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As more and more patients are lining up for pain-free procedures, it’s become apparent that oral sedation is nothing to snore at. By Kerryn Ramsey

Dr  Angelo G Preketes  (left) and Dr Robert Turnbull at  Woollahra Dental & Wellness Centre performing an oral surgical procedure on a patient with IV conscious sedation.
Dr Angelo G Preketes (left) and Dr Robert Turnbull at Woollahra Dental & Wellness Centre performing an oral surgical procedure on a patient with IV conscious sedation.

Oral conscious sedation is one of the most talked-about topics in the dental profession. When the Australian Society of Dental Anaesthesiology (ASDA) scientific meeting takes place in October in Brisbane, 90 per cent of discussions will revolve around this topic. And although there are no official figures available in Australia, as many as 30 per cent of patients are requesting some form of sedation, compared to around six or seven per cent five years ago.

While patients are queuing up for pain-free procedures, a few contentions have flared up over the past few years, particularly following a number of deaths in the USA. The Dental Board of Australia (DBA) quelled these controversies with new regulations implemented in July 2011. It requires that assistance for conscious or IV sedation is by either a registered nurse with training in intensive care and/or anaesthetics; a dentist trained in the monitoring of sedated patients; or a registered medical practitioner.

The Australian Dental Association (ADA) and ASDA, however, follow a different guideline, reflecting “the Australian and New Zealand College of Anaesthetists professional standards guidelines (PS9) where the third person (assistant) is described as ‘an appropriately trained person’ whose sole duty is to monitor the patient”.

“These guidelines mean that a registered nurse or dentist trained in monitoring may not be the only people who could monitor the patient,” explains Dr Greg Mahoney, president of the ASDA. “The DBA guidelines, I believe, were an attempt to define what was an appropriately trained person and one who was registered with the Australian Health Practitioner Regulation Agency.”

Currently, just over 80 dentists across Australia have been endorsed to perform conscious sedation. Dentists must have successfully completed the two-year part-time graduate diploma in clinical dentistry (conscious sedation and pain control) or its equivalent.

“This year, there were 35 applicants for six places and at least one candidate in the last couple of years has failed the final examinations,” says Dr Mahoney. Furthermore, endorsed practitioners are required by the DBA to annually complete a course on medical emergencies in the dental sedation setting.

According to Dr Harry Marget, who runs the East Bentleigh Dental Group in Victoria, he was relieved when the guidelines were implemented. “There was a time when a dentist could pick up a drug like midazolam and stick it in someone’s arm. If that patient then started gagging or developing a spasm in the throat area, that dentist was completely unprepared. The patient needed to have an airway opened and that dentist had no training for this at all,” he recalls.

While Dr Marget employs Dr Barry Creighton, a dentist graduated in conscious sedation, his current concern is that the approved course only takes place at Westmead Hospital, University of Sydney. “There’s a real dichotomy of values here,” he says. “We don’t have people who are able to administer their training facilities properly because they can’t get to the damn courses,” he says. “If you live in Western Australia, it’s not exactly a joyful experience to get on a plane every few weekends when you’re running a busy practice. The course should be more available in all states, not just in Sydney.”

Despite these qualms, Dr Marget has found that conscious sedation is a boon for patients who have dental phobias or are having complicated or prolonged procedures. “I’m not a believer in suffering the pain,” he says. “I went through that as a kid and I don’t think there’s any merit in it.”

While many practices—as well as the media—often refer to conscious sedation as ‘sleep dentistry’ or ‘twilight dentistry’, Dr Mahoney points out that this term is not recognised by the ADA, ASDA or the DBA, as it could refer to an “unconscious state where patients wouldn’t appropriately respond to verbal commands”.

Dr Harry Margets of the East Bentleigh Dental group
Dr Harry Marget of the East Bentleigh Dental group

Despite this terminology, ‘sleep dentistry’ has become a catchphrase for the media, particularly back in July last year when USA newspapers claimed that 31 children across the country had died from dental sedation over the past 15 years. In Australia, the ASDA has stated that two Australian patients have died while undergoing the procedure in the past 20 years.

“The deaths in the US are attributed to untrained or under-trained dentists using polypharmocology (multiple drugs) to achieve levels of sedation beyond the abilities of the dentist to deal with any unintended consequences,” says Dr Mahoney. Consequently, the ASDA supports the DBA guidelines which stipulate that:

• Nitrous oxide sedation will not be used with any other form of sedation by anyone other than those with the graduate diploma;

• Polypharmocology will not be used by anyone other than those with the graduate diploma;

• Sedation for the relief of anxiety by the untrained dentist should be limited to a single low dose of a sedative agent.

According to Dr Marget, 25 per cent of patients at his practice now request sedation, compared to seven per cent five years ago. “Most patients, I find, are time poor so rather than having 15 visits to get their teeth fixed, they say, ‘I’ll just come in, go to sleep and get it all done in one visit’.”

Dr David Cox, who runs one Brisbane and two rural practices, has found a 30 per cent increase in the past four years. But when it comes to minimising pain for young children, he prefers treating these patients with nitrous oxide—inhalation sedation—rather than conscious sedation.

“I’m an advocate that children shouldn’t be seen in a private practice with sedation,” he explains. “It’s really for the mid-teens, early adults and upwards. If it reaches that point where they need sedation, they are better treated under general anaesthetic in a hospital setting.”

Dr Cox is extremely satisfied with the guidelines and brings in Professor Douglas Stewart, director of the Department of Oral Diagnostic Sciences and head of the Sedation Unit at Westmead Hospital, to administer conscious sedation procedures. “Gone are the days of the ‘operator/anaesthetist’,” says Dr Cox. “You have someone looking after the vital signs, monitoring them, administering the anaesthetic or sedation and another person operating on the teeth and looking after that end. We’re not trying to do two jobs at once.”

Dr Cox is well-prepared for the raft of patients who will be queueing up for pain-free procedures in the future—two of his six dentists are undertaking the accreditation course. And, as he and Dr Marget have experienced, extra costs are rarely a concern for patients.

“We’ve found that people have absolutely no qualms when we explain the extra costs,” says Dr Marget. “It’s more like, ‘You’ll put me to sleep and fix my teeth—sign me up! Even I would be one of those people.”

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