Rupert Hoppenbrouwers, DDU senior dento-legal adviser
In any area of clinical work it is important to make sure you are complying with current accepted practice and teaching as would be supported by a responsible body of dental or medical opinion.
If you fail to do so you are at risk of being found negligent in the event of a patient claim for compensation, or your fitness to practise being found to be impaired in the event of a GDC complaint and investigation.
The GDC's Standards for the Dental Team requires you to provide good quality care based on current evidence and authoritative guidance, so it's therefore important to be aware of the currently available guidance in the fields in which you work, and to adapt your clinical practice to reflect the up-to-date position.
This may require extra formal training for you and your staff, so you can demonstrate that you are competent. In this article Dr David Craig, an acknowledged expert in the field of dental conscious sedation, reviews the recent and newly available guidance in this important area of dental clinical practice.
What is the background to the updates to sedation training?
David Craig: In spring 2016 the Scottish Dental Clinical Effectiveness Programme (SDCEP) was asked by the Chief Dental Officers (CDO) of England, Scotland, Wales and Northern Ireland to review the Intercollegiate Advisory Committee for Sedation in Dentistry's (IACSD) 'Standards for Conscious Sedation in the Provision of Dental Care' (2015).
This was in response to concerns expressed by a small number of dentists and those responsible for commissioning sedation services about a 'lack of clarity' in certain areas of the IACSD Standards; for example, starvation regimes, the use of multidrug sedation (especially for children) and the availability of education and training programmes for dentists and Dental Care Professionals. The IACSD Standards were also criticised for not being 'evidence based'.
The SDCEP Guideline Development Group differed from that of IACSD in that it comprised individual sedation experts rather than representatives of the Dental Faculties of the Surgical Royal Colleges, the Royal College of Anaesthetists and specialist sedation societies, for example, the Society for the Advancement of Anaesthesia in Dentistry and the Dental Sedation Teachers Group.
Unfortunately, SDCEP's review of the IACSD Standards resulted in some practitioners, commissioners and trainers becoming even more confused. The SDCEP guideline 'Conscious Sedation in Dentistry' was published in 2017.
What have been the results?
DC: The new SDCEP Guideline is clear and well written but due to its concise style it lacks some of the breadth and depth of the IACSD Standards. It is also heavily dependent on the IACSD report, especially in relation to multi-drug sedation, training and patient information.
The SDCEP group found no new evidence relating to any of the areas about which concern had been expressed in the IACSD Standards. The SDCEP Guideline fails to fully resolve any of the contentious issues on which IACSD had struggled to reach unanimous agreement, such as pre-sedation starvation.
SDCEP's Guideline is most likely to be of help to practitioners using 'basic' conscious sedation techniques (intravenous, oral and intranasal midazolam or inhaled nitrous oxide/oxygen) for straightforward patients in a primary care setting.
What are the implications for dental health professionals as a result of these updates?
DC: The SDCEP Guideline, the IACSD Standards, and also the new NHS England document 'Commissioning Dental Services: Service Standards for Conscious Sedation in a Primary Care Setting') are all closely aligned with the overarching medical and dental sedation guidance from the Academy of Medical Royal Colleges 'Safe Sedation Practice for Healthcare Procedures: Standards and Guidance' (2013, updated 2021) and so publication of the SDCEP guidance should have little or no impact on sedation practitioners and NHS England Commissioners. IACSD's requirements for education and training are unchanged by publication of the SDCEP Guideline.
At the time of writing, only the CDO in England has confirmed how primary care sedation services will be commissioned and delivered. It is unclear how the CDOs of Scotland, Wales and Northern Ireland will act. There may also be some differences in the way education and training is delivered outside England.
The views expressed are those of the author (D. Craig).
Bryan Harvey, DDU senior dento-legal adviser:
Patient safety must be at the forefront for all dental care professionals when treating all patients. Hopefully now that SDCEP guidance has confirmed the validity of the IACSD Standards, dental care professionals can feel confident that when a referral is made for sedation, the individual carrying out that sedation will be complying with the standards set out.
Before referring a patient for sedation or carrying it out themselves the dental care professional should ensure that every effort has been made to manage the patient's treatment needs without sedation. Whilst this may be challenging, it is the dental care professional's duty to attempt the least invasive way to treat a patient.
Hopefully, those commissioning NHS sedation services will be able to refer to the standards as a benchmark for the level of competency of the sedation team, and that the care given to the patients will make sure they are treated in the safest possible way and in their best interests.
Where members are referring patients to sedation practices not provided by the NHS, they need to reassure themselves that the team administering the sedation complies with the new sedation guidelines.