New Guidelines for the use of GA in Special Care Dentistry

The new General Anaesthetic Guidelines have been published by the British Society for Disability and Oral Health... but what do they include?

Who does the Guideline apply to?

The guideline relates to special care patients (those over 16 years old) who might require a general anaesthetic for their dental treatment, where other means of treatment have been exhausted or deemed inappropriate (such as behaviour management or sedation). This could for example be for patients with:
  • Learning Disabilities
  • Dementia
  • Autism
  • Physical or Sensory Disabilities
  • Significant medical complexities
  • Significant dental phobia

Overarching Principles

  1. The use of GA should be based on a comprehensive assessment of patient and clear rationale
  2. Due to risks of GA it should not be a first-choice approach to facilitating dental care, but when other means are contraindicated or not feasible
  3. GA should only be provided where there is expected to be a significant benefit to the patient which outweighs the risks of the GA itself
  4. GA should not be provided for examination alone, but when there is a known or suspected dental condition that required intervention
  5. Dental care planning under GA must take into account each patients' values and preferences
  6. Interprofessoinal collaboration between dental teams, anaesthetic teams and wider health and social care teams should be encouraged
  7. The overall planning of the GA should ideally be lead by a consultant or specialist in Special Care Dentistry 

Summary of Key Points

1. Assessment and Planning

  • Factors to consider in planning of a GA e.g. patient views and preferences, medical history, views of other patient advocates, patient's social history
  • Details to include when referring patients for GA
  • Information to be gathered at patient assessment for GA
  • Dental examination: where possible, examination and investigations to be carried out prior to GA,  with access to a second clinical opinion where necessary
  • Where possible, a consultant or specialist in Special Care Dentistry should lead with treatment planning
  • Dental teams should proactively facilitate access to additional procedures under the same anaesthetic episode if possible for example blood tests, examination by other medical specialities, toe nail cutting
  • Anaesthetic pre-assessment including suitability for day-case or inpatient facilities. 
  • Hospital passports and other information should be gathering including medical information and reasonable adjustments for patients with learning disabilities or potentially challenging behaviour. This includes the possible use of premedication, the need for calm and controlled environment, the possible need for clinical holding and manual handling requirements e.g. use of hoist. 
  • Consent procedures and considerations for patients who have and do not have capacity to consent 

2. Delivery of the GA

  • Settings suitable for GA and the recommendation for a lead anaesthetist for Special Care Dentistry
  • Admission procedures and communication between the teams 
  • The use of anxiolytic premedication and non-pharmacological methods of anxiety management
  • Airway and anaesthetic management

3. Intra-operative Care

  • Full clinical and radiographic examination should be available unless these were obtained prior to the GA
  • Clinical decision making must be carried out by two clinicians, with one of these ideally being a consultant or specialist in Special Care Dentistry 
  • Where possible, all dental treatment should be carried out under a single episode of GA
  • Preventative care should be implemented which may include the application of fluoride varnish
  • Recommendations for restorative and surgical care

4. Post-procedural Considerations

  • Processes for post-op care, recovery and discharge
  • Plans for unforeseen admissions 
  • Follow-up arrangements for patient - telephone review within 48 hours and whether patient remains in specialist service or discharged to a GDP/CDS dentist 

5. Education and Training

  • Training requirements for new starters for dentists and dental nurses: including number of supervised cases before they can lead a GA (20 cases, 15 of which where pre-operative examination prior to the GA is not possible/limited)
  • Log books of clinical experience should be kept
  • Ideally, a lead dental nurse qualified in Special Care Dentistry should support the team

6. Clinical Governance

  • Requirements for record keeping - including adherence to standard operating procedures
  • Audit and research recommendations
  • Regular peer review should be encouraged and review of good practice
  • Patient feedback should be sought, including Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs)

What do you think of the new guidelines? Let me know in the comments below. 

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