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Estimating the Need for Sedation in Patients with Dental Anxiety and Medical Complexities Reporting to Tertiary Care Dental Hospital Using the IOSN Tool

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International Journal of Dentistry
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Objectives. To provide consistent method for assessment of sedation need among patients undergoing dental treatment based on specific risk factors that is dental anxiety, medical status, and treatment complexity of needed dental treatment using IOSN (indication of sedation need) tool for assisting the clinician in decision making process. Methods. A total of 237 patients aged ≥12, ASA I and II were enrolled in the study. A structured questionnaire comprising of three sections was distributed among the participants. Section 1 comprises details about age, gender, literacy level, occupation, monthly income, and previous dental treatment history. Section 2 is based on Modified Dental Anxiety Scale which is a questionnaire comprising of five questions ranging from “not anxious” to “extremely anxious.” The third section was based on using the IOSN tool comprising three components: MDAS (Modified Dental Anxiety Scale) rank score, Systemic Health (ASA status) rank score, and treatment complexity rank scores. The total of three scores was then computed to determine the total rank score which suggested the sedation need. History of past traumatic dental experiences was also inquired from each patient. Results. A total of 237 patients aged ≥12, ASA I and II were enrolled in the study, out of which 56.1% were female. Statistical analysis was conducted by using the IBM SPSS Statistics 23 software. Based on the MDAS score, 47/237 (19.8%) participants were found to be highly anxious related to dental procedures. 34.6% of the participants showed to have a high sedation need while performing a dental procedure. The sedation need was found to be significantly associated with the female gender with a significant p value of p=0.016, higher education status p=0.016, and history of previous traumatic dental experience p
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Research Article
Estimating the Need for Sedation in Patients with Dental Anxiety
and Medical Complexities Reporting to Tertiary Care Dental
Hospital Using the IOSN Tool
Beenish Abbas ,
1
Ayesha Maqsood,
2
Syeda Rabia Rahat Geelani,
2
Madeeha Sattar,
3
Majida Rahim,
4
and Zohaib Khurshid
5
1
Department of Pedodontics, Foundation University College of Dentistry, Islamabad, Pakistan
2
Department of Oral and Maxillofacial Surgery, Foundation University College of Dentistry, Islamabad, Pakistan
3
Department of Operative Dentistry, Islamabad, Pakistan
4
Department of Oral Medicine, Foundation University College of Dentistry, Islamabad, Pakistan
5
Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa 31982,
Saudi Arabia
Correspondence should be addressed to Beenish Abbas; beenishabbas1982@gmail.com
Received 24 November 2021; Revised 8 March 2022; Accepted 18 March 2022; Published 26 April 2022
Academic Editor: Sivakumar Nuvvula
Copyright ©2022 Beenish Abbas et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objectives. To provide consistent method for assessment of sedation need among patients undergoing dental treatment based on
specific risk factors that is dental anxiety, medical status, and treatment complexity of needed dental treatment using IOSN
(indication of sedation need) tool for assisting the clinician in decision making process. Methods. A total of 237 patients aged 12,
ASA I and II were enrolled in the study. A structured questionnaire comprising of three sections was distributed among the
participants. Section 1 comprises details about age, gender, literacy level, occupation, monthly income, and previous dental
treatment history. Section 2 is based on Modified Dental Anxiety Scale which is a questionnaire comprising of five questions
ranging from “not anxious” to “extremely anxious.” e third section was based on using the IOSN tool comprising three
components: MDAS (Modified Dental Anxiety Scale) rank score, Systemic Health (ASA status) rank score, and treatment
complexity rank scores. e total of three scores was then computed to determine the total rank score which suggested the
sedation need. History of past traumatic dental experiences was also inquired from each patient. Results. A total of 237 patients
aged 12, ASA I and II were enrolled in the study, out of which 56.1% were female. Statistical analysis was conducted by using the
IBM SPSS Statistics 23 software. Based on the MDAS score, 47/237 (19.8%) participants were found to be highly anxious related to
dental procedures. 34.6% of the participants showed to have a high sedation need while performing a dental procedure. e
sedation need was found to be significantly associated with the female gender with a significant pvalue of (p0.016), higher
education status (p0.016), and history of previous traumatic dental experience (p<0.001).Conclusion. A simple assessment
tool can enable clinicians in their decision making to identify patients in need for dental treatment under sedation based on
patient-specific risk factors such as past traumatic dental experiences. Need for sedation can be assessed by information on patient
anxiety level towards dental treatment, medical history, and complexity of planned dental treatment. e IOSN tool is a simple
and quick assessment tool that can be applied for preprocedural assessment of sedation need for dental treatment.
1. Introduction
Vicarious learning from anxious peers, past traumatic
dental experiences, and certain personality traits contribute
towards the development of lifelong behavior issues such as
dental anxiety and phobias which may necessitate the need
for sedation. Sedation is also indicated for patients
reporting with medical conditions which may aggravate
under a stressful environment like in angina patients,
anxiety and pain can increase the release of endogenous
catecholamines, thereby increasing the load on the car-
diovascular system. Similarly, asthmatic patients can
Hindawi
International Journal of Dentistry
Volume 2022, Article ID 5824429, 6 pages
https://doi.org/10.1155/2022/5824429
present with an acute episode of breathing difficulty in-
duced by stress [1].
Sedation is a safe and effective pharmacological behavior
management modality which can be used as an alternative to
more complex options such as general anaesthesia in certain
patients. In this pharmacological anxiety reduction protocol,
use of drugs causes depression of the central nervous system
enabling treatment to be carried out in a more relaxed
environment. At the same time, verbal contact with the
patient is maintained throughout treatment [1].
According to the treating clinician and patient per-
spective, sedation for complex dental treatment has been
gaining popularity in recent years, as patients are more
informed about the anxiety reduction treatment options
available. However, adhering to strict standard clinical
screening and individualized patient treatment needs is
essential to ensure good clinical practice [2]. To achieve this,
there is a need for an objective, comprehensive assessment
tool to evaluate the need for sedation as clinical decision
making is complicated. e tool should be useful in selecting
the right patient based on medical history, level of dental
anxiety, and complexity of dental treatment needed. is
aids in optimizing patient safety and setting guidelines for
adequate staff training [3].
is study aims to work on a simple assessment tool to
provide the minimum patient data set needed to establish
the need for sedation. Sociodemographic factors, past
traumatic dental experiences, and dental anxiety will be
assessed using a questionnaire based on a modified dental
anxiety scale. e American Society of Anesthesiologist
classification system will be used to assess the medical status
of the patient, and each patient will be assigned a score to
grade dental treatment complexity level. is novel assess-
ment tool does not take more than a few minutes of treating
clinicians’ time to provide comprehensive patient
assessment.
2. Methodology
e study was conducted after approval from the Ethical
Review Committee of the Foundation University College of
Dentistry, Islamabad, with ERC ref no. (FF/FUCD/632/
ERC001).
e minimum sample size required for this prospective
cross-sectional analytical study was 237, calculated by using
formula (n[deff np(1-p)]/[(d2/z21-α/2 (n-1)+p(1-
p)]-open epi calculator), with 95% confidence level and 5%
margin of error [4]. A nonprobability consecutive sampling
methodology was employed and total (n250) participants
enrolled in the study. Informed written consent was ob-
tained with the assurance of anonymity and confidentiality
from the participants before filling out the questionnaire.
Patients aged >12 years, irrespective of gender, were
recruited in the study. Nonconsenting participants, mentally
incapacitated patients with debilitating mental or physical
illness (ASA 3 and above) and/or already on any psychiatric
or chronic ailment treatments and patients with a history of
insomnia who were on sedatives were excluded from the
study.
A structured questionnaire comprising of three sec-
tions was distributed among all the study participants. e
questionnaire was designed both in Urdu and English
after validation and expert opinion on the subject. Section
1 (anxiety questionnaire to be completed by patient)
comprised the details such as patient age, gender, occu-
pation, monthly income, and past experience of traumatic
dental treatment. Section 2 is based on Modified Dental
Anxiety Scale which is a form of questionnaire comprising
of five questions in which range of each item is from “not
anxious” to “extremely anxious” assessed on following
occasions:
(i) Dental clinic visits.
(ii) While in the waiting room for dental treatment at
the dentist’s office.
(iii) Awaiting in the dental chair for tooth drilling.
(iv) Awaiting in the dental chair for teeth scaling.
(v) Awaiting in the dental chair for local anesthetic
infiltration.
Not anxious is given a score 1 and highly anxious is given
a score 5. e modified dental anxiety scale questionnaire
which is used to assess anxiety component of IOSN tool
provides the summed score between 5 to 25 which is then
converted to rank score of 1—4. ASA I patients were
assigned rank score 1, ASA II patients according to their
medical condition was rank scored as 2. ASA III patients
were allotted rank score 3. ird component of the IOSN
tool was related to treatment complexity of needed dental
treatment routine procedures such as scaling, and single
quadrant restorations were rank scored as 1. Intermediate
complexity procedures such as surgical extraction, scaling
with root planning, or two quadrant restorations were al-
lotted rank score 2. Complex dental procedures such as
periodontal surgery, surgical extraction with bone removal,
apicectomy posterior tooth, multiple quadrant restorative,
and multiple posterior endodontics. First component of the
IOSN tool was MDAS score; modified dental anxiety scale
score (5–9) indicating minimal dental anxiety was ranked
score as 1, MDAS score (10–12) indicating moderate patient
anxiety was given rank score 2. Likewise MDAS score
(13–17) indicative of high patient dental anxiety was
assigned rank score 3. Similarly, MDAS value of (18–25)
showing very high dental anxiety was rank scored as 4. e
second component of the IOSN tool comprised patient
medical status. Periodontal surgery was assigned a rank
score of 3. High complexity dental procedures were allotted
rank score 4. For each patient anxiety score, medical history
score and treatment complexity score was ranked and en-
tered in the IOSN tool and summative score of all three
components of the IOSN tool gives an overall score between
3 and 12 with lowest score 3 indicating minimal need for
sedation. (Figure 1)
2.1. Indicator of Sedation Need Tool
(i) Routine: scale, single rooted extraction of 1 or 2
teeth, small soft tissue biopsy, single quadrant
2International Journal of Dentistry
restorations, crown preparations, or anterior end-
odontic treatment.
(ii) Intermediate: scale and root planning, multirooted
tooth extraction, surgical extraction without bone
removal, apicectomy anterior tooth, 2 quadrant
restorative, and posterior endodontic treatment.
(iii) Complex: periodontal surgery, surgical extraction
with bone removal, apicectomy posterior tooth,
multiple quadrant restorative, and multiple poste-
rior endodontics.
(iv) High complexity: any treatment considered more
complex than above or are multiples of the above.
Statistical analysis was performed by the IBM SPSS
Statistics 23. Descriptive statistics were performed for age
and demographic data. A chi-square test was used to find a
statistically significant association between variables. A p
value of 0.05 was considered statistically significant.
3. Results
e data from 237 participants were considered for analysis
in this study. Out of 237, 104 (43.9%) males and 133 (56.1%)
females were in the study group. e majority of the par-
ticipants, 96 (40.5%) belonged to age group of 41–50 years,
while least, 47 (19.8%), were from 21 to 30 years age group.
Out of 237, 150 (63.2%) were unemployed including stu-
dents, housewives, and retired persons, while the remaining
87 (36.7%) were employed. 48 (20.3%) participants were
with no education, while 49 (20.7%) were graduates and 56
(23.6%) also had postgraduation. e demographic char-
acteristics of the study participants are summarized in Ta-
ble 1 in detail.
Experience of traumatic and fearful dental procedures
was reported by 90/237 (38.0%) of the participants. e
Modified Dental Anxiety Score (MDAS) was calculated to be
12.87 ±4.9 based on five anxiety assessment questions. Based
on MDAS score, 47/237 (19.8%) participants were found to
be experiencing very high anxiety related to dental proce-
dures as shown in Figure 2. e dental procedure anxiety
was significantly associated with female gender (p0.016),
higher education status (p0.012), and past traumatic/
fearful dental procedure (p<0.001). e majority of the
participants 127 (53.5%) reported to feel anxious a day
before going to the dentist for a dental procedure ap-
pointment (grade 2 and above on scale of 1–5). Similarly,
significant portion of participants, 133 (56.1%) said to feel
anxious while sitting in waiting room before getting a dental
procedure done. During the procedure, 189 (79.7%) re-
ported to have felt anxious before getting a tooth drilled
(grade 2 and above on scale of 1–5), 136 (57.3%) felt anxious
before getting scaling/polishing of tooth, while 202 (85.2%)
felt anxious before getting local anaesthesia injection in gum
(grade 2 and above on scale of 1–5), as depicted in Table 2.
In terms of medical and behavioral indicator rank score,
141 (59.5%) participants belonged to ASA grade 1, while the
remaining 96 (40.5%) belonged to grade 2. Concerning
treatment complexity score 24 (10.1%) participants under-
went routine procedures including scaling, single rooted
extraction of 1 or 2 teeth, small soft tissue biopsy, single
quadrant restorations, crown preparations, or anterior
endodontic treatment, whereas 191 (80.6%) participants
underwent intermediate procedures including scale and root
planning, multirooted tooth extraction, surgical extraction
without bone removal, apicectomy anterior tooth, 2 quad-
rant restorative, and posterior endodontic treatment.
Complex procedures including complex periodontal sur-
gery, surgical extraction with bone removal, apicectomy
posterior tooth, multiple quadrant restorative, and multiple
posterior endodontics were performed in only 22 (9.3%)
participants.
Table 1: Demographic characteristics of study participants
(n237).
Demographic characteristics N (%)
Age groups
12–20 years 44 (22.3%)
21–30 years 47 (19.8%)
31–40 years 50 (21.1%)
41–50 years 96 (40.5%)
Gender Male 104 (43.9%)
Female 133 (56.1%)
Occupation
Student 66 (33.3%)
Housewife 82 (34.5%)
Private job 40 (16.9%)
Government job 25 (10.5%)
Self-employed 22 (9.3%)
Retired from army 2 (1.0%)
Monthly income (PKR)
Dependent 150 (63.3%)
20–30,000 22 (9.3%)
31–50,000 27 (11.4%)
>50,000 38 (16.0%)
Education
Less than primary 48 (20.3%)
Primary 46 (19.4%)
Secondary 38 (16.0%)
Graduate 49 (20.7%)
Postgraduate 56 (23.6%)
IOSN Tool
MDAS Rank
MDAS 5-9 MDAS
10-12
NDAS
13-17
MDAS
18-25
Medical &
Behavioral
Score
ASA I ASA II ASA III ASA IV
Treatment
Complexity
Score
Routine Intermediate Complex Highly
Complex
Figure 1: IOSN tool.
International Journal of Dentistry 3
e mean sedation need score based on mean dental
anxiety score (MDSA), medical and behavioral indicator
rank score, and complexity of dental procedure score was
calculated to be 5.83 ±1.35. It was found that 49 (20.7%)
participants had minimal need of sedation during dental
procedure, 106 (44.7%) had moderate need whereas 82
(34.6%) were found to have a high sedation need while
performing a dental procedure. e sedation need was found
to be significantly associated with female gender (p0.034)
and history of previous traumatic dental experience
(p<0.001)as shown in Table 3.
4. Discussion
Various studies have been conducted locally and interna-
tionally, which evaluate the dental anxiety scale of the pa-
tient [5]. Recently published literature supported the need
for risk-based preprocedural assessment to make an ob-
jective decision of providing sedation. Keeping in view the
patient risk factors, preprocedural risk assessment to de-
termine the need for sedation is described as the minimum
standard of care as reported by Sutherland et al. [6].
Nowadays, patient-focused healthcare and decision
making are given prime importance. at is why the pa-
tient’s level of anxiety regarding dental treatment will help
the dentist reach a decision regarding the need for sedation.
e use of sedation enables the patient to have his required
dental treatment without finding it stressful [7]. Use of
sedation is variable among dentists, with some using it
injudiciously, whereas others are not using it at all.
e anxiety component of the IOSN Tool (Indicator of
Sedation Need Tool) was calculated using Modified Dental
Anxiety Scale (MDAS) as it is deemed as a very relevant and
brief tool [8].
Pretreatment compounding factors have positive influ-
ence on anxiety levels such as previous dental procedures
performed and environmental factors which are divided into
three categories including personal factors such as patient
age and mental status. Second important environmental
factor is external factors such as socioeconomic status,
education, and racial factors. Dental factors such as attitude
of dental team are also an important environmental factor to
consider towards patient anxiety [9]. Similarly, females
showed higher level of anxiety while giving local anaesthesia
and tooth being drilled compared to males [10]. Another
study supported that gender (females), age, and education
significantly affect dental anxiety [11]. Similarly, the results
of our study also found that dental procedure anxiety was
significantly associated with female gender (p0.016).
Table 2: Frequency of participant responses to questions related to anxiety related to dental procedure (n237).
Participant responses
1 2 3 4 5
Before going to dentist for treatment tomorrow, how do you feel? 110 (46.4%) 65 (27.4%) 44 (18.6%) 9 (3.8%) 9 (3.8%)
While sitting in waiting room before treatment, how do you feel? 104 (43.9%) 54 (22.8%) 53 (22.4%) 13 (5.5%) 13 (5.5%)
Before getting a tooth drilled, how do you feel? 48 (20.3%) 40 (16.9%) 35 (14.8%) 71 (30.0%) 43 (18.1%)
Before getting tooth scaled and polished, how do you feel? 101 (42.6%) 34 (4.3%) 59 (24.9%) 25 (10.5%) 18 (7.6%)
Before getting local anaesthesia in gum, how do you feel? 35 (14.8%) 34 (14.3%) 33 (13.9%) 35 (14.8%) 100 (42.2%)
Participant responses: 1, not anxious; 2, slightly anxious; 3, fairly anxious; 4, very anxious; 5, extreme anxious.
Table 3: Sedation need while performing dental procedure and its
association with past traumatic dental experience.
Categories of sedation need
Pvalue
Minimal
(n49)
Moderate
(n106)
High
(n82)
Gender
Male 15 (30.6%) 45 (42.5%) 44 (53.7%) 0.034
Female 34 (69.4%) 61 (57.5%) 38 (46.3%)
Past traumatic dental experience
Yes 1 (2.0%) 47 (44.3%) 42 (51.2%) <0.001
No 48 (98.0%) 59 (55.7%) 40 (48.8%)
Bold shows Pvalue of less than .001 is considered statistically significant.
13.20% 23.30%
53.60% 59.60%
86.80% 76.70%
46.40% 40.40%
MINIMAL
ANXIETY
MODERATE
ANXIETY
HIGH
ANXIETY
VERY HIGH
ANXIETY
History of traumatic dental experience
No history of traumatic dental experience
Figure 2: Comparison of mean dental anxiety score (MDAS) classes with past traumatic dental experience.
4International Journal of Dentistry
Dental anxiety is stress-provoking both for patients and
dentist alike, leading to misdiagnosis and an unpleasant
treatment environment due to diminished patient cooper-
ation which may ultimately lead to poor oral, periodontal
health, and increased emergency attendance resulting from
avoidance of dental appointments as reported by Zinke et al.
[12]. Irregular dental visits leading to poor oral health is
associated with dental anxiety and phobias. Younger pa-
tients, females, and patients with previous unpleasant dental
experience were associated with increased MDAS scores.
Likewise, in our study, correlation has been established that
59.60% patients having past traumatic dental experiences
presented with very high dental anxiety [13, 14].
Demographic characteristics of our study participants
regarding their educational status show somewhat equal
distribution of participants regarding their education status,
with graduate and postgraduate being slightly high in
number. Higher the educational status, more was the anx-
iety, as seen in this study (p0.012). Similar findings were
also observed in other studies [11, 15].
Based on MDAS (Modified Dental Anxiety Scale) score,
most of the participants in our study felt anxious while sitting
in a waiting room before getting a dental procedure done
(grade 2 and above on scale of 15), while it was closely
followed by 53.5% who felt anxious a day before going to
dentist. MDAS was selected to measure the dental anxiety
component of the IOSN tool and need for sedation because
this scale is simple and universally well accepted [16, 17].
e patients’ anxiety depends upon the dental procedure
he is undergoing. Our study suggests that quite a high pro-
portion of patients (42.2%) were extremely anxious while
getting local anaesthesia. Another study reported higher
anxiety scores in patients receiving local anaesthesia [18]. is
was contradictory to a study where most of the patients who
were having dental filling exhibited most anxiousness [19].
Recent study reported that patients with traumatic
dental event have higher scores of dental anxiety (p0.028)
which leads to negative perceptiveness about dental treat-
ment and dentist [20]. Our study has a significant associ-
ation of dental anxiety with past traumatic dental experience
(p>0.001). In terms of traumatic and unpleasant past dental
experiences, younger the patient at the time of fearful dental
experience, higher are the chances of translating into more
anxious behavior owing to the emotional vulnerabilities of
adolescents and children. Another study reported significant
higher IOSN scores and need of sedation in 60.3% of patients
having unpleasant dental experiences. Patients who reported
previous traumatic dental experiences were 2.24 times more
likely to need sedation [21]. A recent study by Merdad and
El-Housseiny shows a significant association between
traumatic dental experience and poor oral health-related
quality of life had greater caries experience with more
avoidance behavior towards dental appointments [22].
While comparing the medical risk factors score, most
(59.5%) of the participants belonged to the group ASA Grade
I while the remaining (40.5%) belonged to Grade II. Another
recent study by Dziedzic et al. highlighted the crucial role of
the comprehensive assessment strategy in medically
compromised and special care patients for safe delivery of
conscious sedation as an alternative to general anaesthesia
for vulnerable patient group [23].
In our study, while applying the IOSN tool, 34.6% were
found to have a high sedation need while performing the
dental procedures. is was contradictory to a study which
found that only 2.4% of the patients showed a high need for
sedation when the IOSN tool was applied to their study
population [24].
More the complexity of dental procedure, more is the
need for sedation. at is why we see that in minor oral
surgical procedures such as third molar surgery, many of the
dentists prefer sedation [25]. Many methods for sedation are
being used for third molar impactions. All these methods
aim to achieve better patient outcomes in terms of pain
control as noted in other studies [26]. Also, patients pre-
senting with periodontal disease with higher anxiety levels,
while undergoing scaling and root planning treatments may
exhibit negative clinical outcomes. us, suggesting that
even for simpler procedures sedation can play an important
role to achieve better patient outcomes in terms of pain
control [27].
Preprocedural comprehensive patient evaluation is an
integral part of an up-to-date sedation practice. Detailed
evaluation of patient parameters is of utmost significance in
developing an individualized agreed-upon sedation plan that
reflects minimum standard of dental care with low risk of
complications. Research is lacking on the development and
application of a validated sedation scoring system to predict
requirement of sedation based on individual patient pa-
rameters which would further enhance shared decision
making between clinician and patients as it holds utmost
significance to enhance patient satisfaction [6]. e recent
pandemic has led to increasing demands on the hospitals
with deferral of general anaesthesia and hospital-based se-
dation. erefore, the use of dental sedation is the need of
hour to provide optimal dental services in dental clinics on
out-patient basis. In order to provide required support in
specialized dental care and to meet the current health care
needs, we need more trained personnel in the field of se-
dation [23].
e limitation of this study was a smaller sample size and
a wider age range, and the data were recruited from single-
hospital setting, thus lacking the generalizability. Similarly,
we applied this tool over a variety of the dental procedures,
some complex and some rather simple. e study lacks the
degree of variability because anxiety questionnaire score
revolves around dental treatment events and noncognitive
factor (traumatic dental event). is tool can be further
modified as it has certain limitations. It does not indicate the
level of sedation required for a particular patient, ranging
from mild sedation to general anaesthesia. is study was an
initial step towards applying this innovative tool for cal-
culating the need for sedation in dental patients. In future,
this could be used to carry out multicenter studies which will
help in further validation of this tool. is instrument could
be modified and applied for patients with special needs and
pediatric patients.
International Journal of Dentistry 5
5. Conclusion
A simple assessment tool can enable clinicians in their
decision making to identify patients in need for dental
treatment under sedation based on patient-specific risk
factors such as past traumatic dental experiences. Need for
sedation can be assessed by information on patient anxiety
level towards dental treatment, medical history, and com-
plexity of planned dental treatment.
Data Availability
e data used to support the findings of this study are
available on request.
Conflicts of Interest
e authors have no conflicts of interest to declare.
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6International Journal of Dentistry
... It should be noted that this questionnaire was not administered prior to the initiation of any specific treatment but rather during a general dental examination. Severe anxiety/phobia was observed in only 9.9% of patients in the present study, which is in line with the previous literature [52,53]. Yet the prevalence of anxiety exhibits considerable variation across different countries, gender, and age groups [54][55][56]. ...
... Although only a single quadrant was implanted in each session to avoid increasing anxiety, it increased in proportion to the increase in the number of implants. The number of implants has been linked to surgical complexity in certain studies, and anxiety scores demonstrate a tendency to increase in line with surgical complexity [16,53]. The SAC tool was employed to quantify surgical complexity in the present study. ...
... SAC appears to be a useful tool to assist dentists with less experience in implant dentistry in describing the complexity of the treatment [32]. Similarly, Abbas et al. employed the use of treatment complexity in conjunction with the mDAS score and ASA-PS as an assessment tool to ascertain the necessity for sedation [53]. Similarly, the surgical complexity associated with the extraction of deeply impacted third molars was found to be a contributing factor to dental anxiety [16]. ...
Article
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Background/Objectives: Rehabilitation of missing teeth with dental implants is a strong trigger of dental anxiety. The sympathetic response caused by anxiety can lead to cardiovascular and cerebrovascular incidents, especially in patients at systemic risk (ASA Physical Status-II and ASA Physical Status-III). Dental anxiety can affect physical health by activating the sympathetic response, and the patient’s physical health status may also affect dental anxiety. The aim of this study was to analyze the factors that may reduce anxiety and pain, considering the patient’s physical health status according to American Society of Anesthesiologists (ASA-PS). Methods: A total of 562 implants were placed under local anesthesia in 201 patients with ASA PS-I (healthy) and ASA PS-II and III (comorbid). The effect of patient-, dentist-, and surgery-related variables on dental anxiety and pain perception were evaluated. Modified Corah Dental Anxiety Scale and Numerical Rating Scale for Pain scores were measured and recorded preoperatively (T0) and 1 week postoperatively (T1). The effects of the associated variables were analyzed using binary logistic regression and non-parametric tests (p < 0.05). Results: Age (OR = 1.089), gender (OR = 6.493), ASA-PS (OR = 13.912), and the number of placed implants (OR = 0.807) were significantly associated with reduction in dental anxiety. There were statistically significant differences between the study groups in terms of mDAS score reduction (p = 0.028). Conclusions: ASA-PS, gender and the number of placed implants affected the anxiety of the patients. Age and number of implants seem to be variables with a relative influence that depends on other factors.
... While it has been suggested that clinical guidelines often oversimplify treatment decision-making regarding implants, numerous studies highlighted the importance of considering multiple factors before selecting, preparing, or saving implants, particularly the patient's medical history, bone quality, and implant location [30,[75][76][77]. This was echoed by studies investigating surgical, extractive, and sedative decision making, which suggest consideration of patient factors such as medical history, including oncological prognosis and the level of dental anxiety [78][79][80][81]. ...
... Abbas et al. [81] 2022 ...
... Dentists should consider the specifics of the individual patient, and assess the applicability of existing guidelines. The guidelines suggested by numerous studies emphasised patient-centred care and the importance of considering patient factors during treatment [75,76,78,81]. For example, a history of endocarditis and bisphosphonates may lead to a general refusal of implants [75,76]. ...
Article
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Clinical decision-making for diagnosing and treating oral and dental diseases consolidates multiple sources of complex information, yet individual clinical judgements are often made intuitively on limited heuristics to simplify decision making, which may lead to errors harmful to patients. This study aimed at systematically evaluating dental practitioners’ clinical decision-making processes during diagnosis and treatment planning under uncertainty. A scoping review was chosen as the optimal study design due to the heterogeneity and complexity of the topic. Key terms and a search strategy were defined, and the articles published in the repository of the National Library of Medicine (MEDLINE/PubMed) were searched, selected, and analysed in accordance with PRISMA-ScR guidelines. Of the 478 studies returned, 64 relevant articles were included in the qualitative synthesis. Studies that were included were based in 27 countries, with the majority from the UK and USA. Articles were dated from 1991 to 2022, with all being observational studies except four, which were experimental studies. Six major recurring themes were identified: clinical factors, clinical experience, patient preferences and perceptions, heuristics and biases, artificial intelligence and informatics, and existing guidelines. These results suggest that inconsistency in treatment recommendations is a real possibility and despite great advancements in dental science, evidence-based practice is but one of a multitude of complex determinants driving clinical decision making in dentistry. In conclusion, clinical decisions, particularly those made individually by a dental practitioner, are potentially prone to sub-optimal treatment and poorer patient outcomes.
... La sedación mínima o ansiólisis es un estado durante el cual el paciente responde de forma normal a los estímulos verbales y las funciones respiratoria y cardiovascular no se ven afectadas, aunque las habilidades cognitivas y la coordinación se ven disminuidas 11,12,16 . ...
Article
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Introduction: The possibility of offering dental care under sedation or general anesthesia is increasingly requested by parents or guardians, particularly in pediatric or special needs patients, due to difficulties in communication and poor cooperation with treatment. Objectives: This narrative literature review was conducted with the aim of determining the indications for sedation and/or general anesthesia for dental treatment in children, as well as describing the different options for sedation or general anesthesia, and establishing criteria for the discharge of patients treated under sedation or general anesthesia. Methods: A literature search was conducted in the PubMed database using the keywords "pediatric dentistry," "conscious sedation," and "general anesthesia," with the filter "published in the last 10 years." Relevant publications on the subject, including review articles or observational or cross-sectional studies, were included. Publications on adult patients, as well as case reports, were excluded. Results: Twenty-nine publications were included in this review. Conclusions: The indication for a specific degree of sedation or general anesthesia will depend on the patient's level of cooperation, medical history, and the extent of the dental treatment required. The main risks of these procedures include respiratory alterations and allergic reactions, among others. After the procedure, the patient will be monitored until discharge criteria are met before discontinuing observation.
... They found that almost 20% of study participants were highly anxious due to undergoing dental procedures, and more than 30% of them had high sedation needs, which was significantly associated with the female sex, higher education status, and a history of previous traumatic dental experience. 30 Madouh and Tahmassebi conducted a similar study in the pediatric population. The study included 40 pediatric patients evaluated using the IOSN tool; out of them, 20 scored more than six and were subjected to more advanced methods of DS. ...
... For other patients who are cooperative but unable to maintain an open mouth for long periods, dental sedation may be used for procedures such as root canal therapy, surgical extractions, full mouth rehabilitation or extensive restorative work. 7 Additionally, depending on the patient and treatment needs, several routes of administration for dental sedation may be used: inhalation, intravenous, oral, intranasal and intramuscular. 8 A survey of dentists in the United States and Canada has revealed that 75.7% regularly use conscious sedation in practice; half reported using sedation as many as six times per month, and the other half reported using sedation more than six times per month. ...
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According to the World Health Organisation, approximately 1.3 billion people worldwide experience substantial disability due to physical, mental or sensory impairment. People with special needs require special consideration and more time or altered delivery methods when receiving dental treatments. Various factors, such as patients' lack of cooperation, cognitive impairment and complex medical status, may lead dental practitioners to recommend conscious sedation. Several pharmacological agents and administrative routes are available, which achieve varying levels of sedation ranging from minimal to deep. Pre-operative assessment and careful case selection are necessary to determine the appropriate sedative agent, route of administration and level of sedation for each patient. Thus, a thorough understanding of the pharmacokinetics, risks and benefits, and implications of various sedatives available for PSN is essential to achieve the desired clinical outcomes. This review critically presents the considerations associated with the use of various sedative agents for PSN in dentistry. Considerations include patients' pre-anaesthesia medical comorbidities, cardiorespiratory adverse effects and cooperativeness, and the viable alternative treatment modalities.
... Female patients are more anxious than males. Men are more rational while women are more sensitive [6]. The results of research on the level of anxiety of children about tooth extraction reported that 57.2% of children showed anxiety before the tooth extraction procedure began and 46.2% of children felt anxious during the procedure [7]. ...
Article
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Anxiety is a psychological reaction to something unwanted. Dental anxiety is the thought that something scary will happen before someone has a dental visit or treatment. The results of the initial data collection related to anxiety about tooth extraction at SD Islam Maryam Surabaya, it is known that 86% of children experience severe anxiety. The study aims to determine the relationship between parental knowledge and children's anxiety levels in the act of removing teeth in class IV SD Islam Maryam Surabaya. The type of research used was analytic research with a cross-sectional design, with 65 class IV children as research subjects. Data collection method by means of a questionnaire. The data analysis technique uses the Chi Square test. The test results from the study obtained an Asymp.sig.(2-tailed) value of 0.000, which means that the p value (signification) is smaller than α (0.05) so that parental knowledge is related to the level of anxiety in the act of removing teeth in class IV SD Islam Maryam Surabaya. INDEX TERMS Knowledge, Anxiety, Tooth extraction
Article
Objectives: Although midazolam is commonly used to sedate patients with dental anxiety, it has shortcomings that reduce the satisfaction of patients and doctors. The aim of this study was therefore to explore the advantages of remimazolam as a sedative. Methods: The study design was a prospective randomized controlled trial. Patients with dental anxiety and who were to undergo impacted tooth removal were randomized into remimazolam and midazolam groups. They were sedated with remimazolam or midazolam prior to receiving nerve blocker. The primary variable was the type of sedative, while the primary outcome variables were the onset time, awakening time, recovery time, and postoperative side effects. Secondary outcome variables were the Modified Dental Anxiety Scale score before and after surgery, patient satisfaction and comfort levels scores, and doctor satisfaction level scores. Other variables included the patient demographics and the operation time. Data were analyzed using the Student's t-test, Mann-Whitney test, χ2 test, and two-way repeated measurement ANOVA test (SPSS Version 25.0). Results: A total of 83 patients were included in this study, with 42 randomized to the remimazolam group and 41 to the midazolam group. There were no significant differences between the two groups in terms of demographic features and operation time. Patients in the remimazolam group had significantly shorter onset time, awakening time, and recovery time compared to those in the midazolam group (each P < .001). Postoperative side effects were more frequent in the midazolam group (P < .001). Following surgery, the Modified Dental Anxiety Scale scores in both groups were significantly lower than prior to surgery (P < .001). Satisfaction levels scores for the patients and doctor were higher in the remimazolam group than in the midazolam group (P < .001). Conclusions: The use of remimazolam results in faster onset, more rapid recovery, and lower incidence of postoperative side effects compared to midazolam, leading to improved satisfaction for patients and doctors. Remimazolam therefore appears to have several advantages over midazolam for the sedation of patients with dental anxiety associated with the removal of impacted tooth.
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Dental anxiety is a crucial problem for dentistry because it may represent a significant risk to oral health. Different factors, whether non-cognitive (e.g., traumatic dental events) or cognitive (e.g., the patient's subjective perceptions), may cause dental anxiety. However, previous studies have assessed these factors as independent predictors of dental anxiety, without providing any exploration of potential mediational pathways. The current study assessed the role of certain cognitive dimensions (i.e., the dentist's perceived professionalism and communicational attitudes, and the patient's perceived lack of control) as mediators between traumatic dental events and dental anxiety. The sample comprised 253 patients who had accessed a public university hospital dental surgery. The mediation analysis used a structural equation modeling. Traumatic dental events were positively associated with dental anxiety but, among the cognitive factors, only lack of control was. Furthermore, lack of control mediated the relationship between traumatic dental events and dental anxiety, although this mediation was only partial. This study sheds light on the mechanisms through which non-cognitive and cognitive factors may affect dental anxiety. The clinical implications for dental practice, in terms of improving the psychological well-being of patients, are discussed.
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Background/purpose Patients with periodontal disease have higher dental fear levels, which may have negative effects on their clinical outcome during scaling and root planing (SRP). The present study used the new classification of periodontitis and validated questionnaires to assess the relationship among dental fear, SRP pain and periodontal status. Materials and methods A total of 120 periodontitis patients were enrolled and staging according to the new classification of periodontitis. SRP was performed, and the visual analog scale (VAS) to assess pain was used with every patient after treatment. Questionnaires, including Corah's Dental Anxiety Scale (DAS), Dental Fear Survey (DFS), and short-form Dental Anxiety Inventory (S-DAI) were implemented from the first attendance and subsequent visits after 6 months. The patients were grouped by DAS scores. The statistical analysis was performed using T-test, chi-square, Pearson and Spearman correlative analysis. Results Compared to pre-SRP treatment, the dental fear level on DFS was decreased in the posttreatment period for all periodontitis stages. There were no statistically significant differences in S-DAI and DAS between pretreatment and posttreatment periods in stage I and II; meanwhile, there were statistically differences in stage III and IV. The correlation among periodontitis stages, VAS and dental fear level was significant. The proportion of high periodontitis stages was increased in high dental fear group. Conclusion SRP can reduce dental fear levels in all periodontitis stages, especially in stage III and IV. Correlations exist among periodontal status, dental fear and SRP pain. High dental fear is associated with poor periodontal status.
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Background: Dental anxiety continues to be a widespread problem afecting adult populations. The primary aim of our study was to evaluate the psychometric properties of the Lebanese Arabic version of the Modifed Dental Anxiety Scale (MDAS-A) and to identify the optimal cut-of for assessing dental anxiety and dental phobia among adults in Lebanon. In addition, we sought to assess dental anxiety and phobia as well as their correlates among Lebanese adult patients. Methods: A cross-sectional study was carried out on a sample of 451 dental adult patients aged between 18 and 65 years old. Information about demographic characteristics, previous bad dental experience, trauma’s experience period, perception of a periodontal problem, sensation of nausea during dental treatment, the MDAS-A scale, and the Visual Analogue Scale for anxiety (VAS-A) were collected. Results: MDAS-A exhibited evidence of adequate psychometric properties. The optimal cut-of was 12 for dental anxiety and 14 for dental phobia. Out of the total sample, 31.5% sufered from dental anxiety while 22.4% had a dental phobia. Multivariable analysis showed that the odds of dental anxiety and phobia were higher among females compared to males. Also, patients sufering from periodontal problem perceptions, bad dental experiences during childhood and adolescence, and the sensation of nausea during dental treatment were at a higher risk of developing dental anxiety and phobia compared to their counterparts. However, a higher level of education was found to be a protective factor against dental phobia among Lebanese adult patients. Conclusion: The MDAS-A scale is a suitable tool for the routine assessment of dental anxiety and phobia among Lebanese adult patients. Identifying patients with dental anxiety at the earliest opportunity is of utmost importance for delivering successful dental care.
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Objectives: Administration of medications such as dexmedetomidine as a topical anesthetic has been suggested in the pain control in dentistry. This double-blind randomized control trial study evaluated postoperative pain and associated factors following impacted third molar extraction surgery. Lidocaine alone was taken as the control and lidocaine plus dexmedetomidine as the intervention. Materials and methods: Forty patients undergoing mandibular third molar extraction entered the study and were randomly allocated to the control and interventional groups. 0.15 ml of dexmedetomidine was added to each lidocaine cartridge and the drug concentration was adjusted to 15 μg for the intervention group while only lidocaine was used in the control group. A visual analog scale was used to measure and record pain levels at the end of the surgery and 6, 12, and 24 hours after the surgery and number of painkillers taken by the patients after the surgery was also recorded. Results: Pain scores of the intervention group decreased significantly during the surgery and also 6, 12, and 24 hours after the surgery compared to the control group. The pain score was correlated significantly with our intervention during the surgery and also 6 and 12 hours after that (all P value < 0.05). There was a nonsignificant reduction in the number of painkillers taken by the patients at 6, 12, and 24 hours after surgery (all P value > 0.05). Conclusion: In patients undergoing molar surgery, administration of a combination of dexmedetomidine and lidocaine is beneficial for the pain control. Clinical Relevance. Compared to the injection of lidocaine alone, combination of dexmedetomidine and lidocaine can be used for a better pain control in molar surgeries.
Article
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Objectives It can be challenging to manage patients who are anxious during dental procedures. There is a lack of evidence regarding the effectiveness and safety of oral sedation in adults. This study evaluated the effectiveness and safety of oral sedation in patients undergoing dental procedures. Design Systematic review. Methods Randomised clinical trials (RCTs) compared the oral use of benzodiazepines and other medications with a placebo or other oral agents in adult patients. A search of the Cochrane (CENTRAL), MEDLINE (via Ovid), EMBASE (via Ovid) and Cumulative Index to Nursing and Allied Health Literature (via Ovid) databases was conducted, without any restrictions on language or date of publication. The primary outcomes included the adverse effects and anxiety level. The secondary outcomes included sedation, satisfaction with the treatment, heart rate, respiratory rate, blood pressure and oxygen saturation. Reviewers, independently and in pairs, assessed each citation for eligibility, performed the data extraction and assessed the risk of bias. A narrative synthesis of the data was provided. Results A number of RCTs (n=327 patients) assessed the use of benzodiazepines (n=9) and herbal medicines (n=3). We found good satisfaction with treatment after the use of midazolam 7.5 mg or clonidine 150 µg and reduced anxiety with alprazolam (0.5 and 0.75 mg). Midazolam 15 mg promoted greater anxiety reduction than Passiflora incarnata L. 260 mg, while Valeriana officinalis 100 mg and Erythrina mulungu 500 mg were more effective than a placebo. More patients reported adverse effects with midazolam 15 mg. Diazepam 15 mg and V. officinalis 100 mg promoted less change in the heart rate and blood pressure than a placebo. Conclusions Given the limitations of the findings due to the quality of the included studies and the different comparisons made between interventions, further RCTs are required to confirm the effectiveness and safety of oral sedation in dentistry. PROSPERO registration number CRD42017057142.
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Background Technology advancement has rising in the past decade and brought several innovations and improvements. In dentistry, this advances provided more comfortable and quick procedures to both the patient and the dental surgeon, generating less predictability in the final result. Several techniques has been developed for the preparation of surgical guides aiming at the optimization of surgical procedures. The present study aimed to evaluate the reproducibility and precision of two types of surgical guides obtained using 3D printing and milling methods. Methods A virtual model was developed that allowed the virtual design of milled (n = 10) or 3D printed (n = 10) surgical guides. The surgical guides were digitally oriented and overlapped on the virtual model. For the milling guides, the Sirona Dentsply system was used, while the 3D printing guides were produced using EnvisionTEC’s Perfactory P4K Life Series 3D printer and E-Guide Tint, a biocompatible Class I certified material. The precision and trueness of each group during overlap were assessed. The data were analyzed with GraphPad software using the Kolmogorov–Smirnov test for normality and Student’s t test for the variables. Results The Kolmogorov–Smirnov test showed a normal distribution of the data. Comparisons between groups showed no statistically significant differences for trueness (p = 0.529) or precision (p = 0.3021). However, a significant difference was observed in the standard deviation of mismatches regarding accuracy from the master model (p < 0.0001). Conclusions Within the limits of this study, surgical guides fabricated by milling or prototyped processes achieved similar results.
Article
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Recently, calls for prompt and smart reform of dental education and postgraduate training have been made, reflecting the current global healthcare needs and addressing the most common problems faced by dental care providers. Objectives: Herewith, we propose the enhancement of multilevel dental training in dental conscious sedation (DCS), in order to meet the increasing demands associated with current and post-pandemic times. The temporary suspension of general anaesthesia and hospital-based sedation provision in response to coronavirus disease 2019 (COVID-19) revealed the urgent need for more efficient utilization of a variety of forms of DCS. Whilst the global spread of Severe Acute Respiratory Syndrome novel coronavirus (SARS-CoV-2) has particularly challenged dental sedation teams in community services, the appropriate preparation for similar disruptions in future should be undertaken proactively. In response, dental schools and commissioners are obliged to implement innovations in teaching, with the development of new programs supporting trainer-trainee interactions and focusing on practical sedation skills. Conclusions: The joint efforts of educators, healthcare providers, and commissioners, as well as adequate and robust DCS training utilizing a variety of teaching methods, would allow our profession to face the growing demand for pain and anxiety control measures in light of the current situation, which may increase even further over time. Decision makers are urged to consider making training in DCS more accessible, meeting current healthcare demands, and equally providing essential support for the special dental care sector.
Article
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Background: Dental anxiety is a condition associated with avoidance of dental treatment and increased medical and surgical risks. This systematic review aims to summarize available evidence on conscious sedation techniques used for the management of Dental anxiety in patients scheduled for third molar extraction surgery, to identify best approaches and knowledge gaps. Methods: A comprehensive search was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov and the Cochrane Database of Systematic Reviews through March 2019. Only randomized controlled trials were included. PRISMA guidelines were followed. Risk of bias was appraised as reported in the Cochrane Handbook for Systematic Reviews of Interventions. Results: Seventeen RCTs with a total of 1788 patients were included. Some aspects limited the feasibility of a meaningful meta-analysis, thus a narrative synthesis was conducted. Conscious sedation was associated with improvement in Dental anxiety in six studies. One study reported lower cortisol levels with midazolam vs. placebo, while another study found significant variation in perioperative renin levels with remifentanil vs. placebo. Conclusions: This review found inconclusive and conflicting findings about the role of Conscious sedation in managing Dental anxiety during third molar extraction surgery. Relevant questions remain unanswered due to the lack of consistent, standardized outcome measures. Future research may benefit from addressing these limitations in study design.
Article
In recent years, conscious sedation has grown in popularity as an alternative to general anaesthesia in a primary setting due to its safety and efficiency. It is imperative to carry out a full patient assessment prior to treatment under conscious sedation. Conscious sedation is provided intravenously, by inhalation or oral route. Clinical and physical examination as well as medical, social and mental history play a fundamental role in selecting the right patient. In addition, to optimize safety of patients, it is necessary to follow available guidelines and standards, provide an appropriate environment and adequate staff training. CPD/Clinical Relevance: This article highlights the importance of pre-assessment prior to treatment under conscious sedation. The vast majority of adverse events during sedation occur as a result of inadequate pre-assessment and preparation.