Sedation in dentistry: current sedation practice in Italy

EDITOR: The power of patient sedation to blunt the stress response to surgery is important in dentistry [1,2]. The advantages of the available sedation techniques should be evident to teachers of Dental Schools, to dental students, to dentists, to all involved dental practitioners and, obviously, to dental patients [3–5]. Unfortunately, this knowledge is not so widely shared in Italy, so that the use of patient sedation is still a limited practice among Italian dentists [4,6]. We report information about the current sedation practice in Italy within both academic and private practice. An E-mail or telephone survey was performed in January 2005 to collect data about current sedation practice in Italy. The survey covered all the 33 Dental Schools of Italy and 110 private dental offices of the Veneto region in the north-east of Italy. Data from a previous study [6] of private dental practice in the Friuli Venezia Giulia region were added. The two Italian regions, Friuli Venezia Giulia and Veneto, have 5 730 000 inhabitants, about 10% of the whole Italian population. In Italy there are 18 921 dentists and 34 625 physicians working as dentists. Results from the survey on the education of undergraduate dental students and of private dental practice in Italy are reported in Table 1.Table 1: Survey on undergraduate dental students education and on private dental practice in Italy: patient evaluation, sedation techniques, drugs and practice in Dental Schools and private dental offices.Sedation in Italian Dental Schools is provided mainly by anaesthesiologists (94%) with the remainder by dentists (6%). In private dental practice the situation is different with the anaesthesiologists performing the sedation in about 20% of cases, the remainder being performed by dentists and physicians. Since the foundation of Dental Schools in Italy, in 1981, the teaching of Anaesthesia in Dentistry presented many problems defining a didactic model according to the goal of this specialty. This situation had not improved 20 yr later, after the introduction of the new European Standards (2001) in the academic didactic organization that included teaching of patient evaluation and information, anxiety and pain control, emergency prevention and treatment. This is due to a lack of clinical facilities in Dental Schools and theoretical but not practical adjustment to European Standards together with lack of information among dentists. In Italian Dental Schools all the sedation masters are anaesthesiologists with a clear preference toward topics for anaesthetists and not for dentists: many anaesthesiologists had little knowledge of the training presently available to dentists wishing to practise conscious sedation. It is of great concern that a considerable number of these anaesthesiologists do not feel that is appropriate for dentists to be administering even the simplest method of sedation including the use of nitrous oxide/oxygen inhalation. The sedation techniques taught and performed in the Dental Schools depend on the knowledge and wisdom of the teachers, skill of clinical staff and available resources of the Institution. Oral sedation is widely employed because it is simple to teach, to learn and to perform. Intravenous (i.v.) sedation needs special skill but is suitable for titration. Inhalation of nitrous oxide and oxygen is a relatively frequent technique, but intranasal and sublingual routes of drug administration are less used. The drugs studied in most of the Italian Dental Schools are benzodiazepines and nitrous oxide but general i.v. anaesthetics (ketamine, propofol, barbiturates, opioids, etc.) and halogenated anaesthetics (sevoflurane, desflurane) are, erroneously, also taught. We believe erroneously because these are topics for anaesthesiologists and not for dentists. Special sedation techniques, for children and/or disabled patients are carried out only in a minority of cases because these are considered, mostly, as patients for anaesthesiologists requiring general anaesthesia in the majority of the Institutions. Education is carried out on a theoretical basis, while practice on the patient is lacking in the majority of the Dental Schools. The nearly total absence of academic continuing education about this topic is evident as only two Universities perform such education: Bologna University, where there is an active education programme about Basic Life Support and Defibrillation and Padua University with an education programme regarding patient evaluation and information, anxiety and pain control in dentistry. At Padua University Dental School, sedation is provided by the ‘sedationist’ [7,8], a dentist with a high level of competence based on a solid foundation of theoretical and practical supervised training. In this scenario, the anaesthesiologist is supervisor for the sedationist, and performs also general anaesthesia for particular and limited indications. In other Universities, with few exceptions, the anaesthesiologist performs most of the sedations because the lack of a sedationist. Consequently, in these Institutions there is a prevalence of general anaesthesia compared with sedation. What sort of sedation is practised in private dental practice? The answer is more difficult, because the situation is heterogeneous and depends on many factors such as knowledge, skill, clinical experience of the staff and prevalent activity performed in the dental office. In the private dental practice younger, well-educated and skilled dentists perform conscious sedation techniques, but older well-known dentists depend on anaesthesiologists, who are more likely to perform so-called ‘light general anaesthesia’. The Italian reality is embarrassing: there are no guidelines produced by the Italian Health Ministry, the Italian University Dental Schools or the Italian National Dental Associations. Italian guidelines for sedation in dentistry were published in 2001, by the Italian Association of Dental Anaesthesia (AINOS), in its official publication the ‘Journal of Dental Anaesthesia’ and cover all the aspects of perioperative medicine in dentistry. AINOS is a member of the International Federation of Dental Anaesthesiology Societies (IFDAS) and of the European Federation for the Advancement of Anaesthesia in Dentistry (EFAAD). Effective management of anxiety and pain is very important for patients requiring dental care and conscious sedation techniques are a fundamental component of this [3,4,7,8]. Competently provided conscious sedation is safe, valuable and effective to blunt the stress response to surgery. A high level of competence based on a solid foundation of theoretical and practical supervised training, progressive updating of skills and continuing experience is the key to safe practice.