Download Policy Document - Queensway Dental Clinic

QUEENSWAY ORAL SURGERY SERVICE
COUNTY DURHAM & DARLINGTON
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
CONTENTS
Policy and protocol summary
3
Summary of clinical criteria for referral
3
Patient selection
4
Sedation assessment guidelines
5
How to refer & contact details
7
Tertiary (hospital) oral surgery referral services
8
Fail to attend policy
8
Non third molar extractions
9
Apical surgery
10
Routine extractions in warfarinsed patients
13
Bisphonates and ONJ
14
Antibiotic prophylaxis
16
18 week rules
18
Coronectomy – Information for patients and referring dentists
20
Pre-operative information for patients
21
Instructions following oral surgery procedures
22
OAF instructions for patients
23
Consent forms for oral surgery procedures
25
Pre-sedation assessment form
26
Conscious sedation techniques – patient information
27
Information for patients having intra-venous conscious sedation
29
Instructions for escorts of patients receiving intra-venous conscious sedation
30
2
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Policy and Protocol Summary
Queensway County Durham & Darlington Oral Surgery Service (QDDOSS)
QDDOSS is designed to complement the hospital oral surgery service, managing individuals who
do not need to be in hospital for their care, but where the skills of an oral surgery specialist team are
required. Access to QDDOSS is targeted, quick, efficient, cost effective and free to patients in a safe
primary care environment.
Summary of clinical criteria for referral to QDDOSS
Referrals accepted by QDDOSS:










Patients who have General Medical Practitioners (GMPs) in the County Durham & Darlington
area and who are 17 years or older
Patients who fit into an ASA categories I and II (patients ASA III may be suitable for LA or
Inhalational sedation (IHS/RA) – please contact QDDOSS to discuss individual cases if you are
unsure. (ASA IV are NOT accepted)
Extractions of special difficulty with associated pathology (such as ankylosis) for single and
multi-rooted erupted teeth. Routine extractions will not be undertaken by this service.
Removal of wisdom teeth as indicated by NICE (www.nice.org.uk March 2000, revised
26.4.04)
Removal of buried roots and fractured or residual root fragments
Removal of simple impacted/ectopic/supernumerary teeth (in conjunction with an orthodontic
treatment plan)
Exposure of teeth (removal of gum and or bone over the surface of the tooth preventing
eruption) in conjunction with an orthodontic treatment plan
Surgical endodontics on single rooted anterior teeth, which have a satisfactory orthograde root
filling. A radiograph must be included with the referral. (NB re- RCT may be more appropriate
and re-apicectomy is not usually indicated)
Removal or enucleation of simple dental cysts.
Benign minor soft tissue surgery including removal of simple fibro-epithelial polyps,
mucoceles and denture induced hyperplasia (with no sinister features)
Referrals NOT accepted by QDDOSS




Soft tissue lesions of unknown nature/suspected malignancy – including red/white patches.
Such cases need referral to acute trust +/- as 2WW referral
Routine exodontias including failed LA
Significant medical pathology i.e. ASA III and above
Routine extractions for patients on anticoagulant therapy
Please note: we offer treatment as clinically indicated under LA with or without IHS (RA) or IV (intravenous sedation).
We do NOT offer a GA service. Any patients requiring GA will need appropriate referral to local Oral and Maxillofacial
services.
FROM JANUARY 2016 WE NO LONGER ACCEPT PAPER COPIES OF RADIOGRAPHS . DIGITAL RADIOGRAPHS
ARE TO BE SENT VIA SECURE EMAIL TO [email protected], BY DISC OR
THE ORIGINAL RADIOGRAPGH (FILMS) ARE TO BE SENT WITH THE REFERAL AND WILL BE RETURNED AT
THE END OF TREATMENT.
3
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Patient Selection
The service is for:
 All patients who have a GMP in the County Durham & Darlington area and who are 17 years
or older referred by their primary care dental or medical practitioners.
 Patients who are healthy or have mild systemic disease with no functional limitation - for
example, ASA II and I.
 Warfarinised patients can usually be managed in general dental practice and would not
routinely be accepted by this service (Appendix 3), unless the treatment required meets the
above clinical criteria.
 Patients requiring oral surgery treatment under local analgesia alone or in conjunction with
conscious sedation. Treatment under general anaesthesia will not be provided by this
service.
All patients who fit these criteria should be referred to the Queensway County Durham &
Darlington Oral Surgery Service (QDDOSS) in the first instance.
Patients requiring more complex oral surgery treatment that do not meet the above described
clinical criteria, or those being referred for care due to a complex medical history, should be
referred to a secondary care setting.
Patients with suspicious white/red patches (suspected cancer referrals) should be referred directly
to the Acute Trust. This referral should be made via the two-week rule system.
Patients will be assessed following referral from their general dental or medical practitioner.
Patients, who meet the criteria for treatment in the primary care based intermediate oral surgery
service, will be offered an appointment. Patients who do not meet the criteria specified above may
be either referred on to secondary care or returned to the referring practitioner. Referral patterns
will be audited and this may lead to individual discussion with referring practitioners if
guidelines are not being followed.
Please help the service to improve the care for your patients by providing a full
assessment of the patient’s needs and including the following details:
 Relevant medical history e.g. prescription drugs, heart disease
 Relevant social history e.g. lives alone, does not have own transport, requires a translator
(please state the language)
 Full description of the patient’s clinical condition and reason for referral
 Please ensure that relevant radiographs accompany all requests to avoid unnecessary radiation
exposure to patients. These radiographs will be returned once treatment has been
completed.
4
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Sedation Assessment Guidelines
The American Society of Anaesthesiologists (ASA) - Classification of physical status, see below
ASA I
ASA II
ASA III
ASA IV
ASA V
Normal healthy patients
● No organic, physiological, biochemical or psychiatric disturbance
Patients with mild to moderate systemic disease
May be due to the condition or pathophysiological processes
● e.g. Well controlled asthma, NIDDM- dietary
controlled, mild hypertension
● Also: no systemic disease but: extremely nervous
(high levels of endogenous adrenaline and> risk of
sedation complications), >65years (more sensitive
to sedatives and physiology less responsive), obese
(< respiratory capacity)
Suitable for LA
with or without IV
sedation or
Inhalational
sedation
Patients with severe systemic disease which is limiting but not
incapacitating
● e.g. stable angina, well controlled epilepsy, chronic
bronchitis, congestive heart failure, IDDM, healed
MI.
Patients with severe systemic disorders that are a constant
threat to life
● e.g. recent MI, uncontrolled diabetes, uncontrolled
epilepsy, severe emphysema – requiring O2 therapy,
cardiac insufficiency etc.
Moribund patients not expected to live more than 24hrs.
● Only emergency treatment would ever be provided,
e.g. severe trauma.
Suitable for LA
with or without
Inhalational
sedation
Should be
managed in
secondary care
ASA guidelines in relation to BP – Malamed, 1995
BP mmHg
<140 systolic & <90 diastolic
140 to 160 systolic & 90 – 94 diastolic
160 to 179 systolic & 95-104 diastolic
180 – 199 systolic & 105 – 115 diastolic
>200 systolic & >115 diastolic
ASA classification
I
II
III a
III b
IV
Classification of Body Mass Index (BMI ) - as adopted by WHO 2000
Classification
Underweight
BMI
<18.5
Normal weight
Pre-obese (overweight)
Obese Class I
Obese Class II
Obese Class III
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
>40.0
Risk of non-communicable diseases
Low (but risk of other clinical problems may
be greater)
Average
Increased
Moderate
Severe
Very Severe
5
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Fitness for sedation, based on ASA (FDJ 2010):
ALL patients should be given an ASA grade at the time of assessment
ASA grades & BMI
Treatment modalities
Appropriate setting
I & II
BMI up to 35
Local anaesthetic (LA) alone LA
+ Inhalational sedation (also
known as IHS and RA)
LA + Intravenous (IV) sedation
QDDOSS: in surgery operatorsedationist care
III
BMI >35
Local anaesthetic (LA) alone LA
+ Inhalational sedation (also
known as IHS and RA)
May be suitable for
QDDOSS – in surgery operatorsedationist care. Check on
individual basis
III
BMI >35
LA + IV sedation
Anaesthetic led sedation, in most
cases will require Secondary Care
NB: Maximum weight limit for dental chairs is 150kg
Blood Pressure (BP) pre-assessment and day of treatment
●
●
●
Risks relate to high diastolic values then subsequent use of adrenaline containing LA
and possible further elevation.
Cut-off for listing patients for operator-sedationist IV sedation 180/100 (i.e. within the
ASA III a band taking into to consideration some degree of ‘white coat effect’).
BP values >180/100 should be sent to their GP for monitoring or treatment as appropriate and
follow-up appointment made 6-8 weeks later prior to listing. Patient asked to bring series of BP
values from practice for our records. NB due to TIOSS time parameters patients may need to be
re-referred.
Day of treatment
●
●
●
Pre-operative BP <180/100 – OK to proceed
Pre-operative BP <180/<105 and normal pre-operative values/ readings from GP (‘white coat’
hypertension in non-medicated or medicated anxious patients) – consider proceeding with
caution
Pre-operative BP >180/105 – delay treatment and refer to GP for appropriate
management
Body Mass Index (BMI) & IV sedation (BMI is not an issue with IHS)
●
●
●
●
Patients with BMI >35 are at severely increased risk of co-morbidities including
undiagnosed sleep apnoea, cardiovascular and peripheral vascular disease.
Cut-off at BMI 35 with caveat for clinical judgement for e.g. rugby players
NB maximum weight for dental chairs is 150kg
If in doubt any cases BMI >35 refer to secondary care.
Patients with a BMI > 40 not suitable for primary care.
Refer to appropriate secondary care facility OR offer treatment with LA or Inhalational sedation.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
6
How to refer
Please use the referral form for referral of QDDOSS cases, which can be found in on page 21 (also
available as a separate PDF on the providers website with the summary of clinical criteria for
QDDOSS).
There are three providers of this service in the region – Queensway (Darlington and Ferryhill),
Smiles (Bowburn) and Oasis (Darlington). All referrers must use the referral form, which can either
be faxed or posted. These forms can be downloaded from the provider’s websites.
Urgent referrals can be telephoned through, but will need to be followed through with a
referral form.
Please advise the patient you are making the referral to the service and the patient should
expect to be contacted for arrangement of an assessment appointment (NOT treatment on
the 1st visit). Medico-legally a reasonable ‘cooling off’ period after consent is signed is
essential to ensure valid consent for any proposed procedure – hence treatment at the initial
assessment appointment should be avoided.
“A reasonable cooling-off period gives the patient a chance to reflect on their decision and seek
advice. During this time, you may want to provide explanatory leaflets to support any
discussion and to ensure that the patient is as informed about their treatment as possible”. http://www.theddu.com/press-centre/press-releases/dental-professionals-should-givepatients-a-cooling-off-period#sthash.qoZNzWyh.dpuf
Contact details
Queensway
Address: Queensway Dental Clinic, 293 Yarm Road, Darlington, DL1 1BA
Tel: 01325 381928
Fax: 01325 381865
e-mail: [email protected]
If you require further information please contact Rebecca Hierons on 01325 381928. You
can also obtain information on the Queensway website: http://www.queensway.co.uk.
7
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Tertiary care (hospital) oral surgery services
Referrals in to the hospital acute trust should be made in cases where patients require more
complex treatment than the clinical categories listed in the referral guidelines or where complex
medical conditions require treatment in hospital (e.g. haemophilia, bleeding disorders etc.).
2-Week Rule Referrals:
In cases where red or white patches need urgent investigation immediate referral should be made
to the Acute Trust using the 2–week rule protocols. These patients should not be given the choice of
referral into primary care, as it is inappropriate to see them there and may delay subsequent
oncology treatment.
Urgent referrals and out-of-hours care:
There is a 24-hour on-call service at James Cook University Hospital for urgent referrals such as
facial fractures, uncontrolled oral bleeding, and orofacial infections producing swelling, trismus or
airway problems.
To make enquiries to this service please telephone James Cook University Hospital on 01642
850850 and ask for a member of the on call Oral & Maxillofacial team. Do NOT give the patient a
letter or ask them attend the department or Accident & Emergency without having spoken to the
department. (Darlington Memorial Hospital has an A&E but no Oral and Maxillofacial Service on call
facility).
Fail to attend policy
If your patient fails to attend their assessment appointment they will be contacted by letter or
telephone and offered a second assessment appointment. If they fail to attend a second appointment
and do not get in touch a third assessment appointment will not be offered.
If your patient fails to attend a confirmed treatment appointment and they do not get in touch, a
second treatment appointment will not be offered by this service.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
8
Non-third molar exodontia
The service does not provide a service for "routine" extractions in healthy patients. If a
surgical approach is obviously necessary (e.g. retained roots, ankylosis, etc.) then a referral
should be made.
Indications for referral include:
Associated pathology that needs to be submitted for histological examination (e.g. cysts).
It is rare that a patient's medical history complicates the extraction to such an extent that it needs
to take place within a specialist setting. If the reason for referral is a medical reason, the referral
needs to be made to a hospital setting.
We are unable to accept any referrals without good quality, relevant clinical radiographs showing
the full extent of the tooth/teeth along with the surrounding structures. Please ensure that
relevant radiographs accompany all requests or your referral form will be returned. These
radiographs will be returned once treatment has been completed.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
9
Apical surgery
All teeth should be re-root treated with an adequate root filling well condensed and extending
the full length of the canal prior to referral. Repeat root filling has a higher success rate than
apicectomy and hence should be carried out. The success rate for re- apicectomy is very low and
will not be carried out by the primary care service. The service will not accept referrals for
apicectomies on multi-rooted teeth.
All referrals need to be sent with an up-to-date radiograph to allow triage.
Practitioners should undertake a full clinical assessment of their patient and provide the service
with written details giving the clinical justification for the requirement to have an apicectomy.
See Appendix 1 for more detail.
More comprehensive guidelines for referral for apicectomy are available at:
www.rcseng.ac.uk/dental/fds/clinical_guidelines.
Although there are exceptions referrals should generally meet the following criteria to
be accepted to undergo peri-apical surgery:




Completed primary root canal treatment, whether crowned or not.
Completed root canal RE-TREATMENT, particularly if the primary treatment
appears radiographically sub-optimal (e.g. lack of adequate condensation or short
of apex).
Post removal should be performed to enable root canal re-treatment where risk to root
structure is minimal.
A satisfactory coronal restoration (preferably a permanent restoration) should be
present to ensure good coronal seal of the root canal system.
It is generally agreed that endodontic failures are best approached non- surgically by
undertaking root canal re-treatment rather than peri-apical surgery 1,2,3.
The success rates for apical surgery on molar teeth is low and will not routinely be
undertaken.
Repeat apicectomy has a low success rate and therefore will not routinely be undertaken 2,8.
If a non-surgical approach (re-root treatment) is felt to be appropriate but it is not possible
to meet these criteria in primary care, consideration should be given to referring the
patient to an endodontic specialist.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
10
Indications for peri-apical surgery – based on RCS guidelines: 4
These guidelines apply to cases when it is agreed that orthograde retreatment is either
impossible or will not solve the problem.
1. Failure of initial and repeat conventional orthograde RCT – which appears
radiographically satisfactory.
2. Gutta percha significantly through apex and associated with peri-apical pathology.
3. The presence of peri-radicular disease in a root filled tooth, where non-surgical root
canal re- treatment cannot be undertaken or has failed, or where conventional retreatment may be detrimental to the retention of the tooth.
4. Physical barriers/anatomy – irremovable posts, fractured instruments, sclerosed canals
(clinically and radiographically).
5. The presence of peri-radicular disease in a tooth where iatrogenic or developmental
anomalies prevent non-surgical root canal treatment being undertaken.
6. The need for biopsy of the peri-radicular tissues – significant peri-apical pathology
not resolving following satisfactory orthograde RCT (e.g. radiolucency greater than 1cm
diameter).
7. The need to visualise the peri-radicular tissues and tooth root when perforation, root
crack or fracture is suspected.
8. Fracture and infection of apical third (post traumatic).
Contraindications to surgical endodontics 4
There are few absolute contraindications to endodontic surgery, these
contraindications include:
1. Patient factors including presence of severe systemic disease and psychological
considerations
2. Anatomical factors including:
 Unusual bony or root configurations
 Lack of surgical access
 Possible involvement of the neurovascular bundle
 An unrestorable tooth
 Poor supporting tissue
3. The skill, training and experience of the operator may also have an influence on decision
making
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
11
Surgical Outcomes
First apicectomy
Success rates for apicectomies range from 30% (poorly root treated and
inadequately restored) to 80% (well root treated and restored teeth) 5,6
One newer study using microscopy and MTA suggests a success rate up to 92% 7
Table to show comparison between first and repeat apicectomies: 2,8
Initial surgery:
Second surgery;
Success
Uncertain
64.2%
25.7%
Failure
15.75%
Success
Uncertain
35.7%
26.3%
Failure
38%
References
1. Carrotte P. Surgical endodontics. Br Dent Journal 2005; 198(2): pp 71-79
2. Dummer M. H. Surgical endodontic retreatment success and failure are almost
equivalent. Evidence-Based Dentistry 2003; 4: pp51
3. Guidelines for Apical Surgery, BAOMS website
4. Guidelines for Surgical Endodontics, R.C.S. Eng 2001
5. Jansson L, Sandstedt P, Laftman AC, Skogland. Relationship between apical and marginal
healing in periradicular surgery. Oral Surg, Oral Med, Oral Path, Oral Rad, Endod 197; 83:
596-601
6. Rud J, Andreasen JO, Jensen JE. Radiographic criteria for the assessment of healing after
endodontic surgery. Int J Oral Surg 1972; 1: 195-214
7. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3 year follow- up study.
Int Endod J 2003; 36: 193-198
8. Peterson J, Gutmann JL. The outcome of endodontic resurgery: a systematic review. Int
Endod 2001; 34: pp169-175
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
12
Routine extraction in warfarinised patients
Please do not refer to the service for routine non-surgical extraction just because the patient is on
warfarin.
There has been recent guidance issued related to the removal of teeth in dental practice for patients
who are on warfarin (NPSA 2009). Patients should be managed according to these guidelines in
general practice and not referred to the specialist services for "routine" extractions. The guidelines
stipulate that extractions can safely be carried out in general practice in the following
circumstances:
 when the INR is less than 4.0.
 if the socket is packed and sutured.
Warfarin should not be stopped but the INR must be checked within 24 hours of the planned
extraction (patients can usually co-ordinate this themselves with either their doctor or anticoagulant
clinic).
Patients should be referred to the hospital service if the patient is known to have one or more of
the following:

liver impairment/high alcohol intake

renal failure

thrombocytopoenia


haemophilia
other disorders of haemostasis

is currently receiving chemotherapy

is taking more than one antiplatlet drug

if the INR is maintained at over 4 (this will be recorded in the patient's
anticoagulant book).
Extractions taking place in general practice should be timed appropriately and ideally should
occur at the beginning of the week (such that delayed re- bleeding problems can be managed
during the working week) and in the morning (such that immediate re- bleeding problems can be
managed during the working day).
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
13
Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ)
Clinician and patient information notes
What are Bisphosphonates?
Bisphosphonates are a group of drugs mainly used for the treatment of osteoporosis (taken orally)
but may also used in the treatment of cancer (given intravenously and in higher doses). These drugs
affect the metabolism (turn-over) of bone. Examples of bisphosphonates include: alendronic acid
(Fosamax), risidronate (Actonel), and zoledronic acid (Zometa).
What is Osteonecrosis of the Jaw (ONJ)?
ONJ is diagnoses clinically as the presence of exposed bone in maxillofacial region (upper or lower
jaws) for more than 8 weeks in the absence of radiotherapy to the jaw. It is a rare condition, poorly
understood, with increasing number of cases being seen and while there have been lots of
publications their quality is limited.
How likely is it to affect me?
The risk of developing ONJ if taking oral bisphosphonates is between 1:10,000 and 1:100,000. For
high dose intravenous Bisphosphonates (cancer treatment) the risk rises to 1:10 – 1:100.
Antibiotics and ONJ
The British and American Dental Associations (BDA and ADA) found no evidence for prophylactic
antibiotics after surgical procedures. They recommend the use of antibiotics should be based on
the risk of an infection rather than because the patient is taking a bisphosphonate. Use of
Chlorhexidine mouth wash preoperatively and until the surgical site is fully healed may be
helpful.
Should bisphosphonates be stopped before invasive dental surgery?
The BDA suggests assessing the clinical situation and discussion with the patient’s physician
or oncologist before stopping bisphosphonate therapy. Canadian guidelines recommend
interrupting bisphosphonate for 3-6 months for non-emergency invasive dental treatment,
however, the half-life of bisphosphonates in the skeleton is high and evidence for this
approach is only anecdotal.
Source of information:
Guidelines for bisphosphonate-associated Osteonecrosis of the Jaw – Derek Richards.
Centre for Evidence-based Dentistry, Oxford UK. Evidence-Based Dentistry (2008)
9, 101-102. doi:10.1038/sj.ebd.6400608
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
14
BDA recommendations for patients taking bisphosphonates
Dental procedure
Dental regime
Dental
examination
pre
bisphosphonate
therapy
Extractions
Periodontal
disease
Dentures
Endodontics
Implants
People with osteoporosis or other
non malignant disease who have
taken bisphosphonates for > 3years
Regular dental visits, maintain good
oral hygiene, stop smoking, limit
alcohol
NO. ONJ risk is low, standard dental
care
If not previously a regular attender
– patient should attend for a
dental
examination
with
management as needed
Patients with malignancy, starting
or receiving bisphosphonates
As before
YES.
Before
starting
IV
bisphosphonates
for
bone
metastases.
Invasive
dental
procedures, if needed should be
completed and healed completely
before starting therapy if the
patient’s condition allows. Liaise
with physician/oncologist. If not
possible, need careful follow-up of
surgical sites.
Not contra-indicated as ONJ risk is
Avoid extractions if possible as
increased risk of ONJ. Root treatment
low.
Root
canal
treatment
preferable.
preferable. Atraumatic extractions
For periodontally affected teeth,
and careful follow-up of exposed
only extract if excessive mobility and
bone are recommended.
aspiration risk.
Periodontal surgery is appropriate if it Periodontal surgery is not
reduces or eliminates bone disease. recommended. Non surgical
Can
carry
out
modest
bone periodontal treatment only.
recontouring
Well fitting required
Well fitting +/- soft lining
Avoid apical surgery. Conventional
Avoid apical surgery. Conventional
orthograde root filling rather than
orthograde root filling rather than
extraction if possible. Good coronal
extraction if possible. Good coronal
seal maintenance important.
seal maintenance important.
Currently not contraindicated if taking
Not recommended and avoid
elective surgery such as tori removal
bisphosphonates but prudent to gain
informed consent which should be
documented (risk assessment).
Canadian recommendations for management of patients with ONJ
Patient Groups using
bisphosphonates
All patients
Oncology patients
Osteoporosis patients taking
oral/intravenous
bisphosphonates
Individuals with established
ONJ
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Recommended action by dentist
Stop smoking, limit alcohol intake, maintain good oral hygiene
A thorough dental exam including radiographs should be completed
before commencing IV bisphosphonates. Any invasive dental
procedure ideally to be completed prior to commencing high dose
therapy
Non-urgent procedures preferably to be delayed for 3-6 months
following interruption of bisphosphonate therapy
Dental examination not required prior to initiating therapy if there is
appropriate dental care and good oral hygiene
Best managed with supportive care including pain control, treatment
of secondary infection, removal of necrotic debris, and mobile
sequestrate. Aggressive debridement is contraindicated
15
Antibiotic prophylaxis
The National Institute for Health and Clinical Excellence (NICE) issued a clinical guideline on antibiotic
prophylaxis against infective endocarditis (IE) in March 2008. In a significant change to current clinical
practice, the guideline recommends that antibiotics to prevent IE should not be given to adults and
children with structural cardiac defects at risk of IE who are undergoing dental and non-dental
interventional procedures.
IE is an inflammation of the inner lining of the heart, particularly affecting the heart valves, caused by
bacterial or other infection. It may arise following bacteraemia in patients who have certain preexisting heart conditions (see list below). Although IE is a rare condition, with fewer than 10 people in
every 100,000 developing it each year, it can be life-threatening. It has been accepted clinical practice
to use preventive (prophylactic) antibiotics before dental and some non-dental procedures in people
who are considered to be at risk of IE. However, the effectiveness of this treatment in humans has
never been properly investigated and clinical practice has been dictated by clinical guidelines based
on expert opinion.
This guideline is based on the best available published evidence and a consensus of multidisciplinary,
expert opinion within the Guideline Development Group (GDG).
The guideline concludes that there is no consistent association between having an interventional
procedure, dental or non-dental, and the development of IE and that the clinical effectiveness of
antibiotic prophylaxis is not proven. The evidence also suggests that antibiotic prophylaxis against IE
for dental procedures is not cost effective and may lead to a greater number of deaths through fatal
anaphylactic reactions than not using preventive antibiotics. The guideline makes a number of key
recommendations, including:
Patients should not be offered antibiotics to prevent IE for any of the following procedures:

dental procedures


obstetric or gynaecological procedures, childbirth or procedures on the bladder or urinary
system
procedures on the gullet, stomach or intestines

procedures on the airways, including ear, nose and throat and bronchoscopy
Healthcare professionals should regard people with the following cardiac conditions as being at risk
of developing IE:

acquired valvular heart disease with stenosis or regurgitation

valve replacement

structural congenital heart disease, including surgically corrected or palliated
structural conditions, but excluding isolated atrial septal defect, fully repaired
ventricular septal defect or fully repaired patent ductus arteriosus, and closure
devices that are judged to be endothelialised
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
16

previous IE

hypertrophic cardiomyopathy.
Healthcare professionals should offer people at risk of IE clear and consistent information about
prevention, including:

the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic
prophylaxis is no longer routinely recommended

the importance of maintaining good oral health

symptoms that may indicate IE and when to seek expert advice

the risks of undergoing invasive procedures, including non-medical procedures such as body
piercing or tattooing.
People at risk of IE who are receiving antimicrobial therapy because they are undergoing a
gastrointestinal or genitourinary procedure at a site where there is a suspected infection should be
offered an antibiotic that covers organisms that cause IE.
Investigate and treat promptly any episodes of infection in people at risk of IE to reduce the risk of
endocarditis developing.
The full guidance is available at www.nice.org.uk/CG064
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
17
The 18-week rule
Clock Starts
An 18-week clock starts when any care professional or service permitted by an English NHS
commissioner to make such referrals, refers to:
a) a consultant led service, regardless of setting, with the intention that the patient will be
assessed and, if appropriate, treated before responsibility is transferred back to the referring
health professional or general practitioner;
b) an interface or referral management or assessment service, which may result in an onward
referral to a consultant led service before responsibility is transferred back to the referring
health professional or general practitioner;
An 18-week clock also starts upon a self-referral by a patient to the above services, where these
pathways have been agreed locally by commissioners and providers and once the referral is ratified
by a care professional.
Upon completion of an 18-week referral to treatment period, a new 18-week clock only starts:
a) when a patient becomes fit and ready for the second of a consultant-led bilateral procedure;
b) upon the decision to start a substantively new or different treatment that does not already
form part of that patient’s agreed care plan;
c) upon a patient being re-referred in to a consultant-led; interface; or referral management or
assessment service as a new referral;
d) when a decision to treat is made following a period of active monitoring;
e) when a patient rebooks their appointment following a first appointment DNA that stopped
and nullified their earlier clock
Clock Pauses
A clock may be paused only where a decision to admit has been made, and the patient has declined
at least two reasonable appointment offers for admission. The clock is paused for the duration of the
time between the earliest reasonable offer and the date from which the patient makes themselves
available again for admission.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
18
Clock Stops for Treatment
A clock stops when:
a) first definitive treatment starts. This could be:
i. treatment provided by an interface service;
ii. treatment provided by a consultant-led service;
iii. therapy or healthcare science intervention provided in secondary care or at an interface
service, if this is what the consultant-led or interface service decides is the best way to
manage the patient’s disease, condition or injury and avoid further interventions
b) A clinical decision is made and has been communicated to the patient, and subsequently
their GP and/or other referring practitioner without undue delay, to add a patient to a
transplant list.
Clock Stops for Non-Treatment
An 18-week clock stops when it is communicated to the patient, and subsequently their GP and/or
other referring practitioner without undue delay that:
a) It is clinically appropriate to return the patient to primary care for any non consultant-led
treatment in primary care
b) A clinical decision is made to start a period of active monitoring;
c) A patient declines treatment having been offered it
d) A clinical decision is made not to treat
e) A patient does not attend (DNA) their first appointment following the initial referral that
started their 18 week clock, provided that the provider can demonstrate that the appointment
was clearly communicated to the patient. 1
f) A patient DNA any other appointment and is subsequently discharged back to the care of
their GP, provided that:
i) the provider can demonstrate that the appointment was clearly communicated to the
patient
ii) discharging the patient is not contrary to their best clinical interests;
iii) discharging the patient is carried out according to local, publicly available, policies on
DNA.
iv) these local policies are clearly defined and specifically protect the clinical interests of
vulnerable patients (e.g. children) and are agreed with clinicians, commissioners, patients
and other relevant stakeholders.
1 DNAs for a first appointment following the initial referral that started an 18-week clock nullify the patient’s
clock (i.e. it is removed from the numerator and denominator for Referral to Treatment time measurement
purposes).
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
19
Coronectomy – Information for patients and referring dentists
Coronectomy is an alternative to extraction for a symptomatic impacted wisdom tooth when a tooth is
deemed to be “high risk” of nerve injury (considerably more than the usually quoted 1% risk of
numbness to lip or tongue) when a tooth is vital and the patient is medically well.
The following is quoted from a paper by Professor Tara Renton (British Dental Journal 212, 323 - 326
(2012) Published online: 13 April 2012 | doi:10.1038/sj.bdj.2012.265):
‘A recent review of coronectomy procedures1 has brought to light the significant variance in thresholds
for not only prescribing coronectomy, but the technique of delivering the procedure. Third molar surgery
related to inferior alveolar nerve injury is reported to occur in up to 3.6% cases permanently and 8%
cases temporarily.2, 3 Factors associated with inferior alveolar nerve injury (IANI) are age, difficulty of
surgery and proximity to the IAN canal. If the tooth is closely associated with the IAN canal
radiographically, 20% of patients having these teeth removed are at risk of developing temporary IAN
nerve injury and 1-4% are at risk of permanent injury.2, 3, 4, 5, 6
Radiographic signs indicative of possible IAN risk include:
•
•
•
•
•
Diversion of the canal
Darkening of the root
Narrowing of the root/canal
Interruption of the canal lamina dura
Interruption of the juxta-apical area.
If these plain film radiographic risk factors are identified, removal of the third molar will result in
elevated risk of IANI (2% permanent and 20% temporary).3, 4, 5, 6 If the tooth is 'high risk', carious and/or
the patient is medically compromised, the tooth must be extracted and the patient must be informed
about the elevated risk of nerve injury’.
The procedure involves a surgically removing the crown of the wisdom tooth and retaining the roots,
but if during the course of the planned coronectomy the roots become loose the procedure will need to
be converted to a standard extraction with the associated increased nerve injury risk.
Warnings: 5% risk of dry socket (requiring rinsing and placement of an antiseptic dressing) and 2-5%
need for a further procedure to remove the retained roots in the future (2-5 years after the original
surgery).
References
1. Frafjord R, Renton T. A review of coronectomy. Oral Surg 2010; 3: 1–7.
2. Howe G L, Poyton H G. Prevention of damage to the inferior dental nerve during the extraction of
mandibular third molars. Br Dent J 1960; 109: 355–363.
3. Rood J P, Shehab B A. The radiological prediction of inferior alveolar nerve injury during third molar
surgery. Br J Oral Maxillofac Surg 1990; 28: 20–25. | Article | PubMed |
4. Rud J. Third molar surgery perforation of the inferior dental nerve through the root. Tandlaegebladet
1983; 87: 659–667 | PubMed |
5. Rud J. Third molar surgery: relationship of root to mandibular canal and injuries to inferior dental
nerve. Tandlaegebladet 1983; 87: 619–631. | PubMed |
6. Renton T, Hankins M, Sproate C, McGurk M. A randomised controlled clinical trial to compare the
incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of
mandibular third molars. Br J Oral Maxillofac Surg 2005; 43: 7–12. | Article | PubMed | ISI | CAS
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
20
Pre-operative Information for Patients
Removal of Teeth & Roots
Some teeth and roots require removal to ensure that they do not cause future problems. The common
problems are pain, swelling and infection. Your surgeon will have discussed the reasons for removal with
you. Possible complications after treatment may include soreness, swelling, bruising and jaw stiffness.
These can all be variable and can last from a couple of days to a couple of weeks. There is also a small risk
of bleeding and post-operative infection, especially if you smoke. We recommend you abstain from
smoking for at least 24hrs after tooth removal, but ideally for 3 days. If there is a large filling or crown in
an adjacent tooth it is possible that this may be dislodged during surgery.
Removal of Upper Molars (6’s, 7’s and upper wisdom teeth (8’s))
Occasionally the roots of these teeth are close to the big air sinus in your upper jaw (the antrum). This
means that on removal there may be a small risk of a hole between your mouth and sinus (an oro-antral
fistula or OAF). Your surgeon will discuss the degree of risk of this happening to you at your consultation
appointment. If this happens your surgeon will close it up if appropriate. They would let you know, give you
some antibiotics and decongestants and ask you not to blow your nose for 2 – 3 weeks to allow the hole to
heal up.
Removal of Lower Premolars (4’s & 5’s)
These teeth are close to the mental nerve, which comes out of the lower jaw bone near the root tips and
supplies feeling to your lower lip and chin. This means that there is a small risk of numbness, tingling or
painful tingling of your lower lip and chin region after the procedure. This is normally temporary but can
very rarely be permanent, although it rarely happens.
Removal of Wisdom Teeth
There is great variation in the difficulty of removing wisdom teeth. Some are easy, while others can be
more complicated. At Queensway teeth can be removed under local anaesthesia (injection in the gum to
numb the area), with or without sedation (laughing gas or an injection in the arm or hand to reduce
anxiety) and your surgeon will discuss with you which method is most appropriate. The degree of difficulty
of the surgery, any underlying medical conditions and other personal circumstances will be taken into
account when choosing the best method for you.
As well as the common post-operative complications mentioned above, wisdom teeth are situated close to
two nerves, which give sensation to the lower lip and chin and to the tongue. This means that there is a risk
of bruising or stretching of these nerves during removal of the teeth which may lead to numbness, tingling
or painful tingling of your lower lip and chin region and/or tongue after the procedure. The degree of risk is
related to the proximity of the wisdom tooth to these nerves, which your surgeon will discuss with you
during your consultation. Most people are at low risk but sometimes the tooth can be very close to the
nerves or may be especially difficult to remove – in which case, the risk is greater.
If you have any questions about any aspect of your treatment please ask your surgeon who will
be very happy to answer all your queries.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
21
Instructions Following Oral Surgery Procedures
Cleaning your mouth
It is important to keep your mouth clean. On the first night do not rinse your mouth out but you should carefully
brush the area. In the morning you may use a mouthwash or salt water. After one week you should carefully
brush the sutures to accelerate their breakdown.
Food & activity
Stick with soft food until you can chew comfortably. Remember you have had a minor operation so take things
easy. We advise time off work where necessary. (Sedation 24hrs)
Mouth opening
Mouth opening is usually restricted to about a fingers width between your front teeth for about a week after
wisdom teeth extractions, it then slowly returns to normal.
Stitches
Your stitches are made of absorbable material and will disappear on their own. This can take many weeks(after 7
days gently brush with your toothbrush to break them down quicker) so if you are unsure or concerned
telephone us for advice.
Pain
Dental operations can be painful. Afterwards we recommended that you use normal pain killers from the
chemist for example Ibuprofen 400mg 3x per day (if you are able to take) with doses of paracetamol 1g 2- 3
hours later no more than 8 tablets (4g) per day i.e. alternate between the two pain killers (don’t take at same
time). If you are not improving please contact us for a review appointment.
Bruising
This may appear on your face and neck. Do not worry it is quite normal and soon goes away.
Swelling
Your face may swell up for two days after certain operations. It will then take about five days to return to normal.
If you are not improving please contact us for advice.
Bleeding
You may bleed from your mouth even though you have been stitched. Do not be alarmed. If the ooze becomes
uncomfortable place a cotton handkerchief DIRECTLY over the operation site and bite firmly down for at least 20
minutes whilst remaining quietly seated. Do not rinse your mouth.
Numbness
After some operations your tongue or lip may be numb. This is only temporary but in some cases may last for an
indefinite period. If you are numb, please avoid hot drinks and be careful eating, if numbness persists please
contact us.
Smoking: Please avoid smoking for at least 24 hours post – op but the longer the better!!
If you have any concerns or problems please don’t hesitate to contact us on 01325 381928 – we will be pleased
to help.
Outside normal practice hours, telephone the practice on 01325 381928 and you will be given the dental oncall for further advice.
If you have severe swelling please attend A&E at James Cook University Hospital and ask for the on-call doctor
or Oral and Maxillofacial Surgery.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
22
OAF instructions
What is an OAF?
OAF stands for an oro-antral fistula (opening) occurring in the upper back teeth region (maxillary). It
is a small hole from the upper gum area into the cheek sinus which does not heal after a tooth has
been extracted.
What are the complications of an OAF?
● Air can pass through the opening into the soft tissues of the cheek causing a swelling (usually
seen if patients stifle a sneeze or try to blow their nose).
● With large defects food can sometimes lodge in the sinus and liquid can come down the nose.
● If untreated in some cases the sinus itself can become infected, antibiotics may be prescribed
as appropriate.
How is an OAF treated?
It can be closed by a minor oral surgery procedure either under local anaesthetic alone or in
combination with sedation. The site is sutured (stitched closed) and the following advice is given:
Post-operative advice:
● Avoid rinsing on the day of surgery to allow the wound to settle. The following day rinse
regularly with warm salty rinses up to 4 times a day (one teaspoon of salt in a tumbler of
cooling previously boiled water – take care not to burn yourself) for 5-7 days.
● Brush and clean the area carefully starting on evening of your treatment including around the
stitches.
● It is important not to get air into the sinus (this can cause infection). It is very important not
to blow your nose after surgery for at least 2 weeks (or longer if advised).
● A sneeze must not be stifled but allowed to happen naturally.
● You may be given a prescription for antibiotics (with or without a decongestant).
 You may also use menthol inhalations if you feel congested.
You will be offered a review appointment in 2-3 weeks.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
23
Consent Form for Oral Surgical Procedures – records copy
Patient ID Number:
Name:
Date of Birth:
Address:
Telephone:
PATIENT / PARENT / GUARDIAN
 Please read this form and the accompanying instructions and information sheets carefully.
 If there is anything that you don’t understand about the explanation, or if you want more information, you
should ask the dentist who is assessing you.
 Please check that all the information on this form is correct.
I am the patient / parent / guardian (delete as appropriate)






I agree to the dental treatment proposed, which has been explained to me by the dentist named on this form.
I have been given a clear and full explanation of the conscious sedation techniques available to me and the
advantages and disadvantages of each one.
I agree to proceed and confirm that I have received written instructions and information.
I understand that the treatment for which I give my consent may alter once the procedure has begun. Any
alterations will only be carried out if necessary, if they are in my best interests and if they are clinically justified.
I understand that the procedure may not be carried out by the dentist who has been treating me so far.
I have told the dentist about any additional procedures that I would NOT wish to be carried out straightaway
without having the opportunity to consider them first.
Signature: …………………………………………………………………..
Date: ……./……./…….
Name and relationship to patient (if the person signing is not the patient):
…………………………………………………………………………………………………………………
_____________________________________________________________________________________________
PROPOSED TREATMENT OR INVESTIGATION
USING LOCAL ANAESTHETIC (NUMBING) +/- INHALATIONAL /INTRAVENOUS SEDATION (delete as necessary)
STANDARD WARNINGS:

pain, swelling, stitches, bruising, bleeding, infection, stiff/achy jaw, compromise/damage to adjacent teeth/soft
tissues, possible absence from work
WARNINGS SPECIFIC TO PROCEDURE: (DETAIL BELOW)
I confirm that I have explained the proposed treatment or investigation and the conscious sedation technique to
the patient or parent/guardian of the patient in terms, which in my judgement, have been understood. I confirm
that I have discussed all appropriate treatment and conscious sedation options and have given the patient or
parent/guardian of the patient the necessary information to make an informed choice regarding their treatment.
Signature: …………………………………………………………………..
Date: ……./……./…….
Dentist:
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
24
Consent Form for Oral Surgical Procedures – patient copy
Patient ID Number:
Name:
Date of Birth:
Address:
Telephone:
PATIENT / PARENT / GUARDIAN
 Please read this form and the accompanying instructions and information sheets carefully.
 If there is anything that you don’t understand about the explanation, or if you want more information, you
should ask the dentist who is assessing you.
 Please check that all the information on this form is correct.
I am the patient / parent / guardian (delete as appropriate)






I agree to the dental treatment proposed, which has been explained to me by the dentist named on this form.
I have been given a clear and full explanation of the conscious sedation techniques available to me and the
advantages and disadvantages of each one.
I agree to proceed and confirm that I have received written instructions and information.
I understand that the treatment for which I give my consent may alter once the procedure has begun. Any
alterations will only be carried out if necessary, if they are in my best interests and if they are clinically justified.
I understand that the procedure may not be carried out by the dentist who has been treating me so far.
I have told the dentist about any additional procedures that I would NOT wish to be carried out straightaway
without having the opportunity to consider them first.
Signature: …………………………………………………………………..
Date: ……./……./…….
Name and relationship to patient (if the person signing is not the patient):
…………………………………………………………………………………………………………………
_____________________________________________________________________________________________
PROPOSED TREATMENT OR INVESTIGATION
USING LOCAL ANAESTHETIC (NUMBING) +/- INHALATIONAL /INTRAVENOUS SEDATION (delete as necessary)
STANDARD WARNINGS:

pain, swelling, stitches, bruising, bleeding, infection, stiff/achy jaw, compromise/damage to adjacent teeth/soft
tissues, possible absence from work
WARNINGS SPECIFIC TO PROCEDURE: (DETAIL BELOW)
I confirm that I have explained the proposed treatment or investigation and the conscious sedation technique to
the patient or parent/guardian of the patient in terms, which in my judgement, have been understood. I confirm
that I have discussed all appropriate treatment and conscious sedation options and have given the patient or
parent/guardian of the patient the necessary information to make an informed choice regarding their treatment.
Signature: …………………………………………………………………..
Date: ……./……./…….
Dentist:
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
25
Pre-Sedation Assessment Form
Patient ID Number:
Name:
Date of Birth:
Address:
Telephone:
Relevant Medical History and Necessary Actions:
Allergies:
Height:
Weight:
ASA Classification:
Pre-operative BP:
BMI:
Previous Dental History/Reason for Referral:
Previous Conscious Sedation/GA Experience:
Discussion of anxiety management techniques available with patient/parent and a thorough and clear explanation of
□
the associated risks and provision of patient information.
Justification for use of sedation (please circle): anxiety
procedure
other (detail):
Choice of conscious sedation technique (please circle):
Behavioural
Oral
RA
IV
Pre-operative Advice Verbally Reinforced:
Justification for sedation (please circle):
· Escort
·
·
·
·
·
·
·
·
·
Anxiety Procedure
□
Transport – Car/Taxi
□
Child care
□
Starving – Instructions given
□
EMLA option – Instructions given
□
DNA/late cancellation policy/fee
□
Written treatment plan and estimate
□
Payment policy (if appropriate)
□
Consent
□
All relevant documentation given to patient/parent □
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
Other (detail):
For Simple and Surgical Extractions:
Post-operative pain
Swelling and bruising
Stitches (if appropriate)
Risk of nerve damage (if appropriate)
Limited jaw opening
Possible time off work
26
□
□
□
□
□
□
Conscious Sedation Techniques – patient information
After carrying out a detailed examination and assessment your dentist has recommended that you or your child, are
treated using intravenous conscious sedation. We would like to give you some information about all of the
conscious sedation techniques available so that you are confident about giving us your permission (informed
consent) to treat yourself or your child.
1.
Treatment without local anaesthetic (numbing):
Useful for check-ups, photographs, x-rays, scale and polish or preventative varnish application to teeth (procedures
where there is no pain associated)
2.
Topical anaesthetic and numbing:
Topical anaesthetic gel is used on the gum, which causes some numbing of the gum so that only a very small scratch
is felt when we fully anaesthetise the local area. This is used for the majority of procedures on patients who are not
anxious. No pain is felt, however patients are fully awake and aware of what is happening.
Standard Conscious Sedation Techniques:
3.
Inhalation “Happy Air” Conscious Sedation:
Nitrous oxide is mixed with oxygen to create a pleasant sedative air, which can be breathed in through the nose via
a small soft nose hood. This is a similar technique to “gas and air” used for women during labour. This is an
extremely safe technique that reduces the sensations of pain and anxiety, and creates a semi-hypnotic state for
patients which makes them feel happy and comfortable. Patients will usually be aware of everything that is going
on around them during the procedure but are more relaxed. Although patients are sedated during the procedure
the recovery is fast with most patients feeling totally awake and in control within fifteen minutes after stopping the
inhalation procedure. Therefore adult patients may not need an escort to accompany them.
This technique is suitable for most adults and children with mild anxiety where only a small number of teeth need
filling or extracting, or where the teeth to be treated are in the same area of the mouth. It may also be more suited
to patients with needle phobias or patients with more complex general medical problems who may not be
appropriate for intravenous conscious sedation.
It is best not to eat for 2 hours before having inhalation sedation.
4.
Intravenous Conscious Sedation:
This is the most commonly used technique for patients aged over sixteen years, who are generally fit and well. It is
usually delivered via a small plastic tube in the back of the hand or arm. A sedative medication called midazolam is
given through this tube and the amount required is subject to each patient’s response. For patients who are
anxious about needles we sometimes advise using inhalation conscious sedation to relax them and provide some
pain relief prior to the injection and can also use EMLA cream to numb the back of the hand in advance, or ethyl
chloride (cold numbing spray).
Commonly patients receiving intravenous conscious sedation are more deeply sedated compared with inhalation
conscious sedation. Most patients usually have significant memory loss of the procedure following intravenous
conscious sedation, but some patients may remember small details of the procedure and a very small minority of
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
27
patients may have good memory of the events during the procedure. Unfortunately, we are unable to guarantee
the level of amnesia as all patients respond differently to the medication.
This technique is ideal for highly anxious patients, prolonged or more invasive procedures and procedures involving
the treatment of multiple teeth at multiple sites. Patients require a suitable escort and should not be left alone for
24 hours after treatment and need to be starved for at least two hours prior to their appointment (unless informed
otherwise by their dentist or anaesthetist).
Referral for a General Anaesthetic in a Hospital Setting:
The experienced team here always puts patients’ best interests first. A small number of patients are unsuitable for
any of the above techniques discussed and would be more suitably managed within a hospital environment. The
reasons for this would be discussed with you at your assessment appointment or in the event of our conscious
sedation techniques being unsuccessful.
In most cases it is advisable to try a conscious sedation technique prior to referral for a general anaesthetic.
PLEASE NOTE THAT AT THIS DENTAL PRACTICE WE ARE UNABLE TO PROVIDE DENTAL
TREATMENT UNDER GENERAL ANAESTHETIC - (PUT PATIENTS TO SLEEP).
Remember – we are here to help and advise you. If there is anything in this information you are unsure of and
would like some clarification then please ask a member of our team and we will be pleased to discuss any concerns
you may have.
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
28
Information for Patients Having Intravenous Conscious Sedation
Intravenous conscious sedation is a technique used by your dentist, which will help you to relax and alleviate
anxiety during your treatment. It is usually given by a small injection in the back of the hand or arm. Unlike a
general anaesthetic you will not be asleep, but will feel slightly drowsy during treatment and may continue to do so
for several hours afterwards. The majority of patients remember very little of the treatment carried out under
intravenous conscious sedation.
It is important that the following rules are observed otherwise your sedation appointment may be cancelled:
 You MUST be accompanied by a responsible adult who MUST remain on the premises throughout your
appointment, escort you home afterwards and arrange for you to be looked after for 24 hours after the
procedure.
 Your escort MUST NOT be responsible for any other person except you on the day of your sedation, including
young children and elderly relatives.
 Your escort MUST take you home after treatment by either private car or taxi rather than by public transport.
 You MUST NOT have anything to eat or drink for two hours prior to your appointment (unless you need a small
glass of water to take your regular medication).
 Please remove any nail varnish and items of jewellery e.g. rings, watches prior to your visit as these may
interfere with monitoring equipment.
 Please wear short sleeved, loose fitting and comfortable clothing for your appointment.
 If you are taking any medicines they should be taken at the usual times and should be brought with you so that
the dentist may know what you have taken.
 Any illness occurring before the appointment should be reported immediately, as this may affect you
treatment.
 You MUST NOT drive or operate machinery until 24 hours after sedation.
 You MUST NOT drink alcohol the night before and for 24 hours after sedation.
 You MUST NOT be solely responsible for young children for 24 hours after sedation and alternative child care
arrangements should be made.
 You MUST NOT sign any legal documents until 24 hours after sedation.
 If you know or suspect you are pregnant please notify the practice as soon as possible – treatment under
conscious sedation is best avoided during pregnancy.
If you have any queries please phone the practice on 01325 381928
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
29
Instructions For Persons Acting As Escorts For Patients Receiving Treatment Under
Intra-venous Conscious Sedation
Thank you for agreeing to act as an escort for your family member/friend when they have treatment
under conscious sedation at this practice.
As an escort there are some things YOU need to know:
1. You MUST come to the practice with the person you are escorting, and remain on the premises for
the whole duration of their treatment.
2. You MUST not bring any children with you. Patients who attend with other children WILL have
their treatment postponed.
3. The effects of the sedation may last for up to 24 hours and during this time the patient MUST NOT
be left alone.
4. The patient must:
NOT DRIVE ANY VEHICLE
NOT OPERATE ANY MACHINERY
NOT OPERATE ANY DOMESTIC APPLIANCES
NOT LOOK AFTER CHILDREN
NOT TAKE ANY IMPORTANT DECISIONS OR SIGN DOCUMENTS
NOT DRINK ALCOHOL
NOT TAKE ANY RECREATIONAL DRUGS
REST QUIETLY AT HOME FOR THE REST OF THE DAY
TAKE ANY PRESCRIBED MEDICATION AS NORMAL
FOLLOW ANY INSTRUCTIONS RELATING TO THEIR DENTAL TREATMENT
By agreeing to act as escort it is YOUR responsibility to ensure that the patient obeys the post-operative
instructions.
Please sign and date this form to indicate that:




YOU understand the instructions.
YOU agree to ensure that the patient complies with the instructions.
YOU will be with the patient, or have made arrangements for a responsible adult to be with the
patient, for the 24 hours following their treatment.
If the patient is to be left with another responsible adult, you have made them aware of the
post-operative instructions.
Signed...........................................................................
Name (Print)..................................................................
Date...............................................................................
Averley, Dorman, Hierons
Queensway Dental Clinic
November 2013
30