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Therapeutics and Clinical Risk Management 2013:9 223–233
erapeutics and Clinical Risk Management
Current sedation practice among general
dental practitioners and dental specialists
in Jordan: an example of a developing country
Mohammad H Al-Shayyab1
Soukaina Ryalat1
Najla Dar-odeh1
Firas Alsoleihat2
1Department of Oral and Maxillofacial
Surgery, Oral Medicine, Oral
Pathology and Periodontology,
Faculty of Dentistry, 2Department
of Conservative Dentistry and Fixed
Prosthodontics, Faculty of Dentistry,
University of Jordan, Amman, Jordan
Correspondence: Firas Alsoleihat
Department of Conservative Dentistry
and Fixed Prosthodontics,
Faculty of Dentistry, University of Jordan,
Amman 11942, Jordan
Tel +962 777 946 631
Fax +962 6 530 0248
Email firas.alsoleihat@ju.edu.jo
Purpose: The study reported here aimed to identify current sedation practice among general
dental practitioners (GDPs) and specialist dental practitioners (SDPs) in Jordan in 2010.
Methods: Questionnaires were sent by email to 1683 GDPs and SDPs who were working in
Jordan at the time of the study. The contact details of these dental practitioners were obtained
from a Jordan Dental Association list. Details on personal status, use of, and training in, conscious
sedation techniques were sought by the questionnaires.
Results: A total of 1003 (60%) questionnaires were returned, with 748 (86.9%) GDPs
and 113 (13.1%) SDPs responding. Only ten (1.3%) GDPs and 63 (55.8%) SDPs provided
information on the different types of treatments related to their specialties undertaken under
some form of sedation performed by specialist and/or assistant anesthetists. Approximately
0.075% of the Jordanian population received some form of sedation during the year 2010, with
approximately 0.054% having been treated by oral and maxillofacial surgeons. The main reason
for the majority of GDPs (55.0%) and many SDPs (40%) not to perform sedation was lack of
training in this field. While some SDPs (26.0%) indicated they did not use sedation because of
the inadequacy of sedative facilities.
Conclusion: Within the limitations of the present study, it can be concluded that the provision
of conscious sedation services in general and specialist dental practices in Jordan is inconsistent
and inadequate. This stresses the great need to train practitioners and dental assistants in Jordan
to enable them to safely and effectively perform all forms of sedation.
Keywords: Jordan Dental Association, conscious sedation techniques, specialist anesthetist,
oral and maxillofacial surgeons
Background
Anxiety and pain remain a significant barrier to care for many dental patients.1,2
Therefore, sedation and analgesia are often essential because dentistry is often
strongly associated with fear, anxiety, pain, and apprehension by both children3–5
(defined herein as those aged , 16 years) and adults.6–8 In addition, the management
of mentally and physically handicapped patients usually requires these techniques to
control anxiety and pain. Consequently, the use of sedation is becoming progressively
important as a technique in dental treatment and more practitioners may need to
develop their care in this area.9 It has been shown that conscious sedation via oral,
intravenous, and inhalational routes is both an effective and safe alternative to general
anesthesia (GA) in many cases.10–13 Further, avoiding GA whenever possible and using
alternative techniques such as conscious sedation has also been stressed by guidelines
in the UK.14,15
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Inhalational sedation (IHS), which uses low to moderate
concentrations of nitrous oxide in oxygen has many favorable
properties that allow it to be used alone for effective sedation
or as an atraumatic induction to intravenous sedation (IVS).16
This frequently used technique has a remarkable safety record
that is superior to that of the use of local anesthetic alone.
Further, IHS together with local anesthesia has also been
recommended as an alternative to GA in children12,17–19 and
in adults undergoing orthodontic extraction and minor oral
surgical procedures.20 When comparing previous experiences
of dental treatment under GA, the majority of children (80%)
preferred IHS18 and showed less postoperative psychological
distress when this form of sedation was used.21 The reduction
of the number of local anesthetics used, the reduction of the
appointment duration for each patient, and the increase in
the efficacy of the treatment session were all noted features
after using IHS.
IVS, particularly after the introduction of modern oxygen
monitoring devices such as oximetry, has many favorable
properties rendering it safe for anxiety control. Special
skill is required for its administration, but it is suitable for
titration. Oral sedation is also an attractive way of sedating
patients. It is widely employed because it is simple to teach
and learn as well as to administer to patients. Remarkable
safety continues to be recorded for the use of anxiolytic,
sedative, and anesthetic techniques by appropriately trained
dentists in the dental office and other settings.22,23
In Jordan, the use of sedation is characterized by the lack
of national guidelines on this practice in dentistry. Jordanian
dental practices adopt various international guidelines for the
use of all levels of sedation, such as US guidelines.24 These
are utilized in parenteral, inhalational, and enteral types of
sedation. However, the administration of all levels of seda-
tion – minimal, moderate, and deep – is performed only by
independent qualified anesthesia specialists or health care
providers who must have the appropriate training, skills,
drugs, and equipment that comply with these international
guidelines.
Jordanian studies in 200225,26 and 200527 looked at the
demands placed on sedation services in the country. These
studies, which used a modified form of the Dental Fear
Survey, reported that dental anxiety (fear of the dentist) was
considered a cause of irregular dental attendance in 13.3%
of undergraduate students and 10% of school children.
These levels of dental anxiety are approaching those found
internationally.28 This has raised the need to implement
different pain control techniques in Jordanian dental
practices, especially in pediatric dentistry. Techniques such
as behavioral management and sedation were approved by
patients’ families and practitioners in 2006. Further, the
Jordan University Hospital (JUH) established a new dental
clinic in 2010 designed especially to treat mentally and
physically handicapped patients who sometimes require
different types of dental treatment. Techniques to control
anxiety and pain, such as sedation, may be necessary for
such patients. Practitioners in this center may need to
develop their knowledge of sedation to best care for these
individuals. Additionally, most Jordanian medical centers
have adopted developed countries’ guidelines, such as those
of the UK or USA, which stress avoiding GA whenever
possible and the adoption of alternative techniques such as
conscious sedation. As a result, demand for sedation services
is expected to rise.
To the best of our knowledge, there is no information in
the literature about the practice of sedation in Jordan or in
the Arab world. As such, we developed an electronic survey,
sent by email to dentists regardless of specialty, to collect data
and information on the scope and many aspects of the seda-
tion services performed in dental offices in Jordan. We hope
that this information can be compared with data reported for
other countries and will be of particular use to those in the
dental profession, health care workers, and regulatory agen-
cies. Further, as the number of dentists and specialist dental
practitioners (SDPs) in different dental specialties in Jordan
has dramatically increased during the last decade, it is hoped
that the findings of the present study will shed more light
on which sedation practices have been adopted in Jordanian
academic and private dental practices, and on whether there
is consistency in the instructions relevant to this important
dental procedure.
Methods
The study was designed as a questionnaire-based survey and
was undertaken from April to December 2009. The email
survey, which consisted of a covering letter explaining the
purpose of the study and the questionnaire as an attachment,
was sent to 1683 general dental practitioners (GDPs) and
SDPs who were working in Jordan at the time of the study.
Contact details of these GDPs were obtained from a list from
the Jordan Dental Association (JDA). The first email was sent
in April 2009 and a follow-up email was sent approximately
3 months later to nonresponders or responders who did not
answer all questions. No further emails were sent after the
second. The questionnaire was anonymous and did not contain
any questions that might lead to disclosing the identity of
the respondent. Moreover, none of the questions requested
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Al-Shayyab et al
Therapeutics and Clinical Risk Management 2013:9
any patient identity or confidential patient information. This
type of study does not require the ethical committee approval,
according to the regulations of the University of Jordan, as
no party will be subjected to intervention or harm.
The questionnaire consisted of 17 main questions
(Table 1) and was in English. The questionnaire identified
practitioner details and, if respondents indicated they did not
use patient sedation, elicited their reasons for this. Those who
indicated they did performing sedation in their practices were
asked about the age of patients treated (ie, adults/children);
the type of sedation technique(s) used; training received
for sedation; and issues concerning standards of care, the
utilization of sedation services in dentistry, and the need
for a plan to promote sedation practices in Jordan (Table 1).
This promoting plan could involve the provision of education
and training programs as well as guidelines to govern the
practice of sedation in different places and types of dental
practices in the country.
Data were analyzed using SPSS (v 17.0; IBM, Armonk,
NY, USA) and Microsoft® Excel (Microsoft, Redmond, WA,
USA). Independent samples t-tests were performed using
Statistics Calculator (StatPac, Bloomington, MN, USA) to
assess statistical differences between frequencies. Statistical
significance was set at a P value of 0.05.
Results
A total of 1683 questionnaires were sent via email to
GDPs and SDPs who were working in Jordan at the time
Table 1 Topics investigated to identify the current provision of sedation among general dental practitioners (gDPs) and specialist
dental practitioners in Jordan in 2010
Question topics Question Options or definitions
Demographic characteristics Age
Sex
Type of practice general dental practice, oral and maxillofacial surgery,
periodontics, pediatric dentistry, others
Place of practice Private practice, Ministry of Health, university hospital,
military hospital
Year of qualification Year final degree granted; degree could be: only bachelor
of dental surgery or specialty (master of science, doctor
of philosophy, fellowship or more than one of these)
Question for those not practicing sedation
Reasons for not practicing I did not obtain any training program in this field
No need for it in my practice
it is unsafe for out-patient
Expensive
Patients disagree about its use in dental practice
Poor sedative facilities
Poor availability of well-trained assistants or nurses
Questions for those practicing sedation
Training in the field of
sedation
Present or absent?
Type of training,
if present
As part of undergraduate study, as part of postgraduate
study, as part of undergraduate and postgraduate study,
special courses
Preferred type of sedation in general iV, oral, inhalational, iV and oral, iV and inhalational,
inhalational and oral, iV, inhalational and oral
in children
in adults
Standards of care Does your assistant/nurse have sufficient training in managing sedated patients?
Do you use written preoperative information provided to patients?
Do you use written postoperative information provided to patients?
The use and type of consent required before intravenous sedation?
issues regarding plans to
promote sedation practice
Do you think that it is important to provide education and training for sedation in Jordan?
Should there be guidelines for iV sedation especially in private general practices?
Should the Jordanian Society for Anaesthesiology or Jordan Dental Association
be responsible for preparing these guidelines?
Number of cases treated in the last year
Abbreviation: iV, intravenous.
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Current sedation practice in Jordan
percentage of SDPs performing sedation was significantly
higher than the percentage of GDPs performing sedation
across all qualification year periods considered (Table 4).
However, those SDPs who obtained their qualifications in
the 1990s or 2000s performed more sedations than those who
obtained their qualifications in the 1960s, 1970s, or 1980s,
and this difference was statistically significant (Table 5).
No statistically significant difference was observed in the
proportion of SDPs performing sedation between those who
attained their qualification in the 1990s and those who did
so in the 2000s (Table 5). In addition, when the three earlier
categories (ie, the 1960s, 1970s, and 1980s) were compared
in this regard, no statistically significant difference was found
(Table 5). No statistically significant difference was observed
in the proportion of GDPs performing sedation across all year
of qualification categories considered.
Most practitioners (596 [69.2%]) reported that they
worked in private practice (PP), while 81 (9.4%) worked
for the Ministry of Health (MH), 102 (11.8%) in university
hospitals (UHs), and 67 (7.8%) in military service hospitals
(MSHs). Fifteen (1.7%) did not disclose their place of
practice.
In total, 73 (8.5%) respondents detailed the different types
of treatments related to their specialties that were undertaken
under some form of sedation conducted by a specialist and/or
assistant anesthetist. Most (63 [86.3%]) were SDPs, while
the remainder (10 [13.7%]) were GDPs.
Most GDPs and SDPs who treated patients under
sedation worked in MSHs (27 [37%]); together, the next most
common places of work were PP and UHs (22 [30.1%]).
of this study. Of these, 1003 (60%) responded. Of these,
142 completed questionnaires were excluded because the
replies indicated that the practitioners to whom they were
sent were retired, deceased, or working abroad. Thus, 861
completed questionnaires were found usable, although a
few questions were not answered in a several questionnaires.
Therefore, the number of answers completed for each
individual question was used as the basis for reporting the
percentage results.
Table 2 details respondents’ demographic characteristics.
In total, 472 GDPs were male, 270 were female, and six did
not indicate their sex. Additionally, 73 SDPs were male,
38 were female, and two did not answer the sex question.
The mean age of the practitioners (GDPs and SDPs) was
46.5 years (median 48.0 years, range 24.0–70.0 years,
standard deviation 12.9 years). Eleven practitioners did not
give information about their age.
Practitioners’ year of qualification with relation to
treating patients under sedation is detailed in Table 3.
Twelve GDPs and two SDPs did not provide information
about their year of qualification. It was found that the
Table 2 Respondents’ demographic characteristics
Sex Offers
sedation
Type of
practice
N Age, years
Mean Median SD
Male Yes gDP
SDP
Total
8 54.4 58.5 12.0
48 45.7 45.5 12.5
56 47.0 49.0 12.7
No gDP
SDP
Total
464 46.6 48.0 12.7
25 46.7 50.0 12.9
489 46.6 48.0 12.7
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