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OBJECTIVES: To assess the views of consultants in restorative dentistry on sedation services in secondary care for restorative dentistry and their involvement in the provision of this. DESIGN: Postal questionnaire survey in the UK. SETTING: Consultants in restorative dentistry. RESULTS: There was an 80% response rate from 179 consultants. Among consultants in restorative dentistry there was a perceived need for sedation services in restorative dentistry within NHS hospitals other than for teaching purposes. Anxiety and level of trauma of dental treatment affected whether consultants felt it appropriate for patients to have such treatment under sedation. One third (48) of consultants treated patients under conscious sedation, a significant number of these held NHS posts and had graduated more recently. Of those (41) who provided treatment under conscious sedation in an NHS setting, most (38, 93%) provided treatment under intravenous sedation of whom only eight (21%) acted as operator/sedationist. Nearly all consultants (135, 94%) felt that specialist registrars in restorative dentistry should undergo some form of training in sedation. CONCLUSIONS: Although consultants in restorative dentistry recognise the need for training in and the provision of sedation in secondary care for restorative dentistry, only one third of respondents currently provide this service.

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OBJECTIVES: To describe the socio-demographic characteristics of successful and unsuccessful applicants to one UK dental school over a period of five years. To compare the characteristics of successful and unsuccessful candidates. DESIGN: Retrospective analysis of admissions data for the former United Medical and Dental Schools of Guy's and St Thomas' (UMDS) dental school provided by Universities and Colleges Admissions Service (UCAS) for a five year period (1994-1998). PARTICIPANTS: Applicants to the former UMDS dental school between 1994 and 1998. MAIN OUTCOME MEASURES: Success of candidates at four stages of the application process: initial application; offer made by the dental school; offer accepted or declined by the candidate; candidate accepted by the school (post A level results). Comparisons were made of the success rates among candidates grouped according to socio-demographic characteristics at each transition between these stages. A level performance was not included in the analysis, which must limit the findings, and may explain some of the variation found in the study. RESULTS: The effect of socio-demographic characteristics on the admissions process was small though significant. Approximately 9% of initial applicants reached the final stage and were accepted into the dental school. The most marked effect was a bias towards female entrants (11.5% of women applicants were accepted, compared with 7% of men). Only 5% of applicants from all the Black minority groups were successful. In comparison 17% of applicants of Chinese origin were successful. The proportion of accepted applicants from London and the South East (12%) was greater than from other areas (9%). CONCLUSIONS: Any conclusions must be tempered by the limitations of the study: the retrospective nature of the study together with the lack of information on A level results. Given these caveats, this study has demonstrated that the success of applicants to one former dental school was related to their socio-demographic characteristics. A prospective study including a number of dental schools in the UK which records both predicted and achieved A level grades would provide more definitive information on the impact of socio-demographic factors on admission to dental school.

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The dental care of people with severe learning disability and challenging behaviour presents many problems. The maintenance of oral health by regular examination, prevention and treatment may be difficult because of the limitations in patient cooperation. In many cases the diagnosis of orofacial pain may need to be discounted as a cause of uncharacteristic and sometimes aggressive behaviour. In such cases the use of general anaesthesia for examination and treatment would seem to be the obvious option but this strategy has limitations. This paper undertakes a focused review of sedation techniques as an alternative to general anaesthesia in the treatment of people with challenging behaviour. The use of novel techniques of sedation combining intravenous with oral or intranasal routes is described with patients treated in a community dental health centre. All patients had previously received treatment using general anaesthesia. The techniques described proved effective and safe for use in the primary care setting.

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The provision of dental treatment under both local anaesthesia and sedation has an excellent safety record. However, problems that either complicate treatment or lead to medical emergencies can arise. This paper considers the prevention of foreseeable problems and the treatment of unforeseeable emergencies in the dental surgery.

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The effect of different nitrous oxide concentrations on the performance of psychomotor tests (inspection time, tapping frequency, critical flicker fusion, picture memory and time sense) was investigated in seven healthy volunteers. The results show a dose-related impairment of memory, a reduction in tapping frequency and an increase in inspection time. A paradoxical increase in critical flicker-fusion threshold was observed. There was no effect on critical fusion-flicker threshold or time sense. Recovery was incomplete for memory tests performed 20 min after withdrawal of nitrous oxide. Subjective effects persisted for several hours.

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The recent publication of the Department of Health's report from the Expert Working Party on General Anaesthesia, has made recommendations on sedation in the dental practice. This article discusses the use of benzodiazepines by the general dental practitioner.

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Out-patients attending for removal of at least one lower third molar were randomly allocated to treatment with temazepam elixir (n = 7) or intravenous midazolam (n = 8), as well as local analgesia. Patients were tested prior to drug administration and at the end of surgery. Both drugs increased heart rate and midazolam also decreased diastolic blood pressure. The two drugs caused significant, equal increases in ratings of sedation, but the reduction of anxiety was significant only for midazolam. There was significant amnesia for material presented after drug administration, as well as for dental events and this was significantly greater for midazolam. The effects of these drugs in dental patients were compared with those in normal volunteers treated in an identical manner, but without oral surgery. The drugs had similar significant cardiovascular and amnesic effects in the volunteers and the same effects on mood ratings, even though volunteers and patients differed in their pretreatment levels of anxiety and discontent. The dentist's ratings of the sedation and operating conditions were excellent in both cases. Thus temazepam elixir provided a useful sedative for oral surgery, avoiding the complications of intravenous administration. However, for equivalent levels of sedation, midazolam had greater anxiolytic and amnesic effects than temazepam.

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This paper describes the present system of education and training for doctors and dentists providing general anesthesia or conscious sedation for dental treatment in the United Kingdom. The changing pattern of practice in these areas is outlined in the context of a changing medicolegal climate, together with the possibilities for future development.

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Twenty-one outpatients attending Guy's Dental Hospital received intravenous midazolam prior to the removal of at least one wisdom tooth. The patient's memory for material presented both before and after midazolam was assessed either whilst still in the drug-treated condition (midazolam+placebo) or in the drug-reversed condition (midazolam+flumazenil). There were no differences between the two retrieval conditions in the number of words or pictures correctly recalled or recognized and both groups showed significantly better memory for material presented prior to midazolam administration. In a word completion task both groups showed a significant and equal priming effect, in that they completed more words with those to which they had been previously exposed in a rating task. However, the groups differed significantly in the total number of words correctly completed, with the drug-reversed group completing more. The word completion task is a problem- solving task requiring retrieval from semantic memory. There was further evidence that midazolam might impair retrieval from semantic memory from the number of subjects making spelling errors; this was significantly greater in the midazolam group than in the midazolam+flumazenil group. Finally, free recall of the dental procedures was significantly different in the two retrieval conditions. The midazolam+flumazenil group remembered significantly more items, and this effect was particularly marked for patients who had all four wisdom teeth removed. Flumazenil significantly reversed the midazolam-induced decrease in tapping rate (an objective measure of sedation), significantly attenuated the reduction in self-rated anxiety and significantly increased shaking and trembling.

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The pain experienced after third molar surgery was used as a model to evaluate the analgesic efficacy of a new non-steroidal anti-inflammatory drug, lornoxicam, in a Phase II study. One hundred and fifty fit, young adults participated in this randomised, single dose, double-blind, parallel group clinical study. Three doses of lornoxicam (2 mg, 4 mg, and 8 mg) were compared with aspirin 650 mg and placebo. Patients suffering from moderate to severe pain following surgery were monitored for up to 8 hours. All indices of efficacy showed similar results, all active treatments being associated with highly significant (P less than 0.0001) reductions in pain during the study period. Lornoxicam 8 mg demonstrated significant analgesic efficacy as compared with placebo. The two lower doses of lornoxicam and aspirin all showed apparent degrees of efficacy intermediate between that of placebo and lornoxicam 8 mg, although the trial proved to have inadequate power to show significant differences between these three treatments. Lornoxicam was very well tolerated at all three doses studied, with no adverse events definitely attributable to its administration.

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Fifty-eight patients undergoing restorative dental treatment at Guy's Hospital had been previously allocated on the basis of clinical assessment, including that of their dental anxiety, to treatment under local anaesthetic alone or in combination with i.v. midazolam or inhalation nitrous oxide. They were tested before and after dental treatment to determine their memory of dental procedures and changes in mood and bodily symptoms. The patients allocated to the midazolam treatment had significantly higher pre-treatment scores on the Bond & Lader mood factors of "anxiety" and "discontent". All the groups showed significant pre- to post-treatment reductions in sweating, palpitations, restlessness, dry mouth, muscular tension, nausea, loss of appetite and upset stomach and the extent of these reductions were not different for the different treatments. Midazolam treatment resulted in significantly greater reductions in self-ratings of bodily symptoms of anxiety, shaking and trembling compared with the control (local anaesthetic) group. Nitrous oxide resulted in a significant reduction in irritability, compared with controls. Both midazolam and nitrous oxide significantly reduced the patients' memory of the dental procedures and the impairments in memory were independent of any changes in anxiety or sedation. Of the items remembered there were no differences between the groups in their ratings of how well explained, how pleasant or unpleasant, or how painful the procedures were.

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The effects of intravenous administration of diazepam (average 20 mg) on learning, performance and mood were assessed in dental patients. These patients required sedation due to excessive anxiety in a dental situation, or because they were to undergo stressful surgery. On a verbal learning task, subjects recalled and recognized significantly fewer words from a list presented after drug administration than from a list presented prior to drug administration, when tested at the end of the treatment period. When tested after treatment, subjects recognised few of a series of picture postcards that had been presented to them during the course of treatment. Subjects showed no significant impairments after diazepam treatment on digit-symbol substitution, symbol copying or number cancellation tasks compared to pre-treatment scores; however, there was a small but significant reduction in the number of finger-taps made. Mood-rating scales showed significant increases in sedation and well-being after diazepam treatment compared to pre-treatment scores, and also a significant reduction in anxiety levels. This study shows that the amnesic effects of diazepam are present in a "real-life" stress situation.

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Diazepam in propylene glycol (Valium, Roche) and midazolam (Hypnovel, Roche) were compared as sedatives in 40 patients undergoing minor oral surgery. Twenty patients received each drug. The cardiovascular effects, the acceptability of the drugs to patients and dentists and the incidence of anterograde amnesia and adverse venous sequelae were investigated. Serum benzodiazepine levels were measured and recovery studied by six psychomotor tests repeated over five hours. Both drugs provided safe and acceptable sedation. More amnesia was reported in the midazolam group and more adverse venous sequelae by the diazepam patients. The recovery tests showed that the time taken to return to pre-sedation scores varied with the tests used and there was no significant evidence of the midazolam group recovering more quickly. In particular, significant impairment of delayed memory recall persisted in both groups throughout the investigation period.

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