Dental care for cardiac transplant patients in the UK.

Cardiac transplantation replaces a severely damaged non-functioning heart with a healthy heart from a donor. Within the UK, the number of cardiac transplants being performed each year is increasing, with significant improvements in longer-term survival. Dental professionals are therefore more likely to see and manage these patients in the pre- and post-transplant periods. This paper proposes a protocol for the dental management of these patients, reinforced by a case series from Scotland and London.

The use of general anaesthesia in special care dentistry: A clinical guideline from the British Society for Disability and Oral Health.

BACKGROUND: General anaesthesia (GA) may be required to support the care of those seen in Special Care Dentistry (SCD) services for various reasons, such as enabling extensive dental care for people with severe learning disabilities or severe dental phobia. Guidance is needed for teams delivering SCD using GA due to the potential risks, implications, and costs of using GA to deliver dental care. AIM: To present evidence-based recommendations, where possible, for teams involved in providing GA for dental care for adults within SCD services. METHODS: A multidisciplinary working group, supported by a formal literature search and stakeholder involvement, iteratively produced and refined the recommendations presented. RESULTS: There was little evidence to inform the guidelines. Recommendations are therefore based mainly on the working group's expert consensus opinion. Clinical guidelines are presented as a set of overarching principles followed by six key sections reflecting patients' pathways from referral to dental services through to their care during and after GA. CONCLUSION: Guidelines are presented to support those providing GA to provide SCD. The need for comprehensive and person-centered assessment and planning is emphasized.

Sedation or General Anaesthetic for Special Care Patients?

When faced with an anxious patient with complex needs who requires dental care, it can be difficult to decide on the most appropriate method to manage their pain and anxiety. There are a range of conscious sedation techniques that may be used, and on some occasions, general anaesthesia may be required. This paper describes the methods available and the factors influencing the decision-making process. The general dental practitioner (GDP) may not be able to offer care in their setting, but knowing more about the decision-making process and the information required to make that decision can help them guide patients and their families.

A Review of the use of Flumazenil for the Reversal of Midazolam Conscious Sedation in Dentistry.

The practice of midazolam conscious sedation is well established in dentistry. The drug flumazenil is a specific benzodiazepine antagonist and is an essential requirement in settings where midazolam is used. A literature review has been carried out, examining the available information regarding flumazenil's safety, administration, potential complications and the regulatory documentation which governs its use. Flumazenil is a safe drug to use for the reversal of midazolam induced conscious sedation although the evidence surrounding its use is limited.

Dementia and Dentistry.

Dementia is increasing in prevalence: by 2025 it is estimated that there will be over a million people in the UK with this diagnosis. The condition is likely to affect us all as healthcare providers, whether in our patients, our relatives or ourselves. This article gives an overview of dementia: causes, treatment, how it affects people and provides advice on how to manage patients with dementia who require dental care. CPD/CLINICAL RELEVANCE: By identifying the patient with dementia and being aware of the challenges in providing care the clinician can provide better treatment and reduce the chance of dental problems as the condition progresses.

Dysphagia and dentistry.

Dysphagia is defined as a 'difficulty in swallowing' and is commonly found in the general population, particularly in the elderly. This article gives an overview of the more frequently encountered swallowing disorders and provides advice on how to manage the dysphagic patient in the dental surgery. Clinical Relevance: By identifying patients with dysphagia and being aware of the potential problems that the clinician may experience when treating them, the risk of aspiration, choking and healthcare-acquired upper respiratory tract infections may be reduced.

Sedation for patients with movement disorders.

UNLABELLED: The general features of the movement disorders are outlined and the effects of inhalational sedation with nitrous oxide and oxygen and intravenous sedation, using midazolam, are described.Two case reports of patients with cerebral palsy treated in a community care setting are presented, and the advantages of intravenous and inhalational sedation are explained. CLINICAL RELEVANCE: Inhalational sedation (IS) with nitrous oxide and intravenous sedation (IVS) with midazolam can be useful aids to reduce unwanted movements in patients with movement disorders during dental treatment.

Sickle cell disease, dentistry and conscious sedation.

UNLABELLED: The features of sickle cell disease (SCD) are described. Two case reports of patients treated in a Dental Institute are presented and the dental management of patients with SCD discussed. Since infection is one of the major risk factors for sickle cell crisis, the prevention of oral disease and infection is vital for this group of patients and there is no contra-indication to the delivery of dental treatment under local anaesthetic with inhalational sedation if required in the primary care setting. Since patients with sickle cell disease are particularly vulnerable to the effects of periods of hypoxia, which may produce significant morbidity, and because of the additional practical challenges in sedating this group of patients, intravenous sedation should be undertaken in a specialist unit. CLINICAL RELEVANCE: The increasing prevalence of sickle cell disease highlights the importance of dentists practising in multi-cultural communities having an understanding of this condition and its implications on their clinical practice. This will facilitate the safe management of patients with sickle cell disease.

Neurofibromatosis-1 and the provision of dental care.

UNLABELLED: The general features of Neurofibromatosis-1 are outlined and the oral and maxillofacial features described. Two case reports of patients treated in the Department of Sedation and Special Care Dentistry at King's College London Dental Institute are presented, and the dental management of patients with Neurofibromatosis discussed. CLINICAL RELEVANCE: Neurofibromatosis-1 is a neurocutaneous genetic disease with a prevalence of one in 4000-5000. Dentists may be presented with these patients in their surgery and this article will help them to understand the condition and explain how to manage these patients.

The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London.

OBJECTIVE: To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health. METHODS: Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables. RESULTS: A direct significant association of referral with dental anxiety and attendance patterns was detected, but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience. CONCLUSION: Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can be an important part of comprehensive care where curative treatments are long or unpleasant for patients.

Sedation or general anaesthesia for treating anxious children.

DATA SOURCES: Relevant literature was selected following searches using the following: Cochrane Central Register of Controlled Trials, Medline, Embase (OVID), System for Information on Grey Literature in Europe, Latin American and Caribbean Health Sciences Literature, ISI Web of Science; and searches were made by hand of: Journal of the American Academy of Pediatric Dentistry, Anaesthesia, British Dental Journal, British Journal of Anaesthesia, Dental Update, International Journal of Paediatric Dentistry, Journal of American Dental Association, Journal of Dentistry for Children and Pediatric Dentistry. STUDY SELECTION: Reports were selected if they described randomised controlled clinical trials (RCT) of sedative agents compared with general anaesthesia in children and adolescents aged up to 18 years who were having dental treatment: complex surgical procedures and pseudo-randomised trials were excluded. There were no language restrictions. DATA EXTRACTION AND SYNTHESIS: Titles and abstracts were assessed for inclusion by two authors with relevant information recorded in a specially designed data extraction form. RESULTS: Fifteen studies were identified for potential inclusion after searching the available databases and screening the titles and abstracts, and a further study was found through personal contacts. Following retrieval of the full text of the studies, it was concluded that none was eligible. CONCLUSIONS: RCT that compare the use of dental general anaesthesia with sedation to quantify differences such as morbidity and cost are required.

Potential interactions with herbal medications and midazolam.

UNLABELLED: In the management of patients who require intravenous sedation with midazolam care must be taken if the patient is taking herbal drugs. There is a potential for harmful drug interactions between herbal drugs and midazolam.Assessment of which herbal drugs a patient is taking should be part of the treatment planning stage so interactions can be avoided or anticipated. CLINICAL RELEVANCE: Growing numbers of patients are taking herbal or Chinese medication and may not disclose this to the sedation team. Such drugs have the potential for interactions and can affect induction and recovery from sedation.

Providing dental care for patients with Huntington's disease.

UNLABELLED: This paper describes the genetic condition Huntington's disease and its clinical relevance to dentists. The treatment of two patients with the condition is described: one under general anaesthesia, the other with intravenous sedation. CLINICAL RELEVANCE: Dentists may have patients who develop Huntington's disease in later life, so this paper will help them consider the longer term effects of this disease and help in planning dental care.

Angio-oedema in dentistry: management of two cases using C1 esterase inhibitor.

UNLABELLED: Angio-oedema is a rare condition; it may be a hereditary or acquired form. It results from biochemical defects which cause excessive activation of the complement cascade and result in deep swellings in the skin and alimentary tract, called angio-oedema. These swellings are painful rather than itchy and not associated with urticaria, which helps to differentiate angio-oedema from allergic reactions. Even mild trauma can give rise to swelling, which may be life-threatening in the oral region. Management of two cases, one hereditary and the other acquired angio-oedema, are reported to demonstrate the use of C1 esterase inhibitor prophylaxis. CLINICAL RELEVANCE: It is important that patients giving a history of angio-oedema are thoroughly investigated and, in discussion with the patient's medical team, appropriate prophylactic measures are taken to prevent swelling.

Epilepsy and oral care.

Epilepsy is a common symptom of an underlying neurological disorder. The seizures can take a variety of forms. Both the condition and its medical management can affect oral health. Prevention of oral disease and carefully planned dental treatment are essential to the well-being of people with epilepsy.