Guidance Regulation Standards and Politics
SAAD produced its first guidance document, Guidelines for Physiological Monitoring of Patients during Dental Anaesthesia or Sedation, in 1986. This was authored jointly by dentists and anaesthetists, combining both academic opinion and the opinion of experienced clinicians in primary and secondary care.
From the 2000s, the governance that SAAD developed in combination with The Royal College of Surgeons of England and The Royal College of Anaesthetists led to the further formalisation of standards and ever-closer relations between doctors and dentists. By this point, expected standards of practice concerning staff training, techniques, the management of complications and emergencies, and the overall patient environment were clearly laid down, with SAAD members leading the process of change. Governance subsequently developed in parallel with the various medical specialties until 2013, when the Academy of Medical Royal Colleges Standards and Guidance document set down minimum standards for all medical and dental specialties.
As Christopher Holden and Ian Brett emphasised in their paper on the Society’s history delivered to the 60th Anniversary Symposium, “SAAD has now provided representation or individuals with expertise on every major guidance document in the training and provision of dental pain and anxiety control in the last generation.” SAAD currently has representation on IACSD (Intercollegiate Advisory Committee for Sedation in Dentistry), SDCEP (Scottish Dental Clinical Effectiveness Programme), AoMRC (Academy of Medical Royal Colleges), IEGTSSD (Independent Expert Group on Training Standards for Sedation in Dentistry), DSTG (Dental Sedation Teachers’ Group) and IFDAS (International Federation of Dental Anaesthesiology Societies). Given the overlapping membership of these bodies, “cross-representation” tends to be a naturally occurring process; nevertheless, between 1990 and 2017 SAAD had direct or indirect input into 20 documents, sometimes as an invited member of the group tasked with producing the document, and sometimes via less formal connections.
Since its inception SAAD had been heavily involved in deliberations about the regulation of the dental profession in general anaesthesia, conscious sedation, and resuscitation. In 1971 the government proposed a ban on the operator anaesthetist in dentistry. The effect of this would have been to have abolished provision of the intermittent methohexitone technique on which SAAD's teaching was based at the time. Although not promoted by SAAD the operator anaesthetist was a necessity of the time due to the general lack of services of a separate anaesthetist in general dental practice. Patients faced being denied a safe and effective pain and anxiety control technique based on prejudiced opinion in the Ministry of Health at the time. Along with the British Dental Association, SAAD took on the government. A booklet entitled "Treachery" was sent to every Member of Parliament detailing both the sacrifice of basic rights of patients and professional freedom of doctors and dentists and the potential loss of invaluable years of progress in pain control. Members of Parliament agreed - SAAD and the BDA won. Regulation of general anaesthesia had always been a big issue within the General Dental Council. Although there was little genuine experience amongst its own members, it was fortuitous that there was almost always a member of SAAD Council on the General Dental Council. This was important as regulation of anaesthesia, conscious sedation and resuscitation were always closely connected and issues on which the General Dental Council made frequent recommendations.
Early in SAAD’s history successive Presidents of SAAD including Dr Gerry Holden, Dr Peter Sykes, and Lord Colwyn a Conservative peer, all contributed to maintaining a sensible but safely directed balance of opinion in relation to the regulation of pain and anxiety. Lord Colwyn provided an important link to government during a politically difficult time for anaesthesia and sedation in dentistry.
The definition of conscious sedation drafted by Dr Gerry Holden and Professor Paul Bramley of Sheffield University for the Wylie Report in 1978 was subsequently adopted by the General Dental Council and today remains almost unchanged as the accepted definition of conscious sedation by all UK regulatory bodies.
The foundations of SAAD's interest in starting to proactively develop clinical guidelines began in 1989 with the publication in early 1990 of "Guidelines for Physiological Monitoring of Patients During General Anaesthesia or Sedation", led by Dr Peter Cole. This document was well ahead of its time. It heralded SAAD’s drive for proper standards in education and service provision that cemented the societies position in the profession as a trusted teaching and standard setter. This document was occasionally to the irritation of the “academic authorities” but clearly supported by the profession at large.
In the 1990s a Department of Health sponsored a guidance document on anaesthesia sedation and resuscitation and published "The Poswillo Report". Dr Peter Sykes and Dr David Phillips were influential in stopping the General Dental Council's attempted knee jerk reaction when it considered banning general anaesthesia for dentistry in primary care at a stroke and almost taking conscious sedation with it.
From the early 1990s to this day SAAD has been heavily involved in the production of national guidelines, with representation on nearly every major report concerning anaesthesia, sedation, and resuscitation in dentistry. Particularly active in this area was Dr David Craig, consultant and Head of Sedation and Special Care Dentistry at Guy's Hospital and Dr Christopher Holden, a general practitioner from Derbyshire.
A plethora of guidance occurred in the 1990's due to a few heavily publicised and largely unnecessary deaths associated with general anaesthesia and sedation for dentistry. SAAD was quick to realise that the profession needed a guidance document detailing expected standards, but the Society also took the view that this needed to be guidance which involved all parties interested in the subject.
In 2000 Dr Christopher Holden chaired an Independent Working Party which ultimately produced a report "Standards in Conscious Sedation for Dentistry" the first standards document for conscious sedation in dentistry.
This was later taken forward to a further two documents by a joint committee of the Royal College of Surgeons of England and the Royal College of Anaesthetists. From this standards initiative SAAD played a key role in the production of "Conscious Sedation and the Provision of Dental Care" (Department of Health) in 2003 and "Standards in Conscious Sedation in Dentistry: Alternative Techniques in 2007" (Royal College of Surgeons of England / Royal College of Anaesthetists. At the same time Dr David Craig chaired a report for the Department of Health/Faculty of General Dental Practice (Royal College of Surgeons of England) issuing guidelines for the appointment of dentists with special interest in conscious sedation, importantly providing quality control for NHS Primary Care services.
There was a proliferation of guidance until 2021 to meet the challenges of robust patient safety and political need. The prominent documents over the years were:
General Anaesthesia, Sedation and Resuscitation in Dentistry ('Poswillo')
| 1990 |
Following several deaths in dental practices, the Department of Health charged Professor David Poswillo, a New Zealand maxillo-facial surgeon, with chairing a working party on anaesthesia, sedation, and resuscitation in dentistry. SAAD had considerable influence in this watershed report, the outcome of which was the development of centres for general anaesthesia and £9 million in government grants to facilities for the purchase of new sedation equipment and staff training. As Dr David Craig commented, “The resuscitation section of the report was less well-received but opened up a productive discussion which led eventually to more practical guidance.”
A Basis for Nationally Structured Guidance
At last pathways for training, converging specialty agreement and a minimum standard was agreed and accepted by the medical professions. Three documents providing overarching guidance from the Academy of Medical Royal Colleges, Standards from the Intercollegiate Advisory Committee for Sedation in Dentistry, and implementation guidance form the Scottish Clinical Effectiveness Programme. SAAD’s input was instrumental into achieving this.
