235 eligible dentists participated, with11% drop out rate through the survey. Over half (120/235 = 51.1% 95% CI[44.7–57.4]) had prescribed OBZs to patients for anxiolysis.
Demographics
Most respondents were female (139/235 = 59.1%), aged 22–40 years (142/235 = 60%), general dental practitioners (213/235 = 90.6%) and had qualified in the UK (214/235 = 91.1%). Little difference existed OBZ prescribing experience between general and specialty dentists (51.2% vs 50.0%) (see Table 1). Those qualified before 1992 were twice as likely to have prescribed OBZs as those qualified since 2012 (> 80% compared with 37%).
Table 1
Demographics of survey respondents.
Demographic
|
Total number of respondents (n = 235)
|
Proportion who had prescribed OBZs (95% CI)
|
Gender
|
Male
|
92
|
58.7% (48.5–68.2)
|
Female
|
139
|
46.8% (38.7–55)
|
Prefer not to say
|
4
|
*
|
Type of dentist
|
General dentist
|
213
|
51.2% (44.5–57.8)
|
Specialty dentist/ trainee
|
22
|
50.0% (30.7–69.3)
|
Country qualified
|
UK
|
214
|
52.8% (46.1–59.4)
|
Non-UK
|
21
|
33.3% (17.2–54.6)
|
Year qualified
|
1972–1981
|
3
|
*
|
1982–1991
|
25
|
80% (60.9–91.1)
|
1992–2001
|
33
|
69.7% (52.7–82.6)
|
2002–2011
|
76
|
51.3% (40.3–62.2)
|
2012–2021
|
98
|
36.7% (27.9–46.6)
|
* Numbers too small for statistical analysis.
|
Patterns of OBZ prescribing
Of 120 dentists who had prescribed OBZs, most prescribed pre-medication (103/120=85.8% 95% CI78.3-91.5), 16 for temporomandibular joint problems and 8 solely for conscious sedation. A third of respondents (85/229=37.1%) reported having asked a general medical practitioner (GP) to prescribe OBZs as anxiolysis for a patient.
Of the 114 dentists who had prescribed OBZs, 36%(n=41) had done so most recently in the last year, whilst25% (n=29) reported that it was over 5 years ago. Two-thirds of the 161 dentists (n=108) who did not currently prescribe them for anxiolysis would be interested in doing so.
In response to a scenario about OBZ prescribing for anxiolysis, most prescribed diazepam the night before a procedure and/or 2 hours before a procedure (67.7%=143/211) (see Figure 1).
Barriers and enablers to OBZ prescribing
Barriers, enablers and other factors influencing OBZ prescribing are detailed below and summarised in Figure 2.
Barriers
Confidence in OBZ prescribing - Just 17.8% of all respondents (n=39/219) reported high or very high confidence in OBZ prescribing. More than 70% (n=155/219) wanted further training and some highlighted the lack of clear guidance on OBZs as pre-medication.
“I’m not sure about guidance with prescribing oral medication for dental anxiety and so have avoided it for a number of years”
Confusion about qualification requirements - Dentists who had never prescribed OBZs cited not having a formal sedation qualification (n=54), medicolegal risk (n=43), a preference for other anxiety management approaches (n=28), concerns about safety (n=8), inadequate remuneration (n=6) and concerns about drug effectiveness (n=2) as barriers to their prescribing.
Concern about medicolegal risk – Safety concerns included issues of access to a patient’s complete medical history, which may be important when prescribing OBZs, and the risk of contributing to substance misuse disorder were:
“Unsure of patient’s exact medical histories. It’s easier in secondary care to readily access GP records than it is as a GDP so easier to be more confident there will be no drug interactions.”
By working with the patient’s GP, dentists felt more comfortable as they had access to a complete medical history, which is important for identifying potential drug interactions and any concerns about substance misuse disorder.
“[OBZs are] a controlled drug and drug of abuse - I am concerned my patients may try and coerce myself/others into prescribing oral sedatives more regularly if I make it common practice.”
Perceived difficulties also related to ensuring that the dose given would not inadvertently cause the patient to be sedated.
“One patient was very drowsy and had to stay in the spare surgery to recover – despite our practice not being set up as a sedation practice.”
Enablers
Patients more relaxed and co-operative - Many dentists advocated the benefits of treating patients who had taken OBZs as oral pre-medication:
‘I believe it improved the ability to give care because the patient was less anxious and more cooperative.’
‘It made the procedure easier as the patient seemed a lot more relaxed.’
Long waits for sedation services - Poor access to NHS services for anxious patients were reported as an incentive to using OBZs to facilitate care in general dental practice:
“Long waits for sedation on NHS, so think it’s worth prescribing and trying the oral benzo [sic] as delayed treatment can lead to loss of a tooth which may otherwise have been saved.”
Other factors
Prescribing by GPs - Nearly half of dentists (100/221=45.2%) reported having treated patients who had taken oral sedatives prescribed by a GP without their input (and sometimes even without their knowledge).
“The problem comes when the GP has prescribed and [the patient] has taken the medication without my knowledge. One patient I believed was drunk.”
“Makes it difficult and challenging: the consent process is compromised. Patient safety was compromised as did not always have an escort.”
Drug-seeking behaviour - Anxiolytics were not commonly requested (25/210=11.7%). Respondents identified antibiotics as the most likely drugs to be requested by anxious dental patients (153/210 = 71.5%), followed by opioid analgesics such as dihydrocodeine (46/210=21.5%) and non-opioid analgesics such as ibuprofen (38/210=17.8%).
Alternative approaches to anxiety management
Many dentists reported avoiding the use of OBZs, with most preferring behavioural management techniques (see Table 2).