Inhalation sedation – friend or foe?
Pain control is an invaluable part of the dentist’s toolbox. Often the way this is performed is down to individual preference. Many dentists’ only experience of inhalation sedation will have come as part of their undergraduate training and, as this varies appreciably according to which dental school they attended, can result in a somewhat ‘patchy’ approach to the use of relative analgesia in dental practices.
It is estimated that use of inhalation sedation in the UK could be as low as 15 per cent – and in some geographical areas this drops to zero. Contrast this with the US where the figure rises to somewhere between 50-58 per cent of dentists using this valuable tool on a daily basis. The use, as you travel around European countries, varies significantly, but it is reported that sales of inhalation sedation equipment in the Scandinavian countries have almost reached ‘saturation’ level, suggesting that an extremely high percentage of dentists use this facility.
The recent NICE report actively seeks to encourage more use of conscious sedation. Flexibility of method is the watchword and all forms of pain control are to be encouraged and used wherever possible. Already, practitioners regularly employ varying methods of IV, mucosal, oral and RA sedation – often in combination and whichever seems most appropriate for the individual. In order to utilise this, dental practices will have to equip and familiarise themselves with the relevant equipment. Indeed, there is a school of thought that states: “Sedation should be offered as a matter of course to avoid creating a generation of dental phobics.”
Some members of the profession have stated that they find inhalation sedation “too much of a bother” or “too expensive”. Surely this is over simplification? The technique should not be dismissed purely on these grounds – indeed, it smacks of ‘throwing the baby out with the bathwater’ to ignore this well-proven, safe and valuable asset.
Of all the techniques of conscious sedation, undoubtedly, inhalation sedation, or as more commonly called, relative analgesia, is the one which has the greatest inbuilt flexibility and by far the widest application to all age groups.
The particular concept of relative analgesia dates from 1940 when Harry Langa and other enthusiasts began to use low concentrations of nitrous oxide allied to semi-hypnotic suggestions for their dental patients. They discovered that when fear, anxiety and apprehensions are eliminated and the patient is given a changed mental focus, a number of valuable effects follow. One of the most dramatic of these is a raising of the pain threshold, so that minor discomfort is no longer magnified and exaggerated by fear1.
Once it has been established that relative analgesia can be a great asset to the dental practice, then great care must be taken to ensure the equipment complies with all the latest specification and requirements. This does not necessarily have to be difficult or expensive. Great leaps forward in provision of titrated flowmeters and scavenging sundries have been made in recent years and a comprehensive range of equipment is available to suit all requirements.
If cost remains an issue, re-conditioned equipment should be considered. We are fortunate in the UK as the Quantiflex range used to be manufactured here in the 1960s and 70s, including the MDM, Mark I and Mark II sedation flowmeters. These have proved long lasting – some units currently in daily use are over 40 years old.
A recent article for Dental Nursing, written by a trained sedation nurse, mentions one such unit in almost daily use and comments: “Regularly serviced it still looks as good as new. There are not many pieces of dental equipment that will still be working every day after this length of time.” This clearly illustrates the benefits of taking re-conditioned equipment into consideration when evaluating the costings for setting up of this facility, the only drawback being availability, which is limited at times. There are many indications that the use of inhalation sedation within dental practices – both high street and community are enjoying a period of growth. Indeed, this equipment, which has always traditionally been perceived as solely for dental use, is starting to move outside this, into other areas – being employed in hospital emergency departments – more specifically for paediatric use.
The BDJ has recently published a number of articles around the subject of inhalation sedation. September2 saw a research summary published on The Indicator of Sedation Need (IOSN) a new assessment tool written by a team of six dental professionals headed by Professor Paul Coulthard of Manchester Dental School.
This document, divided into an estimated four or five parts, was launched at the Dental Sedation Teacher Group Meeting (DSTG) in May 2011 and was well received by the large number of delegates. The 22 October issue3 contained an article written by David Craig of Kings College London. This was an explanation of the work of the new Independent Expert Group on Training Standards for Sedation in Dentistry (IEGTSSD) – comprising many former members of the IACSD.
Details of this group, and the work already carried out, were presented to delegates of this year’s Society for Advancement of Anaesthesia in Dentistry (SAAD) held in September. This long-established group saw record numbers attending in 2011 and is a further indication of the increased interest in the whole field of conscious sedation.
A further development is the introduction of training for hygienists in inhalation sedation techniques. The first course took place in 2010 and the second in November 2011.
There appears to be considerable interest although a slight issue appears to have arisen around the area of finding suitable places/mentors to practice. SAAD have declared that their selection process will exclude any candidate who cannot prove that their place of work will provide them with this facility.
This may have the result of discouraging some interested parties and seems a great shame. There does appear to be quite a strong element of interest and articles on the subject are already starting to appear, aimed specifically at dental hygienists and therapists.
Although financial considerations cannot be ignored, the use of relative analgesia as a valuable tool in general dental practice should not be dismissed lightly.
Expert advice should be sought on initial requirement and purchasing of equipment to avoid expensive ‘mistakes’ and the use of an efficient scavenging system is an absolute necessity on grounds of COSHH (Control of Substances Hazardous to Health) and health and safety.
However, once the hurdle of establishing a sedation facility is passed, then the equipment should, if maintained correctly, give many years of trouble free usage, adding an extra dimension to the practice facilities on offer and further cementing the dentist/patient bond.
1 Allen W. Relative Analgesia. Dental Practice Vol.14 no: 5 May 1976
2 BDJ Volume 211 No.5 September 10 2011
3 BDJ Volume 211 No.8 October 22 2011