Dental treatment for people with challenging behaviour: general anaesthesia or sedation?

Abstract

The dental care of people with severe learning disability and challenging behaviour presents many problems. The maintenance of oral health by regular examination, prevention and treatment may be difficult because of the limitations in patient cooperation. In many cases the diagnosis of orofacial pain may need to be discounted as a cause of uncharacteristic and sometimes aggressive behaviour. In such cases the use of general anaesthesia for examination and treatment would seem to be the obvious option but this strategy has limitations. This paper undertakes a focused review of sedation techniques as an alternative to general anaesthesia in the treatment of people with challenging behaviour. The use of novel techniques of sedation combining intravenous with oral or intranasal routes is described with patients treated in a community dental health centre. All patients had previously received treatment using general anaesthesia. The techniques described proved effective and safe for use in the primary care setting.

Sedation with 50% nitrous oxide/oxygen for outpatient dental treatment in individuals with intellectual disability

“…It may also help to increase regular access to routine care, thus avoiding the repercussions of neglect on general health and quality of life in this population. 1 The use of a safe, simplified sedation technique, with a single agent, may be an argument for extending the indications of conscious sedation to other simple acts performed in the institutionalized setting by qualified care staff, such as phlebotomy or wound dressing. 17 It is essential, however, that anaesthetists be involved in the development, standardization, and teaching of such techniques and that mandatory qualifications be put in place around the world.…”

“…Conscious sedation may provide an alternative management method, but these techniques have traditionally been contraindicated for persons with intellectual disability or a psychiatric disorder for fear of aggravating existing behavioural or medical problems, or because of perceived lack of cooperation. [1][2][3][4][5] The effects of inhalation sedation using nitrous oxide in oxygen (N 2 O/O 2 ) are mild, of rapid onset, reversible, short-lasting, and of little systemic impact compared with other sedative drugs. 6 Indeed, the American Society of Anesthesiologists Task Force on sedation and analgesia by non-anaesthetists considers that inhalation of less than 50% N 2 O entails minimal risks and, thus, excluded this mode of anxiolysis from their practice guidelines.…”

Dental Treatment under General Anesthesia in Healthy and Medically Compromised/Developmentally Disabled Children: A Comparative Study

“…6 The use of propofol as an intravenous induction agent is very useful, having been associated with fast clearance and reducing postoperative nausea and vomiting. 7 All the above mentioned advancements have significantly improved the safety of anesthetic technique, a reduction in adverse events, and has resulted in increased patient satisfaction with DGA in an office-based ambulatory setting.…”

“…4 Besides, it has been reported that DGA is used as multidisciplinary approach for oral rehabilitations under DGA that involve personnel with different dental specialities which increase the procedure cost. [4][5][6] The availability of rapid and short-acting anesthetics such as sevoflurane and propofol has improved the general anesthesia (GA) technique and facilitated the early recovery of…”

Retrospective audit of the efficacy and safety of the combined intranasal/intravenous midazolam sedation technique for the dental treatment of adults with learning disability

“…[2][3][4] As an alternative to this radical and limited approach, the use of intravenous sedation provided in primary care as an operator sedation ist has been shown to be an effective management strategy for people with disability. 5,6 The specific technique of using oral or intranasal midazolam to allow cannulation followed by intrave nous sedation of the same drug has made available the option for comprehensive care. This would include effective rou tine examinations, periodontal care, and restorative treatment.…”