P. Coulthard,1 C. M. Bridgman,2 L. Gough,3 L. Longman,4 I. A.

Pretty5
and T. Jenner OBE6

IN BRIEF

There is need to have a tool to support

clinicians in their decision making about

conscious sedation.
Commissioners need to identify patients
who need conscious sedation for dental
treatment in order to plan and deliver
appropriate sedation services.
Conscious sedation need could be assessed
by ranking a combination of information
on patient anxiety, medical history and the
complexity of the clinical treatment.

RESEARCH

Estimating the need for dental

sedation. 1. The Indicator of
Sedation Need (IOSN)
a novel assessment tool
VERIFIABLE CPD PAPER

While the control of pain and anxiety is fundamental to the practice of dentistry, the use of conscious sedation in dentistry
is very variable among dentists. The need for conscious sedation could be considered by assessing and ranking a combina
tion of information on patient anxiety, medical history and the complexity of the anticipated clinical treatment. By undertak
ing this systemtic assessment an indication of sedation need may be developed which would act as an aide to decision mak
ing and, potentially, referral management. Such a tool could also be used by commissioners who need to identify patients
who need conscious sedation for dental treatment in order to plan, commission and deliver appropriate sedation services.
The control of pain and anxiety is fundamental to the practise of dentistry and yet
the use of conscious sedation in dentistry
is very variable among dentists. Some
dentists may overuse conscious sedation
while many may never use a sedation
technique. This is likely to be because of a
wide range in sedation experience, training and interest. However one would not
expect the recommendation or prescription
of sedation to be so variable. Surely some
patients clearly need sedation for dental
treatment while others do not. The principal reason for using conscious sedation
is to enable dental treatment to be carried
out for a patient who is so anxious that he
or she may avoid the treatment completely
1Professor of Oral and Maxillofacial Surgery & Immedi
ate Past Chairman, Dental Sedation Teachers Group,
School of Dentistry, The University of Manchester,
Higher Cambridge Street, Manchester, M15 6FH;
2 Consultant in Dental Public Health & Primary Care
Commissioning Advisor, NHS Manchester, Parkway 3,
Parkway Business Centre, Princess Road, Manchester,
M14 7LU; 3Consultant in Dental Public Health, NHS
Liverpool Headquarters, 1 Arthouse Square, 6169 Seel
Street, Liverpool, L1 4AZ; 4Senior Lecturer in Restora
tive Dentistry & Chairman, Dental Sedation Teachers
Group, School of Dental Sciences, The University of
Liverpool, L69 3BX; 5* Professor of Public Health Den
tistry, The Dental Health Unit, School of Dentistry, The
University of Manchester, Skelton House, Manchester
Science Park, M15 6SH; 6Former Deputy Chief Dental
Officer & Head of Oral Health Policy, Department of
Health, Dental Health Consulting, Dorset, SP8 5EW
*Correspondence to: Professor Iain A. Pretty
Email: iain.pretty@manchester.ac.uk; Tel: +44 (0)161
226 1211; Fax: +44 (0)161 232 4700

Online article number E10

Refereed Paper - accepted 5 May 2011
DOI: 10.1038/sj.bdj.2011.725

British Dental Journal 2011; 211: E10

or find it extremely stressful. Also, some

patients who are happy to undergo routine
dental treatment with local anaesthesia
alone may be distressed if more unpleasant
procedures such as surgical procedures are
undertaken with local anaesthesia alone.
Clinical decision making is a complex
process. Can the decision making about
sedation in dentistry be more objective?
Can it be supported by a tool that would
help individual clinicians and also commissioners of services?
There is increasing emphasis on providing patient-focused healthcare and ensuring patient involvement in the design
of health services. One might expect
that patients contribute to the decision
about sedation by indicating their level
of anxiety. This is not always the case.
Some dentists may dismiss the concern
of their patient. Would it not be better
to simply ask the patient to complete a
simple anxiety measure and obtain an
objective assessment?
Sedation with drugs is not a replacement
for a caring and sympathetic attitude to
the patient and behavioural management
strategies are still required. Psychological
approaches may range from a planned
approach to treatment with simple, more
readily accepted methods before more
advanced, tell-show-do techniques, and
include methods to provide a greater
sense of control. When these are insufficient then conscious sedation or general
anaesthesia may need to be considered.1

Experienced dentists may consider that

they are the expert in determining the level
of anxiety in their patient. However, like
measuring pain, the best way is surely
to ask the patient. If this is done using a
questionnaire, then objective data may be
obtained for use in an assessment tool for
sedation need. There are several patient
report anxiety scales available2 and we
selected the Modified Dental Anxiety Scale
(MDAS) because of its relevance, validity
and brevity.3 The MDAS has been translated into a number of world languages,
many of which have published psychometrics (Chinese,4 Greek,5 Spanish,6 Turkish7).
Clinical decision making with such a
sedation assessment tool should never, of
course, override the clinicians treatment
recommendation for an individual patient
made with his or her experience and the
particular patient factors. However, it
could support decision making or challenge the clinician to consider other treatment modalities for the benefit of patients.

THE IOSN TOOL

Figure1 presents the Indicator of Sedation
Need (IOSN) tool with three components to
be completed: the anxiety component by
the patient and the treatment complexity
and medical indicators by the referring clinician. The tool should take no more than
a few minutes to complete and should form
the basis of a minimum data set for a referral for treatment under sedation. Providers
may wish to add supplemental questions to

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RESEARCH

Table 1 IOSN scoring tool

Fig. 1 The IOSN tool

the form and the medical indicators section

is not designed to replace a full medical
history but rather highlight those aspects
of a patients medical history that would
tend to support the use of IV sedation.
It is proposed that the tool can be used in
two ways: as described above as a referral
tool that can be used within a commissioned service and the second as a health
needs assessment (HNA) tool. The second
paper in this series describes the use of the
tool as an HNA device and provides example data from a service review undertaken
in the North West of England.

Anxiety score
A patients anxiety can be assessed using
a reliable and validated questionnaire, the
Modified Dental Anxiety Scale (MDAS)
that is completed by the patient.3 The
MDAS consists of five questions and gives
a total summed score of 5to 25. It is the
most commonly used anxiety scale in the
UK8 and takes only a few minutes for completion so that it can be integrated into
everyday dental practise.9 Patients can be
provided with the questionnaire by reception staff and complete it in the waiting
room just as they may complete a medical
history questionnaire. Patients are asked to
rate their emotional reaction to the prospect of a dental visit, then their reaction
when in the waiting room, when they were
about to have a tooth drilled, have scaling and finally have a local anaesthetic
injection. The range for each item is from
not anxious to extremely anxious. The

IOSN domain

Scores

Source

Anxiety

1-3

Taken from MDAS score:

MDAS between 511is minimal anxiety, scores 1
MDAS between 1218is moderate anxiety, scores 2
MDAS between 1925is high anxiety, scores 3

Medical history

1-4

A range of medical and behavioural indicators are provided including

gag reflex, fainting attacks, hypertension, angina, asthma, epilepsy,
arthritis and Parkinsons disease.

Treatment complexity

1-4

An indicative list of treatments is provided if the referrer is in

doubt about the complexity of any given treatment they are asked
to score high.

IOSN metric

IOSN descriptor

Sedation need?

3-4

Minimal need for sedation

No

5-6

Moderate need for sedation

No

7-9

High need for sedation

Yes

10-11

Very high need for sedation

Yes

completion of the questionnaire does not

increase the patients fear.10 A cut-off value
of 19 was empirically determined by the
authors of the scale to indicate a high level
of anxiety that may suggest that special
attention by dental staff may be required.
An MDAS score of 19 or above indicates a highly anxious patient, possibly
dental phobic.9
Unfortunately anxiety remains a significant barrier to receipt of dental care. One
might anticipate that improvements in oral
health and contemporary care which offers
less invasive treatments has resulted in the
younger population reporting less anxiety
than the middle aged population but this
is not the case.11,12

Treatment complexity
As already discussed, some patients who
are able to cope with treatment under local
anaesthesia alone for simple, routine dental treatment, may not be able to cope
without the use of a conscious sedation
technique for more complex treatment.
The definition of complex treatment is
not straightforward but may mean more
invasive treatments, typically surgical
in nature, or perhaps multiple quadrant
restorative treatments. However, this can
be determined by the dentist using a guide
with descriptors as described below.
The treatment complexity component of
the work directly evidences Lord Darzis
report on quality within the NHS.13 It is a
hallmark of a quality service that patient
care is personalised for example the

non-anxious patient may not consider

asking for sedation for multiple third
molar extractions, but should be offered
a sedation adjunct if this would make the
procedure more pleasant.
The treatment complexity indicators are
shown in Figure1. It is clearly impossible
to capture all treatments and allocate them
to complexity bandings. Also, additional
clinical and patient factors may change
the complexity of any given procedure.
Clinicians are recommended, if they are in
any doubt about treatment complexity, to
default to a higher score rather than lower.

Medical and behavioural indicators

Some medical conditions may be exacerbated by anxiety or the stress of dental
treatment and these patients benefit from
conscious sedation to reduce the risk of
exacerbation.1,14,15 Increased production
of catecholamines, for example, increases
the load on the cardiovascular system to
the potential detriment of patients with
angina. The patient with asthma may
develop an acute episode of breathing
distress, whereas the epileptic patient may
suffer a seizure when stressed. However,
such patients may also present special
risk for conscious sedation and the benefit
or risk will be determined by the severity of the disease. The American Society
of Anesthesiology (ASA) Physical Status
Classification System is a useful way to
describe severity of disease. Patients with
multiple sclerosis or Parkinsonism may be
eager to cooperate but physically unable

2

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RESEARCH
to do so and benzodiazepine sedation may
be of use because of its muscle relaxation
properties. The decision as to whether to
recommend conscious sedation or not for a
patient should also take into account their
medical history.
Other reasons that patients may require
conscious sedation to enable their dental
treatment to be carried out are as diverse as
learning difficulties and strong gag reflex.
These could be considered as behavioural
indicators and also need to taken into
account by any sedation assessment tool.

HOW THE IOSN TOOL IS USED

A patients need for sedation could
be based on three domains of need as
described above:
1. Anxiety score
2. Medical history
3. Treatment complexity.
For each patient the anxiety score,
clinical complexity and medical history
details are collected, ranked and entered
into the IOSN tool. The summation of the
three ranking scores gives an overall score
between 3 and 12. The lowest score possible is 3, suggesting there is a minimal need
for sedation. The highest score possible is
12. Scores above 9 suggest that a referring
clinician should be considering general
anaesthesia and/or that the sedation episode of care may require a secondary care
environment. This is shown in Table1.
The anxiety questionnaire and the medical history questionnaire are self-administered by the patient. The clinician uses the
MDAS score to produce a rank score that is
entered into the IOSN tool (Table1). MDAS
score of 59 is rank score 1, 1012 is 2,
1317is 3and 1825 produces a rank score
of 4. These rankings were chosen empirically and then modified at piloting at the
University Dental Hospitals at Manchester
and Liverpool and the study described in
Paper 2 within this series. The rank scores
for the medical and behavioural indicators and treatment complexity were similarly determined. This is similar to the way
in which the scores were determined for
tools to indicate the need for orthodontic treatment, cataract surgery and hip
replacement surgery.
Findings from the medical history questionnaire are ranked by the dentist as 1, 2,
3or 4and entered into the IOSN tool. ASA

I patients are ranked 1. Systemic disorders

(not of severity to contraindicate use of
sedation) that may be exacerbated by the
stress of dental treatment are ranked 2, 3or
4. Such disorders include hypertension,
angina, asthma and epilepsy. Conditions
that compromise ability to cooperate such
as multiple sclerosis or Parkinsonism are
ranked 2, 3or 4. As a rule of thumb, ASA
II would generally be a score of 2or 3and
an ASA III would result in a rank score of
4. Similarly someone who reports a gag
reflex or behavioural difficulty would have
a rank score 2or 3 according to severity
entered into the IOSN tool. Patients who
are ASA III are recommended to undergo
dental treatment under conscious sedation
in a secondary care setting.
Where there is a medical history finding,
such as for example an adult with severe
learning difficulties, that compromises a
persons ability to cooperate for even simple procedures under local anaesthesia or
a highly complex clinical procedures is
planned, a rank of 4 in that component
would be recorded.
Any patient with a single rank of 4in
medical history or clinical complexity
can be fast tracked to a decision supporting the need for sedation, as the overall
score will be at least 6. Clinicians need not
complete the whole assessment to support
their decision for the need for sedation.
This would make the IOSN sensitive to
secondary care units who would not want
compromised patients or those who require
a very complex procedure to complete the
MDAS questionnaire.
The anticipated treatment complexity is
also ranked, receiving a 1, 2, 3or 4 score
and entered into the IOSN as the third and
final set of information that is required.
Some examples of routine, intermediate,
complex and high complexity treatment
are given in the tool as guidance, although
the list is not exhaustive. The following
are examples of dental treatments: a scale
or extraction of one or two single rooted
teeth would be described as routine; a surgical extraction requiring bone removal
would be described as complex.
The summation of the three ranking
scores for anxiety, medical and behavioural indicators and treatment complexity
gives an overall score between 3and 12
(Table1) A minimal need or demand for
sedation would be judged to be a patient

with an overall score of 4or below, a moderate need for sedation would be identified
in a patient who has a score of 5or 6, and
a high need for sedation would be identified in individuals who score 7 to 9. A
score of 10to 12 suggests very high need
of sedation and consideration of whether
general anaesthesia might be indicated or
whether the sedation episode may require
a secondary care environment.

CONCLUSION
There is anecdotal evidence to suggest
that some patients who are anxious about
dental treatment are not being offered conscious sedation to facilitate their treatment
and also a suggestion that some sedation
services may be demand rather than needsled. There is a need to have a tool to support clinicians in their decision making.
Commissioners need to understand and
identify patients who need conscious sedation for dental treatment in order to plan
and deliver appropriate sedation services.
The need for conscious sedation could
be considered by assessing and ranking
a combination of information on patient
anxiety, medical history and the complexity of the clinical treatment planned.
While the use of metrics within health
needs assessment work, commissioning
and patient access to services has been
deployed in orthodontics (IOTN), it must
be made clear that the IOSN tool is in the
early stages of development. Care must be
taken in its utilisation and it should be
a clinicians final decision about whether
to refer any given patient or accept them
for treatment.
Dr Iain A. Pretty is funded by a clinician scientist
award from the NIHR, UK.
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