Estimating the need for dental sedation. 2. Using IOSN as a health needs assessment tool

Identifying Persons with Special Healthcare Needs in Dentistry-Development and Validation of the French Case Mix Tool

Providing dental care for certain patient groups is complicated due to difficulties with cooperation, communication, health conditions, and social context, amongst others. The majority of dentists in France work within a public fee-per-item system. A new measure has been introduced providing a financial supplement to dentists for each episode of care for a patient with a severe disability. This supplement is justified by completion of the French Case Mix tool (FCM), a new measure designed to retrospectively identify episodes of dental care that have required adaptation and additional time or expertise. The aim of this study was to investigate the validity and psychometric properties of the FCM. The content validity of the tool was improved at each round of pilot development, involving 392 patient encounters. Test-retest data at 2 weeks for 12 fictional patient treatment episodes were collected from 51 dentists. This phase confirmed inter- and intra-dentist reproducibility, criterion validity, and interpretability. Retrospective analysis of 4814 treatment episodes nationally demonstrated high reliability, internal consistency, and construct validity. Overall, the FCM showed high validity and good psychometric properties. However, the impact of providing a financial supplement on improving access to care for persons with special needs has yet to be evaluated.

Safe intravenous sedation for oral surgery in a primary care setting

Conscious sedation is a useful adjunct in oral surgery due to the invasive nature of procedures and the prevalence of dental anxiety in the general population. The most common conscious sedation technique used in the UK is intravenous sedation with a single drug, midazolam, which has an excellent record of safety. This paper gives an overview of areas to consider when planning oral surgery procedures in primary care under intravenous sedation with midazolam, to enhance success and patient safety. The fundamentals of providing safe sedation include careful patient assessment, patient preparation, a good understanding of the complexity of treatment, and an appropriately trained team. This paper also reviews the current guidance on conscious sedation in the UK, the governance of sedation in dentistry, the medications used, and training of the sedation team.

Estimating the Need for Sedation in Patients with Dental Anxiety and Medical Complexities Reporting to Tertiary Care Dental Hospital Using the IOSN Tool

Objectives

To provide consistent method for assessment of sedation need among patients undergoing dental treatment based on specific risk factors that is dental anxiety, medical status, and treatment complexity of needed dental treatment using IOSN (indication of sedation need) tool for assisting the clinician in decision making process.

Methods

A total of 237 patients aged ≥12, ASA I and II were enrolled in the study. A structured questionnaire comprising of three sections was distributed among the participants. Section 1 comprises details about age, gender, literacy level, occupation, monthly income, and previous dental treatment history. Section 2 is based on Modified Dental Anxiety Scale which is a questionnaire comprising of five questions ranging from “not anxious” to “extremely anxious.” The third section was based on using the IOSN tool comprising three components: MDAS (Modified Dental Anxiety Scale) rank score, Systemic Health (ASA status) rank score, and treatment complexity rank scores. The total of three scores was then computed to determine the total rank score which suggested the sedation need. History of past traumatic dental experiences was also inquired from each patient.

Results

A total of 237 patients aged ≥12, ASA I and II were enrolled in the study, out of which 56.1% were female. Statistical analysis was conducted by using the IBM SPSS Statistics 23 software. Based on the MDAS score, 47/237 (19.8%) participants were found to be highly anxious related to dental procedures. 34.6% of the participants showed to have a high sedation need while performing a dental procedure. The sedation need was found to be significantly associated with the female gender with a significant p value of (p=0.016), higher education status (p=0.016), and history of previous traumatic dental experience (p < 0.001).

Conclusion

A simple assessment tool can enable clinicians in their decision making to identify patients in need for dental treatment under sedation based on patient-specific risk factors such as past traumatic dental experiences. Need for sedation can be assessed by information on patient anxiety level towards dental treatment, medical history, and complexity of planned dental treatment. The IOSN tool is a simple and quick assessment tool that can be applied for preprocedural assessment of sedation need for dental treatment.

Where is the 'wisdom' in wisdom tooth surgery? A review of national and international third molar surgery guidelines

The objective of this narrative review was to identify and evaluate published international guidelines on mandibular third molars (M3M) and to assess their clinical scope and the validity of the recommendations. The search strategy used data obtained from a variety of sources including MEDLINE, national regulatory bodies, national dental and surgical colleges and associations, and military medical departments. Adherence to clinical guideline development was investigated using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation). Sixteen guidelines pertaining to M3M were included in this review. The guidelines produced by the Faculty of Dental Surgery of the Royal College of Surgeons of England (FDS RCS) and Scottish Intercollegiate Guidelines Network (SIGN) were recommended as meeting the criteria for use. Seven other guidelines were recommended but required modifications. The AGREE II instrument provides an excellent framework for guideline assessment. Unfortunately, very few guidelines scored highly across all domains and therefore were not believed to be of high quality. Due to the significant lack of structure and variable standards in guideline development, the conclusions and recommendations of these guidelines are compromised. There is a need for organizations involved in developing M3M guidelines to update guidance periodically in order to ensure that the information available to clinicians and patients is accurate and relevant to clinical practice.

Exploring Dentist Opinions on the Provision of Intravenous Sedation in Primary Dental Care for UK Armed Forces Personnel

Introduction: Anxiety toward dental treatment can lead to preventable morbidity, most notably oral pain and infection. This is of concern to the UK Armed Forces (UK AF), as dental care may not be immediately accessible during deployments and exercises, necessitating aeromedical evacuation. Current Defence Policy states that serving UK AF personnel requiring sedation to tolerate routine dental treatment are to have their Joint Medical Employment Standard (JMES) reviewed to restrict their deployability and employability. This article explores current sedation delivery, dentist opinion, and adherence to policy. Materials and Methods: The total number and type of intravenous (IV) sedation appointments over a 6-month period was assessed using surgical logbooks. Questionnaires were sent to all dentists in primary care responsible for treating military patients to ascertain their attitudes toward the requirement for sedation in support of recruitment and deployability. Ten-year retrospective data analyses were used to identify current trends in sedation use in the UK AF. Results: Responses were received from 117/137 (85%) dentists. All of the responding Civilian Dental Practitioners felt that there was a requirement for IV sedation in contrast to the Royal Navy (RN), where over a quarter (28%) disagreed. The majority, 48 (81%), of Army dentists felt that military patients unable to tolerate routine treatment under local anesthesia alone should not deploy on operations, compared with 7 (63%) of their civilian counterparts. Overall, 72 (62%) respondents felt that patients unable to tolerate routine treatment without sedation should not be recruited. Conclusions: Civilian Dental Practitioners in the sample indicated that they were less likely to recommend a patient for JMES review, less likely to prevent patients from deploying and less likely to believe that individuals requiring sedation for routine treatment should not be recruited into the UK AF. These attitudes are contrary to current Defence direction and could increase the risk of UK AF personnel experiencing morbidity on deployment requiring aeromedical evacuation. Over the longer term, civilianization of Defence dentistry is likely to reduce collective operational experience and Defence must ensure that clinicians understand the management of anxious patients in the military context and their responsibilities in relation to JMES. Furthermore, policy limiting the recruitment of personnel with significant dental anxiety is not being robustly adhered to. Based on the number of dental procedures undertaken under IV sedation in the UK AF, consistent application of this policy would not affect recruitment at an organizational level, but would limit the risk of deploying these personnel. Further work is required to understand dental anxiety within the UK Armed Forces so that the operational morbidity risks can be quantified and provision appropriately planned.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Background

Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.

Research questions

Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?

Design

A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.

Setting

The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.

Participants

Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.

Interventions

A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.

Main outcome measures

Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.

Results

In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.

Conclusions

Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.

Study limitations

The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.

Future work

The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A review of the indicator of sedation need (IOSN): what is it and how can it be improved?

The indicator of sedation need (IOSN) is a tool that has been devised to help with clinical decision-making, health needs assessment and commissioning purposes for the provision of sedation services. It can potentially increase access for patients to sedation when used as a screening tool, however, there are some shortcomings in the IOSN, such as the fact that it is not speciality specific, that can reduce its efficacy. As such, in its current form the IOSN may not be robust enough to be used as a sole commissioning tool and may in fact create barriers to patients that would benefit from sedation. By addressing these issues and understanding its limitations, the IOSN can be used more effectively for its intended purposes.

Development of a decision aid for children faced with the decision to undergo dental treatment with sedation or general anaesthesia

BACKGROUND

Decision aids are tools used to help individuals faced with difficult healthcare decisions. They help patients further understand the treatment options available and encourage the sharing of information between patients and clinicians.

AIM

To develop a decision aid for young patients faced with the decision to undergo dental treatment with inhalation sedation, intravenous sedation, or general anaesthesia (GA).

DESIGN

Qualitative interviews with dental patients (aged 10-16 years), and their parents/guardians were used to inform the content of a draft decision aid. Following further revisions, a pilot evaluation of the decision aid was conducted. Patients referred for dental treatment with sedation or GA were recruited from a UK dental hospital. Patients (n = 15) and parents/guardians (n = 13) assigned to the intervention group received the decision aid and routine clinical counselling, whereas patients (n = 17) and parents/guardians (n = 13) in the control group only received routine clinical counselling. Participants completed measures of knowledge, decisional conflict, and dental anxiety.

RESULTS

Knowledge scores were significantly higher for participants who received the decision aid when compared to standard care. There were no other significant differences between groups.

CONCLUSIONS

A decision aid was successfully developed, and initial findings suggest such tools could be beneficial to dental sedation or GA patients and their parents/guardians. Further research is required on the use of such tools in primary care settings, with particular attention to the impact of the decision aid on attendance and completion rates of treatment.

Utilising a paediatric version of the indicator of sedation need for children's dental care: a pilot study

AIM

To assess the treatment outcomes of using inhalation sedation for comprehensive dental care in children by utilising a modified version of the indicator of sedation need tool.

METHODS

Investigating the outcomes of dental treatment of patients referred to the sedation unit at the Leeds Dental Institute when the paediatric version of the indicator of sedation need (p-IOSN) was utilised.

RESULTS

Forty patients of mean age 9.99 (SD = 3.14) years were followed up to ascertain treatment outcomes when the p-IOSN was used. Of the total of 40 children included, 20 scored 6 on p-IOSN. Treatment completion rate was 72.5 %. Although major differences existed between age and treatment outcomes, they failed to achieve statistical significance. No significant association was found between gender and p-IOSN of any score with any treatment outcome.

CONCLUSIONS

p-IOSN may be a useful tool that can be used to predict those child patients who would benefit from sedation for their dental treatment. However, the p-IOSN is still in a developmental stage and further research is required prior to its use on clinical grounds.

Conscious sedation: is this provision equitable? Analysis of sedation services provided within primary dental care in England, 2012-2014

Aim:

Patients receiving primary dental care may occasionally require conscious sedation as an adjunct to care. It is one of a range of options to support anxious patients or those undergoing difficult procedures. The aim of this study was to examine patterns of conscious sedation within primary dental care in relation to patient demography, deprivation status, geography (local authority, region) and type of care (Band) within England to examine equity in distribution of service provision.

Materials and Methods:

Descriptive analysis of cross-sectional primary dental care data, obtained from national claims held by the National Health Service (NHS) Business Services Authority, on patients who had received one or more courses of care involving sedation.

Results:

Just under 137,000 episodes of care involving sedation are provided for over 120,000 patients per year, the majority of which are for adults. Four out of ten (41%) patients were children, with 6–12-year-olds forming the largest group; 6% were aged under six years. Eleven per cent of patients had more than one course of care involving sedation, with adults aged 25–34 years having the highest rate: 1.17 (s.d.: 0.887) in 2012/2013 and 1.16 (s.d.: 0.724) in 2013/2014. There was a clear social gradient, whereby the most deprived quintile had the highest volume of patients that had received sedation at least once in primary dental care in both years (31.5%). Whilst there was a clear social gradient amongst children and young adults who received sedation, the gradient flattened among middle-aged and was flat amongst older adults. The majority of courses of care involving sedation were associated with Band 2 claims for care (88.6% in 2012/2013; 88.8 in 2013/2014). Whilst one or more patients in all higher tier local authorities received care involving sedation, there were marked geographic inequalities.

Discussion:

Patients receive sedation in support of NHS primary dental care across the life course and social spectrum. Whilst the pattern of uptake of care parallels the social gradient in younger age groups overall, there are clear geographical inequalities in provision. As sedation is only one of a series of adjuncts to care which may be provided across different sectors of the health system, a wider systems analysis should be undertaken as the findings raise important issues about equitable access to appropriate care. Furthermore, there should be a greater emphasis on prevention to reduce the need for care. The implications for child oral health, access and quality are discussed.

Assessing sedation need and managing referred dentally anxious patients: is there a role for the Index of Sedation Need?

AIM

To conduct an exploratory investigation of public dental service (PDS) practitioners' planned sedation modality using a structural equation modelling approach, in order to identify the explanatory value of using the Index of Sedation Need (IOSN), or its component parts, to predict sedation modality in patients referred with dental anxiety.

METHODS

A convenience sample of patients referred to the PDS for dental anxiety management was invited to take part. The IOSN was completed for each patient (patient dental anxiety, medical and behavioural indicators and dental treatment complexity) as well as the American Society of Anesthesiologists Physical Status Classification System and the Case Mix Tool. The practitioners completed details of their planned sedation modality and identified normative dental treatment need. The data were entered onto an SPSS v21 database and subjected to frequency distributions, t-tests, correlation analysis and exploratory partial structural equation modelling (SEM).

RESULTS

Ninety-five percent of patients were ranked as MDAS 3 or 4, indicating high dental anxiety; 69% had a medical condition, which might impact on dental treatment and 82% had a dental treatment need, which was classified as intermediate/complex according to the IOSN. Eighty-eight percent of the patients in accordance with the IOSN required sedation: 62% of patients were assessed as requiring intravenous sedation. The IOSN discriminated between patients who were assessed as requiring more complex sedation modalities and had a greater normative treatment need. The SEM showed that the patient dental anxiety (P <0.02) and dental treatment complexity (P <0.02) predicted planned sedation modality. Functional morbidity was less strong, as a predictor, and was significant at the ten percent level.

CONCLUSIONS

The IOSN is a useful and valid assessment of sedation need and predicted sedation modality for patients referred with high dental anxiety states and secondly, that component parts of the IOSN add explanatory value in practitioners' choice of planned sedation modality.

Current UK dental sedation practice and the 'National Institute for Health and Care Excellence' (NICE) guideline 112: sedation in children and young people

AIM

Describe current dental sedation practice for under 19-year-olds in the UK and compare it with the recommendations of NICE guidance 112.

METHOD

Members of the Society for the Advancement of Anaesthesia in Dentistry and members of the Dental Sedation Teachers Group were invited to participate in an online survey.

RESULTS

Two hundred and sixty-six dentists and doctors completed the survey. Eighty-two percent were operator and sedationist (operator-sedationist). Ninety-five percent provided written information and 94% obtained written consent. Eighty-four percent kept a written or electronic sedation record. Eighty-six percent complied with life support training expectations. Eighty-six percent had immediate access to resuscitation equipment. Sixty-seven percent of sedationists reported that treatment could not be completed under sedation for <10% of cases during the previous year. When sedation was unsuccessful, 61% said they would schedule general anaesthesia and 54.5% would schedule advanced sedation care. Forty-nine percent believed that a dentist was an appropriate person to provide advanced sedation for 12-18 years. Only 24% thought a dentist should provide advanced sedation for children<12 years, with 75% preferring an anaesthetist. The appropriate setting for advanced sedation was thought to be primary care by 33% and secondary care by 68%.

CONCLUSIONS

We found good agreement between the current practice of sedation and the recommendations of the NICE guidance 112.

Safety and predictability of conscious sedation in dentistry -- a multi-centre regional audit: South and West Wales experience

INTRODUCTION

There are no previously published reports of audits in conscious sedation from a group comprising the general dental services (GDS), community dental services (CDS) and hospital dental services (HDS).

AIM

The main aim of this audit was to assess current practice within the group in relation to the safety and predictability of dental treatment undertaken with the aid of conscious sedation.

METHODS

A total of nine centres collected data prospectively on 1,037 sedation episodes over the course of one year. Audit standards were locally agreed based on current evidence and local experience. They were set at a completion rate of 90% and an adverse incident rate of 2% or less.

RESULTS

Based on the data collected, a completion rate of 92% and a minor adverse incident rate of 2.6% were recorded.

CONCLUSIONS

The participating centres met the standards set locally for this audit. Current practice in the participating centres was found to be safe and predictable. The audit tool is being refined to improve the quality of data collection. Further research and service evaluation is recommended.

The indicator of sedation need (IOSN)

Conscious sedation in dentistry is usually indicated because a patient's anxiety can prohibit the necessary dental treatment being undertaken. It may also be indicated because of unpleasant or lengthy treatment or to prevent exacerbation of a patient's medical or behavioural condition by anxiety. The indicator of sedation need (IOSN) tool has been developed to help support dentists in their clinical decision-making and uses information about a patient's anxiety, medical and behavioural status and treatment complexity. The IOSN has been used to measure sedation need and has shown that 5.1% of patients attending general dental practices have a high need of conscious sedation. IOSN has also been used to investigate the need for conscious sedation in the general population among dental practice attenders and those who don't attend. The proportion was found to be 6.7%.

CLINICAL RELEVANCE

Some patients require conscious sedation in order to access dental care. The indicator of sedation need (IOSN) tool helps in the decision-making process.

Estimating the need for dental sedation: evaluating the threshold of the IOSN tool in an adult population

AIM

The aim of this study was, through a service evaluation, to assess the use of the IOSN tool in determining whether threshold values were appropriate for identification of IV sedation and general anaesthetic (GA) cases from a referral population.

METHODS

A total of 105 patients were taken from a dental minor oral surgery referral service within a north west primary care trust over the course of six months. The IOSN tool was completed to assess: treatment complexity, medical and behavioural factors and patient anxiety levels. Each patient was then followed through to treatment. The type of sedation modality they received was compared to their IOSN score previously calculated and these results evaluated.

RESULTS

The findings suggest that 94% of patients were treated within primary care by the MOS service, of which 58% received local anaesthetic (LA) alone and 42% were treated by LA with IV sedation. There was a general marked trend as the IOSN score increased so did the treatment modality from LA, through sedation to GA. Logistic regression using the components of the IOSN tool to predict sedation use indicated the IOSN predictors distinguished between those who required sedation and those who didn't (chi-square = 56.411, p <0.0001, df = 3) with treatment complexity (Exp B = 10.836, p <0.0001) and anxiety (Exp B = 4.319, p <0.0001) shown to be significant factors in determining sedation need.

CONCLUSIONS

The data collected have shown that there is a positive relationship between the IOSN score and the type of treatment modality the patient received, suggesting that the threshold values are correctly set. It is concluded that IOSN tool is a useful means of aiding the clinician in both assessing and referring patients for that sedation need.