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The multidisciplinary use of intranasal/intravenous conscious sedation: four case reports Lucy Wray Graham Manley Dental Update 2024 41:10, 707-709.
Authors
LucyWray
BDS
Specialist in Special Care Dentistry, DipDSed, Senior Dental Officer, Solent NHS Trust, New Milton Dental Clinic, New Milton Health Centre, Spencer Road, New Milton, Hants
Conscious sedation provides the dentist with the opportunity to provide dental treatment for patients unable to accept care in the usual way. Often these challenging patients are in need of other medical interventions which they are also unable to accept. The use of conscious sedation utilizing intranasal midazolam improves access to dental care for those with profound needle phobia, movement disorders or a learning disability. The following four case reports describe the use of conscious sedation to provide dental treatment in conjunction with other necessary medical treatment. All four cases were treated in primary care by experienced dental sedationists who were familiar with treating this patient group.
Clinical Relevance: Experienced dental sedation teams may wish to consider combining dental treatment with other necessary medical interventions during the treatment window which sedation provides.
Article
The practice of dentistry, particularly within the field of Special Care Dentistry, requires the clinician to have a holistic approach to healthcare, recognizing that we are dealing with people not just teeth. Intranasal sedation is becoming a more widely used method for facilitating safe cannulation amongst certain patient groups. The evidence for the safety and efficacy of this technique was provided by articles by Ransford et al,1 and a related article by Manley et al.2 These articles described the successful use of intranasal and intravenous sedation in the treatment of 429 adults with severe disabilities. (Of these 429 patients, 71% had varying degrees of learning disability. The remainder had medical conditions which included epilepsy, cerebral palsy, brain injury, spina bifida, Huntington's disease and severe mental illness.)
Patients groups who may benefit from this technique include patients with movement disorders, moderate or severe learning disabilities or profound needle phobia. Anxiety relating to needles may be particular to intra-oral injections or to injections in any part of the body (total needle phobic). Many clinicians will be familiar with patients who present with multiple piercings or tattoos but will not allow any form of intra-oral injection for dental care.
Dentists are not the only group of clinicians who may find these groups of patients difficult to treat. Sir Jonathan Michael's inquiry3 into access to healthcare for people with learning disabilities found ‘convincing evidence’ that they had ‘higher levels of unmet need and receive less effective treatment’. The Department of Health sponsored a briefing paper by the Learning Disability Observatory4 which reported that health screening of adults with learning disabilities registered with GPs revealed a high level of unmet physical and mental health needs. Challenging behaviours (aggression, destruction, self-injury and others) are shown by 10–15% of people with learning disabilities. In some instances, challenging behaviours result from pain associated with untreated medical disorders. Regarding oral health, a survey in Northern Ireland5 showed that one in three adults with learning disabilities and four out of five adults with Down's syndrome have decayed teeth and poor periodontal health. A further survey showed that adults with learning disabilities living with their families had more untreated decay and poorer oral hygiene than similar adults living in residential services who had more missing teeth. This study also showed that patients with learning disabilities had similar levels of caries experience as the general population. However, these adults with learning disabilities had higher levels of missing teeth and fewer filled teeth, suggesting that extractions had been used as the primary form of treatment.6 The charity Mencap conducted an online survey of more than 1,000 doctors and nurses which showed that almost half of the doctors and more than a third of the nurses believe that people with learning difficulties receive poorer healthcare than the rest of the population.7
Some of the more simple medical treatments or screening procedures may be avoided or delayed for many reasons. This delay may increase the time that a patient suffers unnecessarily or even (as in Case 4) have potentially serious consequences.
The following four case reports are examples of the multidisciplinary use of dental sedation.
Background
All four of the following cases were treated in primary care facilities by clinicians who were experienced in both sedation and in the treatment of patients with special needs. All of the patients were assessed (at a separate sedation assessment appointment) as being either ASA I or ASA II (American Society of Anaesthesiologists).8
All four patients were assessed as to their capacity to give informed consent. The criteria stipulated in the Mental Capacity Act (2005) were used as the basis for this assessment. Patients 1 and 3 were found to lack the capacity to consent. Discussion with their relatives, GPs and carers concluded that it was in the patient's best interests for both sets of treatment and sedation to be carried out. Patients 2 and 4 both had the capacity to consent. Written and informed consent was given for sedation, dental and other medical treatment.
Each of the patients received intranasal midazolam (10 mg is the usual bolus dose) to allow safe cannulation. The intranasal midazolam was given using a 1ml insulin syringe which is attached (via a luer-lok mechanism) to a Mucosal Atomization Device (MAD) (Figure 1). After approximately 5 minutes the patient was usually sufficiently sedated to allow safe cannulation and further (intravenous) titration of midazolam against response was given until a recognized sedation endpoint was achieved. Both clinical monitoring and the use of a pulse oximeter were maintained throughout the treatment and a second sedation qualified person (dental nurse) assisted with the procedure. There were no adverse events either during the treatment or recovery.
Figure 1. Equipment for intranasal midazolam administration (MAD and 1ml insulin syringe).
Case 1
A 63-year-old patient suffered a cardiac arrest in 1993 resulting in post-resuscitation hypoxic brain damage. As a result of this neurological damage the patient now exhibits child-like behaviour, combined with bouts of challenging behaviour which makes both dental treatment and other medical interventions extremely difficult. This patient also has asthma and is needle phobic. The patient originally worked as a dental nurse and her husband is keen that her dental health is maintained as this would have been her wish prior to her brain damage.
This patient was also under the care of the podiatry team who needed to remove the left first toe nail (avulsion) and provide phenolization of the nail bed.
A joint appointment with the dental and podiatry teams was arranged. The patient's husband had applied Ametop (4% tetracaine local anaesthetic gel) to the right dorsum of the hand and the left first toe prior to the patients' arrival.
Following the intranasal/intravenous sedation the patient remained relaxed and co-operative throughout the period of treatment (Figure 2). A full dental examination followed by scaling and polishing was carried out. The podiatry team completed a total nail avulsion of the left first toe with phenolization under local anaesthesia. Recovery of the patient was normal and uneventful.
Figure 2. Case 1: Patient undergoing dental and podiatry treatment simultaneously after being sedated with intranasal/intravenous sedation. (Consent was given for this photograph by the patient's husband.)
Case 2
A 40-year-old patient suffers from a longstanding and profound needle phobia. Similarly, fear of vomiting and nausea induce a state of panic for this patient. The aforementioned problems have prevented the patient from accessing dental care for over 25 years. Any medical treatment creates similar levels of stress and avoidance has been the main coping strategy used by the patient. A dental examination and radiographs were taken confirming dental caries.
This patient is employed by a large petro-chemical company in the local area. He had recently been promoted. To ensure the ‘fitness to work’ status of their employees, the company policy is to have regular medicals, including a blood test every two years for those employees in designated positions of responsibility. Despite the patient undergoing hypnotherapy to address his needle phobia, he was unsuccessful on two attempts at having the blood samples taken. Explanatory and supportive letters from his GP and from his psychiatrist had failed to prevent the patient from being demoted. The impact of this situation was having a profound affect on the self-esteem of the patient, not to mention the family's finances.
Intranasal midazolam initially proved difficult to administer. The patient was hyperventilating and this was initiating feelings of nausea, thus adding to the problem. Resolution of these symptoms was achieved by instructing the patient to cup his hands in front of his mouth and to re-breathe the expelled air. Reassurance was given and the intranasal midazolam was administered. Intravenous sedation was titrated against the patient's response.
A full examination, a deep restoration under local anaesthesia and a scale and polish were completed while the phlebotomist took the necessary blood samples. Following the results of the blood tests, this patient has been re-instated in his promoted position at work. Following the advice given at the sedation assessment appointment the patient has completed a course of cognitive behavioural therapy (CBT). This has enabled the patient to have blood taken without the need for sedation.
Case 3
A 56-year-old patient has Down's syndrome with severe learning disabilities and challenging behaviour. On previous occasions he has thrown equipment (including a chair) at the GP and has caused injury to staff. He has had to have a general anaesthetic (GA) on several occasions for treatment to his eyes. Induction for GA is a stressful occasion for ALL involved. According to the patient's brother (who is the patient's strongest advocate) the last occasion required four people to use ‘clinical holding’ to allow cannulation for induction despite pre-medication. Previously, all dental treatment for this patient had been provided using general anaesthesia.
More recently, the patient had received dental treatment using intranasal and intravenous sedation with minimal stress. Dental care had included examination, periodontal treatment and extractions. The success of this had been assisted by the support of the carers who had familiarized the patient with the MAD which they had placed in the patient's nostril several times a day.
The patient had developed a significant volume of wax in his ears and the care home staff had managed to get the patient to accept drops in his ears to soften this wax but no-one was able to contemplate the procedure of syringing the ears owing to the lack of co-operation.
The patient's brother asked the dentist if an attempt could be made to have his brother's ears syringed at the same time as his next dental treatment under sedation.
The dental treatment and ear syringing were successfully completed with help from the GP, practice nurse, dental team and the patient's brother, a true team effort (Figures 3, 4). Intranasal and intravenous midazolam were used to sedate the patient. His blood pressure recorded during the sedation was noted to be slightly hypotensive, and this was reported to the patient's GP and the care home for follow-up. Supplemental oxygen was given to the patient during the sedation purely as a precaution to compensate for the macroglossia and its potential to reduce or obstruct the airway. Saturation levels remained within the normal range throughout treatment and recovery was normal and uneventful.
Figure 3. Case 3: Patient undergoing ear syringing while sedated. (Consent for this photograph was given by the patient's brother.)Figure 4. Case 3: Patient undergoing examination with an auriscope while sedated. (Consent for this photograph was given by the patient's brother.)
Case 4
A 42-year-old woman has athetoid cerebral palsy, is wheelchair bound and lives independently in the community. Although fully competent and very intelligent, her verbal communication is problematical with hypernasal speech and severe dysphonia. She is severely needle phobic to the extent that when attending for hospital visits she presents any clinical staff involved with her care with a large laminated sign stressing that she hates needles. All her dental treatment has been provided using intranasal and intravenous midazolam. Treatment has included scaling, fillings and extractions. Over the years she has developed a trust and confidence in the dental practitioner providing care. She presented for a routine examination and was found to require a scaling and small filling. However, she stated that she ‘had a problem.’ When questioned she explained that she needed to have a cervical smear. She had attended for this at a medical practice, however, did not feel that her problems had been fully appreciated and refused the process, becoming very upset. She requested help. Contact was then made with the sexual health/family planning service and arrangement was made for her to have a cervical smear taken by a sexual health consultant at the same time as her dental treatment was provided using intranasal and intravenous midazolam. Written consent was obtained for both procedures and confirmed with the dental and medical practitioner involved. The cervical smear was undertaken by the consultant assisted by a Specialist Sexual Health Registered General Nurse, and following this all dental treatment was provided. The sedation and all procedures were completed satisfactorily and without any untoward event. The histopathology demonstrated a C3 lesion and further urgent treatment was then provided at a local hospital under general anaesthetic, with intranasal midazolam premedication and gas induction.
Discussion
The health inequalities of people with learning disabilities are well recognized.3,4 Some of these health inequalities may be reduced when dental care is being provided using conscious sedation. A comprehensive medical history is always taken at the pre-sedation assessment appointment and this information can act as a springboard for investigation into unmet needs. The opportunity for other healthcare professionals to utilize the treatment window provided by the sedation for dental care should be investigated.
Conclusion
The four case reports described above are good examples of the multidisciplinary use of dental sedation. This multidisciplinary approach has many benefits:
It enables maximum use of the treatment window provided by sedation;
It avoids the need for a general anaesthetic (and its increased risk and cost) for this challenging group of patients;
It is beneficial for all clinicians involved to appreciate the work of their colleagues while maximizing the benefit to the patient;
There is a saving in time and a reduction in the number of visits for the patient.
The pre-requisites for this combination of treatments are that:
The dental team are trained in the use of conscious sedation and are also familiar with treating this patient group;
Both sets of clinicians must be flexible enough in their approach to treatment to accommodate their colleagues in a limited area;
A positive approach, ensuring the maximum benefit from the sedation window for the patient;
Informed consent, including a judgement of capacity and best interests where appropriate, must be obtained for both sets of treatment prior to commencement;
All necessary equipment must be available for the different procedures to be carried out and the clinicians must be comfortable with working in an unfamiliar environment.
It is hoped that, by describing these cases, clinicians using conscious sedation may be encouraged to ask relatives, carers, the GP or the patient whether they have other medical procedures that they find difficult to accept. Hopefully, by combining treatments in this way, there will be a reduction in both the barriers to care for this patient group and the health inequalities that this group currently experiences.
