muscles of mastication were tender because of this. There was evidence of heavy palatal erosion due to dietary acids, which the patient was unaware of. Calculus, plaque, and gingivitis were present throughout the mouth.

Bitewings and an OPG were taken for a full assessment of the patient’s dentition which showed:

LR7 is fractured and requires vitality testing and then cuspal coverage.

LR6 is a root filled tooth which has been prepared for a crown and will require a new crown.

LR5 is fractured with deep caries and has been recommended for extraction.

LL5 retained root recommended for extraction.

UR6 is a root fragment and requires extraction.

UR2-UL2 are fractured. Wear and exposed dentine can be seen clinically.

UL4 is a metal post crown with a questionable long-term prognosis.

UL6 and UL7 are root filled retained roots with signs of periapical pathology around UL7.

UL8 LL8 are unerupted.

There is mild generalized horizontal bone loss with vertical bone loss around the UL6 retained root.

Pre-treatment photographs

Diagnostic summary

1. Mild periodontitis (Stage 2 Grade A), which is active at present, with poor oral hygiene due to demotivation to look after oral health since onset of Parkinson’s disease.
2. Buccal caries on the lower premolars.
3. Retained roots which will require extraction. Multiple fractured teeth requiring cuspal coverage.
4. Palatal wear of the upper anteriors and fractured upper and lower incisors due to erosion, attrition and tooth position.
5. Post-extraction spaces which will require fixed, long-term space replacement to keep the bone stimulated and prevent bone loss from occurring in these areas.

Aims and objectives of treatment

1. Stabilisation of oral hygiene and gingival inflammation
2. Strengthening of enamel to reduce the risk of future decay and prevent tooth wear with high fluoride toothpaste
3. Elimination of any causes of disease, and to bring about a state of health, function and self-confidence
4. Alleviation of dental anxiety using treatment under IV sedation.

Treatment plan

1. Prevention advice: oral hygiene to be reinforced with emphasis on motivating the patient to introduce interdental cleaning into her regime. To discuss use of plaque disclosing tablets to aid removal of biofilm. Duraphat toothpaste to be prescribed to strengthen enamel against decay and prevent further tooth surface loss, which is of multifactorial origin (attrition and erosion)
2. Oral hygiene stabilisation with hygienist and periodontist involvement
3. Extraction of poor prognosis teeth and socket preservation in the upper left region as the patient would like to consider fixed space replacement, in the form of dental implants, if her oral hygiene permits this in the future. The patent is aware of the risks associated with dental implants including peri-implantitis. This phase of treatment will be carried out under IV sedation using remimazolam, due to the better sedative profile than that of the current drugs, including rapid onset and offset of sedation and a predictable duration of action
4. Caries stabilisation of lower premolars which require filling cervically
5. Fractured teeth to have cuspal coverage restorations and post crown to be monitored
6. Fractured anterior teeth and palatal exposed dentine to be repaired
7. Patient is also a heavy bruxist and will need some form of protection at the end of treatment. 

Treatment undertaken

• The initial presentation was as a new patient at an emergency appointment in February 2023 during which an assessment was carried out, a periapical radiograph (PA) was taken and referral for full mouth Orthopantomogram (OPG) made. Antibiotics were prescribed to prevent the further spread of infection and the patient was advised to return for a full mouth detailed clinical examination. Even though there were no signs of septicaemia or cellulitis, the patient’s reduced co-operation and compromised oral hygiene until this point was taken into consideration as a risk factor for further spread of infection.
• The patient then saw the periodontist and had multiple sessions with the hygienist every three weeks where disclosing tablets were used to aid oral hygiene instruction.
• She expressed her concerns about undergoing dental treatment and explained that she was nervous. We discussed the possibility of sedation, and she filled out an Indicator of Sedation Need form. Her pre-operative sedation score was 21 indicating a very high Modified Dental Anxiety Scale (MDAS) score. Given her underlying medical health and considering the treatment complexity this gave a score of ‘very high need’ for sedation.
• We elected to use remimazolam due to its superior properties over midazolam such as rapid induction, rapid recovery, and less respiratory depression.¹ The patient then attended in May 2023 for extraction of all retained roots, UR5, UL6, UL7, LR5, LL5 and socket preservation in the upper left quadrant (ULQ). At this stage the drug was in its infancy for use in general dental practice sedation cases, as remimazolam was approved for use in dentistry in the UK in January 2023.

Treatment findings

A total of 17.5 mg of remimazolam was administered over the course of 1 hour 15 mins. An initial 5 mg dose was administered. With every subsequent 2.5 mg increment given the patient demonstrated jerky movements and signs of un-cooperation. Her legs started to jerk, and her jaw would clamp down which would impede the procedure but then she would settle down. A brief timeline of events is as follows:

11.54: Rapid induction of remimazolam (5 mg over 2 mins)

11.58: The patient did not like the administration of local anaesthetic

12.06: 2.5 mg administered, patient became unco-operative and was very jerky during the upper left quadrant extractions

12.28: 2.5 mg administered. The patient reported ‘this is a great experience’.

12.32: 2.5 mg administered. Bone grafting of the upper left quadrant.

12.36: The patient was much more relaxed.

12.42: Sutures placed and collagen plug.

12.53: Patient is relaxed during further suturing

13.00: 2.5 mg administered, patient is unco-operative again

13.10: Patient is more aware of what is going on

13.13: 2.5 mg administered

13.20: Patient did not like local anaesthetic (LA)

13.35: Patient was co-operative for extractions

13.49: Patient settled down and was more co-operative but was aware of treatment

13.55: Remaining lower surgical extraction was completed

14.00: Procedure finished

Long term treatment and future considerations

 In future, we could consider giving a reduced dose over a longer administration period. However, reducing the duration of the drug use would make it unsuitable for long surgical types of procedures. It is worth considering that now that she has been reintroduced to dental work after several years, she may have a lower sedation score in future and may not need treatment under sedation going forward. Her next phase of treatment would be restorative and only when we come to implant placement may she feel a need to revisit the idea of sedation.

We could consider trying to manage her pre-operative anxiety using other relaxation techniques such as deep relaxation with diaphragmatic breathing or hypnotherapy². We could also consider the use of midazolam as there are case reports to support the use of this drug to ease the symptoms of Parkinson’s disease.²

At present the patient is still mid-restorative phase due to a fall and subsequent hip injury, causing a delay in the completion of her treatment. The anterior restorative work which has been carried out so far was unremarkable and was undertaken under local anaesthetic with ease.

Discussion and reflection about case presented

As remimazolam was only approved for use in dentistry in UK in January 2023, the seditionist had limited experience of practical cases with this drug. In hindsight, she could have started with a lower induction dose and could have given lower top-up doses, as the patient swung from being co-operative to unco-operative immediately after top-up increments.

On a follow up phone call the next day, the patient reported that the sedation was ‘fabulous’, she didn’t remember anything about the treatment apart from the tail end of the appointment and the patient was much more co-operative at this point. She felt normal upon leaving the practice and was delighted with the outcome.

Oral surgery can be difficult in patients with chorea-like dyskinesia (involuntary movements) which is common in those on long-term levodopa medication for Parkinson's disease,³ and we know of no conclusive evidence to indicate whether conscious sedation with midazolam is effective in such cases. However, there are case reports of a patient in whom levodopa-induced chorea-like dyskinesia disappeared when midazolam was given intravenously for conscious sedation, so this drug could be preferred in such patients.³

References

1. Kim K M. Remimazolam: Pharmacological Characteristics and Clinical Applications in Anaesthesiology. Anesth Pain Med (Seoul) 2022; 17: 1–11.

2. Wang R, Huang X, Wang Y, Akbari M. Non-pharmacologic approaches in preoperative anxiety: a comprehensive review. Front Public Health 2022, 10: 852673.

3. Shibuya M, Hojo T, Hase Y, Fujisawa T. Conscious sedation with midazolam intravenously for a patient with Parkinson's disease and unpredictable chorea- like dyskinesia. Br J Oral Maxillofac Surg 2018; 56: 546-548. 

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