Considerable progress is being made with a number of innovative techniques. Oral midazolam for children and patient-controlled propofol show very promising results. More research is needed before propofol can be recommended for use without anaesthetic staff. The recently published systematic review of sedation in children outlines gaps in the literature and contains recommendations for future work.
Consent and capacity legislation varies across the UK, however, the principles remain similar, with protective and supportive roles and responsibilities in place. Appropriate information should be shared in order to empower the patient. Every effort should be made to overcome barriers to communication, and it is essential for the dental team to have a sound understanding of legal and ethical principles underpinning assessment of capacity, thereby ensuring continued, valid consent. Patients lacking capacity to consent attempt to access primary care dental services frequently and with difficulty, with the increasing complexity of chronic medical conditions, dementia, mental ill health potentially causing social challenges. CPD/Clinical Relevance: This paper defines common terms relating to consent and capacity, provides an overview of UK legislation, and discusses practical dilemmas that the dental team may face.
SummaryPrevious volunteer studies of an effect-site controlled patient-maintained sedation system using propofol have demonstrated a risk of oversedation. We have incorporated a reaction time monitor into the handset to add an individualised patient-feedback mechanism. This pilot study assessed if the reaction time-feedback modification would prove safe and effective in 20 healthy patients receiving sedation while undergoing oral surgery. All patients successfully sedated themselves without reaching any unsafe endpoints. All 20 maintained verbal contact throughout. The mean (SD) lowest peripheral blood oxygen saturation was 98.0 (2.1)% breathing room air. No patient required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.6 (0.5) lg.ml À1. The present system was found to be safe and effective, allowing oral surgery treatment under conscious sedation, but preventing oversedation. Effect-site controlled, patient-maintained sedation with propofol allows the patient to control target controlled infusions of propofol, and hence his/her level of sedation, using a hand-held demand button. The system sets a target effect-site concentration [1] at a low level initially, which can be increased incrementally by the patient pressing the handset button twice within 1 s. The system increases the plasma concentration up to 100% greater than the target effect-site concentration to 'force' the drug rapidly into the effect site, and then reduces the plasma concentration as the target effect-site concentration is approached. Instead of a traditional time-based lockout, the patient is not able to obtain a further increment until the plasma concentration decreases to within 10% of the target effect-site concentration -an 'effect-site lockout'. As the brain is the site of action of propofol, this allows for equilibration between the blood and brain. This technique was found by our group to be safe and effective in patients having dental surgery [2], but the potential for oversedation was demonstrated in volunteers who were instructed to try deliberately to oversedate themselves [3][4][5].
Assessment of capacity is a fundamental part of everyday clinical dental practice in all settings. The legal and ethical principles underpinning assessment of capacity, and our responsibility to act in our patients' best interests must be understood by the dental team. The dental team must be aware of how and when to act in the best interests of the adult patient who lacks capacity, and where it is appropriate to seek further advice. The dental profession is in the privileged position of making decisions on behalf of patients, and must fulfil its responsibilities to this potentially vulnerable patient group. CPD/Clinical Relevance: This paper defines common terms relating to capacity, provides an overview of UK capacity legislation, and discusses how to provide care for adults who lack capacity to consent for their treatment.
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