Intravenous sedation for adults with profound acquired brain injury undergoing dental treatment - a seven-year service evaluation.
How do you provide effective dental care to patients who are unable to open their mouths? This is one question that practitioners of special care dentistry are faced with on a daily basis. Special care dentistry is a dental speciality dedicated to improving oral health for patients with physical, intellectual, medical, mental, sensory or social impairments/disabilities. In practice, this covers a huge range of patient populations.
This article focused on one such population – patients with an acquired brain injury (ABI). An acquired brain injury is an injury to the brain occurring after birth and can be categorised as traumatic (resulting from external trauma, commonly road traffic accidents or falls) or non-traumatic (resulting from internal damage, for example, after stroke, cancer, or anoxia). Some patients with profound ABI are cared for in specialist units such as the Royal Hospital of Neurodisability (RHN).
The RHN has an onsite, dedicated dental clinic and team which frequently provides dental care to medically complex patients. Many of these patients have cognitive impairments and cannot cope with opening their mouths and/or staying still for precise dental treatments. Some may have involuntary movements or paralysis of the muscles involved in opening/closing the mouth. Others still may be one of the high percentage of the population with dental anxiety. Supporting these patients to receive dental care when needed therefore often requires certain adjuncts.
One such crucial adjunct to dental care is intravenous conscious sedation (IVS) by (most commonly) midazolam. Although it has a wide and established safety profile when used by dentists in the general population, there is less literature about conscious sedation in medically complex patients, and less so again in patients with ABI. The dental team at RHN, with wider support, therefore set up to evaluate and disseminate the success/complication rate of IVS with midazolam over the past seven years. The goal was to ensure that a high success rate (and low complication rate) was being achieved and to share good practice, adding to evidence that, when used appropriately, IVS with midazolam is a safe and effective adjunct even in more medically complex patient groups.
303 patients over seven years were included in the service evaluation (and had dental care under IVS) with 279 (92.1%) being classified as American Society of Anesthesiologists (ASA) grade 3 – a general grading of anaesthetic complexity where many other projects with IVS in dentistry include only less complex grades 1 and 2. 91.4% (277/303) of these patients had the planned dental care (examination and/or treatments) completed successfully. The complication rate was 7.6% (24/303) but all complications were transient and minor – e.g. 13 of the total 25 complications were for desaturation which was rectified by simple supply of supplemental oxygen through a nasal cannula. No long-term complications occurred.
There are some important points to discuss about this good success rate and low complication rate. The IVS is being delivered at a specialist care facility (RHN) – while not a hospital, it does have a medical presence onsite including a clinical response team if urgent medical care is needed. The sedation is being delivered by consultants in special care dentistry with established experience in delivering conscious sedation as dentists.
Regardless of the above points, we believe this article is the first to demonstrate a good success rate and low complication rate of dentist-led IVS with Midazolam in ABI patients when used appropriately. The authorship team hopes that this will allow other practitioners to safely use IVS with Midazolam on medically complex patients elsewhere, and thereby contributing to removing barriers for people with impairment/disability to receive safe and effective dental care.
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BDJ Open
This is an international, peer-reviewed, open-access, online-only journal publishing dental and oral health research from all disciplines. The journal is owned by the British Dental Association (BDA) and is the sister journal of the British Dental Journal.
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