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A Conscious Decision: A review of the use of general anaesthesia and conscious sedation in primary dental care

  • Document type:
    Publication
  • Author:
    Department of Health
  • Published date:
    1 July 2000
  • Primary audience:
    Professionals
  • Gateway reference:
    21967
  • Pages:
    54
  • Copyright holder:
    Crown

Report by a Group chaired by the Chief Medical Officer and Chief Dental Officer.

1. General anaesthesia is one of the methods used to reduce pain and anxiety associated with dental treatment. Others include local anaesthesia and conscious sedation.

2. The use of general anaesthesia for dental treatment in the NHS outside hospital has changed over time. Key features of the trend have been:

  • an overall fall in the use of general anaesthesia for dental treatment since the mid-1960s;
  • an increased use, after 1992, which coincided with the emergence of specialist services offering general anaesthesia to dental practices;
  • in only one other European country, for which information was available, are general anaesthetics for dental treatment given outside hospital;
  • a small number of dentists accounted for the majority of general anaesthetic use. In the period from July to September 1999 just 45 dentists (about 0.25% of the total) provided treatment for 69% of all general anaesthetics used in NHS general dental practice;
  • a striking fall in general anaesthesia for dental treatment after November 1998 following the introduction of new General Dental Council (GDC) guidance;
  • marked regional variations in the use of general anaesthesia for dental treatment with the highest provision in the North;
  • a growth in the use of conscious sedation as an alternative to general anaesthesia for dental treatment, particularly since November 1998;
  • no comparable data are available for private dental treatment.

Deaths of patients who had received general anaesthesia for dental treatment

3. Although deaths are uncommon during or immediately after general anaesthesia for dental treatment they are more likely to occur than with other pain and anxiety reduction methods. Moreover every death is a tragedy for the individual and family concerned. Investigation of deaths has too often highlighted factors which seemed potentially avoidable.

4. The key features of trends in deaths associated with general anaesthesia for dental treatment outside hospital are:

  • a reduction in the number of deaths since the 1960s in line with the decrease in the use of general anaesthesia in dental practice;
  • in only seven years in the last 35 years there were no deaths associated with general anaesthesia for dental treatment outside hospital;
  • three consecutive years in the 1990s (1993-1995) in which there were no such deaths followed by the four subsequent years (i.e. 1996-1999) in which there were eight deaths, of which five were children.

5. Investigations and inquiries into these recent deaths have been critical of the standard of care provided in fundamental areas such as: pre-operative assessment; monitoring of electrical heart activity, blood pressure, oxygen and carbon dioxide levels; start of resuscitation and transfer to specialist critical care.

Current policy directed at standards of care

6. Current policy related to the protection of patients is based on guidance produced by a number of expert committees over recent years. Most notable amongst these was the Working Party chaired by Professor Poswillo. The Report in 1990 made over 50 recommendations aimed at reducing the risk of death or adverse health effects during dental treatment, including treatment under general anaesthesia. The recommendations included the following areas: standards of dental anaesthesia practice; equipment and facilities; training; inspection and registration of premises.

7. The Poswillo recommendations were implemented in the NHS through the Regional Health Authorities, backed by £20 million of government funding. It is clear that implementation has not been comprehensive or consistent. High quality practice, based on these and other standards to assure patient safety has not always been provided. Nor are the standards rigorously monitored and enforced.

8. In 1998 the General Dental Council acted to strengthen the standards relating to the provision of general anaesthesia for dental treatment. Although this was followed by a substantial reduction in the use of general anaesthesia for dental treatment, two further deaths have occurred outside hospital, and one in hospital following general anaesthesia for dental treatment.

9. NHS regulations governing the use of dental general anaesthesia outside hospital are now more permissive than the GDC guidance because they still allow dentists to give general anaesthetics.

10. There is a lack of statutory regulation of general anaesthesia given in private dental practices. The Care Standards Bill, which is expected to receive Royal Assent in the summer, will regulate general anaesthesia provided by dentists working outside the NHS.

Conclusions

11. Standards aimed at protecting patients from the effects of serious complications of general anaesthesia or conscious sedation administered during dental treatment are not rigorously applied or enforced.

12. Despite a large number of expert reports which have been aimed at improving such standards, it seems that patients are still vulnerable to unexpected death or non-fatal complications occurring outside hospital in circumstances which seem to be avoidable.

13. It is unlikely that further attempts to refine general anaesthesia in dental practice outside hospitals through guidance, inspection and enforcement will provide sufficient assurance.

14. It is important that conscious sedation as an alternative to general anaesthesia for dental treatment continues to be as safe as possible.

15. It is essential that standards in private dental practice are properly regulated.

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