The use of oral benzodiazepines for the management of dental anxiety: a web-based survey of UK dentists

A general lack of confidence about OBZ prescribing exists, together with a desire for further training in prescribing anxiolytics, even among current prescribers. More recently qualified dentists were less likely to have ever prescribed OBZs. Treating patients who had taken anxiolytics was generally reported to be a positive experience, with care facilitated by more relaxed and cooperative patients. Most dentists preferred, however, to use behavioural management techniques to facilitate treatment of anxious patients. Long waiting lists for referral to specialist NHS services for anxious patients was motivating some dentists to consider prescribing anxiolytic premedication to their patients in general dental practice. However, changes in the legal framework for controlled drugs and the introduction of the IACSD sedation guidelines in 2015 introduced confusion for many, including whether additional qualifications are required for prescribing anxiolytic pre-medication.7

Diazepam was the preferred OBZ among respondents, consistent with routinely collected NHS prescribing data.9 However, it is more prone to interactions and has a longer half-life than temazepam.6 For these reasons, the British National Formulary recommends temazepam as more suitable when it is important to minimise any residual effect the following day.6 By contrast, the Scottish Dental Clinical Effectiveness Programme (SDCEP) drug prescribing guidelines recommend only diazepam as pre-medication.13 These sorts of discrepancies between the two documents are examples of the lack of clear guidance for dentists on OBZ prescribing.

However, the UK Misuse of Drugs Regulations 2001 classifies diazepam as a Schedule 4 controlled drug (CD) and temazepam as a Schedule 3 CD (which has additional requirements in relation to prescribing).14 For NHS patients, the standard FP10D prescription form can be used for both diazepam and temazepam. For private patients, Schedule 3 drugs must be prescribed on a private CD prescription form (FP10PCD) which can be obtained from the NHS, even if the dentist has no contractual relationship with the NHS.8 Various additional legal requirements for prescribing Schedule 3, but not Schedule 4, CDs exist, including the requirement to specify 'for dental treatment only'.8

Confusion was also expressed in the study about whether dentists without additional qualifications can prescribe OBZs. While the IACSD's Standards for conscious sedation in the provision of dental care and the SDCEP's Conscious sedation in dentistry guidelines both cover pre-medications, some ambiguity is clear.6,13 These inconsistencies and ambiguities within current guidance could be a contributing factor in dentists' self-reported lack of confidence in prescribing OBZs. USA guidelines are much more explicit on the requirements that a dentist must satisfy before prescribing OBZs at anxiolytic doses.15 Further research is indicated to produce clear UK guidance about pre-medication, including doses and the need for additional qualifications.

This study demonstrates that some GPs have been playing a role in the management of dentally anxious patients by prescribing OBZs, both with and without the involvement of their patient's dentist. No previous research has specifically explored the prescription of OBZs by GPs for dental reasons; however, previous studies show that GPs are often approached by patients for the management of dental conditions and that dental anxiety and difficulty accessing dental services are contributing factors.3,16,17 This places an increasing burden on GPs, as well as posing a significant medico-legal risk for dentists treating patients without knowledge that they had taken OBZs.18,19 Displacement of anxious dental patients to GPs may help explain the significantly lower OBZ prescription rate found in England compared to the USA and Australia.9 GPs have been advised by the British Medical Association (and required by NHS commissioners in many areas) that they should not be managing dental conditions (including prescribing).19,20 A further patient safety concern relating to the prescribing of OBZs was the lack of access for dentists to a patient's complete medical history. Summary Care Records are an electronic record of important patient information, created from GP medical records.21 They can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care, such as community pharmacists.21 Extending access to primary care dentists would improve dental patient safety generally and could facilitate the safe prescription of OBZs by dentists. Further research is needed to develop strategies to safely manage dentally anxious patients across primary care settings, including understanding patient perspectives on OBZs.

The main strength of this study was that it provided insight into the previously underexplored area of OBZ prescribing by UK dentists. The use of social media for recruitment allowed the survey to be conducted on a national scale. However, compared to the demographics of UK dentists registered with the General Dental Council, this recruitment strategy has resulted in recruitment bias towards a cohort of dentists who were more likely to have been trained in the UK (91% of respondents vs 74% of GDC-registered dentists) and slightly younger (60% of respondents were 22-40 years old vs 48% of GDC-registered dentists).22 Selection bias also seems to have been an issue, with those trained to provide conscious sedation more likely to participate, as evidenced by the considerable number of dentists indicating that they had used intravenous sedation to manage dental anxiety. The proportion of respondents with experience of prescribing OBZs was higher than originally estimated in the sample size calculation, which had the effect of making the 95% CIs around this estimate wider than originally intended. However, as this is a hypothesis-generating, exploratory study, the intention was to gather initial information rather than produce a very accurate and/or representative estimate. Given the relatively large proportion of participants who had previously prescribed OBZs, and the likelihood of the survey respondents self-selecting due to an interest in the topic of OBZ use, the finding of low knowledge and confidence is particularly interesting and suggests that there may be a significant training need nationally. That younger dentists were less likely to have prescribed OBZs suggests that dental schools may need to boost their teaching about the pharmacological management of anxious dental patients with OBZs as pre-medication.

The authors are not recommending wide-spread use of OBZs for the management of dental anxiety, as it is well-known that these drugs have the potential for abuse and are associated with side effects.23 While sedation can be an effective adjunct for anxiety management, other techniques, such as behaviour management techniques, are preferred by many respondents, and CBT has been shown to aid long-term reduction of anxiety.24,25,26,27 The development of pathways to care for anxious dental patients, involving both pharmacological and non-pharmacological elements, should improve access to oral health care for dentally anxious patients and reduce the burden from dental patients on GPs. Further research to develop clear national guidelines on safe OBZ prescribing can support implementation of these care pathways.

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