'Caring for an increasingly complex population - personal insights and personalised care'
SAAD Symposium and AGM
Saturday 30th September 2023
Royal Society of Medicine, London
This year’s symposium returned to the historic Royal Society of Medicine in London, where SAAD President, Sadie Hughes, kicked off the day by welcoming the many delegates who had managed to sidestep rail transport disruptions to make the journey. Sadie expressed her gratitude to Ashleigh Stamp for organising an exciting program.
The first lecture in the scientific program was provided by Frank Clough, a primary care clinician, who described his experiences using remimazolam. There was a neat continuity in starting here because the 2022 SAAD Symposium had concluded with Bryan Kerr describing the characteristics and potential applications of this novel benzodiazepine. The ‘take home message’ was that remimazolam, although expensive, does offer certain operational and clinical advantages over midazolam. For example, the reduced time to discharge results in reduced recovery infrastructure and improved patient experience – particularly for those with a history of prolonged recovery, such as elderly patients.
Stacey Clough and Zahra Shehabi, both Consultants in Special Care Dentistry at Bart’s Health NHS Trust, followed this first lecture with an alternative perspective on the implementation of remimazolam specifically within a hospital service. The pair described their challenges in decrypting the various governance milestones as part of the lengthy drug approval process within their Trust, as well as their positive clinical experience with remimazolam while working with a complex patient population.
The third lecture was a thought-provoking exploration of the emotional and psychological challenges that survivors of child sexual abuse (CSA) may experience in the dental setting. The talk was powerfully delivered, with Viv Gordon, CSA Survivor Artist Activist, describing how the dental environment had resurfaced negative emotions. She was joined by Akhila Muthukrishnan, Clinical Lead of Community Services in Swansea Bay, and together they discussed the evidence demonstrating the link between CSA and dental anxiety and actionable ways to improve the experience of CSA survivors.
These lectures were followed by a break filled with excited chatter about the morning’s topics.
The lecture program resumed with Dave Booth, Consultant Anaesthetist on Teesside, sharing his approach to patient assessment. His talk began with a discussion of patient suitability factors and indicators, which included airway and sleep apnoea, BMI and the ASA classification. He went on to discuss obese patients, diabetic patients and epileptic patients in more detail - all of whom are commonly encountered in primary care. Dave’s philosophy encourages clinicians to think about the pre- assessment as an opportunity to bring together a composite view of factors that may affect the way a patient responds to sedatives.
What followed was an update from Marija Borisovaite-Petruliene on her SAAD-funded PhD research project entitled The short and long-term effects of nitrous oxide / oxygen sedation as compared with general anaesthesia on childrens’ future level of dental anxiety and acceptance of dental treatment.
Jennifer Hare and Carole Boyle delivered the final lecture before the lunch break, covering NHS England’s Clinical Guide for Dental Anxiety Management. This document has been developed to offer clinicians in primary care a framework to guide them in their decision-making in relation to anxious patients. The clinical guide places sedation as a dental anxiety management tool within a continuum of care to help address a patient’s needs.
Following lunch, Hamza Hossenally delivered a lively lecture on the impacts of drug misuse on conscious sedation techniques linked to his experience working as a Special Care Consultant in East London. His talk described the pharmacodynamics of common substances of misuse and how this might affect our practice or prevent us from offering IV sedation. Finally, Hamza gave us pause for thought in his retelling of a situation where he had gone back to basics and bypassed the need for IV sedation through the use of non-pharmacological behaviour management techniques.
The next talk was from a Consultant Anaesthetist based in the Cotswolds, Heather Rodgers, who went to great lengths to share her wealth of experience in clinical practice and the ways that we could apply her learnings in the context of sedation. Heather reminded us of the importance of using a combination of assessment tools, some of the limitations of pulse oximetry, instances where capnography might offer us more, and the physiological impact of obesity before finishing off with expert tips and tricks for venous access.
The final lecture was a thoughtful analysis of the role that capnography might play in dental sedation. Paul Brady, a specialist Oral Surgeon at Cork University Dental School, described some of the benefits of using capnography and shared real-world examples via video recordings that helped to demonstrate the usefulness of capnography in patient monitoring, so long as the team is trained to read the waveforms and manage complications as they arise.
The day was brought to a close by Sadie Hughes who thanked delegates for coming and making the day such a great success.
Frank Clough, SAAD Board Member
SAAD annual symposium speaker abstracts
Incorporating remimazolam into care provision
- A primary care perspective
- A secondary care perspective
Frank Clough BDS PGDip MCGDent
Clinical Lead for Sedation, Sharrow Dental Care
Stacey Clough BChD MFDS Dip.MJDF MSCD MSc CILT
Consultant in Special Care Dentistry, The Royal London Hospital, Barts Health NHS Trust
Correspondence to: stacey.clough1@nhs.net and francis.clough@nhs.net
The use of remimazolam for short procedural sedation is gaining momentum across Medicine and Dentistry. In this presentation, we will gain insight into the first-hand experience of the acquisition and use of remimazolam within special care dentistry at The Royal London Hospital.
This will include discussion in relation to the experience of the local application process for a new drug and related policy. An overview of experience will be shared along with case examples highlighting the benefits of this drug in the care of medically complex patients.
Childhood sexual abuse and its impact upon dental care
Akhila Muthukrishnan BDS MPhil FDSRCS FFDRCSI PGCME FHEA
Consultant in Special Care Dentistry, Swansea Bay Health board
Clinical Lead, Community Dental Services, Swansea Bay Health board
Viv Gordon
Child Sex Abuse (CSA) Survivor Artist Activist and Artistic Director of Viv Gordon Company
Correspondence to: akhila.muthukrishnan@wales.nhs.uk
The impact of childhood sexual abuse (CSA) is first explored through the lens of the survivor using the medium of theatre, with Viv Gordon, artistic director of the Viv Gordon Company (www.vivgordon.com).
This is in keeping with the overarching theme of the SAAD 2023 conference, ie ‘enhancing support which healthcare professionals provide to patients – increasing awareness of and tailoring care to individual patient needs’.
Childhood sexual abuse (CSA) is defined as ‘…the use of a child for any form of sexual activity or behaviour by an adult or adolescent and is a betrayal of trust by someone who has power over the child.’ It is estimated that the prevalence of CSA may be 10 to 20% globally. Survivors of CSA can present in any healthcare setting, and face multiple challenges at a personal, social, healthcare and systemic level. Providers of conscious sedation and special care dentistry services may see an increased proportion of these individuals due to the long-term consequences of CSA.
NICE guidance on the management of post-traumatic stress disorder (PTSD) explains the impact of CSA and other forms of trauma and their management. Trauma Informed Care frameworks provide training and guidance for management of CSA survivors at an organisational and individual level. Signposting to support for CSA survivors is included in the holistic management of this patient group. Oral health care providers and dental educators working in the field of pain and anxiety management have an important role in increasing awareness of CSA and providing person centred care.
Learning outcomes:
- Understand the oral health impact of Childhood Sexual Abuse (CSA) on adult survivors
- Be aware of developments in Trauma Informed Care
- Consider how to embed Trauma Informed Care in clinical practice.
When is out of hospital sedation not appropriate?
Dave Booth MBBS, FRCA, CertMedEd
Consultant Anaesthetist, South Tees Hospital NHS Foundation Trust
Correspondence to: david.booth1@nhs.net
This talk is designed for the sole GDP in primary care. The aim is to update and assist with the decision-making process surrounding patients who require sedation for a dental procedure.
Learning outcomes include:
- Understanding the airway assessments an anaesthetist would make in patients prior to sedation
- Revision of ASA grading and an increased awareness of how subjective this score can be
- Updating knowledge about obesity and sleep apnoea assessment
- A medical view regarding pitfalls in common presenting disease states such as diabetes and epilepsy
- As healthcare practitioners we are treating increasingly complex patients for procedures and techniques that simply may not have existed over a decade ago. The decision to treat or refer should integrate both the proposed dental plan and the particular health or behavioural issues that patients present with. Producing an exhaustive list of factors involved in this process would be nigh on impossible and beyond the scope of this session. However, this presentation will attempt to cover some of the more controversial aspects of this process to inform and trigger reflection in attendees.
Research Update SAAD-funded PhD
Marija Borisovaite-Petruliene MSc Paed Dent
Certified Dentist and PhD Student at University of Leeds
Correspondence to: marija.borisovaite@gmail.com
Dental anxiety and fear of dental treatment in children are recognised as a public health dilemma in many countries since they can lead to impeding or even precluding successful dental care. Such a condition represents a problem to both dentists and patients considering anxiety and fear may result in management difficulties in dental clinic. One of the pharmacological management techniques for dental anxiety is general anaesthesia, which is also the most common modality for managing unco- operative children. However, concerns due to its capability to cause harmful effects as nausea, vomiting, the risk of significant morbidity and, occasionally, mortality in children have been raised.
It is widely accepted that conscious sedation is safer than general anaesthesia and should be considered as the first choice management option instead of general anaesthesia. Inhalation conscious sedation represents an effective and safe method to obtain co-operation, even in very young patients, and it could reduce the number of paediatric patients referred to hospitals for general anaesthesia.
Although multiple questionnaires are available for assessing anxious and phobic patients, none of these existing instruments has been regarded as a gold standard, as each has its own limitations. It is apparent that there is a lack of literature showing the long-term effects on the reduction of dental anxiety and future quality of dental treatment. Currently, there are no specific measures on the long-term effect of sedation techniques on dentally anxious patients, and this is therefore an important area for future research.
The aim of this study is to evaluate the short and long-term effects of nitrous oxide / oxygen sedation as compared with dental general anaesthesia on children’s future level of dental anxiety and acceptance of dental treatment.
In order to assess a child’s anxiety before, during and after the treatment, E4 wristbands (to record the physiological parameters) and a newly designed questionnaire are used. The online questionnaire consists of two parts – standard fMCDAS and a second part with emoji faces to answer the questions. It was piloted with paediatric patients in Leeds Dental Institute and amendments were made after the pilot study due to the response of the participants. Now it is being used to follow up the patients after completion of the treatment.
In conclusion, the preliminary findings relating to the comparison of dental anxiety in both groups (inhalation sedation and general anaesthesia) 12 months after the treatment will be discussed.
Learning Objectives
- Assess and compare dental anxiety using physiological (Blood Volume Pulse, Acceleration, Heart Rate, Temperature) and psychological parameters (fMCDAS)
- Recognise the necessity to assess dental anxiety before, during and after treatment
- Identify the best way to evaluate dental anxiety in children of certain age.
NHS England Clinical Guide for Dental Anxiety Management
Carole Boyle BDS, MMedSCi , FDS RCSEng, MSND RCSEd, FDS RCSEd, FDT RCSEd
Clinical Lead Sedation and Special Care Dentistry Guy's and St Thomas' NHS Foundation Trust London
Jennifer Hare D.Health.Psy, Associate Fellow (AFBPsS) of BPS and Division of Health Psychology, PG.Dip.CBT
Consultant Health Psychologist and Clinical Lead, Dental Psychology Service at Guy’s and St Thomas’ NHS Foundation Trust
Correspondence to: Carole@saad.org.uk or jennifer.hare@kcl.ac.uk
In January 2023 NHS England published a new Clinical Guide for Dental Anxiety Management, which is to replace the service standard for conscious sedation last published in 2017. The new guidance highlights a sea change in the management and treatment of dental anxiety for patients undergoing dental treatment in community and primary care settings, covering behavioural therapies, conscious sedation and referral for treatment under general anaesthesia.
This session provides an overview of the guidelines and the implications of what this will mean in practice, with a particular focus on either ends of the anxiety management spectrum.
What’s the use in understanding misuse?
Conscious sedation for patients with substance misuse
Hamza Hossenally BDS MFDS RCS MSCD RCSEd MSc CiLT
Consultant / Specialist in Special Care Dentistry, The Royal London Dental Hospital and Whittington Health Community Dental Service.
Correspondence to: hamzahossenally@nhs.net
What is the impact of Drug misuse on the delivery of conscious sedation?
How to assess and identify patients with substance misuse.
How do the various illicit drugs impact on the body and delivery of sedation.
Tips on how to manage patients with substance misuse and anxiety.
Beginning with ABC - a more detailed look at airway, ventilation and venous access
Heather Rodgers MBChB FRCA
Consultant Anaesthetist in Aneurin Bevan Health Board
Correspondence to: Heather.Rodgers@wales.nhs.uk
Airway assessment in anaesthesia is routine and consists of two main parts – risk of difficulty in intubating and risk of difficulty in mask ventilation. No one tool is ideal, but the use of multiple scoring systems can identify those likely to be at increased risk.
In Dentistry, this can then be paired with an understanding of respiratory physiology to understand which patients are more likely to have problems with sedation.
Finally, we will look at some tips and tricks to establish venous access in difficult patients.
Learning outcomes:
- Improve understanding of structured airway assessment, and predicting a difficult airway
- Consider why oxygenation does not equal ventilation
- Develop tricks that may help with difficult IV access
SAAD annual symposium poster presentation abstracts
1st Prize
Remimazolam: is it safe?
X. Yeo BDS MFDS (RCPS Glas.) MSc Dent DipConSed PgCert in Dental Education*1
Z. Shehabi BDS MFDS MSc MSpec Care Dent (RCS) CILT2
S. Clough BChD MFGDP (UK) MFDSRCS (Eng.) MJDF MSpec Care Dent MSc Dent CILT3
1Specialty Registrar in Special Care Dentistry, Bart’s Health NHS Trust
2,3Consultant in Special Care Dentistry, Bart’s Health NHS Trust
Correspondence to: Xin Hui Yeo
Email: x.yeo@nhs.net
Background
Remimazolam is a novel benzodiazepine with sedative and amnestic properties. Compared to midazolam, it has a quicker onset and recovery.
Aim
To assess the safety and effectiveness of remimazolam after its introduction as a new sedative agent at the Royal London Dental Hospital.
Method
We present preliminary prospective review of 5 cases using remimazolam for procedural sedation for dental procedures. Patients’ age ranged from 30 to 67 years. Remimazolam administration regimen included a bolus dose of 5mg followed by subsequent titration of 2.5mg to sedation endpoint and additional titrations according to sedation window and length of procedure. Monitoring of haemodynamic status (heart rate and oxygen saturation) was carried out throughout the sedation.
Results
The total dose of remimazolam used ranged from 7.5 to 15mg. Operating conditions and patient satisfaction were positive, and no adverse incidents were recorded.
Conclusion
Remimazolam offers an alternative to midazolam with similar safety profile, but with quick onset and recovery. This case series showed some encouraging data regarding the potential safety profile and effectiveness of remimazolam in dental sedation when used by experienced sedationists; however, larger scale studies are required to provide the evidence base to guide clinical recommendation in different scenarios.
2nd Prize
Patient reported outcome measures (PROMs) for intravenous sedation (IVS), Second Cycle
D. Drysdale BDS MFDS DipConSed MSc MPaedDent*1
A. Aspinall BDS MFDS DipConSed MPaedDent2
P. Anand BDS IQE MMedSc (Oral Surg) FDSRCS (Eng.) MPaedDent, FDS (Paed Dent) Cert. Pain and Sedation3
1ST3 Paediatric Dentistry, Royal National ENT and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust
2Specialist, Royal National ENT and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust
3Consultant, Royal National ENT and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust
*Correspondence to: David Drysdale
Email: daviddrysdale@nhs.net
Aim
The aim of this study was to undertake a second cycle of patient reported outcome measures (PROMs) of patients aged 12-16 years, attending for dental procedures under intravenous sedation (IVS) in the department of Paediatric Dentistry at the Eastman Dental Hospital.
Method
A simple traffic light questionnaire was used to gather data. Data was collected on IV experience on the day, prior and after surgery. Data was also collected on quality of life 1 day, and 10 days after treatment.
Results
90% patients felt they were given treatment choice, 60% of patients were anxious about the dental treatment, prior to surgery. 99% patients were satisfied with all the aspects of treatment under IVS. 100% of the patients would have treatment under IVS again if needed. 100% of parents said IVS relieved their child’s anxiety. 100% of parents said their child did not have pain for more than 5-7 days.
Conclusion
Intravenous sedation with midazolam used to manage anxiety in young people having dental procedures is reported by patients to reduce anxiety and reported 100% satisfaction.
Pilot video consultations to assess high BMI paediatric patients’ suitability for the provision of dental treatment under general anaesthesia at a Day Surgery Unit
B. Tailor BDS MSc*1
N. Seth FRCA2
N. Bhujel FDSRCS3
1Specialty Dentist, Department of Paediatric Dentistry Guy’s and St Thomas’ NHS Foundation Trust, London
2Consultant Paediatric Anaesthetist, Paediatric Anaesthetic Department, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London
3Consultant in Paediatric Dentistry, Department of Paediatric Dentistry, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London
*Correspondence to: Bina Taylor
Email: bina.tailor@gstt.nhs.uk
Background
Pilot video consultations were introduced for children and young people between the ages of 2 and 18 years who were clinically overweight, with a body mass index (BMI) percentile above 91. Childhood obesity is an increasing healthcare challenge as these children are at an increased risk of peri-operative complications. Suitability of treating these patients at our Day Surgery Unit (DSU) was assessed while ensuring that high-risk patients receive treatment at an in-patient general anaesthetic (GA) facility.
Aim
To enhance safe delivery and recovery of GA for high BMI paediatric patients requiring dental treatment.
Method
All children planned for dental treatment under GA with a BMI over 91 calculated using the NHS BMI calculator and ASA score of I or II were booked a pre-anaesthetic assessment via video consultation. We collected patient demographics and the outcome in terms of having their GA at DSU or an in-patient setting.
Results
Twenty-seven patients had video consultation. Twenty patients were deemed suitable for GA at DSU and seven were treated in the in-patient setting. There were no adverse events under GA. New departmental guidance was implemented to signpost the patients either at DSU or an in-patient setting.
Conclusion
Video consultation is a suitable alternative to face-to-face pre- operative assessment for high BMI paediatric patients.
Service evaluation of the IV sedation service for NHS priority group patients on the Adult Dental Health Department at Bristol Dental Hospital
Z. Ahmed BDS MFDSRCS (Eng.)*1
T. Friend BDS MJDF SAAD PG Cert MSc Endo Practice M Endo (RCS Edin.)2
1DCT in Restorative Dentistry, University Hospitals Bristol and Weston NHS Foundation Trust
Correspondence to: zunera.ahmed@uhbw.nhs.uk
2Specialist Dentist in Restorative Dentistry, University Hospitals Bristol and Weston NHS Foundation Trust
*Correspondence to: Zunera Ahmed
Email: zunera.ahmed@uhbw.nhs.uk
Aims
To evaluate the care provided on the Adult Dental Health department at the Bristol Dental Hospital, in accordance with the IACSD 2020 Standards. To evaluate the efficiency of the sedation service provided for NHS priority group patients.
Methods
Retrospective data collection of 39 adult dental health patients who had IV sedation over a 24-month period. Data was assessed in accordance with the standards provided in IACSD 2020. NHS service evaluation factors were also assessed.
Results
The average wait time between sedation assessment and treatment was 14 weeks. Based on the IACSD standards the department was compliant in the majority of factors evaluated. However, 71% of patients did not have an anxiety score or alternative anxiety management options recorded.
Conclusions
Bristol Dental Hospital provided an efficient service for IV sedation for NHS priority groups with regards to waiting times and financial efficiency. An action plan has been devised to ensure that the service provided is in accordance with the IACSD 2020 standards. A preoperative sedation proforma will include airway assessment and BMI. The indicator of sedation need (IOSN), anxiety questionnaire will also be made available on the department to allow anxiety assessment and discussion for alternative anxiety management options.
Use of capnography for special care dentistry patients receiving anaesthetist-led IV sedation
G. George MBBS FCARCSI (Dublin)*1
C. Wilson-Dewhurst BDS MFDS (RCS Edin.) DipSCDRCS (Edin.) MSCDRCS (Edin.) DDSc2
A. McPherson BDS MFDSRCS (Edin.) MSNDRCS (Edin.) FDSRCS (Edin.) DipConSed PGCTLCP FHEA3
1Consultant Anaesthetist, Liverpool University Dental Hospital
2Specialist in Special Care Dentistry, Liverpool University Dental Hospital
3Consultant in Special Care Dentistry, Liverpool University Dental Hospital
*Correspondence to: Giju George
Email: giju.george@liverpoolft.nhs.uk
Background
Capnography is a respiratory monitoring device and helps88 diagnose hypoventilation or apnoea potentially earlier than standard sedation monitoring.
Additional monitoring with capnography is recommended in dental sedation and anaesthetic guidance where the patient is ASA III or IV, or if there is a loss of verbal contact.
Aims
- To assess the impact of using capnography for monitoring anaesthetist-led IV sedation
- To assess whether capnography alters the management of patients receiving sedation for dental treatment.
Method
A prospective service evaluation was completed over a year for patients. Data was collected on patient demographics, sedation technique and monitoring, management of hypoxia, complications of sedation and treatment success.
Results
Data was collected in 44 cases. Propofol was administered as an intravenous bolus or targeted infusion. The apnoea alarm sounded in 13 cases and desaturation (SpO2 <90%) was recorded in four cases. Operating conditions were recorded as good in 28 cases. Of the respondents, 45% (20 / 44) identified capnography as a useful adjunct to standard monitoring.
Conclusion
Monitoring using capnography helped to identify apnoea Mandatory use of capnography for all Anaesthetic led sedations Documentation of level of sedation.
Beyond benzodiazepines: alternative advanced conscious sedation drugs in dentistry
H. Muhammad BDS*1
T. Nagpal BDS MFDSRCS (Edin.) PG Cert PG2
A. Gupta BD MFDS RCPSG PG Cert3
1OMFS Dental Core Trainee, Bedfordshire Hospitals NHS Foundation Trust
2,3Oral Surgery Registrar, Bedfordshire Hospitals NHS Foundation Trust
*Correspondence to: Hanan Muhammad
Email: hanan.muhammad@nhs.net
Conscious sedation offers an effective pharmacological means for achieving anxiolysis, thereby facilitating the provision of dental treatment for patients suffering with dental anxiety or phobia without requiring general anaesthesia.
The benefits of conscious sedation also extend to enabling more complex treatment to be performed in primary care for patient ease and access. The use of benzodiazepines is well recorded for conscious intravenous sedation in dentistry; the most common drug being midazolam.
The aim is to provide an overview of alternative drugs used for conscious sedation in dentistry, including their pharmacokinetics and pharmacodynamics, risks and benefits. It is important to note that the use of such alternative drugs, either in isolation or in conjunction with a benzodiazepine is considered an advanced sedation technique. As such, this warrants additional experience and further postgraduate training in order to demonstrate competency in safe delivery and management.
Anaesthetist-led conscious sedation in special care dentistry – a case series
A. Kahatab BDentSc BA DipPCD (RCSI) MFD (RCSI)*1
M. Doshi MBE BDS(Hons) MFDRCS (Eng.) MSc SCD2
A. Bewaji MB.Bch FRCA3
R. Fitzgerald BDS MSCD (RCPSG), DSCDRCS(Ed.) BSc (Oral Sc) PGCert (Med Ed) PGCert (Clin Res)4
1StR in Special Care Dentistry, East Surrey Hospital
2,4Consultant Special Care Dentistry East Surrey Hospital
3Consultant Anaesthetist East Surrey Hospital
*Correspondence to: Ahmed Kahatab
Email: ahmed.kahatab@nhs.net
Anaesthetist-led sedation provides an alternative treatment modality to dental-led sedation and general anaesthesia that can be patient-centred and cost-effective, as demonstrated by these cases.
Case 1
A patient with severe dental anxiety failed to achieve adequate anxiolysis after 16mg of midazolam during dental-led sedation. Subsequently, the patient underwent anaesthetist-led sedation, avoiding a general anaesthetic.
Case 2
A patient with dementia underwent anaesthetist-led sedation as dental-led was not suitable given her frailty and treatment needs. This successfully allowed the completion of treatment without the need for general anaesthesia, thereby mitigating the risk of post-operative delirium.
Case 3
A patient with a learning disability and epilepsy required dental examination under anaesthetist-led sedation. However, due to the complexity of the dental treatment necessary after examination, the patient transitioned from sedation to general anaesthesia intra-operatively.
These cases highlight the versatility of anaesthetist-led sedation in various scenarios, including patients for whom general anaesthesia presents a greater risk. There is a lower risk of post-anaesthetic delirium, and it can be more effective than dentist-led sedation for certain patients. However, certain risk factors, such as high BMI, obstructive sleep apnea, and respiratory comorbidities, must be considered to ensure airway safety.
Airway assessments for conscious sedation – is it time for an update?
I. Rehman BDS (Hons) MJDF PGCert (DentEd)*1
A. Wright BDS MFDS RCPS (Glas.) MRCPS (Oral Surg) (Glas.)2
C. Weir BSc(Hons) MBChB FRCA PhD3
A. Heffernan BDS BSc (Hons) MSc MFDS RCPS (Glas.) M(Spec Care Dent) RCPS (Glas.) FHEA4
S. Sammut BChD (Hons) MFDS M Clin Dent (Oral Surgery) M Oral Surg FDS (OS) RCPSG5
1Specialty Registrar in Oral Surgery, Blackpool Victoria Hospital/Lancashire Oral Surgery
2Consultant in Oral Surgery, Dundee Dental Hospital
3Consultant Anaesthetist / Hon. Senior Clinical Lecturer, Ninewells Hospital & Medical School
4Consultant in Special Care Dentistry, Dundee Dental Hospital
5Consultant in Oral Surgery, Dundee Dental Hospital
Correspondence to: Ilyaas Rehman
Email: ilyaas.rehman1@nhs.net
Objectives
Certain patients carry an increased risk of respiratory depression during conscious sedation. Dundee Dental Hospital offers both dentist-led and anaesthetist-led sedation, to cater for higher-risk patient groups. There is no gold standard method for airway assessment. The aim of this project was to implement a validated airway assessment tool, STOPBang, then modify it to align relevance to conscious sedation for dentistry.
Methods
Sedation pre-assessments forms were assessed before and after implementation of the STOPBang assessment tool. The assessment tool was subsequently modified by a multidisciplinary team and re-introduced as the ‘SOBN’ airway assessment.
Results
An initial closed-loop audit identified 100% compliance with the STOPBang assessment tool. The modified ‘SOBN’ assessment tool now simplifies risk for the dental team, allowing more appropriate triage and treatment by dentist or anaesthetist-led sedation teams.
Discussion
The unique sedation service at Dundee Dental Hospital allows a wider range of patients to receive their treatment, who may otherwise be referred for anaesthetist-led care. While STOPBang is validated for assessing obstructive sleep apnoea, we propose that our novel ‘SOBN’ airway assessment tool is more closely aligned with identifying airway risk posed by conscious sedation.
The role of virtual reality adjuncts in conscious sedation
K. Nandhra BDS, MFDS (RCS Eng.)*1
T.S. Nagpal BDS, MFDS (RCS Edin.), PG Cert, PG Dip2
A. Gupta BDS, MFDS RCPSG, PG Cert3
1Dental Core Trainee in Oral and Maxillofacial Surgery, Bedfordshire Hospitals NHS Foundation Trust
2,3Oral Surgery Registrar, Bedfordshire Hospitals NHS Foundation Trust
Correspondence to: Kieran Nandhra
Email: Kieran.Nandhra@ldh.nhs.uk
Abstract
Conscious sedation is a treatment modality widely used by anaesthesiologists and non-anaesthesiologists for anxiolysis and analgesia, dependent on the drug administered. Immersive virtual reality (VR) has demonstrated that it is an effective distraction technique involved in non-pharmaceutical management to facilitate sedation; with some articles proposing it is an effective sedation-sparing technique modulating both pain and anxiety. VR can range from full headsets with audio- visual output to, more involved, body suits. As VR equipment and software becomes less expensive and more realistic, sedationists should look to it as a peri-procedural and intra-operative adjunct. We have summated the current literature on the ability for VR to modulate both pain and anxiety in order to improve patient and clinician satisfaction peri-operatively and intra- operatively when conscious sedation is provided.
Capnography: how much will it cost? A rapid scoping review and heuristic estimate
M. Ismail BDS MFDS Dip SCDRCS (Edin.)*1
B. Kerr BDS MSc Sedation & SCD, MSCDRCS (Glas.)2
H. Flynn BChD MFGDP(UK) MFDSRCS (Eng) MSc (RestDent) DipOralSurgRCS (Eng.) DipDentSed PGCertClinEd FHEA3
1Speciality Registrar in Special Care Dentistry, Guy’s and St Thomas’ NHS Foundation Trust
2Consultant in Special Care Dentistry, Guy’s and St Thomas’ NHS Foundation Trust
3Speciality Dentist in Special Care Dentistry, Guy’s and St Thomas’ NHS Foundation Trust
*Correspondence to: Maryam Ismail
Email: Maryam.ismail@gstt.nhs.uk
The current requirement for capnography monitoring during conscious sedation in dentistry in the UK is not obligatory. The 2020 Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) guidelines assert that its non-mandatory status is attributed to the absence of research specific to dentistry and the proven safety of intravenous midazolam sedation.
Capnography, which can detect hypoventilation more swiftly than pulse oximetry and potentially enhance safety, particularly for medically compromised patients, is becoming more widespread globally. The increasing body of evidence may prompt a shift in the UK's stance, making capnography monitoring mandatory for all patients receiving intravenous sedation.
In this presentation, we explore the potential financial implications of mandating capnography. This encompasses the expenses related to acquiring the necessary machines, additional equipment, and the training essential for its proper use. Additionally, we provide an estimate of the quantity of capnography equipment that would need to be procured on a national scale.