Queensway Anxiety Management - Management Techniques

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Introduction
Referral Procedures
Assessment Visit
Patient Selection
Management Techniques
Preoperative Help
Consent
Treatment Appointment
Clinical/Admin. Follow-up
Audit
Reference For Referrers
Medical Considerations
Appendix

Choice of Anxiety Management Techniques

Our aim is to reduce the number of general anaesthetics, ensure compliance with GDC guidance and where possible to provide treatment under oral, inhalation or intravenous sedation.

Each patient's individual concerns and fears are assessed by careful and delicate discussion.

The anxiety management strategy of choice will be a conscious sedative technique. Relative analgesia will be offered as a first line management technique if patients fulfil the following criteria

Children aged 3 years and over.
Children who speak English as a first language and are not educationally impaired.
Children who sit in the dental chair at assessment and are able to tolerate an examination.
Children who have non obstructed nasal airways.
Children who do not present with acute oro-facial swellings.
Children and parents who are able to give informed consent to treatment with inhalation sedation.
Children requiring elective treatment.

The preference of conscious sedation over a general anaesthetic is implicit in the recent changes to the legal status of general anaesthesia for dental procedures. Children who are unable to accept treatment under Local anaesthesia with relative analgesia alone will be assessed and due to one or more of the following:-

The child's level of anxiety is four or more on the visual analogue scale (Wong Baker 1988)
The dentist's assessment of the child's co-operation is three or more on the Venham Scale. (Venham Bengston et al 1977)

The dental treatment required is particularly invasive (e.g. multiple or difficult extractions)

These patients will require consultant anaesthetist-given conscious sedation with sevoflurane inhalation conscious sedation, IV midazolam or in exceptional circumstances a combination of inhalation and IV conscious sedation will be used. During treatment the level of consciousness will be observed continuously using a six point scale for conscious sedation (Girdler Hill 1998). Children will be maintained between level three and four.

Where there is a compelling clinical need for treatment and we have established that other available behavioural management techniques are unsatisfactory or inappropriate we will prescribe a general anaesthetic in line with our protocols. We will refer to the appropriate "Hospital setting" on your behalf and furnish you with a copy of the referral letter.

The following categories are likely to be appropriate for general anaesthesia, in suitably selected patients, at this clinic if there is a compelling clinical need.

Children 0-4 years old in pain and having disturbed sleep
Acute conditions such as dental abscesses that have given repeated bouts of pain and swelling.
Failed local anaesthesia, relative analgesia, conscious intravenous sedation with one or more of the above.
Patients who do not have an adequate degree of comprehensions and understanding regarding the treatement (if necessary with the support of interpretation services).

Orthodontic extractions

The anxiety management strategy of choice will be a conscious sedation technique. Relative analgesia will be the first line management technique for children referred for orthodontic extractions. Conscious intravenous sedation may be appropriate in older children and young people. We do not consider orthodontic extractions a justification to prescribe a general anaesthetic.