what is it and how can it be improved?

Transcription

1 fcialjournalofthebrtishdentalasociation.a review of the indicator of sedation need (IOSN): what is it and how can it be improved? B. Shokouhi* 1 and B. Kerr 2 GENERAL In brief Suggests the IOSN can be a useful tool for clinical decision-making, health needs assessment and commissioning purposes for sedation services. Suggests the IOSN has a number of drawbacks and is not robust enough to be used as a sole commissioning tool to determine access to sedation. Proposes that some alterations, particularly with respect to being speciality specific, can make the IOSN a more useful tool. The indicator of sedation need (IOSN) is a tool that has been devised to help with clinical decision-making, health needs assessment and commissioning purposes for the provision of sedation services. It can potentially increase access for patients to sedation when used as a screening tool, however, there are some shortcomings in the IOSN, such as the fact that it is not speciality specific, that can reduce its efficacy. As such, in its current form the IOSN may not be robust enough to be used as a sole commissioning tool and may in fact create barriers to patients that would benefit from sedation. By addressing these issues and understanding its limitations, the IOSN can be used more effectively for its intended purposes. Introduction There are various routes through which sedation services can be provided in the UK, varying from NHS or private practice in primary care to hospital or community services in secondary care. The decision as to whether sedation is required lies mainly with the clinician, through a discussion with the patient. However, more than often it is not a simple situation of being able to easily identify those in need and those who can be managed without sedation. As such a tool would be useful in this decision-making process, which is in essence the Indicator of Sedation Need (IOSN) and the main discussion point of this paper. Need for an assessment tool The prevalence of dental anxiety varies widely in different populations and demographics. 1 Senior Speciality Dentist in Oral Surgery, Oral Surgery Department; 2 Consultant in Sedation and Special Care Dentistry, Sedation and Special Care Department Guy s Hospital Great Maze Pond, London, SE1 9RT *Correspondence to: Bizhan Shokouhi bizhan.shokouhi@gstt.nhs.uk Refereed Paper. Accepted 17 October 2018 DOI: /sj.bdj In the UK it has been estimated that 11% of patients have dental anxiety 1 although it is accepted that this is a difficult statistic to acquire accurately due to the nature of gaining information from respondents. Other countries have reported anxiety levels ranging from 4 21% of the population. 2 Furthermore, the need for sedation is not only based on dental anxiety levels but also the complexity of treatment and providing care in a comfortable and non-threatening manner. Evidence shows that a particularly bad experience may well lead to a previously absent fear of dentistry, 3 which may lead to an increased need for sedation services in the future care of that patient. With these facts and figures considered, it is evident that the provision of sedation can be an integral part of a patient s care pathway. Current estimates in England suggest that approximately 5% of patients attending the dentist will at some point in their life require sedation as part of their treatment. 4 However, the provision of sedation services can be a rather subjective matter when deciding who requires sedation and who doesn t. There is evidence that the need for such services is higher than what is currently available to some patients and that they would attend the dentist more frequently should sedation be available as part of their management. 2 As such it is clear that a tool would be useful in the decisionmaking process for the provision of sedation. This is particularly important in the NHS with dental services moving to a national commissioning model, which will require a robust method of measuring the need and demand of a particular service and a way of providing care to those most at need. In some ways this can be compared to the index of orthodontic treatment need (IOTN) which has been used in the commissioning and provision of orthodontic treatment. 5 The Intercollegiate Advisory Committee for Sedation (IACSD) has released guidance with regards to this and states that services should be patient-centred and also appropriately funded. 6 The IOSN could potentially be used for such a purpose across all sedation services in primary and secondary care. Another use for the IOSN would be as an aid to clinicians in their decision-making and treatment-planning, particularly those with less experience in the management of anxious patients or requiring complex treatment. As it is a relatively simple and quick process, no additional training would be required for this and any clinician could use the IOSN to help them decide whether the patient would benefit from treatment under sedation. BRITISH DENTAL JOURNAL Advance Online Publication JANUARY O

2 fcialjournalofthebrtishdentalasociation.general The IOSN and its uses The IOSN is a tool comprised of three components: Patient anxiety Treatment complexity Medical history. These areas are each assigned a score which are combined to give a final IOSN score. This final score is suggested to allow the clinician to decide whether there is a need or no need for sedation for that particular patient (Appendix 1). It was first described in a four-part series of publications in 2011 using data based in the North West of England. 4,7 9 Patient anxiety This is assessed via the use of the modified dental anxiety score (MDAS) which is completed by the patient. This questionnaire comprises of five questions (Appendix 2) which are ranked from not anxious to extremely anxious and totalled to give a final anxiety score. Research supports the validity of this scoring system as a measure of anxiety 10 and it has been shown that the completion of the form does not increase the patient s anxiety pre-operatively. 11,12 It is worth noting that the MDAS is a modified version of the Corah s dental anxiety score (CDAS) that is intended to have more clinical relevance, however, a review of 15 measures of dental anxiety found that the CDAS can be a more accurate measure of anxiety. 13 This study found that the CDAS had questions which were more situational and with a higher sensitivity to anxiety in adults, however, it must be noted that in their review, the CDAS had the largest evidence base and as such their conclusions may have been biased due to this. Clinicians may prefer to use the CDAS and make use of a published conversion table 14 to create an MDAS score for use in the IOSN. This may provide a more accurate anxiety score although further research is required in this area. Treatment complexity Using a provided table of potential treatment types, a score is given for either routine, intermediate, complex or highly complex treatments. It is recognised that dental treatments are often multi-factorial and thus assigning a single score for the complexity is a difficult process and if in doubt a higher score is recommended. The idea of assessing treatment complexity is derived from aiming for a more holistic approach to patient management as outlined by the Darzi report, 15 which places an emphasis on overall patient care and comfort. This means that even for non-anxious patients, consideration should be given to the appropriateness of providing sedation for more complex and potentially uncomfortable procedures. Medical history This section of the tool is used by taking into account the patient s overall medical status and assigning a score of 1 4 depending on the number of medical conditions that exist. It should be noted that certain behavioural aspects such as gagging are also considered and given a score in this section. The relevance of medical history when considering sedation mainly related to those conditions which may be exacerbated during dental treatment such as asthma or cardiovascular disease, 16 or those that may hinder treatment such as movement disorders or severe gagging. The combined measures of these sections gives an overall score of between Scores of 3 6 are considered not to need sedation whereas scores of 7 12 would suggest a need for sedation. The main purpose of the IOSN has been proposed to be either as a referral tool for use in commissioning of services or as a health needs assessment (HNA) tool. 7 Potential problems The validity of MDAS as an anxiety score It has already been stated that the MDAS is a well-researched and validated tool for the assessment of anxiety. However, the publications in question were not speciality specific, and again there is an issue with this that may potentially underestimate the anxiety levels of certain patients. Considering the questions posed in the MDAS (Appendix 2), it is evident that they are all rather generic in nature and more relevant in routine general practice. There is no consideration for extraction of teeth, root canal treatment or any other potentially lengthy and uncomfortable procedure. Interestingly, a study found that pre-operative anxiety was highest for extractions when compared to other treatment types. 17 This can clearly have an impact on the overall anxiety score, as a patient may not be anxious about most of the questions posed, but may be extremely anxious about having an extraction carried out. As such this will underestimate the total level of anxiety and give a lower IOSN score leading to a recommendation for no need for sedation, which may not be the correct mode of management for that patient. Finally, there are groups of patients who will not be able to complete an anxiety questionnaire adequately, such as those with dementia and learning disabilities. This can make it impossible to fully complete the IOSN, thus rendering it useless in these situations. Medical history questionnaire Currently, a higher weighting is given to the scoring with more severe medical histories. This does not take into account specific conditions and for example, the IOSN would potentially suggest that someone with severe respiratory disease requires sedation whereas this can in fact be dangerous for the patient. Unrepresentative data used in publications The original papers that were published to describe and validate the IOSN used a sample of 606 patients gathered from four general dental practices in primary care in the North West of England. 4 It can be argued that this is not a representative sample to be used on a larger scale, particularly when considering different specialities such as oral surgery and special care dentistry. Using data from general practices in primary care and attempting to apply them to a very different type of practice in secondary care can be argued to be unrepresentative and can potentially underestimate or overestimate the need for sedation. This is further discussed below. Additionally, the mean age of respondents in the sample was 54, which is recognised to be relatively high for such a sample size. For example, patients requiring third molar surgery often present at a much younger age with some studies quoting a mean age of As such, again the data used to validate the IOSN may not be representative when considering different specialities that may have a different set of demographics. Applying the IOSN to different specialities The IOSN is intended to be used as a HNA and referral tool across different fields of dentistry whereas the original data gathered were from 2 BRITISH DENTAL JOURNAL Advance Online Publication JANUARY O

3 fcialjournalofthebrtishdentalasociation.general general practices in primary care. This creates the potential problem that certain specialities may have particular dynamics that are not recognised in general practice and as such using a tool to make decisions in these fields may not produce the desired results. It has been recognised that many more oral surgery procedures will require sedation than general dentistry. 2 For example, a scenario which is actually described in one of the original publications 4 is that of a healthy non-anxious patient who would normally attend the dentist for routine care without the need for sedation, but may require or prefer to have sedation for the removal of a complex third molar tooth. Using the IOSN, even if this treatment is considered to be highly complex, the overall score would be 6, which would indicate that there is no need for sedation. Also, there is no thought given to a patient s previous dental history which can have a significant impact on their ability to cope with treatment. For example, for a treatment of equal complexity, a patient with no previous dental treatment may require sedation more than someone with extensive previous treatment. However, it can be argued that in a way, this is something which would be assessed at the anxiety scoring stage. Using the IOSN as a commissioning tool In the scenario just described, it can be argued that in such a situation the IOSN can be overruled and a separate decision made by the clinician. However, this brings into question the actual use of such a tool as the IOSN if its results are not robust enough to be used with every case. This is particularly important if the IOSN is to be used as a commissioning tool to decide who needs sedation and who doesn t, as if it were to be used as a black-and-white yes or no type tool, it will invariably limit the services to some who are at need. In comparison, the IOTN that is used to commission orthodontic services is more of an objective tool, taking into account precise measurements. The assessment of anxiety and treatment complexity is a much more subjective matter with a magnitude of factors that can be very difficult to convert into a simple scoring system. The correct usage of the IOSN If the IOSN is to be used as a direct yes or no referral tool to decide which patients need sedation, then it can be rather easy to manipulate the form to score higher and create a need for sedation. Patients who demand sedation can quite easily score 5 on all MDAS questions (even if not entirely true) and the treatment complexity can be scored higher (being a subjective topic) to achieve a final score needing sedation. This can again create a demand-led service rather than a need based one, which is something the IOSN aimed to reduce. Obviously this is an issue with any referral system, and if a patient or clinician is determined enough to attempt to demand a particular service, there is often little that can be done to alleviate the situation. This is nonetheless an important issue that needs careful consideration if the IOSN is to be used as a commissioning tool. Potential IOSN improvements As we have seen, the IOSN is a useful tool in the clinical decision-making and referral process for sedation services, however, it has a number of potential shortfalls that have been identified. One of the main issues surrounding the treatment planning for sedation is that a patient s anxiety is rather complex and multi-factorial in nature. Although anxiety scores such as MDAS are useful in providing guidance on the patient s overall anxiety, it is unrealistic to expect such a score to be applicable in every situation within the patients care pathway. A modified version of the MDAS could potentially be useful within different specialities to specifically ask questions that are related to the treatment being proposed. For example, in the current MDAS there is no question regarding tooth extraction and dental surgery such as bone removal. Even though a patient may not be particularly anxious regarding injections and routine fillings, the thought of having a tooth extracted may be much more anxiety provoking. The absence of this vital information can create a drastically lower anxiety score than what the patient is really feeling. This would potentially underscore the final IOSN that may advise a no need for sedation, whereas in reality that patient would have benefited from sedation. As previously mentioned, studies have found that oral surgery procedures tend to result in higher levels of anxiety compared to other treatments 17 and as such this is an area that needs careful consideration to provide a more accurate anxiety and IOSN score. At the time of writing, no oral surgery specific anxiety score was identified. A modified version of the MDAS could prove to be useful in this regard. For example, the question regarding scaling and polishing of teeth could be replaced with If you were about to have a tooth extracted with jaw bone removal, how would you feel? This would be a much more relevant anxiety question for oral surgery procedures and may then result in more accurate IOSN scores to allow the identification of a more accurate number of patients suitable for sedation. This is something that will require further studies first but the proposal for an OSDAS (oral surgery dental anxiety score) to be used for oral surgery specific referrals may be relevant. With regards to the treatment complexity, some thought also needs to be given to account for particularly unpleasant procedures that would benefit from sedation irrespective of anxiety. For example, as discussed previously, a non-anxious patient having a highly complex treatment (such as a complex wisdom tooth removal) would still score below the IOSN threshold for sedation need. To account for this, the current weightings of certain procedures could be increased to gain a more accurate IOSN score for these cases. Finally, it may be useful to somehow incorporate the clinician s thoughts and experience into the scoring system. For example, a dentist that knows their patients very well may be in a good position to advise on whether they are likely to benefit from sedation or not. To this effect, an additional question could be incorporated into the IOSN to score the clinician s subjective assessment of the sedation need, which may provide a useful input in the final IOSN score. Additionally, the inclusion of a final scoring of green, amber and red can be used where green indicates a no need for sedation, red indicates a clear need for sedation and amber can take into account the clinician s opinion and other significant modifying factors. These are thoughts that will require further research and study but could potentially increase the benefit of the IOSN. Conclusion The intended use of the IOSN would be useful in clinical decision-making, health needs assessment and commissioning purposes for the provision of sedation services. It can also be a useful screening tool to identify those patients that would benefit from sedation BRITISH DENTAL JOURNAL Advance Online Publication JANUARY O

4 fcialjournalofthebrtishdentalasociation.general services. Such a tool can potentially increase access to populations where sedation is not readily available or sought and also reduce the number of cases being treated that were not necessarily needed. This is an important aspect of commissioning, so as to encourage a needsbased service as opposed to a demand-led one. As such, identifying patients who do not require sedation can be as equally important as identifying those who do. It has been shown that 100% of patients who received sedation would request it again. 9 This can clearly be a disadvantage as it may lead to a reliance on sedation where it is not necessarily needed. However, due to the factors discussed in this paper, the IOSN in its current format has some drawbacks and is not robust enough to be used as a sole commissioning tool to determine access to sedation. There is a risk that it will underestimate or overestimate the need for sedation in a significant number of cases. One of the main reasons for this appears to be a result of the IOSN not being speciality specific and not taking into account the significance of treatment complexity of certain procedures, which in a non-anxious patient may potentially create iatrogenic phobias following treatment. Given the high levels of dental anxiety, it is evident that there is a need for a screening tool and these are issues that could potentially be rectified by some alterations to the IOSN. Further studies are warranted to explore these areas in more detail. 1. Humphris G, King K. The prevalence of dental anxiety across previous distressing experiences. J Anxiety Disord 2011; 25: Dionne R A, Gordon S M, McCullagh L M, Phero J C. Assessing the need for anaesthesia and sedation in the general population. J Am Dent Assoc 1998; 129: McNeil D W, Berryman M L. Components of dental fear in adults? Behav Res Ther 1989; 27: Pretty I, Goodwin M, Coulthard P et al. Estimating the need for dental sedation. 2. Using IOSN as a health needs assessment tool. Br Dent J 2011; 211: E Lunn H, Richmond S, Mitropoulos C. The use of the index of orthodontic treatment need (IOTN) as a public health tool: a pilot study. Community Dent Health 1993; 10: The Intercollegiate Advisory Committee for Sedation in Dentistry. London: The Royal College of Surgeons of England, Coulthard P, Bridgman C, Gough L, Longman L, Pretty I, Jenner T. Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) a novel assessment tool. Br Dent J 2011; 211: E10E. 8. Goodwin M, Pretty I. Estimating the need for dental sedation. 3. Analysis of factors contributing to nonattendance for dental treatment in the general population, across 12 English primary care trusts. Br Dent J 2011; 211: Goodwin M, Coulthard P, Pretty I, Bridgman C, Gough L, Sharif M. Estimating the need for dental sedation. 4. Using IOSN as a referral tool. Br Dent J 2012; 212: E Humphris G M, Freeman R, Campbell J, Tuutti H, D Souza V. Further evidence for the reliability and validity of the Modified Dental Anxiety Scale. Int Dent J 2000; 50: Humphris G M, Hull P. Do dental anxiety questionnaires raise anxiety in dentally anxious adult patients? A twowave panel study. Prim Dent Care 2007; 14: Humphris G, Clarke H, Freeman R. Does completing a dental anxiety questionnaire increase anxiety? A randomised controlled trial with adults in general dental practice. Br Dent J 2006; 201: Newton J T, Buck D J. Anxiety and pain measures in dentistry: a guide to their quality and application. J Am Dent Assoc 2000; 131: Freeman R, Clarke H, Humphris G. Conversion tables for the corah and modified dental anxiety scales. Community Dent Health 2007; 24: Department of Health. High quality care for all: NHS next stage review final report. NHS, Malamed S F. Sedation: a guide to patient management. Elsevier, Stabholz A, Peretz B. Dental anxiety among patients before different dental treatments. Int Dent J 1999; 49: Lysell L, Rohlin M. A study of indications used for removal of the mandibular third molar. International journal of oral and maxillofacial surgery. 1988; 17: BRITISH DENTAL JOURNAL Advance Online Publication JANUARY O

5 Appendix 1 Indicator of sedation need form GENERAL BRITISH DENTAL JOURNAL Advance Online Publication JANUARY OficialjournaloftheBritishDentalAssociation.

6 Appendix 2 Modified dental anxiety scale GENERAL 6 BRITISH DENTAL JOURNAL Advance Online Publication JANUARY OficialjournaloftheBritishDentalAssociation.