Carole Boyle

The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London

OBJECTIVE To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health. METHODS Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables. RESULTS A direct significant association of referral with dental anxiety and attendance patterns was detected, but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience. CONCLUSION Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can be an important part of comprehensive care where curative treatments are long or unpleasant for patients.

Obesity and dentistry: a growing problem

Obesity has increased at an alarming rate in recent years. It is now a worldwide public health problem. The World Health Organisation (WHO) classifies obesity as a chronic disease. Affected individuals are at increased risk of hypertension, heart disease and other illnesses. There are also important social implications.Within dentistry and particularly in the provision of conscious sedation, obesity can be a potential complicating factor. For example, the position of anatomical landmarks may be less obvious if surrounded by fatty tissue. Very obese patients may be housebound or have difficulty accessing dental surgeries. Dental chairs may not be of an appropriate design to accommodate some obese patients. However, little information or advice on this topic is available in the literature.This article reviews obesity from a dental perspective. Challenges in providing dental care for obese patients are identified and practical recommendations made for their management.

Intranasal/intravenous sedation for the dental care of adults with severe disabilities: a multicentre prospective audit.

Objective This study was designed to provide an evaluation of the combined intranasal/intravenous midazolam sedation technique. It involved adults with severe disabilities which prevented them from being able to co-operate with dental treatment and intravenous cannulation for sedation.Method Following a previous retrospective audit, additional treatment centres were enrolled and a standardised form used to collect prospective data about the effectiveness of the technique in facilitating cannulation, dental examination and treatment. Data was also collected on safety and patient acceptability.Results In a total of 316 sedation episodes in primary and secondary care settings, cannulation was achieved in 96.2% (304). Dental examination and treatment was able to be carried out without major interference from the patient in 78.8% (241) episodes. Adverse sedation events occurred in 6.0% (19), the most frequent being desaturation which was easily managed. There were no incidents with serious sequelae. Favourable acceptability ratings were given by carers regarding advantages of ease of administration and speed of onset of the intranasal dose, plus reduction in the stress associated with cannulation and treatment.Conclusions This study provides further evidence to support the effectiveness, safety and acceptability of this technique. The authors suggest this provides sufficient basis to justify its use by suitably trained dental practitioners in primary care as part of the spectrum of anxiety and behaviour management for this group.

Acceptability of behaviour therapy for dental phobia

OBJECTIVE To determine how people with dental phobia rate the acceptability of behavioural therapy. METHODS One hundred and twenty individuals with dental phobia participated in a three-factor experimental vignette-based design. The three factors examined were dental treatment history, nature of intervention (intravenous sedation or behavioural therapy) and treatment outcome. There were eight different vignettes representing all combinations of the three experimental variables, and 15 participants completed each vignette. RESULTS Treatment outcome had a strong effect on rated acceptability (F = 115.76, P < 0.001). There was a weaker effect of treatment type (F = 5.49, P < 0.05) with behavioural therapy rated as more acceptable than intravenous sedation. Previous history of intravenous sedation was associated with a decreased perception that it is possible to overcome dental fear. CONCLUSIONS The perceptions of individuals with dental phobia of the acceptability of behavioural approaches to management are influenced by the perceived outcome of the treatment.

What happens after referral for sedation

Objective To follow up 100 referrals to the sedation clinic, examining dental anxiety and background of patients, and to assess how many patients attended for treatment planning, initial treatment and how many completed treatment, and describe the characteristics of each. For those who attended for initial treatment, to investigate which type of sedation they received and the level of clinician they saw.Design Descriptive, cross-sectional survey and review of case notes.Subjects and methods Subjects were 100 consecutive new patients to the Department of Sedation and Special Care Dentistry at Guys and St Thomas NHS Foundation Trust. The notes were analysed by an experienced member of staff (CAB) and data entered into an Excel spreadsheet and an SPSS data file created. These data were merged with a dataset containing their responses to the initial questionnaire and medical history for analysis.Results Of the 100 patients initially referred, 72 attended the treatment planning session, 66 of the 72 (92%) attended for initial dental treatment, and 33 of 66 (50%) completed treatment. Dental Fear Survey (DFS) scores were related to attendance at the initial treatment visit but not to completion of treatment. Only 33 of 100 referred patients completed treatment.Conclusions Attendance for treatment planning and initial treatment was high. Attendance is related to fear and mental health. Overall completion of treatment from referral was 33%.

Changes in oxygen saturation using two different sedation techniques

Pulse oximetry was used to assess the degree of hypoxia observed in patients receiving simple midazolam sedation for removal of lower third molars and compared to that seen in patients receiving a combination sedation technique using nalbuphine and midazolam. Results showed that the degree of hypoxia experienced by patients receiving the combination technique was significantly more profound in both incidence and depth than that seen in the group receiving midazolam alone (p less than 0.05).

Sedation or general anaesthesia for treating anxious children

Data SourcesRelevant literature was selected following searches using the following: Cochrane Central Register of Controlled Trials, Medline, Embase (OVID), System for Information on Grey Literature in Europe, Latin American and Caribbean Health Sciences Literature, ISI Web of Science; and searches were made by hand of: Journal of the American Academy of Pediatric Dentistry, Anaesthesia, British Dental Journal, British Journal of Anaesthesia, Dental Update, International Journal of Paediatric Dentistry, Journal of American Dental Association, Journal of Dentistry for Children and Pediatric Dentistry.Study selectionReports were selected if they described randomised controlled clinical trials (RCT) of sedative agents compared with general anaesthesia in children and adolescents aged up to 18 years who were having dental treatment: complex surgical procedures and pseudo-randomised trials were excluded. There were no language restrictions.Data extraction and synthesisTitles and abstracts were assessed for inclusion by two authors with relevant information recorded in a specially designed data extraction form.ResultsFifteen studies were identified for potential inclusion after searching the available databases and screening the titles and abstracts, and a further study was found through personal contacts. Following retrieval of the full text of the studies, it was concluded that none was eligible.ConclusionsRCT that compare the use of dental general anaesthesia with sedation to quantify differences such as morbidity and cost are required.

Specialist training in special care dentistry

Special care dentistry is the most recent dental specialty to be recognised by the General Dental Council. It differs from most dental specialties as it is defined by the patients rather than by specific dental procedures.