This is a 10-year follow-up survey of a 1996 study of all dentists in Illinois holding a permit to administer sedation or general anesthesia. The survey describes the scope of sedation and anesthesia services provided in dental offices in Illinois. A mail survey was sent to 471 dentists who were registered with the department of professional regulation to administer sedation or general anesthesia. Classification by specialty area of practice showed: 63% (84% in 1996) are oral and maxillofacial surgeons, 20% (11% in 1996) general dentists, 6% (5% in 1996) periodontists, 9% (0% in 1996) pediatric dentists, 1% (less than 1% in 1996) dentist anesthesiologists. Advanced cardiovascular life support (ACLS) training was reported by 90% (85% in 1996) of the respondents. The total number of sedations and general anesthetics administered for the year was 115,940. Two mortalities and two cases of long-term morbidity were reported for the 10-year period. Respondents reported that 30 patients required transfer to a hospital but suffered no long-term morbidity. Other practice characteristics were detailed.
Dental sedation; Dental anesthesia; Morbidity and mortality; Practice parameters
An abstract of this study was presented at the American Association for Dental Research (AADR) Dental Anesthesiology Research Group in Honolulu, Hawaii, in March of 2004. This study was conducted to correlate the intraoperative and postoperative morbidity associated with moderate and deep sedation, also known as monitored anesthesia care (MAC), provided in a General Practice Residency (GPR) clinic under the supervision of a dentist anesthesiologist. After internal review board approval was obtained, 100 parenteral moderate and deep sedation cases performed by the same dentist anesthesiologist in collaboration with second year GPR residents were randomly selected and reviewed by 2 independent evaluators. Eleven morbidity criteria were assessed and were correlated with patient age, gender, American Society of Anesthesiology Physical Status Classification (ASAPS), duration of procedure, and anesthetic protocol. A total of 39 males and 61 females were evaluated. Patients' ASAPS were classified as I, II, and III, with the average ASAPS of 1.61 and the standard deviation (STDEV) of 0.584. No ASPS IV or V was noted. Average patient age was 33.8 years (STDEV, 14.57), and the average duration of procedure was 97.5 minutes (STDEV, 42.39). Three incidents of postoperative nausea and vomiting were reported. All 3 incidents involved the ketamine-midazolam-propofol anesthetic combination. All patients were treated and were well controlled with ondansetron. One incident of tongue biting in an autistic child was regarded as an effect of local anesthesia. One patient demonstrated intermittent premature atrial contractions (PACs) intraoperatively but was stable. Moderate and deep sedation, also known as MAC, is safe and beneficial in an outpatient GPR setting with proper personnel and monitoring. This study did not demonstrate a correlation between length of procedure and morbidity. Ketamine was associated with all reported nausea and vomiting incidents because propofol and midazolam are rarely associated with such events.
Dental sedation; Sedation training; Sedation outcomes
Dentists in the state of Illinois who possess a permit to administer sedation or general anesthesia were surveyed. A 71% response rate was achieved. Of the respondents, 86% held permits for deep sedation/general anesthesia and 14% held permits for parenteral conscious sedation. By practice specialty, 84% were oral and maxillofacial surgeons, 11% were general dentists, 5% were periodontists, and fewer than 1% were dental anesthesiologists. Advanced Cardiac Life Support training was possessed by 85% of the respondents. The most common anesthesia team configuration (82%) was a single operator-anesthetist and two additional assistants. Only 4% reported use of a nurse anesthetist, and 2% used an additional MD or DDS anesthesiologist. The vast majority (97%) of the practitioners do not intubate in the office on a routine basis. Supplemental oxygen was used by 81% of the respondents whenever intravenous agents were used. A total of 151,335 anesthetics were administered during the year. One mortality occurred in a patient with an undisclosed pre-existing cardiac condition. Four other events were reported that required medical intervention or hospital evaluation; however, no permanent injuries were reported. Other practice characteristics were described.
Practice-based research networks (PBRNs) aim to improve clinical practice by engaging dental practitioners in studies that are directly relevant to daily clinical practice. A dental PBRN called “DPBRN” (Dental Practice-Based Research Network) comprises dentists from seven U.S. states and three Scandinavian countries.
All DPBRN dentists complete an enrollment questionnaire about their practices and themselves; to date, 1,086 have done so. To quantify how similar DPBRN dentists are to U.S. dentists at large, we compared DPBRN practice characteristics to those of dentists who responded to the 2004 ADA Survey of Dental Practice, which is not limited to ADA members.
DPBRN dentists were similar to dentists nationally with regard to dentist’s gender, race, ethnicity, number of offices, percentage of patients with insurance coverage, number of operatories, patient visits per week, days for a new appointment, and waiting room time. DPBRN dentists were statistically more likely to be recent graduates.
DPBRN practitioners have much in common with U.S. dentists nationally.
Commonalities between DPBRN dentists and dentists nationally should increase the likelihood that DPBRN studies will be applicable to U.S. practices, thereby fostering knowledge transfer in both the research-to-practice and practice-to-research directions.
practice-based research; dentistry; private practice; health-services research; multi-center studies
Using a stratified random sample, a questionnaire was mailed to 400 practicing dentists and 200 directors of nursing (DONs). Response rates were 58.3% for dentists and 50% for DONs. Dentists were representative of Iowa dentists, with 85% male, mean age 49.1 years, and 22.4 years in practice. All DONs were female, with mean age of 44.9 years. Of the participating dentists, 86% had provided dental care for nursing home residents, but the majority of care was completed in dental offices. Three-quarters of dentists were somewhat/not interested in nursing home dentistry.
Dentists and DONs held common perceptions of the most frequent problems related to care provision at nursing homes: low financial reimbursement, especially for Medicaid patients; no portable dental equipment; no suitable area for dentistry; dentist's preference to treat patients at their dental practice; and transportation of residents to a dental practice. Dentists and DONs had some differing perceptions about oral health care (p<0.01). Minimal dental care was provided on-site at Iowa nursing homes.
nursing homes; access to care; barriers; elderly; geriatrics
Evidence suggests that caries prevention reduces caries in adults. This study tested the frequency of recommended caries prevention agents for children compared to adult patients.
This study surveyed 467 Dental Practice-Based Research Network general dentists who practice within the United States and treat both pediatric and adult patients. Dentists were asked the percentage of their patients who are administered or recommended dental sealants, in-office and at-home fluoride, chlorhexidine rinse, and xylitol gum.
Adults were less likely to receive in-office caries preventive agents compared to pediatric patients. However, the rate of recommendation for at-home preventive regimens was very similar. Dentists with a conservative approach to caries treatment were the most likely to use caries prevention at similar rates in adults as in children. In addition, practices with a greater number of patients with dental insurance were significantly less likely to provide in-office fluoride or sealants to adult patients than to their pediatric patients.
In-office caries prevention agents are more commonly used by general dentists for their pediatric patients compared to their adult patients.
Some general dentists should consider providing additional in-office prevention agents for their adult patients who are at increased risk for dental caries.
Caries; Prevention; Adults
The relative efficacy and safety of drugs and combinations used clinically in dentistry as premedicants to alleviate patient apprehension are largely unsubstantiated. To evaluate the efficacy and safety of agents used for parenteral sedation through controlled clinical trials, it is first necessary to identify which drugs, doses, and routes of administration are actually used in practice. A survey instrument was developed to characterize the drugs used clinically for anesthesia and sedation by dentists with advanced training in pain control. A random sample of 500 dentists who frequently use anesthesia and sedation in practice was selected from the Fellows of the American Dental Society of Anesthesiology. The first mailing was followed by a second mailing to nonrespondents after 30 days. The respondents report a variety of parenteral sedation techniques in combination with local anesthesia (the response categories are not mutually exclusive): nitrous oxide (64%), intravenous conscious sedation (59%), intravenous “deep” sedation (47%), and outpatient general anesthesia (27%). Drugs most commonly reported for intravenous sedation include diazepam, methohexital, midazolam, and combinations of these drugs with narcotics. A total of 82 distinct drugs and combinations was reported for intravenous sedation and anesthesia. Oral premedication and intramuscular sedation are rarely used by this group. Most general anesthesia reported is done on an outpatient basis in private practice. These results indicate that a wide variety of drugs is employed for parenteral sedation in dental practice, but the most common practice among dentists with advanced training in anesthesia is local anesthesia supplemented with intravenous sedation consisting of a benzodiazepine and an opioid or a barbiturate.
General descriptions or “snapshots” of sedation/general anesthesia practices during dental care are very limited in reviewed literature. The objective of this study was to determine commonalities in dental sedation/anesthesia practices, as well as to accumulate subjective information pertaining to sedation/anesthesia care within the dental profession. This questionnaire-based survey was completed by participating anesthesia providers in the United States. A standardized questionnaire was sent via facsimile, or was delivered by mail, to 1500 anesthesia providers from a randomized list using an online database. Data from the returned questionnaires were entered onto an Excel spreadsheet and were imported into a JMP Statistical Discovery Software program for analyses. Quantitative evaluations were confined to summation of variables, an estimation of means, and a valid percent for identified variables. A total of 717 questionnaires were entered for data analysis (N = 717). Data from this study demonstrate the wide variation that exists in sedation/anesthesia care and those providing its administration during dental treatment in the United States. The demographics of this randomized population show anesthesia providers involved in all disciplines of the dental profession, as well as significant variation in the types of modalities used for sedation/anesthesia care. Data from this study reveal wide variation in sedation/anesthesia care during dental treatment. These distinctions include representation of sedation/anesthesia providers across all disciplines of the dental profession, as well as variations in the techniques used for sedation/anesthesia care.
Anesthesia; Dentistry; Practice characteristics; Techniques
The authors conducted a study to describe the general dentists, practices, patients and patient care patterns of the dental practice-based research network (PBRN) Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT).
Northwest PRECEDENT is a dental PBRN of general and pediatric dentists and orthodontists from five U.S. states in the Northwest: Idaho, Montana, Oregon, Utah and Washington. The authors collected data from general dentists in Northwest PRECEDENT (n = 101) regarding the diagnosis and treatment of oral diseases in a survey with a systematic random sample of patients (N = 1,943) visiting their practices. They also obtained demographic data from the general dentists and their patients.
The authors found that 50 percent of the general dentists were 51 to 60 years of age, 14 percent were female and 76 percent were non-Hispanic white. More than one-half (55 percent) of the dentists had practiced dentistry for more than 20 years, 83 percent had private solo practices and 32 percent practiced in rural community settings. The majority (71 percent) of patients visiting the dental practices was in the age range of 18 to 64 years, 55 percent were female and 84 percent were non-Hispanic white. In terms of reasons for seeking dental care, 52 percent of patients overall visited the dentist for oral examinations, checkups, prophylaxis or caries-preventive treatment. In the preceding year, 85 percent of the patients had received prophylaxis, 49 percent restorative treatments, 34 percent caries-preventive treatments and 10 percent endodontic treatments.
Northwest PRECEDENT general dentists are dispersed geographically and are racially and ethnically diverse, owing in part to efforts by network administrators and coordinators to enroll minority dentists and those who practice in rural areas. Estimates of characteristics of dentists and patients in Northwest PRECEDENT will be valuable in planning future studies of oral diseases and treatments.
Dental private practice; dentists; office visits; research
Intravenous sedation has been used in dentistry for many years because of its perceived advantages over general anesthesia, including shorter recovery times. However, there is limited literature available on recovery from intravenous dental sedation, particularly in the private general practice setting. The aim of this study was to describe the recovery times when sedation was conducted in private dental practice and to consider this in relation to age, weight, procedure type, and procedure time. The data were extracted from the intravenous sedation records available with 1 general anesthesia-trained dental practitioner who provides ambulatory sedation services to a number of private general dental practices in the Perth, Western Australia Metropolitan Area. Standardized intravenous sedation techniques as well as clear standardized discharge criteria were utilized. The sedatives used were fentanyl, midazolam, and propofol. Results from 85 patients produced an average recovery time of 19 minutes. Recovery time was not associated with the type or length of dental procedures performed.
Relative analgesia (RA), defined as the use of inhalation sedation with nitrous oxide and oxygen, is one of the most common pharmacological behavior management techniques used to provide sedation and analgesia for dental patients. This study aimed to assess RA licensed Brazilian dentists’ practices and opinions about nitrous oxide/oxygen sedation in the dental setting.
A cross sectional national survey was conducted with 281 dentists who were certified to perform RA, using an electronically mailed self-administered questionnaire containing closed questions about their practices and opinions regarding RA. Practice and opinion were individually analyzed by descriptive statistics. Non-parametric tests assessed the relationships between RA practice and independent variables. To test the interplay between practices and opinions, a k-means clusters analysis was used to divide the group for statistical comparisons.
The response rate was 45.2%. Women made up 64.6% of the respondents, the mean age was 39.1 years (SD = 9.8), and the mean time since graduation in dentistry was 16 years (SD = 9.7). Seventy-seven percent of respondents reported the use of RA in clinical practice, most of them ‘sometimes’ (53.5%), and focusing more on adult patients. Patients with certain physical or mental deficiencies were indications associated with RA practice. ‘Equipment acquisition’ (p < 0.001) and ‘living in Southeast and South regions’ (p < 0.02) were also associated with RA practice. The scores for dentists’ opinions ranged from 15 to 41 points (mean 29.2, SD = 5.6), based on nine items scored from 1 to 5. Two clusters representing more favorable (n = 65) and less favorable (n = 55) opinions were established. Dentists who were women (p = 0.04), practiced RA in dental settings (p < 0.01) or practiced it frequently (p < 0.001), had more favorable opinions about RA.
Most of the RA licensed Brazilian dentists interviewed currently use RA. Current practice of RA and frequency of use determined the degree of favorable opinion about this inhalation sedation among this group of respondents.
Relative Analgesia; Nitrous Oxide; Dental Clinics; Cross Sectional Survey
Pediatric sedation is a challenge which spans all continents and has grown to encompass specialties outside of anesthesia, radiology and emergency medicine. All sedatives are not universally available and local and national regulations often limit the sedation practice to specific agents and those with specific credentials. Some specialties have established certification and credentials for sedation delivery whereas most have not. Some of the relevant sedation guidelines and recommendations of specialty organizations worldwide will be explored. The challenge facing sedation care providers moving forward in the 21st century will be to determine how to apply the local, regional and national guidelines to the individual sedation practices. A greater challenge, perhaps impossible, will be to determine whether the sedation community can come together worldwide to develop standards, guidelines and recommendations for safe sedation practice.
Complementary and alternative medicine (CAM) is growing in popularity, especially within the pediatric population. Research on CAM practitioners and their specialties, such as pediatrics, is lacking. Within the chiropractic profession, pediatrics is one of the most recently established post-graduate specialty programs. This paper describes the demographic and practice characteristics of doctors of chiropractic with a pediatric diplomate.
218 chiropractors with a pediatric diplomate were invited to complete our survey using either web-based or mailed paper survey methods. Practitioner demographics, practice characteristics, treatment procedures, referral patterns, and patient characteristics were queried with a survey created with the online survey tool, SurveyMonkey©®.
A total of 135 chiropractors responded (62.2% response rate); they were predominantly female (74%) and white (93%). Techniques most commonly used were Diversified, Activator ®, and Thompson with the addition of cranial and extremity manipulation to their chiropractic treatments. Adjunctive therapies commonly provided to patients included recommendations for activities of daily living, corrective or therapeutic exercise, ice pack\cryotherapy, and nutritional counseling. Thirty eight percent of respondents' patients were private pay and 23% had private insurance that was not managed care. Pediatrics represented 31% of the survey respondents' patients. Chiropractors also reported 63% of their work time devoted to direct patient care. Health conditions reportedly treated within the pediatric population included back or neck pain, asthma, birth trauma, colic, constipation, ear infection, head or chest cold, and upper respiratory infections. Referrals made to or from these chiropractors were uncommon.
This mixed mode survey identified similarities and differences between doctors of chiropractic with a pediatric diplomate to other surveys of doctors of chiropractic, CAM professionals, and pediatric healthcare providers. The pediatric diplomate certificate was established in 1993 and provides didactic education over a 2 to 3 year span. The results of this study can be used for historical information as this specialty continues to grow.
Objectives. To review our sedation practice and to evaluate the clinical effectiveness of an anesthesiologist-administered intravenous sedation outside of the main operating room for pediatric upper gastrointestinal endoscopy (UGIE) in Thailand. Subjects and Methods. We undertook a retrospective review of the sedation service records of pediatric patients who underwent UGIE. All endoscopies were performed by a pediatric gastroenterologist. All sedation was administered by staff anesthesiologist or anesthetic personnel. Results. A total of 168 patients (94 boys and 74 girls), with age from 4 months to 12 years, underwent 176 UGIE procedures. Of these, 142 UGIE procedures were performed with intravenous sedation (IVS). The mean sedation time was 23.2 ± 10.0 minutes. Propofol was the most common sedative drugs used. Mean dose of propofol, midazolam and fentanyl was 10.0 ± 7.5 mg/kg/hr, 0.2 ± 0.2 mg/kg/hr, and 2.5 ± 1.2 mcg/kg/hr, respectively. Complications relatively occurred frequently. All sedations were successful. However, two patients became more deeply than intended and required unplanned endotracheal intubation. Conclusion. The study shows the clinical effectiveness of an anesthesiologist-administered IVS outside of the main operating room for pediatric UGIE in Thailand. All complications are relatively high. We recommend the use of more sensitive equipments such as end tidal CO2 and carefully select more appropriate patients.
A number of articles have addressed gender differences in the productivity of dentists, but little is known about differences in practice patterns for caries management. This study compared the use of a comprehensive range of specific diagnostic methods, preventive agents, and restorative decision making for caries management between male and female dentists who were members of The Dental Practice-Based Research Network(DPBRN).
This study surveyed general dentists who were members of DPBRN and who practiced within the United States. The survey asked about dentist, practice, and patient characteristics, as well as prevention, assessment, and treatment of dental caries. Differences in years since dental school graduation, practice model, full/part-time status, and practice owner/employee were adjusted in the statistical models, before making conclusions about gender differences.
Three hundred ninety-three male (84%) and seventy-three female (16%) dentists participated. Female dentists recommended at-home fluoride to a significantly larger proportion of their patients, whereas males had a preference for using in-office fluoride treatments with pediatric patients. Female dentists also choose to restore interproximal lesions at a significantly later stage of development, preferring to use preventive therapy more often at earlier stages of dental caries. There were few differences in diagnostic methods, time spent on or charges for restorative dentistry, and busyness of their practices.
DPBRN female dentists differ from their male counterparts in some aspects of the prevention, assessment, and treatment of dental caries, even with significant covariates taken into account. Practice patterns of female dentists suggest a greater caries preventive treatment philosophy.
Caries; Prevention; Fluoride; Female; Practice patterns; Sealant; Adult; Pediatric; Radiographs; Caries risk assessment
Aims. (1) To assess the efficacy and safety of pediatric office-based sedation for ophthalmologic procedures using a pediatric sedation service model. (2) To assess the reduction in hospital charges of this model of care delivery compared to the operating room (OR) setting for similar procedures. Background. Sedation is used to facilitate pediatric procedures and to immobilize patients for imaging and examination. We believe that the pediatric sedation service model can be used to facilitate office-based deep sedation for brief ophthalmologic procedures and examinations. Methods. After IRB approval, all children who underwent office-based ophthalmologic procedures at our institution between January 1, 2000 and July 31, 2008 were identified using the sedation service database and the electronic health record. A comparison of hospital charges between similar procedures in the operating room was performed. Results. A total of 855 procedures were reviewed. Procedure completion rate was 100% (C.I. 99.62–100). There were no serious complications or unanticipated admissions. Our analysis showed a significant reduction in hospital charges (average of $1287 per patient) as a result of absent OR and recovery unit charges. Conclusions. Pediatric ophthalmologic minor procedures can be performed using a sedation service model with significant reductions in hospital charges.
During routine deep sedation for endodontic therapy, a dentist-anesthesiologist observed premature ventricular contractions (PVCs) on a 62-yr-old woman's electrocardiogram (EKG) tracing. The dentist was able to complete the root canal procedure under intravenous (i.v.) sedation without any problems. The dentist-anesthesiologist referred the patient for medical evaluation. She was found to be free from ischemic cardiac disease with normal ventricular function. The patient was cleared to continue her dental treatment with deep sedation. She subsequently continued to undergo dental treatment with deep intravenous sedation without incident, although her EKG exhibited frequent PVCs, up to 20 per minute, including couplets and episodes of trigeminy. This article will review indications for medical intervention, antiarrhythmic medications, and anesthetic interventions for perioperative PVCs.
Safety is always the primary concern of surgeons and patients in any office-based procedure. With the growing use of safe intravenous sedation in this setting, a need for a standardized protocol for dissociative anesthesia exists. We have accomplished this task by using a sedation monitoring system, which could easily be implemented in any existing office-based operating setting. Our sedation monitor, abbreviated SeMo, provides a standardized means of monitoring deep intravenous sedation administration to patients in the operating room setting. The idea of SeMo is to develop a stand-alone system capable of integrating all facets of the operating room staff through a common communication media to improve efficiency and safety.
Dissociative anesthesia; intravenous sedation; sedation monitor; office-based protocol
The Certification for Imaging Informatics Professionals (CIIP) program is sponsored by the Society of Imaging Informatics in Medicine and the American Registry of Radiologic Technologists through the American Board of Imaging Informatics. In 2005, a survey was conducted of radiologists, technologists, information technology specialists, corporate information officers, and radiology administrators to identify the competencies and skill set that would define a successful PACS administrator. The CIIP examination was created in 2007 in response to the need for an objective way to test for such competencies, and there have been 767 professionals who have been certified through this program to date. The validity of the psychometric integrity of the examination has been previously established. In order to further understand the impact and future direction of the CIIP certification on diplomats, a survey was conducted in 2010. This paper will discuss the results of the survey.
PACS administration; Informatics training; Medical informatics applications
This study describes what training programs in pediatric dentistry and dental anesthesiology are doing to meet future needs for deep sedation/general anesthesia services required for pediatric dentistry. Residency directors from 10 dental anesthesiology training programs in North America and 79 directors from pediatric dentistry training programs in North America were asked to answer an 18-item and 22-item online survey, respectively, through an online survey tool. The response rate for the 10 anesthesiology training program directors was 9 of 10 or 90%. The response rate for the 79 pediatric dentistry training program directors was 46 of 79 or 58%. Thirty-seven percent of pediatric dentistry programs use clinic-based deep sedation/general anesthesia for dental treatment in addition to hospital-based deep sedation/general anesthesia. Eighty-eight percent of those programs use dentist anesthesiologists for administration of deep sedation/general anesthesia in a clinic-based setting. Pediatric dentistry residency directors perceive a future change in the need for deep sedation/general anesthesia services provided by dentist anesthesiologists to pediatric dentists: 64% anticipate an increase in need for dentist anesthesiologist services, while 36% anticipate no change. Dental anesthesiology directors compared to 2, 5, and 10 years ago have seen an increase in the requests for dentist anesthesiologist services by pediatric dentists reported by 56% of respondents (past 2 years), 63% of respondents (past 5 years), and 88% of respondents (past 10 years), respectively. Predicting the future need of dentist anesthesiologists is an uncertain task, but these results show pediatric dentistry directors and dental anesthesiology directors are considering the need, and they recognize a trend of increased need for dentist anesthesiologist services over the past decade.
Demand for services; Dental anesthesiologist; Pediatric dentist
The authors conducted a study to identify factors associated with material use by dentists in The Dental Practice-Based Research Network (DPBRN) when placing the first restoration on permanent tooth surfaces.
A total of 182 DPBRN practitioner-investigators provided data on 5,599 posterior teeth with caries. Practitioner-investigators completed an enrollment questionnaire that included the dentist’s age, gender, practice workload, practice type, and years since graduation. When a consented patient presented with a previously un-restored carious surface, practitioner-investigators recorded patient and tooth characteristics.
Amalgam was used more often than direct resin-based composite (RBC) for posterior carious lesions. Practitioner/practice characteristics (years since graduation and type of practice); patient characteristics (gender, race, age, and dental insurance); and lesion characteristics (tooth location and surface, pre-and post-operative depth) were associated with the type of restorative material used.
There are several practitioner/practice, patient, and lesion characteristics significantly associated with use of amalgam and RBC: region, years since graduation, dental insurance, tooth location and surface, and pre-and post-operative depth.
Amalgam remains a material commonly used by United States dentists to restore posterior caries lesions.
direct resin-based composite; amalgam; practice-based research; multi-center studies; clinical research
The administration of sedatives in terminally ill patients becomes an increasingly feasible medical option in end-of-life care. However, sedation for intractable distress has raised considerable medical and ethical concerns. In our study we provide a critical analysis of seven years experience with the application of sedation in the final phase of life in our palliative care unit.
Medical records of 548 patients, who died in the Palliative Care Unit of GK Havelhoehe between 1995–2002, were retrospectively analysed with regard to sedation in the last 48 hrs of life. The parameters of investigation included indication, choice and kind of sedation, prevalence of intolerable symptoms, patients' requests for sedation, state of consciousness and communication abilities during sedation. Critical evaluation included a comparison of the period between 1995–1999 and 2000–2002.
14.6% (n = 80) of the patients in palliative care had sedation given by the intravenous route in the last 48 hrs of their life according to internal guidelines. The annual frequency to apply sedation increased continuously from 7% in 1995 to 19% in 2002. Main indications shifted from refractory control of physical symptoms (dyspnoea, gastrointestinal, pain, bleeding and agitated delirium) to more psychological distress (panic-stricken fear, severe depression, refractory insomnia and other forms of affective decompensation). Patients' and relatives' requests for sedation in the final phase were significantly more frequent during the period 2000–2002.
Sedation in the terminal or final phase of life plays an increasing role in the management of intractable physical and psychological distress. Ethical concerns are raised by patients' requests and needs on the one hand, and the physicians' self-understanding on the other hand. Hence, ethically acceptable criteria and guidelines for the decision making are needed with special regard to the nature of refractory and intolerable symptoms, patients' informed consent and personal needs, the goals and aims of medical sedation in end-of-life care.
terminal sedation; palliative care; ethics; symptom control; attitudes; advance directives
The purpose of this study was to evaluate sedation practice in UK intensive care units (ICUs), particularly the implementation of daily sedation holding, written sedation guidelines, sedation scoring tools and choice of agents.
A national postal survey was conducted in all UK ICUs.
A total of 192 responses out of 302 addressed units were received (63.5%). Of the responding ICUs, 88% used a sedation scoring tool, most frequently the Ramsey Sedation Scale score (66.4%). The majority of units have a written sedation guideline (80%), and 78% state that daily sedation holding is practiced. A wide variety of sedating agents is used, with the choice of agent largely determined by the duration of action rather than cost. The most frequently used agents were propofol and alfentanil for short-term sedation; propofol, midazolam and morphine for longer sedation; and propofol for weaning purposes.
Most UK ICUs use a sedation guideline and sedation scoring tool. The concept of sedation holding has been implemented in the majority of units, and most ICUs have a written sedation guideline.
Sedation and analgesia are provided by using different agents and techniques in different countries. The goal is to achieve early spontaneous breathing and to obtain an awake and cooperative pain-free patient. It was the aim of this study to conduct a survey of the agents and techniques used for analgesia and sedation in intensive care units in Germany.
A survey was sent by mail to 261 hospitals in Germany. The anesthesiologists running the intensive care unit were asked to fill in the structured questionnaire about their use of sedation and analgesia.
A total of 220 (84%) questionnaires were completed and returned. The RAMSAY sedation scale was used in 8% of the hospitals. A written policy was available in 21% of hospitals. For short-term sedation in most hospitals, propofol was used in combination with sufentanil or fentanyl. For long-term sedation, midazolam/fentanyl was preferred. Clonidine was a common part of up to two-thirds of the regimens. Epidural analgesia was used in up to 68%. Neuromuscular blocking agents were no longer used.
In contrast to the US 'Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult', our survey showed that in Germany different agents, and frequently neuroaxial techniques, were used.
The purposes of this study were to (1) quantify dentists' practice patterns regarding caries prevention and (2) test the hypothesis that certain dentists' characteristics are associated with these practice patterns.
The study used a cross-sectional study design consisting of a questionnaire survey.
The study queried dentists who worked in outpatient dental practices who were affiliated with the Dental Practice-Based Research Network Japan, which seeks to engage dentists in investigating research questions and sharing experiences and expertise (n=282).
Dentists were asked about their practice patterns regarding caries preventive dentistry. Background data on patients, practice and dentist were also collected.
38% of dentists (n=72) provided individualised caries prevention to more than 50% of their patients. Overall, 10% of the time in daily practice was spent on caries preventive dentistry. Dentists who provided individualised caries prevention to more than 50% of their patients spent significantly more time on preventive care and less time on removable prosthetics treatment, compared to dentists who did not provide individualised caries prevention. Additionally, they provided oral hygiene instruction, patient education, fluoride recommendations, intraoral photographs taken and diet counselling to their patients significantly more often than dentists who did not provide individualised caries prevention. Multiple logistic regression analysis suggested that the percentage of patients interested in caries prevention and the percentage of patients who received hygiene instruction, were both associated with the percentage of patients who receive individualised caries prevention.
We identified substantial variation in dentists' practice patterns regarding preventive dentistry. Individualised caries prevention was significantly related to provision of other preventive services and to having a higher percentage of patients interested in caries prevention, but not to the dentist's belief about the effectiveness of caries risk assessment. (Clinicaltrials.gov registration number NCT01 680 848).
EPIDEMIOLOGY; ORAL MEDICINE; PREVENTIVE MEDICINE; PUBLIC HEALTH