L5 Anxiolysis and GA

Management of Anxiety During Surgery¹²³

This document outlines the clinical and practical approaches to the management of patient anxiety within a surgical environment.

Upon completion of this section, practitioners should be able to:


Learning Outcomes⁴

• Describe non-pharmacological and pharmacological strategies for managing patient anxiety.
• Explain the difference between sedation levels and understand the limitations of training.

Scope of Practice

Distinguish between different sedation levels and understand the limitations of current training scopes to ensure patient safety and regulatory compliance.

• Have knowledge of the prescriptions for oral anxiolysis.
• Justify selection of treatment.
• Navigate clinical decision-making using a structured approach to determine appropriate sedation pathways for anxious patients

Effective management of patient anxiety is a critical component of surgical care, influencing both the patient’s physiological response and the overall surgical outcome.

Preoperative Assessment and Communication

• Conduct a thorough preoperative interview to identify specific triggers and the level of patient apprehension.
• Provide clear, concise information regarding the surgical procedure, anesthesia, and recovery process.
• Encourage patients to ask questions to alleviate fears stemming from the unknown.

Pharmacological Interventions

1. Anxiolytics: Administration of benzodiazepines (e.g., Midazolam) to provide rapid relief of acute anxiety.
2. Sedatives: Use of sedative-hypnotics to facilitate a calm state prior to induction.
3. Analgesics: Addressing anticipated pain, which is often a primary driver of surgical anxiety.

Non-Pharmacological Techniques

• Cognitive-Behavioral Strategies: Utilizing relaxation techniques, guided imagery, or deep breathing exercises.
• Environmental Control: Maintaining a quiet, professional atmosphere in the holding area and operating suite.
• Music Therapy: Offering calming music to reduce autonomic nervous system arousal.

Intraoperative Support

• Maintain continuous verbal reassurance if the patient is awake or undergoing regional anesthesia.
• Ensure physical comfort through proper positioning and temperature regulation (e.g., forced-air warming blankets).
• Monitor vital signs closely, as tachycardia and hypertension can be physiological indicators of escalating anxiety.

Non-Pharmacological Strategies

Effective communication is essential to creating a relaxing clinical experience. Key approaches include:

Communication Strategies⁵

• Expressing empathy and providing constant reassurance to the patient.
• Providing clear, concise explanations of procedures.
• Utilizing non-threatening language to describe clinical steps and tools.
• Predictive warning: Informing patients about specific sensations like pressure or clicking to prevent panic spirals.
• Behavioral management: Maintaining a calm practitioner demeanor to prevent "doom spirals" where practitioner panic induces patient panic.

Modifying the clinical environment can significantly reduce patient stress through sensory distraction:

Environmental Considerations⁶

• Visual Distraction: Installing televisions on the ceiling to display relaxing imagery or using Virtual Reality (VR) for an immersive alternate reality experience
  • Drone videos of scenic locations are particularly effective for ceiling-mounted displays..
• Auditory Comfort: Utilizing ambient sounds, calming music, or noise-cancelling headphones.
• Olfactory Management: Using ambient scents and diffusion to mask clinical smells with more pleasant scent profiles
  • Masking the smell of eugenol is critical as patients often associate it with previous painful experiences..

Acupuncture has origins dating back over 2500 years in Chinese medicine. In 2003, the WHO endorsed its use for dental pain, including TMJD, facial pain, and postoperative pain.

Clinical Benefits

• Reduction of general patient anxiety.
• Suppression of the gag reflex.
• Effective pain management.

Acupuncture⁷⁸⁹

Key Acupuncture Points

• CV-24 (Conception Vessel 24): Located on the face; highly effective for gag reflex suppression. Can be stimulated via traditional needling or red-light soft magnetic field laser.
• PC-6 (Pericardium 6): Located on the wrist; used for gag reflex control and anxiety. Can be stimulated via needling or pressure bands

Case Study: Acupuncture and Acupressure in Dental Practice

A demonstration involving Dr. Hay receiving acupuncture at CV-24 during an Alginate impression confirmed the technique is painless. For needle-phobic patients, applying firm thumb pressure to PC-6 for 60 seconds or using wristbands has proven effective for gag suppression during pediatric mouthguard impressions. .

Acupuncture is a proven treatment with a history of over 2500 years. The WHO (2003) recognizes its efficacy in treating dental pain, TMJD, and postoperative discomfort.

Therapeutic Applications

• Anxiety and Pain: Demonstrated benefits in reducing patient distress and physical pain during and after procedures.
• Gag Reflex Management: The points CV-24 and PC-6 are specifically identified as highly effective for patients with a sensitive gag reflex.

For patients who are needle-phobic or where traditional acupuncture is not preferred, alternative stimulation methods can be utilized at the same therapeutic points:

• Low-Level Laser Stimulation: Using red-light soft magnetic field lasers (e.g., on point CV-24) instead of traditional needles.
• Acupressure: Applying physical pressure or using specialized bands (e.g., a button band on point PC-6) to achieve similar results in suppressing the gag reflex.

Hypnosis in a clinical setting differs from stage performances; it often functions as a state of focused relaxation similar to a daydream.

Hypnotic Suggestion

This involves using calming language to focus patient thoughts. An example of a simple hypnotic script includes:

“I want you to imagine that you are going to let yourself relax and breathe out deeply. With each breath I want you to imagine yourself to becoming more and more relaxed.”

    

Hypnosis¹⁰¹¹

Clinical Applications and Limitations

• Severe Anxiety: Professional hypnotherapy can assist in managing high-level dental phobia.
  • Adjunct to sedation: Hypnotic suggestion can be used to enhance the effects of inhalation sedation.
• Behavioral Change: Shown to have positive effects on smoking cessation.
• Susceptibility: It is important to note that not every patient is susceptible to hypnotic techniques.

Hypnosis has a long history in surgical care, with the first recorded use for dental extraction anaesthesia occurring in 1829.

Advanced Applications

• Anaesthesia: Recent clinical cases have demonstrated the ability to perform complex procedures, such as the extraction of third molars (wisdom teeth), using only hypnotic suggestion for pain and anxiety control.
  • A 2013 study specifically documented the successful removal of simple lower third molars without local anesthetic using only hypnotic suggestion.
  • Suggestibility: Approximately 8% of the population is highly suggestible to these deep hypnotic states.
• Training Requirements: While basic suggestion is simple, deeper forms of hypnotic anaesthesia require significant time and specialized training for the operator to perform safely.

Cognitive Behaviour Therapy (CBT) represents the intersection of cognitive and behavioural therapies. Rather than seeking a root historical cause, it focuses on identifying current beliefs that drive specific thoughts and behaviours.

Benefits in Dentistry

• Reduces self-reported dental anxiety.
• Improves long-term patient attendance and compliance.
• Serves as an effective complementary therapy alongside pharmacological sedation.

Cognitive Behaviour Therapy¹²

Implementation Requirements

• Requires the patient to have an active desire to manage their condition.
• Typically involves referral to specialized psychology services.

Pharmacological Management

Midazolam is a common pharmacological agent used for the management of anxiety.

Midazolam Injection, USP Details:

• Concentration: 50 mg/10 mL (5 mg/mL)
• Formulation: Midazolam (as the hydrochloride)
• Administration: For IM (intramuscular) or IV (intravenous) use only
• Note: Contains benzyl alcohol

Sedation Framework and Definitions

According to TGA Guidelines, sedation is categorized into the following levels:

• Minimal Sedation (Anxiolysis)
  • A drug-induced state of diminished anxiety where patients remain conscious.
  • Patients respond purposefully to verbal commands or light tactile stimulation.
  • Agents: Oral benzodiazepines or inhaled agents (nitrous oxide or, less commonly, methoxyflurane).
  • Impact: Cognitive function and coordination may be impaired, but no interventions are required to maintain a patent airway, spontaneous ventilation, or cardiovascular function.

Definitions of Sedation Levels¹³

• Moderate Sedation

  • A drug-induced state of depressed consciousness.
  • Patients retain the ability to respond purposefully to verbal commands and tactile stimulation.
  • Methods: Involves intravenous drugs or a combination of oral drugs and inhalational techniques.
  • Impact: In exceptional circumstances, interventions may be required to maintain a patent airway, spontaneous ventilation, or cardiovascular function.

• Deep Sedation

  • A drug-induced state of depressed consciousness where patients are not easily roused.
  • Patients may respond only to noxious stimulation.
  • Impact: Features include impaired ability to maintain an airway, inadequate spontaneous ventilation, and impaired cardiovascular function.

Clinical Scope and Requirements

• General Dentists
  • Restricted to providing minimal sedation, provided they have received appropriate training.
    • Requires a 6.5-hour CPD course specifically for inhalation sedation.

Practitioner Scope and Training¹⁴

• Endorsed Dentists

  • Can provide moderate sedation if endorsed by the Dental Board.
  • Endorsement requires completion of an approved course of study, currently limited to the University of Sydney Graduate Diploma in Clinical Dentistry (Conscious Sedation and Pain Control).
    • This is a two-year Graduate Diploma program.

• Medical Practitioners and Anaesthetists

  • Deep sedation is strictly restricted to trained medical practitioners and anaesthetists operating within approved facilities.

Guedel (1937) described four distinct stages of anaesthesia:

Stages of Anaesthesia¹⁵

1. Stage 1: Stage of Analgesia

   • From induction through to the loss of consciousness.

2. Stage 2: Stage of Excitement

   • From the loss of consciousness to the onset of automatic breathing.
   • Often referred to as the excitement or delirium stage.

3. Stage 3: State of Surgical Anaesthesia

   • From the onset of automatic breathing to respiratory paralysis.
   • This is the stage where general anaesthetic surgery takes place and where patients are maintained.

4. Stage 4: Respiratory Paralysis

   • Leads to death if not managed.

Clinical Application

Anaesthetists aim to move patients rapidly through Stage One, minimize Stage Two, and maintain procedures in Stage Three. Relative analgesia operates at the upper end of Stage One.

Relative Analgesia and Nitrous Oxide¹⁶¹⁷¹⁸

Relative Analgesia (RA) is commonly known as inhalation sedation (ADA Code 943, per 30 minutes or part thereof). It should be considered the first-line option for children requiring sedation.

  

Overview of Relative Analgesia¹⁹

Properties of Nitrous Oxide (N₂O)

• Colourless, sweet-smelling gas.
• 1.5 times heavier than air.
• Non-irritating.
• Stored as a liquid in a blue cylinder.
• Non-flammable but will support the combustion of other agents.
  • Supports combustion of other agents such as Vaseline.
• Effective analgesic agent; 50% N₂O is comparable to 10–15 mg of morphine.

Mechanism of Action

• Acts as an N-Methyl-D-aspartate (NMDA) receptor antagonist, producing a dissociative anaesthetic effect.
• Releases endogenous opioids acting on opioid receptors to produce an analgesic effect.
• GABA-A activation produces an anxiolytic effect.
• Acts in Stage 1 of Guedel’s stages (state of analgesia).

Pharmacology of Nitrous Oxide²⁰

Diffusion Hypoxia

Due to rapid elimination at the end of the procedure, N₂O entering the alveoli can displace O₂ causing diffusion hypoxia. - Nitrous oxide rushes from the bloodstream to the alveoli upon cessation, displacing oxygen. This is prevented by administering 100% O₂ for 2–5 minutes at the conclusion of the procedure.

Clinical Indications

• Fear and anxiety.
• Pain control.
• Medical conditions exacerbated by stress.
• Gagging.
• Traumatic or complex dental procedures.
  • Posterior regions are preferred for complex procedures due to equipment constraints.
  • Useful for breakthrough pain when full local anaesthesia is difficult to achieve.

Indications and Contraindications of Nitrous Oxide²¹

Contraindications

• Psychosocial Factors
  • Claustrophobic patients.
  • Lack of understanding of the process (due to age or learning difficulties).
  • Severe anxiety.
  • High complexity of dental treatment.
• Medical Factors
  • Nasal obstructions or upper respiratory tract infections.
  • ASA III, IV, or V (severe systemic disease).
  • COPD.
  • Pregnancy (1st trimester). - Staff pregnancy concerns are also relevant during the first trimester.
  • Severe psychiatric disorders.
• Dental Factors
  • Upper anterior procedures.

Clinical Advantages

• High safety profile.
• Rapid onset and recovery (low blood solubility of 0.47).
• Easily regulated titration.
• Drug is not metabolized by the body.
• No adverse effects on the cardiovascular system, respiratory system, liver, or kidneys.
• Effective analgesia.
• Limited amnesia.

**Advantages and Disadvantages Of Nitrous Oxide **²²

Clinical Disadvantages

• Requires specialized equipment.
• Large variation in individual patient response.
• Risks associated with chronic exposure for staff.
• Potential for abuse.
• Limited amnesia.
  • Limited amnesia can be advantageous as it allows for patient recall of uneventful procedures.

While more commonly associated with healthcare workers in operating theatres, long-term chronic exposure to nitrous oxide can cause:

Risks of Chronic Exposure²³

• Deactivation of vitamin B12, leading to neurological symptoms such as peripheral neuropathy.
• Toxic hepatic effects through the inhibition of liver enzymes.
• Depression of leukocyte production.
• Spontaneous abortion and other reproductive issues.

Gas Delivery Systems

• Bottled Gas: Supplied on a mobile trolley.
• Piped Gas: Integrated into the facility infrastructure.

Equipment Setup²⁴²⁵²⁶

Control Unit (Quantiflex MDM)

The control unit is similar for both delivery methods but differs from Entonox units used in delivery suites. Key controls include:

• N₂O flow rate.
• O₂ flow rate.
• % N₂O control.
• Flow rate adjustment.
• O₂ Flush.
  • Flow meters utilize glass vials with ball bearings to indicate gas flow.
  • Total flow is adjusted via a specific adjustment knob.

Patient Interface and Scavenging

• Reservoir Bag: Attached to the system to monitor breathing and provide extra gas volume
  • The reservoir bag (grey balloon) evens out respiratory variations..
• Nasal Hood: Delivers the gas mixture to the patient.
• Scavenging: A critical safety component. Active scavenging is generally used by connecting a suction hose to the hood.
• Fit: Requires a secure seal to be effective; various sizes are available to ensure a good fit.

Hood Design

Various types of hoods exist, but the double-hood system is the most effective:

• Inner Hood: Delivers the fresh gas mixture.
• Outer Hood: Connected to the scavenging system.
• One-way Valve: Allows exhaled gases into the outer hood for removal
  • The outer white channel scavenges while the inner blue channel delivers gas..

The equipment includes several built-in safety mechanisms:

Safety Features²⁷

• Pin Index System: Prevents incorrect gas bottle attachment.
• Colour Coding: Standardized identification for gas types.
• Oxygen Flush: Provides immediate 100% oxygen.
• Oxygen Fail-Safe: Automatically shuts off nitrous oxide if oxygen pressure fails.
• Reservoir Bag: Visual monitor of respiration.
• Minimum O₂ Delivery: Ensures a minimum of 30% oxygen is always delivered.
• One-way Valves: Prevents rebreathing of exhaled gases.

1. Consent: Must be obtained at a prior visit

• Written consent is required because capacity is impaired during sedation..

2. Chaperone: Ensure a chaperone is present in the room.
3. Initial Oxygenation: The patient places the hood. Start 100% O₂ at a flow rate of 4-6 L/min. Adjust for a comfortable, sealed fit, ensuring no leakage over the eyes.
4. Breathing Technique: Ensure the patient uses nasal inspiration and expiration only; this may require practice.
5. Monitoring: Pulse oximetry is recommended as good practice.
6. Titration: Increase N₂O in increments of 5-10% every 1-2 minutes until the desired level is reached (typically 35-45%).
7. Induction: Peak brain levels are reached in 5-7 minutes. Hypnotic suggestion can be used to enhance the sedative effect.

Procedure Steps²⁸

Clinical Indicators of Sedation

• Patient appears relaxed and comfortable.
• Tingling sensations in the hands and feet.
• Reduction in spontaneous movements.
• Light giggling or feelings of euphoria.
• Reduced awareness of physical stimuli.
• Patient indicates they are happy to proceed with treatment.

Clinical Assessment

• Ensure the patient remains responsive throughout the procedure.
• Monitor skin colour and check pulse oximetry periodically.
• The primary challenge is assessing the flow rate to avoid under- or over-delivery of the gas mixture.
  • Continuous observation of the reservoir bag inflation/deflation is required to match the respiratory rate.
  • Frequent titration is necessary as patient respiration varies with levels of anxiety versus relaxation.

Monitoring During Sedation²⁹

Post-Procedure Steps

• Oxygenation: Once treatment is complete (or nearing completion), deliver 100% O₂ for 5 minutes to prevent diffusion hypoxia.
• Discharge: Remove the nasal hood, sit the patient upright, and ensure they do not feel dizzy.
• Supervision: Children must be accompanied by an adult and supervised for the remainder of the day
  • Adults must be advised not to drive following the procedure..

Recovery Protocol³⁰

Professional Training

Practical training is required to support the use of N₂O in practice. The ADA WA conducts an annual course sufficient for introducing this modality into clinical practice.

Course Details:

• Title: Anxiolysis and Relative Analgesia (N₂O) in Modern Dental Practice
• Duration: 6.5 CPD hours
• Location: Perth
• Cost: From $1,095.00 incl. GST

Methoxyflurane

Methoxyflurane (marketed as Penthrox) is an inhaled analgesic indicated for the emergency relief of pain associated with trauma and for analgesia in monitored conscious patients during surgical procedures.

Dental Applications and Limitations

• Used off-label in dental settings with a limited overall role.
• May be effective for pain mitigation during short procedures, such as the treatment of alveolar osteitis (dry socket).
  • Useful for dry socket cases where local anaesthetic is undesirable
  • Less suitable than nitrous oxide due to fat solubility (slower reversal) and enzyme metabolism

Clinical Use and Considerations³¹

Pharmacokinetics and Administration

• The drug is absorbed into fatty tissues, which results in a slower reversal of effects compared to other inhaled agents.
• Patients must be instructed to exhale through the activated carbon filter attached to the inhaler device to minimize environmental exposure.

Administration Details

The liquid vial (3-3.3ml) is poured onto an internal sponge within the whistle device. The patient inhales through the mouthpiece, and covering or uncovering the top hole allows them to regulate the concentration.

Dosage Constraints

• Maximum recommended usage limits are strictly defined as:
  • 6 mL per day (Correction to previous guidelines)
  • Metabolism by hepatic enzymes necessitates these strict dose restrictions to prevent toxic effects
  • 6 mL per week; or
  • A maximum of 15 mL per week in specific clinical scenarios.


Oral Benzodiazepines

Clinical Advantages

• Well-accepted by patients
• Cost effective
• Easy to administer
• Provides anxiolysis prior to the procedure
• High patient acceptance and familiarity (commonly known as "Valium")
• Can provide pre-operative night dosing to ensure restful sleep before procedure

Advantages and Disadvantages³²

Clinical Disadvantages

• Slow onset and long duration of action
  • Supervision required post procedure
• Variable response
• Cannot be titrated rapidly
  • Once administered, effect cannot be rapidly adjusted; must wait 1+ hours to assess efficacy
• Used in caution with certain patients
  • Older, frail, or cognitively impaired patients
  • Patients with Obstructive Sleep Apnea (OSA)
• Cannot be used if the patient does not have an escort or carer to look after them

Indications

• Dental anxiety
• Short procedures (1-2 hours maximum)

Indications and Contraindications³³

Contraindications

• Prolonged procedures
• Severely limiting heart, cerebrovascular, lung, liver, or kidney disease
• Allergies or other adverse events in relation to drugs used in sedation, analgesia, or anaesthesia
• Severe anxiety that has not been managed effectively with minimal sedation
• Substance abuse
• Prior patient-reported inefficacy (e.g., "I've tried temazepam/lorazepam/diazepam and none worked")

Name of drug	Dose (for >13yrs)	Notes
Temazepam 10mg tablet	10mg, orally, 1 hour prior to the procedure. To be taken at the dental practice.	If ineffective, consider increasing the dose to 20mg (caution in >75yrs or frail).
Lorazepam 1mg tablet	1mg, orally, 1 hour prior to the procedure. To be taken at the dental practice.	If ineffective, consider increasing the dose to 2mg (caution in >75yrs or frail).
Diazepam 2mg tablet	2-5mg, orally, 1 hour prior to the procedure. To be taken at the dental practice.	Use the lower end of the dose range for >75yrs or frail.

Historical Note on Lorazepam

Previous guidelines recommended 3mg for males and 2mg for females; however, clinicians have found the current 1mg guideline to be less effective.

Limitation on Combining Agents

Combining oral benzodiazepines with nitrous oxide constitutes moderate sedation, which is outside general dental scope without additional training. If one agent fails, switch to alternative benzodiazepines rather than combining with other sedation methods. |

Drug Administration³⁴

Clinical Technique and Requirements

• Consent: Obtain written consent prior to the day of the procedure.
• Medical History: Perform a thorough medical history review to ensure the patient is not already taking these medications.
• Patient Instructions: Provide clear instructions for the day of the procedure, including the requirement for someone to drive them home.
• Prescribing Protocol:
  • Issue a prescription to dispense medication for the procedure only.
  • If multiple visits are required, provide a prescription at each visit.
  • This ensures patients are only supplied with one dose and allows for dose adjustments if necessary.
• Scheduling: Schedule the patient to arrive at the practice one hour beforehand to take the medication.

Case Study: Prescribing Practices and Patient Management

In private practice, oral benzodiazepines are often used for patients who tolerate checkups but require sedation for invasive procedures like crowns, root canals, or extractions. Patients must present the pharmacy vial with a single tablet to the practice; medication is not dispensed from dental stock due to storage requirements.

• Observation: Taking medication in the practice waiting area allows for observation of adverse reactions and precise onset timing.


Technique and Protocol³⁵

E Block Specific Requirements

• If required, Temazepam 10mg is the benzodiazepine dispensed.
• Medication is dispensed on site, 1 hour prior to the procedure.
• Note: IV sedation is not currently available at the E-Block facility.

Practice-Specific Protocol³⁶

- ==Titrability: Unlike oral sedation, IV sedation is highly titrable to the patient's needs.==

Intravenous Sedation³⁷

Intravenous (IV) sedation is classified as moderate sedation and must be managed by qualified personnel.

Personnel Requirements

• Qualified Providers:
  • Dentist: Limited to single-drug sedation.
  • Medical Practitioner: Anaesthetist or GP Anaesthetist.
• Staffing: At least three staff members must be present in the room: the proceduralist, the sedationist, and an assistant
  • Some clinical setups may include a registered nurse, forming a 4-person team..

Facility and Training Standards

• Facilities must allow for rapid access by emergency services.
• Training: Enhanced dental team training is required, specifically advanced life support with oxygen therapy (HLTAID015 or equivalent).
• Equipment: An Automated External Defibrillator (AED) and airway adjuncts must be available
  • Facilities must be prepared for moderate sedation risks, specifically potential airway compromise..

 

Provider Qualifications and Requirements³⁸

Patient Monitoring

Sufficient monitoring must be performed, including:

• Heart Rate (HR)
• Blood Pressure (BP)
• Oxygen (O₂) saturation
• Ideally, expired capnography

Reference: ANZCA PG09 – Guideline on procedural sedation 2023

Midazolam

• Usage: The primary drug used for dentist-led sedation (single pharmacy); used in combination with other drugs when administered by an anaesthetist.
• Mechanism: A benzodiazepine acting on GABAa receptors, enhancing the affinity for GABA.
• Administration and Metabolism:
  • No pain on injection.
  • Metabolised in the liver.
• Pharmacokinetics:
  • Short half-life (2 hours).
  • Clinical working time of approximately 45 minutes.
• Effects: Provides some amnesia, though the effect decreases over time.
• Reversal Agent: Reversible with Flumazenil.
  • Caution: Risk of rebound sedation as Flumazenil has a half-life of 50 minutes.

Pharmacological Agents³⁹⁴⁰

Propofol

• Classification: Anaesthetic induction agent.
• Administration: Short half-life (2–5 minutes) requiring delivery via continuous infusion on a pump.
• Function: Provides the primary sedation.

Remifentanil

• Classification: Short-acting synthetic opioid.
• Usage: Used synergistically with propofol.
• Function: Provides a level of analgesia.

Adjunctive Medications

In addition to sedative agents, other medications may be administered intravenously as required:

• Antibiotics
• Steroids
• Other analgesics

Clinical Advantages

• Allows the operator to focus entirely on the dental procedure.
• Generally well tolerated by patients.
• Effectively suppresses the gag reflex.
• Effectively suppresses patient anxiety.

Advantages and Disadvantages⁴¹⁴²

Financial Disadvantages

• Cost Considerations:
  • Dentist-led: Billed under code 942 (sedation – IV – per 30 minutes).
  • Anaesthetist-led: The operator charges code 949, and the anaesthetist bills separately, resulting in higher overall costs.

Medicare Standard Rebates

Upon completion of sedation and finalization of payment, a receipt is provided to claim Medicare rebates. As an out-of-hospital service, this is typically not covered by Private Health Insurance.

Fee and Rebate Schedule (as of 1 July 2024):

TIME	45 mins	1 hour	1 hr 30 m	2 hours	2 hr 30 m	3 hours
FEE	$1,090	$1,220	$1,480	$1,740	$2,010	$2,280
REBATE	$214.90	$234.05	$272.40	$310.70	$368.20	$425.70

TIME	3 hr 30 m	4 hours	4 hr 30 m	5 hours	5 hr 30 m	6 hours
FEE	$2,550	$2,820	$3,090	$3,360	$3,630	$3,900
REBATE	$483.20	$540.70	$598.25	$655.75	$713.25	$780.25

Extended Medicare Safety Net

Medicare may provide additional rebates once an annual calendar year threshold for out-of-pocket costs for out-of-hospital medical services is reached. Once the threshold is met, Medicare may reimburse up to 80% of out-of-pocket costs for the remainder of the calendar year. Patients should confirm eligibility and current rebate rates with Medicare.

• Operator can focus on dentistry.
• Well tolerated by the patient.
• Suppresses gag reflex.
• Suppresses anxiety.

Disadvantages and Requirements

• Cost:
  • Dentist-led: Code 942 (sedation – IV – per 30min).
  • Anaesthetist-led: Operator charges 949 and anaesthetist bills separately.
• Staffing: Requires specifically trained staff.
• Facilities: Must meet specific facility requirements.
• Time: Procedural time is significantly increased
  • Increased time is due to setup, airway management (e.g., nurse performing chin lift/jaw thrust), and complexities in rubber dam placement..

Pre-Procedural Requirements

• Consent forms must be signed ahead of the procedure.
• The patient must fast prior to attending the appointment.

Procedural Phases

1. Induction: The sedation provider gains IV access and establishes operating conditions (typically 5–20 minutes).
2. Treatment: The dental procedure is performed. Note that treatment generally takes 20–40% longer under sedation than without

Case Study: Cost and Time Implications

The longest IV sedation performed was 3.5 hours for four wisdom teeth, costing the patient approximately $3,500 out-of-pocket. A typical four wisdom teeth case under IV sedation requires 1-1.5 hours of anaesthetist time. IV access establishment alone can take 5-20 minutes depending on patient anxiety levels and vascular access difficulty. .

Technique and Recovery⁴³

Recovery and Discharge

• Initial Recovery: Variable time of 10–30 minutes to leave the surgery room.
• Observation: The patient will continue to recover for a further 20–30 minutes in a safe, supervised environment.
• Discharge: Patients are discharged home with a responsible person.
• Post-Sedation Restrictions (24 Hours):
  • No driving.
  • No operating heavy machinery.
  • No signing legal documents.

There is no current IV Sedation service available at E block.

• Patients requiring this level of sedation must be referred externally.

Practice-Specific Availability⁴⁴

General Anaesthesia

The primary goal of general anaesthesia is to render a patient unconscious and unable to feel painful stimuli while controlling autonomic reflexes.

Facility Settings

General anaesthesia takes place in specialized facilities, which may be:

• Private or public institutions
• Day case facilities or hospitals requiring overnight stays

Overview and Indications⁴⁵

Clinical Indications

The decision to utilize general anaesthesia (GA) may be based on several factors:

• Procedural difficulty and the ability to achieve adequate anaesthesia with local anaesthetic (LA)
• Procedural length
• Unpleasantness of the procedure
• Patient preference

Risk Assessment

Practitioners must balance patient preference against safety, as certain patient cohorts demanding GA for minor procedures may carry higher mortality risks; clinicians must protect patients from themselves regarding risk assessment.

In Perth, provider accreditation and operational capacity vary by dental specialty:

Provider Accreditation and Facilities⁴⁶

• General Dentists: Typically only accredited to a small number of private day hospital facilities. For restorative treatment, all necessary equipment and materials must be transported from the clinic.
• Oral and Maxillofacial (OMF) Surgeons: Accredited across both private and public hospitals.
• Special Needs Dentists: Operate within departmental configurations at Royal Perth Hospital (RPH) and Fiona Stanley Hospital (FSH).
• Paediatric Dentists: May operate across both public and private facilities depending on their specific job role
  • Access to Perth Children's Hospital (PCH) and various private facilities..

Oral Health Centre of Western Australia (OHCWA) utilizes Southbank Day Surgery as their primary operating facility. This facility has specific patient acceptance criteria that must be met:

Practice-Specific Referral Protocol⁴⁷⁴⁸⁴⁹

• Weight: <130kg
• BMI: <40 (exceptions can be made up to 42 in specific circumstances)
• No Obstructive Sleep Apnoea (OSA)
• Manual handling limitations also affect high muscle mass individuals (e.g., bodybuilders or rugby players) whose weight may exceed table or trolley limits despite physical fitness.

Admission Criteria Based on Weight and BMI

1. Weight > 130 kg

   • Not accepted for surgery (Not negotiable).

2. BMI 40 - 42 (Any weight)

   • Requires consultation with the GM/DON, Operations Director WA, or National Clinical Governance Director.

3. BMI 38 - 40 (Any weight)

   • Requires consultation with the GM/DON.

4. BMI ≤ 35 (Weight < 130 kg)

   • Accepted if clinically approved by the Anaesthetist.

5. BMI 35 - 38 (Weight < 130 kg)

   • Must meet the following specific criteria:
     • ASA 1 or 2 (BMI excluded from ASA criteria)
     • No Sleep Apnoea
     • No significant respiratory disease
     • No anticipated airway difficulty
     • Patient is normally ambulant with minimal assistance
     • Booked as morning cases or first on the afternoon list
     • Reviewed by Anaesthetist prior to surgery and approved by DON / Clinical Nurse
     • Early consultation at Anaesthetist’s rooms prior to admission is preferred

Manual Handling Protocols

• Patients over 90kg: Should self-ambulate to the operating table if capable and not sedated.
• Patients over 100kg: Use of a Hovermat should be considered.
• Patients over 115kg: Use of a Hovermat is mandatory.
• Refer to the policy: “MANUAL HANDLING OF THE BARIATRIC PATIENT”

Case Study: BMI and Weight Limitations in Day Surgery

The BMI <40 and weight <130kg restrictions at Southbank exist because patients over BMI 40 generally exhibit more difficult intubations and higher complication rates. Furthermore, manual transfer from the operating table to a trolley requires 4-6 staff members; exceeding weight limits creates significant occupational health and safety risks for the facility team.

OHCWA utilizes Southbank Day Surgery as their operating facility, subject to the following criteria:

• Weight <130kg
• BMI <40 (exceptions up to 42)
• No OSA

Alternative Referral Pathways

If a patient requires or requests GA but is unsuitable for Southbank Day Surgery, they will be referred to public system colleagues at RPH, SCGH, or FSH, depending on the patient’s postcode.

Clinical Communication

When referring patients to E Block, it is vital not to promise the patient a general anaesthetic. Prematurely promising GA can lead to difficult and confrontational clinical conversations if the patient is later deemed unsuitable for the facility.

Communication Strategy

Inform patients that options will be discussed at the specialist consultation rather than promising GA; this maintains dignity and respect if weight/BMI restrictions necessitate a different treatment pathway.

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Audio Appendix

Additional Audio Content

The following sections from the lecture audio did not correspond to any heading in the main document.

Clinical Decision Making

Decision Tree for Sedation Selection

A structured approach to determining appropriate management:

1. Skill Assessment: Do you have the skills to perform the procedure?

   • No: Refer to appropriate practitioner
   • Yes: Proceed to anaesthesia assessment

2. Local Anaesthesia Feasibility: Can the procedure be done under local anaesthetic?

   • Yes: Is the patient happy to proceed under LA?
   • Yes: Proceed with LA
   • No: Treat as if LA not possible
   • No: Proceed to sedation options

3. IV Sedation Assessment: Can you bring in a sedationist?

   • Yes: Is patient medically suitable and willing to pay?
   • Yes: IV Sedation (preferred option)
   • No: Consider alternatives or temazepam, or refer
   • No: Proceed to oral sedation assessment

4. Oral Sedation Assessment: Can it safely be done under oral sedation + LA?

   • Yes: Proceed with oral benzodiazepine protocol
   • No: Proceed to non-pharmacological options

5. Non-Pharmacological Assessment: Can non-pharmacological strategies suffice?

   • Yes: Implement communication/environmental/acupuncture/hypnosis techniques
   • No: Refer to higher level of care (GA or specialist sedation services)

Application Example: For straightforward wisdom teeth extractions in anxious patients, this decision tree facilitates selection between LA, oral sedation, IV sedation, or GA based on patient factors, practitioner capabilities, and facility availability.

 

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