What are dental non-attenders' preferences for anxiety management techniques? A cross-sectional study based at a dental access centre

OBJECTIVE

Dental anxiety is a barrier to attendance. Dental non-attenders may seek emergency care and may prefer to receive anxiety management measures for treatment required. Little is known about the preferences of these dental non-attenders for different anxiety management techniques. Understanding such preferences may inform management pathways, improve experiences, alleviate anxieties and encourage a more regular attendance pattern. As such, the aim of this study was to gain a greater understanding of the dental anxiety of patients attending a dental access centre for emergency dental treatment and to ascertain preferences for different anxiety management techniques.

DESIGN

Cross-sectional study involving self-completed questionnaires and clinical observation.

SETTING

NHS Dental Access Centre, York, UK.

SUBJECTS AND METHODS

Two hundred participants not registered with a general dental practitioner, aged 18 years or over, experiencing pain and self-referred were recruited on a consecutive sampling basis. Participants completed a questionnaire eliciting demographic and dental history details, dental anxiety and preferences for dental anxiety management options.

MAIN OUTCOME MEASURES

Correlation of the modified dental anxiety scale with preference for different dental anxiety management techniques.

RESULTS

No significant predictive factors were found that explained preferring local anaesthetic to sedation, or general anaesthesia for restorations or extractions. Those highly anxious were less likely to consider tell-show-do techniques (p=0.001) or watching explanatory videos (p=0.004) to be helpful for overcoming their anxieties than the low or moderate anxiety groups.

CONCLUSIONS

People attending access centres may represent a group who are unwilling to explore non-pharmacological methods to overcome their anxieties. This supports the need for sedation to provide treatment. Future work may include exploring in more depth the thoughts and opinions of this group of patients to improve understanding of their complex dental attitudes. From this, more effective strategies may be developed to encourage regular dental attendance.

Escorts' knowledge of their duty of care to patients who have undergone intravenous sedation

AIM

To assess escorts' understanding of their responsibilities to the patient 24 hours following dental treatment under intravenous sedation.

STANDARDS

One hundred per cent of escorts: have been informed of their duties, have read the information sheet, expect at least a one hour appointment, identify the hazardous activities patients should avoid following sedation, travel by private transport, are aware that medications are taken as normal, should have care in place 24 hours following sedation.

METHOD

This was a prospective questionnaire-based audit. Questionnaires were handed to escorts of patients receiving treatment under intravenous sedation in Newcastle Dental Hospital sedation department.

RESULTS

Of 104 responses, 91.3% of escorts were informed about their duties and 79.8% had read the information sheet prior to the appointment. Boiling a kettle and Internet use were the most selected hazardous activities that escorts deemed safe for patients to carry out postoperatively (19.2%, 23.0%.) Private transport home was mainly used (car 73.1%, taxi 24.9%.) Following sedation, 93.3% of patients had an escort for 24 hours.

CONCLUSION

Escorts' basic knowledge fell short of the standard. Improvements are needed to ensure patient safety.

RECOMMENDATIONS

At the pre-assessment, the patient might be given an information sheet solely for the escort and encouraged to explain this to the escort. More comprehensive information listing activities hazardous to the patient 24 hours following sedation and emphasising that taking medications as normal preoperatively could be available on the treatment day. Transport information in the appointment letter might improve access. A Trust website link, a DVD and posters in the waiting room could further inform.

Anxiety and quality of life in phobic dental patients

Little is known about the anxiety patients experience before attending for dental treatment. The aim of this study was to determine, in dentally phobic patients, the temporal relationship of pre-operative anxiety levels, and the disruption to daily life caused by this. Twenty-four phobic and 19 comparison (non-phobic) dental patients were recruited. Four validated questionnaires were used to assess anxiety and quality of life, which each patient completed for 5 days prior to, and on the day of, treatment. Those in the experimental group were found to have significantly greater levels of dental and general anxiety, and a significantly lower quality of life compared with those in the comparison group. Significant temporal relationships were found with all of the questionnaires. Dental and general anxiety scores were significantly correlated with quality-of-life measures. This study suggests that phobic dental patients are experiencing significant increased anxiety, and significant negative quality-of-life effects, in this period.

Development of a screening tool to assess the suitability of people with a disability for oral care under sedation or general anesthesia

The aim of this study was to develop a screening tool to assess the suitability of people with disabilities for oral care in different settings. The objectives were to investigate retrospectively the uptake of general anesthetic (GA) services and use this information to develop a composite tool. One hundred cases referred for GA were reviewed to generate data for a Delphi Panel. Patients with disabilities were the subject of a tool, devised by the Delphi Panel, to appropriately allocate patients to the most suitable care, including the patients' medical, behavioral, and social status as well as planned dental treatment complexity. A total of 124 patients, between the ages of 4 and 75 years, in seven centers were treated under sedation or GA, according to the tool. Agreement on behavior assessment between dentists and anesthesiologists was poor. The tool has the potential to identify which people with disabilities can be effectively allocated for treatment under sedation or GA.

Comparison of transmucosal midazolam with inhalation sedation for dental extractions in children. A randomized, cross-over, clinical trial

BACKGROUND

The transmucosal route for conscious sedation in children has been reported widely in the field of medicine, but less so in dental patients. The aim of this study was to evaluate the efficacy and safety profile of midazolam (0.2 mg/kg) administered by the buccal transmucosal route, in comparison with nitrous oxide/oxygen inhalation sedation, for orthodontic extractions in 10-16-year-old dental patients.

METHODS

Each patient attended for two visits and was randomly allocated to receive buccal midazolam (0.2 mg/kg) or nitrous oxide/oxygen titrated to 30%/70% at the first visit, the alternative being used at the second visit. The patients' vital signs, sedation levels and behavioural scores were recorded throughout. Post-operatively, side-effects, recall of the visit and satisfaction levels were recorded via questionnaire.

RESULTS

Thirty-six patients, with a mean age of 12.9 years, completed both arms of the trial. The maximum level of sedation was achieved with buccal midazolam in a mean time of 14.42 min, compared with 7.05 min with inhalation sedation. The vital signs with both types of sedation remained within acceptable limits and the reported side-effects were of no clinical significance. Buccal midazolam was found to be acceptable by 65.7%. Only 28.6% of cases preferred this technique, the main disadvantage being the taste of the solution.

CONCLUSION

Buccal midazolam sedation (0.2 mg/kg) seems to be equally as safe and effective as nitrous oxide/oxygen for the extraction of premolar teeth in anxious children. However, further research is required to refine the midazolam vehicle to improve acceptability.

A comparison of oral midazolam and nitrous oxide sedation for dental extractions in children

The aim of the study was to compare oral midazolam and inhaled nitrous oxide as sedative agents during the management of children aged 5-10 years presenting for extraction of primary teeth under local anaesthetic. Subjects required two visits for the extraction of four primary teeth, one in each quadrant of the mouth, and were randomly allocated to be given nitrous oxide 30% in oxygen or oral midazolam 0.3 mg.kg(-1) at the first visit, the other technique being used at the second visit. Vital signs, sedation levels and behavioural scores were recorded, and postoperative recall and satisfaction were reported by the patients. Thirty-five children, with a mean [range] age of 7.4 [5-10] years, completed the treatment. The mean dose of oral midazolam given was 8.6 [3.3-16.5] mg. The mean times taken to achieve the maximum level of sedation for midazolam and nitrous oxide sedation were 15.9 [2-30] min and 6.8 [2-10] min, respectively. Physiological parameters remained within acceptable clinical limits for both types of sedation. Oral midazolam was considered acceptable by 59% and was preferred by 36%. Oral midazolam sedation in 5 to 10-year-old children was shown to be as safe and effective as nitrous oxide in oxygen sedation for extraction of primary teeth but would not be the method of choice for all patients.

The use of an intra-oral injection of ketorolac in the treatment of irreversible pulpitis

AIM

To examine whether an intra-oral injection of a nonsteroidal anti-inflammatory drug (ketorolac), in association with conventional local anaesthetic techniques, would improve the pulp extirpation rate in teeth with irreversible pulpitis.

METHODOLOGY

A two group double-blind clinical trial was undertaken in the Dental Casualty Department of the University of Manchester School of Dentistry. Patients were randomly allocated to either the test or control group. The test group received an intra-oral injection of ketorolac (30 mg in 1 mL) in the buccal sulcus adjacent to the tooth being treated. After an interval of 15 min, they then received 2.2 mL of 2% lidocaine with 1 : 80 000 epinephrine by buccal infiltration in the maxilla or by inferior dental block in the mandible. The control group received an intra-oral injection of normal saline (1 mL) in the buccal sulcus adjacent to the tooth being treated, followed by the same local anaesthetic regime as the test group after the 15 min interval. Fifteen minutes after the local anaesthetic injections, pulp extirpation was attempted. All patients completed the short-form McGill pain questionnaire prior to treatment and completed identical questionnaires at 6 and 24 h after treatment.

RESULTS

The study protocol set the number of patients to be treated at twenty. However, as the study progressed it became apparent that the intra-oral injection of ketorolac caused significant pain to four of the five patients who received it; therefore the study was terminated after ten patients had been treated. The results from the patients treated showed no significant difference in the pulp extirpation rate between the test and control groups. However, patients with higher pain scores at baseline were less likely to have the pulp completely extirpated, irrespective of whether they were in the test or control group. Pain scores for all patients decreased significantly from baseline to 24 h.

CONCLUSION

An intra-oral injection of ketorolac did not improve the pulp extirpation rate in a small group of patients with irreversible pulpitis compared with a placebo. In addition, it was associated with such significant pain on injection that it cannot be recommended as a treatment in this situation.

A study to assess the validity of clinical judgement in determining paediatric dental anxiety and related outcomes of management

OBJECTIVE

The aim of the present study was to determine the validity of subjective anxiety assessment and the outcomes of management of children receiving operative dental treatment.

SETTING

The study was conducted at the Departments of Sedation and Child Dental Health, Newcastle Dental Hospital, Newcastle upon Tyne, UK.

SUBJECTS AND METHODS

One hundred children and adolescents aged between 8 and 15 years participated in the study. Clinicians subjectively allocated 50 children for treatment with local analgesia alone (low anxiety), and identified 50 children who had the potential to benefit from nitrous oxide and oxygen sedation (high anxiety). Participants then completed the State-Trait Anxiety Inventory for Children (STAIC), the Venham Picture Test (VPT) and the Child Fear Survey Schedule-Dental Subscale (CFSS-DS). A global rating scale classified behaviour during dental treatment.

RESULTS

State anxiety and dental fear prior to treatment were significantly higher in children allocated to receive inhalation sedation (P = 0.004 and P = 0.005, respectively). There was no significant difference in trait anxiety or post-treatment state anxiety between the two groups (P = 0.69 and P = 0.06, respectively). Only 11% displayed 'negative' behaviour during treatment: 82% of this group represented those allocated to receive sedation.

CONCLUSION

Children receiving inhalation sedation were significantly more anxious prior to treatment than children receiving treatment with local analgesia alone. The findings support the subjective assessment of anxiety in children; however, objective anxiety measures may assist clinicians in identifying specific fears, which may ultimately aid patient management.

An RCT pilot study to test the effects of intravenous midazolam as a conscious sedation technique for anxious children requiring dental treatment--an alternative to general anaesthesia

AIM

To add to the evidence base for acceptable and effective paediatric conscious sedation techniques in dental primary care.

OBJECTIVES

To compare three conscious sedation techniques for primary care as an alternative to dental general anaesthesia (DGA) in children. To assess the feasibility and practicality of running the trial in general dental practice. To form the basis for sample size calculations and assess scales of measurement.

DESIGN

Single centre, randomised control trial (RCT).

SETTING

Queensway Anxiety Management Clinic (QAMC). A primary care based general and referral dental practice for the management of anxious patients.

SUBJECTS, MATERIALS AND METHODS

Sixty five children too anxious for management with relative analgesia, requiring invasive dental procedure for which dental general anaesthesia (DGA) will be required if an alternative cannot be found.

INTERVENTIONS

Group 1 (n = 20) - A combination of inhaled medical air and titrated intravenous midazolam. Group 2 (n = 22) - A combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam. Group 3 (n = 23) - A combination of an inhaled mixture of 0.3% sevoflurane and 40% nitrous oxide in oxygen with titrated intravenous midazolam.

MAIN OUTCOME MEASURES

Successful completion of the intended dental treatment with a child who is co-operative and responsive to verbal commands.

RESULTS

Fifty per cent (ten children) successfully completed treatment in Group 1, 73% (16 children) in Group 2 and 83% (19 children) in Group 3. This difference was not significant at a 5% level (chi(2) = 5.53, df = 2, P = 0.07) Of the total of 20 failures, eight children in Group 1 and one child in Group 2 were successfully treated with the addition of sevoflurane and nitrous oxide in oxygen. Only two children required referral to a hospital setting for DGA and the remaining nine children were managed with an alternative conscious sedation technique.

CONCLUSION

This pilot shows that intravenous midazolam especially in combination with the addition of inhaled nitrous oxide or sevoflurane and nitrous oxide were promising safe and effective techniques, sufficient to justify progression to a definitive RCT with appropriate methods.

A randomised crossover trial of post-operative cognitive and psychomotor recovery from benzodiazepine sedation: effects of reversal with flumazenil over a prolonged recovery period

OBJECTIVE

To study the post-operative cognitive and psychomotor recovery from midazolam conscious sedation, after reversal with the benzodiazepine antagonist flumazenil over a prolonged recovery period.

DESIGN

A prospective, double-blind, randomised, crossover trial.

SETTING

Out-patient Sedation Department, Newcastle Dental Hospital and School

METHOD

Eighteen patients, ASA I or II, received midazolam on two separate occasions to undergo equivalent dental treatment. Following treatment patients were reversed with intravenous flumazenil or saline (placebo) at alternate appointments. Assessment of mood and cognitive function was undertaken using a highly sensitive and specific computerised battery of cognitive tests administered by telephone. Cognitive and psychomotor tests were administered prior to sedation and every hour for 6 hours post reversal.

RESULTS

Results indicated no significant effect of flumazenil on simple reaction time and choice reaction time but did show a trend of reversing the effects of midazolam on numeric working memory and word recognition.

CONCLUSION

The cognitive and psychomotor effects of the sedation were not fully reversed by flumazenil. Cognitive impairments were still present up to 6 hours post-reversal, despite patients appearing clinically more alert. This has important implications for treatment protocols and discharge instructions.

A randomised controlled trial of paediatric conscious sedation for dental treatment using intravenous midazolam combined with inhaled nitrous oxide or nitrous oxide/sevoflurane

Failure of dental treatment due to anxiety is a common problem in children. The aim of this study was to establish whether the use of a combination of intravenous midazolam with inhalation agents (nitrous oxide alone or in combination with sevoflurane) was any more likely to result in successful completion of treatment than midazolam alone. A further aim was to evaluate the clinical viability of these techniques as an alternative to general anaesthesia. In total, 697 children too anxious for management with relative analgesia and requiring invasive dental procedure for which a general anaesthetic would usually be required, were recruited and randomly assigned to one of three groups given the following interventions: group 1 - a combination of inhaled medical air and titrated intravenous midazolam, group 2 - a combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam, and group 3 - a combination of an inhaled mixture of sevoflurane 0.3% and nitrous oxide 40% in oxygen with titrated intravenous midazolam. The primary outcome measure was successful completion of the intended dental treatment with a co-operative child responsive to verbal commands. In group 1, 54% (94/174 children) successfully completed treatment. In group 2, 80% (204/256 children) and in group 3, 93% (249/267 children) completed treatment. This difference was significant at the 1% level. Intravenous midazolam, especially in combination with inhaled nitrous oxide or sevoflurane and nitrous oxide, are effective techniques, with the combination of midazolam and sevoflurane the one most likely to result in successful treatment.

A survey of the opinions of consultant anaesthetists in Scotland of sedation carried out by dentists

OBJECTIVES

To elicit the attitudes and opinions of consultant anaesthetists working in Scotland, with regard to conscious sedation carried out by dental practitioners.

METHOD

A questionnaire was designed to gauge opinion of consultant anaesthetists in Scotland on the practice of conscious sedation by dentists. The questionnaire was sent to 353 consultant anaesthetists working in 49 hospitals within the 15 health boards in Scotland.

RESULTS

Of the 366 questionnaires sent, 249 were returned of which 235 were valid. This gave a response rate of 64%. In general, those questioned felt that the provision of sedation in a hospital setting was more appropriate than in general dental practice. A majority (65%) thought that it was unrealistic for anaesthetists to provide all sedation for dental treatment, although many (58%) felt that anaesthetists should take more responsibility in this area. Again, a majority (60%) agreed that dentists should be trained to use sedation techniques for their patients but a significant number (63%) disagreed with the practice of operator/sedationist.

CONCLUSION

It is of concern to the dental profession that a significant number of anaesthetists do not feel that it is appropriate for dentists to be administering even the most simple methods of sedation. At present there are no clear, recognised guidelines as to the level of formal training required for the practice of conscious sedation by dentists. It is in the interests of the dental profession and the public to ensure that those choosing to practice sedation do so safely by following recognised guidelines in the training and practice of sedation.

Randomized, controlled, cross-over clinical trial comparing intravenous midazolam sedation with nitrous oxide sedation in children undergoing dental extractions

BACKGROUND

The use of benzodiazepines for paediatric dental sedation has received limited attention with regard to research into clinical effectiveness. A study was therefore designed to investigate the use of midazolam, for i.v. sedation in paediatric dental patients.

METHOD

The aim of the study was to assess the effectiveness of i.v. midazolam in a randomized, controlled, cross-over trial. Children aged 12-16 yr (ASA I and II), requiring two appointments for equivalent but contralateral dental extractions for orthodontic purposes, were recruited. Conscious sedation with either i.v. midazolam titrated at 0.5 mg x min(-1), to a maximum of 5 mg, or nitrous oxide/oxygen titrated to 30%/70% inhalation sedation was used at the first visit, the alternative being used at the second visit. Vital signs including blood pressure, arterial oxygen saturation and ventilatory frequency, as well as sedation levels and behavioural scores, were recorded every 2 min.

RESULTS

Forty patients, mean age 13.2 yr (range 12-16 yr), participated in the trial. A mean dose of midazolam 2.8 mg was administered in the test group. The median time to the maximum level of sedation was 8 min for midazolam compared with 6 min for nitrous oxide (P<0.001). Vital signs for both treatments were comparable and within acceptable clinical limits and communication with the patient was maintained at all times. The median (range) lowest arterial oxygen saturation level recorded for midazolam was 97 (91-99)% compared with 97 (92-100)% for nitrous oxide. The mean (range) recovery time for midazolam was 51.6 (39-65) min and 23.3 (20-34) min for nitrous oxide (P<0.0001). Fifty-one per cent said they preferred i.v. midazolam, 38% preferred nitrous oxide, and 11% had no preference.

CONCLUSION

I.V. midazolam sedation (0.5 mg x min(-1) to a maximum of 5 mg) appears to be as effective as nitrous oxide sedation in 12-16-yr-old healthy paediatric dental patients.

A randomised, controlled, crossover trial of oral midazolam and nitrous oxide for paediatric dental sedation

A randomised, controlled, crossover trial was designed to assess the safety and effectiveness of oral midazolam sedation for orthodontic extractions. Forty-six ASA physical status I children aged 10-16 years were recruited. Each child required two treatment sessions. Sedation with either oral midazolam 0.5 mg.kg-1 or nitrous oxide in oxygen was used at the first visit, the alternative being used at the second visit. Blood pressure, heart rate, arterial oxygen saturation, and sedation and behavioural scores were recorded every 5 min. Anxiety levels and postoperative satisfaction were also recorded. Blood pressure, heart rate and arterial oxygen saturation in both groups were similar and within acceptable clinical limits. The median [range] lowest arterial oxygen saturation levels for subjects in the midazolam and nitrous oxide groups were 95 [90-100]% and 98 [93-100]%, respectively. The median [range] time to the maximum level of sedation in the midazolam group was 20 [5-65] min compared with 5 [5-10] min in the nitrous oxide group (p < 0.001). The median [range] duration of treatment was similar in both groups (midazolam group: 10 [5-30] min, nitrous oxide group: 10 [5-25] min). Seventy-four per cent of subjects were prepared to have oral midazolam sedation again, 54% preferring it. Oral midazolam appears to be a safe and acceptable form of sedation for 10-16-year-old paediatric dental patients.

A randomised, controlled trial of cognitive and psychomotor recovery from midazolam sedation following reversal with oral flumazenil

Flumazenil is traditionally administered intravenously to reverse the adverse effects of over sedation with benzodiazepines. The aim of this study was to test postoperative cognitive and psychomotor recovery from midazolam conscious sedation, following reversal with orally administered flumazenil. It was hypothesised that when administered by the oral route, flumazenil may enhance recovery over a prolonged period, thus increasing safety. Eighteen patients requiring intravenous midazolam sedation for dental treatment completed a randomised, double-blind, crossover trial. Following treatment the patients' sedation was reversed using either flumazenil or saline (as placebo), administered orally, on alternate appointments. Assessment of mood and cognitive function were undertaken using ClinPhone.cdr(R), a highly sensitive and specific computerised battery of cognitive tests administered by telephone prior to sedation and every hour for seven hours post reversal. Results indicate that within 20 min of administration, oral flumazenil is capable of partially reversing some cognitive and psychomotor impairments but the attentional and stimulus discrimination effects of midazolam sedation still remain.

A study of the effectiveness of oral midazolam sedation for orthodontic extraction of permanent teeth in children: a prospective, randomised, controlled, crossover trial

OBJECTIVES

To assess the safety, effectiveness and acceptability of o:ral midazolam sedation for orthodontic extraction of permanent teeth in children.

DESIGN

A prospective, randomised, controlled, crossover trial.

METHODS

A total of 26 children aged 10-16 (ASA I), referred for orthodontic extraction of premolar or canine teeth under sedation, were included in the study. Each child required two treatment sessions for the extraction of equivalent teeth on opposite sides of the mouth. Each subject was sedated with either ora midazolam (0.5 mg/kg) or nitrous oxide and oxygen (30%/70%) at the first visit and the alternative form at the second visit. At each visit two teeth were extracted, one upper and one lower. Heart rate, arterial oxygen saturation, respiration rate, sedation and behavioural scores were recorded every five minutes. Overall behaviour, patient acceptance and patient satisfaction were recorded at the end of treatment.

RESULTS

Of the 26 children included in the study there were 12 males and 14 females. The mean age was 12.5 years. The mean heart rate and respiratory rate for both groups were similar and within acceptable clinical limits. The lowest mean arterial oxygen saturation levels for nitrous oxide and midazolam sedation were 97.7% and 95.0% respectively. Although midazolam caused greater oxygen desaturation, the range (91%-100%) was within safe limits for conscious sedation. The mean level of sedation was greater in the midazolam group compared with the nitrous oxide group and all but one case completed treatment. A total of 23 patients (88%) said they would be prepared to have ora midazolam sedation again and 17 (65%) actually preferred oral midazolam to nitrous oxide sedation.

CONCLUSION

Oral midazolam (0.5mg/kg) appears to be a safe and acceptable form of sedation for 10-16 year old paediatric dental patients.

Competency in sedation

Conscious sedation has become an integral part of the undergraduate dental curriculum. The attributes of the competent graduate in sedation are defined and all providers of sedation education should be aiming towards this standard. It is important that students receive appropriate theoretical and practical training which must include hands-on clinical experience in sedation techniques.

A randomised, double-blind, placebo-controlled, comparative study of topical skin analgesics and the anxiety and discomfort associated with venous cannulation

OBJECTIVES

To compare the effect of topical skin anaesthetic agents on the discomfort and anxiety associated with venous cannulation.

DESIGN

Randomised, double-blind, placebo-controlled, within subject, volunteer trial.

METHODS

20 healthy volunteers underwent venous cannulation on three separate occasions having received topical skin application of either 4% amethocaine gel (Ametop), 5% eutectic mixture of lidocaine and prilocaine (EMLA) or E45 cream (placebo). Visual analogue and verbal rating scales were used to assess pain and anxiety associated with the venous cannulation, and anticipated anxiety for future cannulation, under each drug condition.

RESULTS

Subjects were aged 22-53 years (mean 32.8 years). The mean visual analogue scores (VAS) for discomfort were found to be significantly lower (p< 0.001) with Ametop (VAS = 18mm) and EMLA (VAS = 29mm) compared with the control (VAS = 38mm). There was a positive correlation (R2 = 72%, p<0.001) between discomfort and the predicted anxiety if cannulation was to be repeated with the same cream. With the placebo a positive correlation (R2 = 19.8%, p = 0.05) was found between the level of anxiety before cannulation and the level of discomfort recorded.

CONCLUSIONS

Ametop and EMLA topical anaesthetic agents produce effective skin analgesia for venous cannulation. The use of topical analgesia can reduce perceived anxiety about future cannulation procedures. This has application in the management of anxious patients undergoing intravenous sedation, suggesting that topical analgesia prior to venous cannulation may significantly aid anxiolysis.

Dose-dependent effects of flumazenil on cognition, mood, and cardio-respiratory physiology in healthy volunteers

OBJECTIVES

To assess the possible effects of flumazenil on cognitive processing, physiology, and mood. Design A double-blind, placebo controlled, four-way cross-over study, using healthy volunteers.

METHODS

On each of 4 separate visits, 16 participants received 0.5 mg, 2.5 mg, 5.0 mg of flumazenil, or normal saline. They then performed a computerised test battery assessing cognitive function. Measures of pulse rate, arterial oxygen saturation and mean arterial pressure were also taken. Finally, participants completed visual analogue scales assessing their subjective mood state.

RESULTS

The majority of cognitive tasks showed dose-dependent declines in performance. Mean arterial pressure was significantly reduced, as was pulse rate. Subjective alertness showed a similar decline.

CONCLUSIONS

Flumazenil has been clinically described as an agent with few intrinsic properties, whose primary effect lies in its ability to reverse benzodiazepine-induced states. This study has shown that flumazenil does possess intrinsic activity which have a significant effect on cognition, cardiovascular physiology and mood. Clinicians need to be aware of these effects.

A prospective randomised controlled study of patient-controlled propofol sedation in phobic dental patients

The safety and effectiveness of patient-controlled propofol sedation was prospectively assessed in 18 healthy, phobic dental patients. Using a randomised, crossover design each patient received two sessions of equivalent dental treatment under patient-controlled or clinician-controlled propofol sedation. The patient-controlled technique used 29.8% less drug (time-weighted dose) than the clinician-controlled method (p = 0.011). There was a high correlation between number of demands and number of doses actually infused during the patient-controlled technique (r = 0.99, p < 0. 001). Clinically, the level of sedation was lighter and the degree of operator satisfaction was higher with patient-controlled sedation. Blood pressure and arterial oxygen saturation showed minimal changes and remained within normal ranges during both techniques. Patient-controlled sedation produced a greater reduction in dental and general anxiety compared with clinician-controlled sedation, but the difference did not reach statistical significance. Three times the number of patients expressed a preference for the patient-controlled, compared with the clinician-controlled, technique. Patient-controlled sedation provides safe and acceptable intra-operative anxiolysis for phobic dental patients, but with reduced propofol dosage.

A survey of the teaching of conscious sedation in dental schools of the United Kingdom and Ireland

AIM

To assess and compare, for the first time, the quantity and quality of dental undergraduate teaching in conscious sedation in the dental schools of the UK and Ireland. This was achieved using a prospective, questionnaire-based survey.

METHODS

Questionnaires were designed to collect information about undergraduate sedation education from teaching staff and final year dental undergraduates at the 16 dental schools in the UK and Ireland. Staff questionnaires were distributed to a nominated sedation teacher at each dental school and sought details of didactic and clinical sedation teaching methods, plus the quantity and perceived quality of sedation teaching. Student questionnaires were distributed to 5th year dental students and enquired about the quantity and quality of clinical sedation teaching received. The survey was undertaken during May-June 1998.

RESULTS

Thirteen dental schools returned staff questionnaires (81%). Seven also provided a student response (44%). The proportion of final year students within the 7 schools who returned completed questionnaires was 38%. Sedation teaching was undertaken primarily by oral surgery and paediatric dental departments. Three schools also utilised anaesthetic departments and 2 schools had dedicated dental sedation departments. All but 2 schools provided didactic teaching on sedation (mean: 4.2 lectures, 1.8 seminars). Of the 7 schools which returned staff and student questionnaires, all provided some clinical training using inhalational and intravenous demonstration cases (mean 5.1 and 4.4 cases, per student, respectively). All but one school provided hands-on inhalational sedation experience (mean 2.6 cases per student) but only two schools provided any hands-on intravenous sedation experience. The quantity of hands-on experience was greater at the two dental schools with dedicated dental sedation departments. Across the schools students rated the overall quality of sedation teaching at average or above, but most staff graded the overall quality of teaching at below average.

CONCLUSION

Dental undergraduate sedation teaching shows considerable variation across the dental schools surveyed. At most schools students gained little or no hands-on experience in sedation, especially in intravenous techniques. The undergraduate foundation for sedation education must improve if conscious sedation is to become the principal alternative to general anaesthesia in dental practice.

Cognitive properties of sedation agents: comparison of the effects of nitrous oxide and midazolam on memory and mood

OBJECTIVES

To compare the effects of nitrous oxide and midazolam on cognition and mood.

DESIGN

A three-way, counterbalanced, cross-over study, using patients receiving conscious sedation for routine dental treatment.

METHODS

On each of three separate visits, patients performed a computerised test battery to determine baseline cognitive performance. Then, following administration of either midazolam, nitrous oxide, or no drug, patients re-performed the test battery. Finally, patients completed visual analogue scales assessing their subjective mood state.

RESULTS

Relative to baseline performance, midazolam administration produced significantly slower reaction times compared with nitrous oxide and no-drug conditions. Furthermore, patients receiving midazolam were impaired in accuracy relative to the other conditions on many of the cognitive tasks, particularly those assessing the recall of information. Patient performance in nitrous oxide and control conditions did not significantly differ. These results could not be explained by differences in mood between the conditions, as subjective mood ratings during midazolam or nitrous oxide administration were very similar.

CONCLUSIONS

It is important for clinicians to be aware that peri-operative recall of information is reduced in patients who have undergone midazolam sedation. This is an advantage for patients who are anxious, and do not wish to be aware of the operative treatment being performed. However, as the cognitive impairment is enduring, an adult escort and written post-operative instructions should be mandatory for midazolam sedation patients. In contrast, the use of nitrous oxide sedation does not significantly impair higher cognitive tasks and thus patients receiving nitrous oxide sedation can resume normal activities in the post-operative period.

An investigation into the need for supplementary steroids in organ transplant patients undergoing gingival surgery. A double-blind, split-mouth, cross-over study

Organ transplant patients are frequently medicated with triple immunosuppressive therapy that includes both cyclosporin and the corticosteroid, prednisolone. Many of these patients experience gingival overgrowth that necessitates surgical intervention. Chronic dosing with corticosteroids can lead to suppression of the hypothalamic-pituitary axis, and subsequent adrenocortical suppression. To circumvent possible suppression, supplementary steroids are administered to such patients prior to so-called "stressful events". We have examined the need for supplementary steroids in 20 organ transplant patients undergoing gingival surgery under local anaesthesia to correct their drug-induced gingival overgrowth. All patients were operated upon in the first half of the morning. Prior to gingival surgery, resting blood pressure (BP) and serum ACTH concentrations were determined. Immediately before surgery patients received either intravenous hydrocortisone 100 mg or placebo in random, double-blind order. Each patient required 2 gingivectomies and thus acted as their own placebo control. BP was measured at various time points throughout surgery and upto 2 h postoperatively. On completion of surgery, a further blood sample was taken to determine ACTH concentration. There was no significant difference (p>0.05) between placebo and hydrocortisone treatments for BP and ACTH measurements. No patient experienced any symptoms that were suggestive of adrenocortical suppression. One patient did experience postural hypotension prior to gingival surgery, but this is attributed to his antidepressant medication. We can conclude from this study that immunosuppressed organ transplant patients taking the maintenance dose of prednisolone (5-10 mg/day) do not require corticosteroid cover prior to gingival surgery under local anaesthesia. We would however, advocate monitoring of their blood pressure throughout the procedure.

The emergency drugs box--time for action?

Many GDPs are confused about which emergency drugs they should stock. There is a lack of uniform advice on this topic. Most recommended lists of emergency drugs contain superfluous medications which GDPs would never be expected to use. This paper rationalises the content of the emergency drugs box and provides clear, standardised guidance. A list of ten essential emergency drugs is presented, all of which can be administered by simple routes. Every GDP should be trained and competent to use these essential emergency drugs.

Prevalence of emergency events in British dental practice and emergency management skills of British dentists

Medical emergencies in dental practice are generally perceived as being rare but when an emergency does occur it can be life-threatening. The ability of the dentist to initiate primary management is the key to minimising morbidity and mortality. Accurate data on the prevalence of emergency events, required so that dentists can adequately prepare to deal with emergency situations, is sparse and obsolete. This study aimed to determine the current prevalence of medical emergencies and the perceived emergency management skills of dentists. A questionnaire, distributed to 887 dentists working in general dental practice across five counties of Northern England, produced a response rate of 34%. The most frequently reported emergency was vasovagal syncope (1.9 cases, per dentist per year), followed by hypoglycaemia (0.17), angina (0.17), epileptic fit (0.13), choking (0.09), asthma (0.06), hypertensive crisis (0.023) and anaphylaxis (0.013). Myocardial infarction and cardiac arrest were extremely rare with an incidence of 0.003 and 0.002 cases per dentist per year, respectively. The total prevalence of all emergency events (excluding syncope) was 0.7 cases per dentist per year. Only 20.8% of dentists felt competent to diagnose the cause of a collapse in the dental surgery. However the majority believed that they would be able to undertake initial treatment of most common emergencies. Despite this more than 50% felt unable to manage a myocardial infarction or anaphylaxis, and 49.7% did not know how to insert an oral airway or undertake an intravenous injection. Future postgraduate training in emergency care for dentists needs to be more accurately targeted to the known prevalence of emergencies and deficiencies in dentists' emergency skills.

In vitro synthesis and characterization of a cartilaginous meniscus grown from isolated temporomandibular chondroprogenitor cells

Internal derangement of the temporomandibularjoint can lead to perforation of the intra-articular meniscus and osteoarthritic degeneration. Current methods of repairing damaged menisci are limited by lack of biological compatibility of graft materials. This project aimed to synthesise and characterise a primate cartilaginous meniscus in vitro from harvested mandibular chondroprogenitor cells. Isolated cells from the mandibular cartilage of 12 young adult marmosets, aged 9-12 months, were grown in monolayer culture. After 21 days confluent colonies were resuspended and dispersed into a unpolymerised solution of type I collagen and fibrinogen. The resultant cell suspension was infiltrated into a resorbable type I collagen sponge carrier and allowed to polymerise. Aliquots of the cell-infiltrated sponge were maintained in organ culture for a further 14 days. Cultures were characterised using histochemical and immunocytochemical localisation of collagen and proteoglycan species. Two-thirds of cells in confluent 21-day monolayers expressed cartilage-specific type II collagen and chondroitin-4-sulphate. After 35 days organ cultures had formed a viable, organised, three-dimensional tissue mass consisting of mature chondrocytic cells interspersed in a dense cartilaginous matrix. The cartilaginous tissue generated in vitro may have potential application in the repair or replacement of damaged menisci in vivo.

Investigation of nitrous oxide pollution arising from inhalational sedation for the extraction of teeth in child patients

OBJECTIVES

(i) TO test whether the exposure of dental staff to nitrous oxide during inhalational sedation with nitrous oxide/oxygen for extractions in children complies with specified occupational exposure standards, and (ii) to assess the atmospheric nitrous oxide concentration at one site close to the breathing zone of the operator/sedationist and to determine which patient- and sedation-related factors affect the level of nitrous oxide pollution.

DESIGN

Prospective study.

SETTING

Dental hospital sedation department, Newcastle Dental Hospital, UK.

SAMPLE AND METHODS

20 inhalational sedation clinics each of 2 hours duration were evaluated, during which a total of 60 children aged 4-15 years had extractions carried out. Nitrous oxide was administered via a nose mask from a Quantiflex MDM inhalational sedation machine and active scavenging was used throughout. Exposure of dental staff was measured using personal dosimetry. Atmospheric nitrous oxide pollution at one fixed point, close to the breathing zone of the operator/sedationist, was assessed using infra-red gas analyser.

RESULTS

Mean exposure of the operator/sedationist to nitrous oxide during a single treatment clinic was 211 ppm, for the close support nurse 77 ppm and for the second nurse 67 ppm. Expressed as an 8 hour time-weighted average, the mean exposures were 39 ppm for the operator/sedationist, 17 ppm for the close support nurse and 15 ppm for the second nurse. The atmospheric nitrous oxide concentration varied during the clinics, with a maximum concentration of 538 ppm an a minimum that exceeded 100 ppm. There was a 71 minute delay following discharge of the last patient before atmospheric levels fell to zero. During sessions the degree of atmospheric pollution was inversely related to patient age (rc = -0.61, P < 0.05). There was a positive correlation between atmospheric pollution at the single point and the maximum percentage of nitrous oxide administered to each patient (rc = 0.57, P < 0.05).

CONCLUSIONS

In this study, staff exposure to nitrous oxide complied with the national occupational exposure standard but there was still considerable atmospheric nitrous oxide pollution during inhalational sedation for paediatric exodontia.

The role of mandibular condylar cartilage in articular cartilage repair

The articular hyaline cartilage of synovial joints has a very limited capacity for repair after injury. In contrast, the mandibular condylar cartilage of the temporomandibular joint possesses as intrinsic potential for regeneration. This study aimed to test the hypothesis that cultured allografts of mandibular condylar cartilage could be used to promote biological repair of injured orthotopic joint surfaces. Using a primate animal model, cultures of mandibular condylar cartilage cells were grafted into surgically created defects in a recipient hyaline cartilage joint surface. Articular wound healing was assessed macroscopically and histologically over a postoperative period of 52 weeks. Mandibular condylar cartilage cells scheduled for allogenous transplantation were initially characterised in vitro. Expansion of primary colonies in organ culture provided the allogenic cellular material for in vivo grafting. Grafting of osteochondral articular wounds with 5-week cultures of mandibular cartilage cells led to wound regeneration with complete reconstitution of articular surface continuity by 52 weeks. There was novel synthesis of cartilage collagens and sulphated glycosaminoglycans within the repair tissue and no evidence of immunological rejection. Healing of grafted defects was thought to occur by a combination of donor cell proliferation and ingress of host mesenchymal cells. In contrast, grafted control wounds underwent largely fibrous repair with incomplete articular regeneration. In conclusion, transplanted allografts of cultured mandibular condylar cartilage appeared to have the ability, in this primate model, to promote cartilaginous repair and regeneration of orthotopic articular wounds.

The effect of epidermal growth factor mouthwash on cytotoxic-induced oral ulceration. A phase I clinical trial

A double-blind clinical trial was performed to study the effect of epidermal growth factor (EGF) mouthwash on the healing and recurrence of oral ulceration in 12 patients undergoing cancer chemotherapy. The oral distribution or cytotoxic-induced ulcers corresponded to the salivary gutters. There was no difference in the rate of healing of established ulcers between the experimental and placebo groups. However, there was a small delay in the onset and severity of recurrent ulceration. It was concluded that EGF mouthwash does not accelerate ulcer healing, but it may have the potential to protect the oral epithelium from cytotoxic damage.

Facial airgun wound

A case is presented of a patient who received an airgun wound to the soft tissues of the right orbit. Because the pellet ricocheted off the bony orbital rim, it did not penetrate the globe and vision was not impaired. The increasing incidence of airgun wounds in Great Britain is also discussed.

Fatal sequel to dental implant surgery

The rare complication of fatal venous air embolism arising as a direct result of dental implant surgery in the mandible is depicted. The deaths arose from the erroneous use of an air/water coolant mixture with internally irrigated implant drills. The pathogenesis and consequence of air embolism is discussed. Practitioners are warned about the dangers of using air-driven equipment during implant surgery.

Repair of articular defects with autologous mandibular condylar cartilage

Unlike hyaline cartilage, mandibular condylar cartilage can respond to injury by complete healing. We have used the reparative potential of mandibular cartilage to promote repair of defects in a hyaline cartilage joint surface. In 12 adult marmosets, articular fibrocartilage from the mandibular condyles was transplanted into full-thickness defects created in the femoral condyles. Additional defects acted as an ungrafted control group. The grafted defects showed good incorporation of the transplant with restoration of the articular surface within six months. Repair was by proliferation of the fibrocartilaginous graft and chondrogenesis of hyaline cartilage. The repopulating cells were distributed in a matrix of maturing collagen and sulphated glycosaminoglycans. Ungrafted control defects were only partly repaired with fibrous tissue, leaving articular deficiencies. We conclude that transplanted mandibular fibrocartilage can promote reconstitution of wounded hyaline cartilage joint surfaces in primates.