EFAAD

On October 14-15, 2010, EVIAN-LES-BAINS hosted the EFAAD2010 meeting with participants from all over Europe, including : France, Switzerland, United Kingdom, Germany, Spain, Italy, Croatia, Russia, Israel, the Netherlands...

There was a soul in this meeting, which came up to our expectations, opening new perspectives for the future of patient management in dentistry.

Following are the abstracts of our lecturers.

 

Pr Eliezer KAUFMAN : The need for sedation in modern dentistry : we've come a long way.

The achievements in dentistry since its establishment as a profession have been incredible with the contribution of such outstanding dentists like Horace Wells, Thomas William Green Morton, Niels Bjorn Jorgensen and Drummond Jackson being crucial to the field of pain and anxiety control. 

However, there are often obstacles in treating patients. Dental fear and phobia, uncooperative patients (children, special need patients), increased gagging, ineffective local anesthesia, medically compromised patients and patient comfort in long or invasive procedures, are examples of what can compromise our ability as dentists in delivering our dental wonders. From all strategies possible, office based sedation stands out as one of the most promising ways to treat these needy patients.  The demand for anxiety and pain free dentistry is a growing pattern in western societies mostly due to an aging population with more systemic disorders, the great prevalence of dental fear as well as more daring surgical procedures such as bone augmentation and implants. 

Office based conscious sedation is developing very rapidly and new interesting approaches are emerging. Patient Controlled Sedation (PCS) provides interesting fusion of pharmacology and psychology. Target Control infusion System (TCI) is a computer assisted technique which seeks to quickly achieve and maintain therapeutic concentration of drug in the blood or brain based on pharmacokinetic modeling of distribution and metabolism. Bispectral Index (BIS) is another computer assisted technique utilizing brain activity EEG to evaluate the depth of anesthesia. Combining BIS and TCI is a promising office based sedation technique which can be easily mastered by the intelligent dentist who wants to fulfill his mission of safe, anxiety and pain free modern dental treatment. 

Dr Nigel D Robb : The complicated european situation

Pain and anxiety control is a fundamental part of the practice of dentistry.  This can be accomplished in a variety of pharmacological and non-pharmacological techniques. Recent changes in legislation within the European Union (EU) have lead to greater freedom of movement of workers between countries within the EU. This fact coupled with a well-publicised shortage of dentists in the United Kingdom (UK) has lead to an influx of foreign dental graduates into the UK.In any country patient expectation and demands for postgraduate education depend on the expectation of what dentists should be able to provide and the education received by dental students whilst at university. Disparities between dental graduates education may cause problems in the delivery of service and the provision of postgraduate education.The Aim of this study was to assess the differences in dental education between countries in Europe to establish whether there were significant differences between the countries.

A questionnaire was devised and distributed to all the Council Members of the European Federation for the Advancement of Anaesthesia in Dentistry (EFAAD) with the request that they be distributed to all the Undergraduate Dental Schools in that Country. Completed questionnaires were to be returned to the EFAAD reps prior to central collection.

The analysis would be a qualitative analysis of the differences in education in the different countries.

The expectations of the dental graduate vary greatly between the countries in Europe. There is little consensus on the teaching of pain and anxiety control in terms of the methods that are taught or the location of the teaching within the course.

There is little consensus regarding what is part of dentistry, with different interventions being permissible in different countries.

The differences in practices between the countries in the European Union are a potential problem for an increasingly mobile workforce. It is possible that some dental graduates may feel under pressure to provide treatments for which the have not been trained. The discrepancies in practice may also cause frustration for those who are not able to practice the techniques that they have studied.

There should be greater consensus as to what treatment modalities are part of dentistry to improve the consistency of teaching across the dental schools in the European Union. 

Pr Enrico FACCO : The spectrum of sedation in Dentistry. How to deal with anxiety in dentistry.

Chair of  Dental Anesthesia, Dept. of  Medico-Surgical Specialties, University of Padua, Italy.

Dental fear can be considered as an universal phenomenon with different cultural features; it affects about 25-30% of patients, leading to delay or avoid attendance. The origin of dental anxiety is multidimensional and includes both endogenous and exogenous causes. Several psychological disorders are more frequent in patients with high dental anxiety. Trait anxiety, panic attacks and post-traumatic stress disorders may increase anxiety  in the dental setting; on the other hand, dental phobia may be due to previous traumatic experiences and/or bad information causing distrust of dental professionals, patient’s helplessness, threat for autonomy loss and violation. Severe systemic diseases may also increase dental anxiety, related to previous bad experience with medical invasive procedures.  As a result, dental anxiety is far from being a simple entity and makes psychology and  behavioural sciences an essential component of dentist’s competence.

Dental anxiety involves a wide ranging and dynamic impact in patients’ life, besides avoidance behaviour. The expected suffering and pain perception during dental treatment care impairs the patient’s capability of understanding the information provided before treatment and causes a relevant increase of anxiety and stress reaction during dental treatment, thus increasing the risk of  emergencies.

An appropriate psychological assessment and the use of conscious sedation with pharmacological and/or behavioral techniques (such as iatrosedation and hypnosis) are an essential step to assure both safety and quality of care in dentistry.

Dr Nigel ROBB : How do we teach Conscious Sedation ?

Sedation is a success area in dentistry. In comparison with our medical colleagues, we practice safely and have a long history of appropriate training.

Conscious sedation is, and must continue be considered as an integral part of dentistry and dental education at all levels.

All teaching of conscious sedation must not only include didactic teaching but supervised clinical practice. This is the best way to ensure that we continue to practice safe conscious sedation.

Every effort must be put into providing adequate and appropriate education at the undergraduate level, as this is the key to being able to provide the proper continuum of education to the dental profession.

Pr Monika DAUBLAENDER : Emergency requirements in the dental office.

Emergency situations in the dental office occur suddenly, at any time and in any patient and can lead to disturbances of the vital functions. Therefore it is necessary to react immediately and have special knowledge and equipment. A lot of critical situations are human factor associated errors and they can sum up to a critical incident. Special training of the whole dental team is very important to reduce stress in the acute situation. Another crucial thing is adequate equipment. That means a well maintained emergency kit, oxygen and a few drugs. Every dental office should provide a special emergency plan. That means a plan for the in office procedures and for calling the emergency medical services.

Pr Monika DAUBLAENDER : Updates in Local Anesthesia.

Local anaesthesia is crucial for a modern and painless dental treatment. A lot of the treatment opportunities can’t be performed with a sufficient pain management. 

The rate of side effects is 4,5 %. One reason for these side effects is an inadvertent partial intravasal injection in 20 % of the cases. In that condition a small amount of LA and more recognisable of epinephrine gets to the intravasal space with the result of special systemic effects like tachycardia, high blood pressure. To minimize these effects LA-solutions with a lowered epinephrine concentration should be used. Because there is a greater cardiovascular depression after the intravenous injection of Lidocaine compared to Articaine and a stronger synergistic effect of Articaine and catecholamines than in combination with Lidocaine lower epinephrine concentrations should be used.

Even the Articaine solutions with a reduced epinephrine concentration (1:400.000) are able to reduce the systemic LA plasma levels to 50 %. After local application there was no statistical difference between the epinephrine levels of Articaine without Epinephrine and the reduced concentrations. 

The anaesthetic efficacy was tested in healthy volunteers with infiltration in the upper front teeth. The result was a direct dependency of the area under the curve from the epinephrine concentration due to differences in duration of anaesthesia. The solution with epinephrine 1:400.000 showed pulpal anaesthesia of 35 min, with epinephrine 1:200.000 of 45 min and 1:100.000 of 55 min. These results underline the importance and the regulatory effect of the vasoconstrictor for this technique. This is different to conduction anaesthesia where the diffusion distance and barriers are larger. It seems that a reduced vasoconstrictor concentration leads to an advantage for better anaesthesia.

In summary that means that there is need for a differentiated use of local anaesthetic and vasoconstrictor in dependency of the kind of treatment (duration and painfulness), risk factors of the patient, injection technique, needs of the patient and experience of the dentist.

Beside the drug it is also necessary to look at the optimal delivery system. The dentist cannot control rate or pressure with this simple mechanical system (hand) exactly. The computer controlled local anaesthesia devices (C-CLAD) combine a micro motor and a computer for higher precision and optimized injections. Due to a controlled pressure there is an optimization in injection dynamics, reduction of injection pain, quicker onset of anaesthesia and reduction of the volume needed. To decrease pain and anxiety of a local anesthetic injection pressure less than 306 mmHg (6 psi) should be used in movable mucosa. The correlation between tissue type and exit pressure can be measured and leads to the differentiation of 3 different kinds of injection site. The highest pressure and density exists in the intraligamentary space, second is the palatinal mucosa and the lowest measurements can be found in the movable mucosa during infiltration and block anaesthesia. 

Additional to the pain a high pressure injection into the intraligamentary space can cause tissue damage. The single tooth anaesthesia unit (STA) with it’s rationale:

•  Guidance to the target 
•  Identification of the specific tissue
•  Continuous Feedback (Visual & Audible) during the injection
•  Detection of occlusion & leakage 

is able to provide the dentist with all these option to increase the quality and efficacy of the injection. Specially when treating children and anxious patients these advantages get evident and reduce not only the stress of the patient but also the dentist’s one.

Pr Serguey SOKHOV : Problems and solutions with L.A.

Modern dentistry suggests local injection anesthesia as the basic method of pain prevention for treatment of the basic dental diseases. This method remains in the lead all over the world on all continents. Ten million injections are carried daily each having different safety and efficiency level.  Local anesthesia is subjected to the number of regulations that is based on such factors as social and economic development of the country and its health service, requirements of society to the quality of rendering dental assistance, financial abilities of clinics and patients, qualification of doctors and some others. Both practitioner and patient face two main challenges that are safety and efficiency of local anesthesia and following dental treatment. Safety and quality of dental treatment are two sides of one coin. Safety of local anesthesia is composed of the choice of anesthetic, its concentration and injected quantity. It is dependant on the concentration of vasoconstrictor adrenaline (epinephrine) or noradrenalin (nor epinephrine). It is affected by the applied methods (infiltration, nerve block, intraligament, diploic, etc.) and the correct choice of a “tool” to make injection (from simple syringes to computer injection devices). To perform safe and efficient anesthesia it is essential to take into consideration age of the patient, the duration, volume and traumatic rate of dental treatment, if there are any associated pathologies of cardiovascular, endocrine, respiratory or other systems. The skill of practitioner to reveal the patients of high risk group, to prepare them for treatment in collaboration with other experts is extremely important. Another important aspect is the constant supervision (monitoring) of vital functions of organism while performing anesthesia.

Thus, the safety and efficiency of local anesthesia can be achieved through the control and perfection of all stages of the procedure of local pain prevention, the right choice of anesthetic, instrument of injection, estimation of patient general state of health and use of alternative means of anesthesia and sedation in some cases.

Dr Wolfgang JAKOBS : Safety of local anesthetics.

Despite the fact that the administration of local anesthetics in modern dentistry is a very safe and reliable method of pain control, local and systemic complications following the use of local anesthetics may occur.

The systemic complications of local anesthetics include undesired or harmful effects like toxic reactions to the local anesthetic, the vasoconstrictor or allergies to the preservatives or additives of the local anesthetic solution.

Local complications associated with the administration of local anesthetics can be related to the drug,the vasoconstrictor, the technique used or can be caused by the patient`s medical condition, eg patients under anticoagulative therapy.

The local adverse effects of local analgesia include neurovascular complications such as haematomas, prolonged anesthesia, paresthesia,dysaesthesia  or infection at the injection site. Temporary sensory disturbances following the injection of local anesthetics are relatively rare, permanent nerve damage after local anesthesia is extremely rare.  

The published incidence rates of neurological complications after local anesthesia   are unreliable with a variation between 1:18500 and 1:1 000 000.

The risk of temporary or permanent nerve injuries varies between the different locations and injection techniques,route of administration and the total dose administered  

The neurologic complications (sensory disturbances) are defined as a local adverse effect of local anesthetics, no particular local anesthetic is more likely to cause the effects.

The exact mechanism of the nerve damage caused by local anesthetics remains unclear.

The common theories to explain the nerve damage after local anesthesia are mechanical violations or chemical-toxic reactions.

- neurotoxicity of the anesthetic solution

- excessive fluid pressure in a confined space

- severing of nerve fibers or the perineurium with the injection needle

- injection site haematoma or inflammation.

After an inferior alveolar nerve block a temporary or permanent paresthesia, dysesthesia or anaesthesia of the alveolar nerve and /or the lingual nerve can occur.

A temporary dysfunction of the sensible nerve lasts up to 3-6 months, after 12 month a permanent damage of the nerve must be considered.

According to the literature the vast majority of those effected (up to 94%) recover within 6- 8 weeks.

We differentiate between several qualities of malfunction of the sensible nerve (LaBlanc 1992 Trigeminal nerve injury.)

1. Quantitative disturbance : anaesthesia, Hypaesthesia/Hypalgesia, Hyperaesthesia/Hypalgesia

2. Qualitative disturbance : Dysaesthesia, Allodynie

3. Dissociative disturbance : Paraesthesia,burning sensation,numbness or prickling.

Since the publications by Haas (J Can.Dent.Assoc.1995.61 (4)319-326 and Hillerup and Jensen 2006 .Int .J Oral Maxillofac.Surg 2006.35 (5)437-443 suggested a higher rate of nerve complications after inferior alveolar nerve blocks with 4% articaine (and 4% prilocaine) we see a contoversal discussion about the possible risk associated with the use of Articaine especially for an inferior alveolar nerve block.

Articaine is in clinical use since 1976. Articaine products have a market share of more than 92% in Germany, furthermore Articaine is the most commenly used local anesthetic in Europe.

Articaine was approved for sale in the USA by the FDA in 2000, and was used in Canada since 1996.

Because of the clinical properties of  the drug:profound anesthesia,fast onset of action and superior safety because of Articain`s relatively short plasma  half-life   with a reduced risk for systemic toxic reactions Articaine became the most commenly used local anesthetic in Germany.

Dr John MEECHAN : Pain control in L.A.

Pain-free dentistry is the aim of all caring practitioners. It is unfortunate that patients associate the use of local anaesthesia with he production of pain. This presentation will consider those factors that produce discomfort during the delivery of intra-oral local anaesthesia. 

A number of things affect discomfort during intra-oral local anaesthetic injections. These can be divided into the following categories:

•  Equipment factors 
•  Patient factors
•  Dentist factors.

This presentation will describe those aspects that the dentist can control and consider strategies to reduce injection discomfort.

The influence of the following items of equipment will be discussed

•  The needle
•  The syringe
•  The cartridge (carpule)

In addition the dentist can influence the following factors that influence injection discomfort:

•  The area of the mouth to be injected
•  The technique of local anaesthesia employed

The choice of injection site in relation to discomfort will be discussed and aspects of injection technique such as speed of delivery and the use and efficacy of surface preparations for example topical anaesthesia will be described.

Pr Jean-Louis SIXOU : Diploïc Anesthesia.

While pain management during dental treatments in patients has progressed over the past several decades, performing local anesthesia can still be a problem for practitioners: not always efficient (15 to 75% failure rate for mandibular nerve block), risk of injection within vessels, sensation of numbness leading to the risk of self-biting numbed soft tissues. Diploïc anaesthesia, by mean of intraosseous injections, make it possible to place local anesthetic solutions directly into the cancellous bone adjacent to the teeth to be anesthetized. Since the anaesthetics is placed close to the apices, anaesthesia is immediate, efficient and restricted to the teeth, the surrounding soft tissue remaining unaffected. Three major techniques are available: transcortical anaesthesia, osteocentral (trans-septal) anaesthesia and anaesthesia in retromolar trigonum. Better results are obtained when using anaesthetics associated to vaso-constrictors. Most recent articles have reported results obtained with four proven commercial delivery systems (Stabident"!, X Tip"!, Quick Sleeper"!, and Intra Flow"!). This presentation aims at showing that, with respect to local and general indications, diploïc anaesthesia is an efficient primary or a supplemental technique for local anaesthesia in adults and children, including patients with handicap, that combines efficacy and a lower risk of soft tissue injuries by self-biting. These intraosseous injections may thus also be a good alternative to classic infiltration techniques.

Pr Jean-Louis SIXOU : New trends in L.A. in pedodontics.

Dental anaesthesia (DA), because it is mainly associated with pain, is one of the most important factors related to fear and discomfort in children and adolescents. DA in children can be divided into infiltration methods (buccal infiltration, mandibular nerve block, intraligamentory injection, AMSA, naso-palatine injection ...) and diploïc anaesthesias (transcortical, osteocentral, retromolar trigonum anaesthesias). The delivery of local anaesthetic solutions and the puncturing the mucosa by the needle during traditional infiltration procedures can be uncomfortable in spite of topical anaesthesia. The use of computerized systems to deliver the anaesthetic at a constant rate and pressure can be helpful. Infiltration methods may also be associated with mucosal numbing and self-biting of soft-tissues. Diploïc anaesthesias (intraosseous injections) which are an alternative to traditional infiltration techniques, make it possible to inject local anaesthetic directly in the cancellous bone adjacent to the tooth to be anaesthetized. The use of a computerized system to deliver the anaesthetic solution allows to decrease the risk of putative heart effects. The overall success rate in children is 92 % with no or mild pain in 84% of cases and no risk of self-biting. The aim of this presentation is to point out the characteristics, advantages and limits of both infiltration and diploïc methods in children and to show that combining both types of DA leads to less stress and more comfort to both children and practitionners.

Pr Martine HENNEQUIN : Conscious sedation in France : Reinventing the wheel.

Conscious sedation with a N2O/O2 mixture has been studied extensively in dentistry, and the short-term, per-operative effects of the technique have been well documented for various concentrations of N2O in O2 during administration with both a 2-bottle system and with a 50% N2O/O2 premix. However, despite the high number of studies, the rigorous standards of pharmacological drug testing have not been applied to the medical gases, even though they are also used for therapeutic reasons. For example, theses standards imply that evidence for tolerance and efficacy has to be established for a fixed concentration of N2O, with prospectively defined criteria for efficacy and safety. Administration of nitrous oxide inhalation by titration using a 2-bottle system is not compatible with such evaluation, as the percentage of N2O given to each patient is variable. Moreover, there is no consensus between studies on the criteria used to prospectively define either efficacy or adverse events. In this historical context, the majority of studies that have been conducted in dental sedation are not in accordancewith the Guidelines for Good Clinical Practice in clinical trials. In some countries, the lack of high quality evidence could be a barrier to the development of inhalational sedation for dental care. Conscious sedation has traditionally been neglected in France. In order to convince both the dental profession and the health authorities of the need for, and the safety of, conscious sedation in dentistry, it has ben necessary to go back to first principles. Original research within the french context has had to be provided to give evidence of the safety and efficacy of the techniques proposed. In response to this change, a series of clinical trials were performed to produce evidence of the pharmacological effects of a 50% N2O/O2 premix when administered as a sedative drug during dental care in the hospital environment as outside of hospital practice. As a result of this process, N2O/O2 sedation has recently been authorized for use by dentists in France.

The development of conscious sedation in France has obvious repercussions for both undergraduate and postgraduate training in the country. The current teaching programmes will be briefly outlined here. In addition, the development of conscious sedation has improved recognition of the role of the dental nurse and helped to initiate debate into training of the dental team.

Dr Elinor BOUVY-BERENDS : The N₂O experience in Special needs patients.

Since 1981 about 500 dentists in the Netherlands are trained to apply nitrous oxide sedation. About half of them uses the technique regularly: mostly in Centers for Special Care Dentistry.

Doreen Vermeulen-Cranch, emeritus professor Anesthesiology ( University of Amsterdam) and former EFAAD Council-member played the central role in the formal approval by Dutch Health Authorities  (1986) of the use of N₂O/oxygen for sedation by dentists. 

N₂O sedation has high rates of success, and a well-documented safety record. It enables a respectful handling of the disabled patient, enhances his coping skills, provides better working conditions for the dentist with quality care as a result. A proper indication and patient selection is the key to its success. Cognitive development and level of reasoning of the disabled patient indicate the appropriate techniques for dental behavior management of the disabled patient. N₂O sedation for special needs patients requires extra awareness of the occupational exposure to nitrous-oxide involved; a well-controlled ( titrated) sedation technique is recommended.

It is concluded that nitrous oxide sedation for the dental patient with a disability is a valuable asset in the hands of a capable dentist, if based on a good working knowledge of physical and intellectual impairments and adequate behavior management skills. General anesthesia support remains indispensable for many disabled patients.

Dr Claire LASSAUZAY : Conscious sedation with a 50% N2O/O2 premix in a group of elderly with dementia.

Conscious sedation using 50% N2O/O2 may be an alternative to treatment under G.A. in patients who have difficulties to cope with dental treatments. The safety of administration during dental care in children and young adults with disabilities were previously described. Few studies however aimed to evaluate the efficacy of 50% N2O sedation during dental treatment in elderly patients with dementia.

This study aims to evaluate the effectiveness, tolerance and procedures of 50% N2O/O2 sedation in elderly patients with dementia.

This prospective study was undertaken within the geriatric clinic of the dental service oa the University Hospital of Clermont-Ferrand in 2006. Ten patients with dementia who had been referred to the clinic after failure to treat in general dental practice, were included in the study. Outcome measures were success (ability to perform treatment), tolerance (adverse events) and measurment of salivary cortisol levels (marker of anxiety).

This type of conscious sedation seems to be appropriate for an elderly population with dementia. However, as the neurological disease evolves, G.A. may still be necessary at a later date.

Dr Denise FAULKS : Reoxygenation after N2O/O2 sedation : Science or dogma ?

The protocols for administration of N2O sedation vary greatly between countries and available equipment. In particular, differences concern the systematic administration of oxygen at the end of the session. This prospective randomized, comparative and double blind, phase III study compared variations in blood oxygen concentration between patients given either oxygen or air in the recovery period following N2O/O2 conscious sedation. After completion of dental treatment under 50% N2O/O2, patients were randomly selected to receive either medicinal oxygen or medical air for 5 minutes during recovery. Both gases were conditionned in blinded cylinders and were regulated at a flow rate of 4 to 15 l/min. SpO2 was recorded before, during and after treatment and recovery.

Mean SpO2 values did not differ between groups before induction. During 50% N2O/O2 administration, SpO2 increased slightly in both groups. During recovery, SpO2 increased slightly in the group receiving supplemental O2 whilst it decreased in the group receiving air. No differences were clinically significant.

Systematic reoxygenation after administration of 50% N2O/O2 premix for sedation in dentistry is unnecessary for ASA I or ASA II patients.

Dr Jean-Frédéric ANDRE : IV Sedation in the Dental Office.

Modern mouth rehabilitation techniques work wonders for our patients, offering esthetics, comfort and proper function. Full mouth or extensive rehabilitations will induce long appointments. Pain is delt with local and regional anaesthesia. Stress and anxiety however, have often been overlooked in Europe, and appropriate patient management may be required for some patients. Conscious sedation techniques are available and add safe, easy and effective patient management for those long and uncomfortable steps. One sedative technique stands out for our activity : single-drug intravenous sedation. The advantages of the technique are numerous : ease of use, remarquable safety, tremendous patient acceptance. The presentation will describe the protocol supported by EFAAD, the European Federation for the Advancement of Anaesthesia in Dentistry. Patient selection is the cornerstone of successful patient management. The IV sedation technique then requires monitoring, venipuncture, drug administration and titration. Requirements involving training, in-office equipment, patient information and consent, staff will be described. Data gathered from patients after surgery will show the exceptional acceptance of this sedative technique. Our team has been using this technique for 15 years, with over 5000 documented cases. Satisfaction is shared by patient and practicionner.

Dr Gastone ZANETTE : Comparison by means of Bispectral Index Score (BIS) between sedation induced by intravenous diazepam and midazolam.

Provision of anxiety control is both a right for the patient and a duty placed on the dentist. Conscious sedation is the safer technique to achieve this goal in dentistry. BIS is an objective tool to assess the sedation depth. Benzodiazepines have different pharmacological profiles and diazepam may be safer than midazolam in this setting. The aim of this study was to compare BIS values observed during sedation after diazepam and midazolam in dental patients.

BIS values were evaluated as Area Under the Curve (AUC) and compared by variance analysis. AUC values were significantly lower after midazolam compared to AUC values after diazepam.

Diazepam has a safer profile, with BIS values and clinical conditions according to the definition of minimal and/or moderate sedation. Diazepam represents the safest drug for anxiety management in dentistry, because it regularly produces a state of minimal sedation during which verbal contact with the patient is maintained and carries a margin of safety wide enough to render loss of consciousness unlikely.

Dr Michael WOOD : An overview of Paediatric dental sedation techniques during 2008.

During 2008 1004 children were sedated by an operator-sedationist in a sedation referral dental clinic in the UK. Techniques used include IV sedation using a variety of drugs including ketamine, propofol, or midazolam. Oral sedation used as premedication or as sole sedative agents are discussed. Intranasal sedation using a bespoke 40mg/ml midazolam with  lignocaine formulation will be discussed as well as combinations of techniques. Patient safety and side-effects will be discussed. Patient/parent satisfaction will be assessed as well as operator operating conditions will be analysed for the various techniques.

Dr Valerie COLLADO : IV Midazolam for dental care in patients with intellectual disability compared with patients with dental anxiety. 

This study aims to evaluate the efficacy and tolerance of intravenous sedation with midazolam for dental care in patients with intellectual disability (ID) compared with patients with dental anxiety.

98 patients with ID and 44 with DA were treated under IV midazolam in a special care unit over 187 and 133 sessions respectively. The success rate was evaluated by the percentage of sessions when the planneddental treatment could be performed. The level of cooperation was analyzed using the modified Venham scale. The percentage of adverse effects reflected the tolerance of the procedure.

The mean duration of the sessions was 72 min and 103 min for patients with ID and DA respectively. A 50% N2O/O2 premix was associated for canulation in 51% and 61% of sessions for the ID and the DA groups respectively. Oral or rectal midazolam was co-administered in 31.3% of sessions for patients with ID and 3% for patients with DA. The mean dose of midazolam administered intravenously was 8.8mg and 9.8mg for those with ID and DA respectively. The dental treatment was successfully performed in 90% of  cases for both groups. Side effects were recorded for 16,6% and 6.8% of sessions in patients with ID and DA respectively. During dental  care, patients were relaxed in 64.4% and 79.9% of sessions for ID and DA groups respectively, and very disturbed in 14.4% and 0.8% respectively.

In conclusion, sedation with IV midazolam is an effective and well tolerated procedure when administered by dentists both for persons with ID and DA.

Pr Solomon RABINOVICH : Perspectives in dental patient management.

By estimations of the World organization of public health more than 93 % of the adult population has dental diseases. Such a big percent can be explained by accessibility of this region for different mechanical, chemical factors, pathogenic microflora and etc.

According to Dental  association of Russia annually dental help appears in our country in volume about 150 million visitings.Most of dental operations associated with pain if we do not use adequate anesthesia.

Development of modern dentistry allows to spend big on volume and duration operations in out-patient clinic. But for all this operations we need adequate methods of local anesthesia and sedation. Adoption of new technology in local anesthesiology in Russia wasn’t gradual, a stage behind a stage as in the West. It was like "landslide", during the last 15 years that is connected with sharp change of economic relations in the country.

Within several years in Russia were presented lots of new medications, tools and materials. For understanding of all these innovations needs years and our doctors were not ready to do it in one moment. Therefore education questions goes on the forefront.Features of the modern concept of local anaesthesia consist in association of separate components in complete technologies which provide: high efficiency, safety, long-range forecast of local anaesthesia in out-patient clinic.

The main components of the state-of-the-art techniques in local anaethesia in dentistry.

1- The knowledge and practical skill on questions of psychophysiology, anatomy, pharmacology, gerontology, anaethesia and dentistry.

2- The medications for local anaethesia (anaethetics and vasoconstrictors)

3- the ways of use of local anaethesia

4- the medical tool (syringes and needles, additional accessories)

5- General anaethesia is applied only under strict indications. 

The most effective and safe are artican local anesthetics with adrenaline in concentration 1:200000, Ultracain D without adrenaline (was presented in 2006) which have high anesthetic activity, low toxicity and high diffusion ability.

For decreasing of risk of systematic complications we recommend to use for lower molars periodontal types of local anesthesia – intraceptal and intraligamental blocks. Also possible to use intraossal local anesthesia. 

The most effective types of local anesthesia on the mandible for molars are Gow-Gates block (1973) with our modifications (S.Rabinovich, O.Moskovets) and inferior alveolar nerve block which effective and safe modification was invented by P. Egorov (1985). For lower premolars, canine and incisors we recommend to use our intraossal part of mental nerve block which was invented by Y. Vasiliev and S. Rabinovich in 2009.

Modernization of the technique of local anesthesia is the perspective for efficiency rising.