The Use of Oral Benzodiazepines for the Management of Dental Anxiety: A Web-based Survey of UK Dentists

The Use of Oral Benzodiazepines for the Management of Dental Anxiety: A Web-based Survey of UK Dentists | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research The Use of Oral Benzodiazepines for the Management of Dental Anxiety: A Web-based Survey of UK Dentists Wendy Thompson, Kathryn Finn, Deborah Moore, Yvonne Dailey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2203925/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Oral benzodiazepines can facilitate treatment of dentally anxious patients and are widely used in countries such as Australia and the United States. Dentists in the United Kingdom (UK) prescribe them much less often. Aims To examine oral benzodiazepine prescribing by dentists in the UK, including patterns of practice, barriers to use, and alternative anxiety management strategies. Methods An online mixed-methods survey was conducted utilising Qualtrics™. Participants were recruited via the Facebook private group: For Dentists, By Dentists during April to June 2021. Quantitative data were analysed with descriptive statistics and qualitative data with thematic analysis. Results 235 dentists participated, with 91% being general dentists. Only 18% were confident in their use. Half had previously prescribed oral benzodiazepines, of which 36% were in the last year. Diazepam was the anxiolytic preferred by respondents. Two thirds of dentists who had never prescribed anxiolytics were interested in doing so in the future. Concerns about managing anxious patients with benzodiazepines included: inadequate training, confusion about guidelines, medico-legal risk, and issues of GPs prescribing anxiolytics to dental patients unbeknown to their dentist. Conclusions A lack of confidence prescribing oral benzodiazepines for anxiolysis exists among UK dentists. Guidelines should be clarified, and training provided. Health sciences/Health care/Dentistry/Dental pharmacology Health sciences/Health care/Dentistry/Special care dentistry Figures Figure 1 Figure 2 In Brief Points Most UK dentists are not confident prescribing oral benzodiazepines for the management of anxious patients, even those who have prescribed them in the past. A training need exists for the pharmacological management of anxious patients in general dental practice and clear guidance would be helpful. Many dentists had experienced patients attending for treatment who had taken oral benzodiazepines prescribed by their general medical practitioner. Concern was expressed that dentists did not often know when patients had taken these drugs before an appointment and the impact this had on patient safety and consent. Diazepam is the drug of choice for most dentists, even though BNF recommends temazepam when it is important to minimize the effects the following day. Introduction Dental anxiety is common, with 12% of adults reporting extreme levels of dental anxiety in the most recent adult dental health survey. 1 Anxiety has been shown to be a major factor in the avoidance of regular dental care and diversion of patients to medical rather than dental services. 2 , 3 As such patients with dental anxiety are more likely to have untreated dental disease and to only attend when they have a dental problem. 1 , 4 Furthermore, highly anxious patients may find that their anxiety prevents them from accepting dental interventions, further restricting their access to care. 5 Whilst non-pharmacological methods such as behavioural management techniques and cognitive behavioural therapy (CBT) can be successful in managing patient anxiety, a study of dental non-attenders demonstrated that those with high levels of anxiety were less willing to explore these methods. 5 Pharmacological methods are, therefore, sometimes used to facilitate the delivery of dental care for the most anxious patients. Prescribing of oral benzodiazepines (OBZs) as anxiolytics/hypnotics is widespread but dependence (both physical and psychological) and tolerance occur, particularly if the patient has been taking them regularly for more than a few weeks. 6 Diazepam and temazepam are the OBZs included in the UK Dental Practitioners Formulary and can be prescribed as either pre-medication or oral sedation prior to clinical procedures. 6 According to the 2015 Intercollegiate Advisory Committee for Sedation guidelines, conscious sedation can only be provided by dental practitioners who have received additional training. 7 However, all dental practitioners can prescribe OBZs at anxiolytic doses as pre-medication. Pre-medication is defined as the self-administration of a small dose of an oral sedative to alleviate anxiety, often at home. 7 Oral sedation is the administration of a much larger dose of an oral sedative at the dental practice. 7 The distinction between the two relates to the effect on the patient. Sedative doses result in a mild impact on the patient’s physiological function and response to verbal stimulus whereas anxiolytic doses reduce a patient’s anxiety whilst maintaining a normal response to verbal commands and physiological functions are unaffected. 8 A much lower rate of OBZ prescribing exists in England compared to other countries, such as Australia and the United States. 9 Even before the COVID-19 pandemic, access to National Health Service (NHS) sedation services varied across England. 10 This study aimed to explore the prescribing of OBZs for anxiety management by dentists in the United Kingdom (UK), including: prescribing patterns, barriers and enablers to prescribing, and alternative approaches employed to manage dentally-anxious patients. Methods An on-line questionnaire was designed, pilot tested (with 13 general and specialty dentists) and finalised as a combination of demographic, quantitative and qualitative questions (see online Supplementary Information). Participants were recruited through the Facebook private group, For Dentists By Dentists between April and June 2021. The recruitment message explained that the study aimed to explore drug prescribing for patients with dental anxiety. The study sample size was calculated as 138, based on a target of 5% precision around an estimate of the proportion of participants that had ever prescribed OBZ, with 95% confidence. The calculation assumed that 10% of participants would have previously prescribed OBZs (from NHS prescribing data in 2019). 11 The estimated population size was based on the Facebook group membership of 17300. Descriptive statistics were used to present the quantitative results of this study, with confidence intervals calculated using the Wilson Score interval within the Qualtrics survey tool and using SPSS software where necessary. Qualitative data from the free text answers were analysed using thematic analysis. 12 Ethical approval for the study was granted by University of Manchester UREC (Ref: 2021-11318-18298). All participants consented to participate in the study and to have their data used as part of the research. Results 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: “L ong 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). Table 2 Proportion of dentists using each of the other anxiety management techniques Choice Proportion Confidence Interval (95%) Behavioural management techniques 89.5% 84.7–92.9% Intravenous Sedation 31.1% 25.3–37.5% Systematic Desensitisation 22.4% 17.4–28.3% Inhalation Sedation 16.9% 12.5–22.4% Cognitive behavioural therapy 9.6% 6.4–14.2% Hypnosis 7.3% 4.5–11.5% Other 7.3% 4.5–11.5% None 5.0% 2.8–8.8% Acupuncture 3.2% 1.6–6.4% Discussion A general lack of confidence about OBZ prescribing exists, together with a desire for further training in prescribing anxiolytics, even amongst 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 Intercollegiate 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. 13 However, it is more prone to interactions and has a longer half-life than temazepam. 6 For these reasons, the British National Formulary (BNF) recommends temazepam as more suitable when it is important to minimise any residual effect the following day. 6 By contrast, Scottish Dental Clinical Effectiveness Programme (SDCEP) drug prescribing guidelines recommend only diazepam as pre-medication. 14 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). 15 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 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. Whilst the Intercollegiate Standards for Conscious Sedation in the Provision of Dental Care and the SDCEP Conscious Sedation in Dentistry guidelines both cover pre-medications, some ambiguity is clear. 6 , 21 These inconsistencies and ambiguities within current guidance could be a contributing factor in dentists self-reported lack of confidence in prescribing OBZs. US guidelines are much more explicit on the requirements that a dentist must satisfy before prescribing OBZs at anxiolytic doses. 16 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. 17 , 18 3 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. 19 20 Displacement of anxious dental patients to GPs may help explain the significantly lower OBZ prescription rate found in England compared to the US 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). 20 , 21 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 (SCR) are an electronic record of important patient information, created from GP medical records. 22 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. 22 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). 23 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% confidence intervals 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. 24 Whilst 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. 25 – 28 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. Conclusion A lack of confidence in prescribing OBZs for anxiolysis exists among UK dentists. Diazepam was preferred by dentists despite its residual effects lasting longer when compared to temazepam GPs are prescribing OBZs both with and without dentists’ input to alleviate patients’ dental anxiety. This impacts on both patient safety and ability to provide valid consent during dental appointments. In view of these findings, guidelines for dentists and GPs should be clarified and training provided to enhance patient safety, reduce the burden on GPs and broaden access to dental care for anxious patients. Declarations Declaration of interests The authors declare no conflicts of interest Author contributions statements The authors were involved as follows: Conception - WT. Design of the Work – All authors. Data collection – KF and WT. Data analysis and interpretation – KF and WT. Drafting the article – KF and WT. Critical revision of the article and final approval of the version to be published – all authors. 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Additional Declarations There is no duality of interest Supplementary Files SupplementarymaterialQuestionnaire.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 09 Jan, 2023 Review # 2 received at journal 19 Dec, 2022 Reviewer # 2 agreed at journal 13 Dec, 2022 Review # 1 received at journal 05 Dec, 2022 Reviewer # 1 agreed at journal 18 Nov, 2022 Reviewers invited by journal 14 Nov, 2022 Editor assigned by journal 26 Oct, 2022 Submission checks completed at journal 26 Oct, 2022 First submitted to journal 25 Oct, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2203925","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":151915571,"identity":"b24be650-b875-47a3-bc1c-09faaf573937","order_by":0,"name":"Wendy Thompson","email":"data:image/png;base64,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","orcid":"","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Thompson","suffix":""},{"id":151915572,"identity":"867b4fbc-5be4-4589-90d9-24ce0801b7e8","order_by":1,"name":"Kathryn Finn","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kathryn","middleName":"","lastName":"Finn","suffix":""},{"id":151915573,"identity":"5de13148-97c3-43fb-b87d-318f953b63b1","order_by":2,"name":"Deborah Moore","email":"","orcid":"https://orcid.org/0000-0001-9965-9371","institution":"University of Manchester","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Moore","suffix":""},{"id":151915574,"identity":"307f1405-cc77-4db0-8251-2ee3347eac99","order_by":3,"name":"Yvonne Dailey","email":"","orcid":"","institution":".","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yvonne","middleName":"","lastName":"Dailey","suffix":""}],"badges":[],"createdAt":"2022-10-25 23:40:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2203925/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2203925/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":29208094,"identity":"27bc55ce-4ca8-449e-b5a1-fa2124e850d9","added_by":"auto","created_at":"2022-11-17 19:49:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18358,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-2203925/v1/df68f88e7dab2378873d36d0.png"},{"id":29208093,"identity":"8567056e-f6eb-48d4-b900-33e7ef2afb4b","added_by":"auto","created_at":"2022-11-17 19:49:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":159717,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-2203925/v1/b5a5d4d4e81ea047dfed1e12.png"},{"id":29208096,"identity":"b717481f-f389-4d79-ac32-0b365ba52f45","added_by":"auto","created_at":"2022-11-17 19:49:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":505215,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2203925/v1/2c8e2b98-ae77-4ac3-97fc-96bad9d1b778.pdf"},{"id":29208095,"identity":"8deb76da-6010-474a-b072-c510df283de2","added_by":"auto","created_at":"2022-11-17 19:49:19","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":29977,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-2203925/v1/a8e0b9a993eb7bdfd5b2a616.docx"}],"financialInterests":"There is no duality of interest","formattedTitle":"The Use of Oral Benzodiazepines for the Management of Dental Anxiety: A Web-based Survey of UK Dentists","fulltext":[{"header":"In Brief Points","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eMost UK dentists are not confident prescribing oral benzodiazepines for the management of anxious patients, even those who have prescribed them in the past. A training need exists for the pharmacological management of anxious patients in general dental practice and clear guidance would be helpful.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMany dentists had experienced patients attending for treatment who had taken oral benzodiazepines prescribed by their general medical practitioner. Concern was expressed that dentists did not often know when patients had taken these drugs before an appointment and the impact this had on patient safety and consent.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDiazepam is the drug of choice for most dentists, even though BNF recommends temazepam when it is important to minimize the effects the following day.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eDental anxiety is common, with 12% of adults reporting extreme levels of dental anxiety in the most recent adult dental health survey.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Anxiety has been shown to be a major factor in the avoidance of regular dental care and diversion of patients to medical rather than dental services.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e As such patients with dental anxiety are more likely to have untreated dental disease and to only attend when they have a dental problem.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Furthermore, highly anxious patients may find that their anxiety prevents them from accepting dental interventions, further restricting their access to care.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhilst non-pharmacological methods such as behavioural management techniques and cognitive behavioural therapy (CBT) can be successful in managing patient anxiety, a study of dental non-attenders demonstrated that those with high levels of anxiety were less willing to explore these methods.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Pharmacological methods are, therefore, sometimes used to facilitate the delivery of dental care for the most anxious patients. Prescribing of oral benzodiazepines (OBZs) as anxiolytics/hypnotics is widespread but dependence (both physical and psychological) and tolerance occur, particularly if the patient has been taking them regularly for more than a few weeks.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Diazepam and temazepam are the OBZs included in the UK Dental Practitioners Formulary and can be prescribed as either pre-medication or oral sedation prior to clinical procedures.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccording to the 2015 Intercollegiate Advisory Committee for Sedation guidelines, conscious sedation can only be provided by dental practitioners who have received additional training.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e However, all dental practitioners can prescribe OBZs at anxiolytic doses as pre-medication. Pre-medication is defined as the self-administration of a small dose of an oral sedative to alleviate anxiety, often at home.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Oral sedation is the administration of a much larger dose of an oral sedative at the dental practice.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The distinction between the two relates to the effect on the patient. Sedative doses result in a mild impact on the patient\u0026rsquo;s physiological function and response to verbal stimulus whereas anxiolytic doses reduce a patient\u0026rsquo;s anxiety whilst maintaining a normal response to verbal commands and physiological functions are unaffected.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA much lower rate of OBZ prescribing exists in England compared to other countries, such as Australia and the United States.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Even before the COVID-19 pandemic, access to National Health Service (NHS) sedation services varied across England.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e This study aimed to explore the prescribing of OBZs for anxiety management by dentists in the United Kingdom (UK), including: prescribing patterns, barriers and enablers to prescribing, and alternative approaches employed to manage dentally-anxious patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAn on-line questionnaire was designed, pilot tested (with 13 general and specialty dentists) and finalised as a combination of demographic, quantitative and qualitative questions (see online Supplementary Information). Participants were recruited through the Facebook private group, For Dentists By Dentists between April and June 2021. The recruitment message explained that the study aimed to explore drug prescribing for patients with dental anxiety. The study sample size was calculated as 138, based on a target of 5% precision around an estimate of the proportion of participants that had ever prescribed OBZ, with 95% confidence. The calculation assumed that 10% of participants would have previously prescribed OBZs (from NHS prescribing data in 2019).\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The estimated population size was based on the Facebook group membership of 17300.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to present the quantitative results of this study, with confidence intervals calculated using the Wilson Score interval within the Qualtrics survey tool and using SPSS software where necessary. Qualitative data from the free text answers were analysed using thematic analysis.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was granted by University of Manchester UREC (Ref: 2021-11318-18298). All participants consented to participate in the study and to have their data used as part of the research.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e235 eligible dentists participated, with11% drop out rate through the survey. Over half (120/235\u0026thinsp;=\u0026thinsp;51.1% 95% CI[44.7\u0026ndash;57.4]) had prescribed OBZs to patients for anxiolysis.\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents were female (139/235\u0026thinsp;=\u0026thinsp;59.1%), aged 22\u0026ndash;40 years (142/235\u0026thinsp;=\u0026thinsp;60%), general dental practitioners (213/235\u0026thinsp;=\u0026thinsp;90.6%) and had qualified in the UK (214/235\u0026thinsp;=\u0026thinsp;91.1%). Little difference existed OBZ prescribing experience between general and specialty dentists (51.2% vs 50.0%) (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Those qualified before 1992 were twice as likely to have prescribed OBZs as those qualified since 2012 (\u0026gt;\u0026thinsp;80% compared with 37%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographics of survey respondents.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDemographic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal number of respondents (n\u0026thinsp;=\u0026thinsp;235)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eProportion who had prescribed OBZs (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58.7% (48.5\u0026ndash;68.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e139\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.8% (38.7\u0026ndash;55)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrefer not to say\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eType of dentist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral dentist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e213\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51.2% (44.5\u0026ndash;57.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpecialty dentist/ trainee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.0% (30.7\u0026ndash;69.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCountry qualified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e214\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52.8% (46.1\u0026ndash;59.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-UK\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.3% (17.2\u0026ndash;54.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eYear qualified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1972\u0026ndash;1981\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1982\u0026ndash;1991\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80% (60.9\u0026ndash;91.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1992\u0026ndash;2001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.7% (52.7\u0026ndash;82.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2002\u0026ndash;2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51.3% (40.3\u0026ndash;62.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2012\u0026ndash;2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36.7% (27.9\u0026ndash;46.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e* Numbers too small for statistical analysis.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003ePatterns of OBZ prescribing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf 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.\u003c/p\u003e\n\u003cp\u003eOf 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.\u003c/p\u003e\n\u003cp\u003eIn 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).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBarriers and enablers to OBZ prescribing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBarriers, enablers and other factors influencing OBZ prescribing are detailed below and summarised in Figure 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConfidence in OBZ prescribing\u003c/em\u003e\u003c/strong\u003e - 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m not sure about guidance with prescribing oral medication for dental anxiety and so have avoided it for a number of years\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConfusion about qualification requirements\u003c/em\u003e\u003c/strong\u003e - 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConcern about medicolegal risk\u003c/em\u003e\u003c/strong\u003e \u0026ndash; Safety concerns included issues of access to a patient\u0026rsquo;s complete medical history, which may be important when prescribing OBZs, and the risk of contributing to substance misuse disorder were:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Unsure of patient\u0026rsquo;s exact medical histories. It\u0026rsquo;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.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBy working with the patient\u0026rsquo;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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[OBZs are] \u003c/em\u003e\u003cem\u003ea controlled drug and drug of abuse -\u003c/em\u003e \u003cem\u003eI am concerned my patients may try and coerce myself/others into prescribing oral sedatives more regularly if I make it common practice.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePerceived difficulties also related to ensuring that the dose given would not inadvertently cause the patient to be sedated.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eOne patient was very drowsy and had to stay in the spare surgery to recover \u0026ndash; despite our practice not being set up as a sedation practice.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEnablers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatients more relaxed and co-operative\u003c/em\u003e\u003c/strong\u003e - Many dentists advocated the benefits of treating patients who had taken OBZs as oral pre-medication:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;I believe it improved the ability to give care because the patient was less anxious and more cooperative.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;It made the procedure easier as the patient seemed a lot more relaxed.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLong waits for sedation services\u003c/em\u003e\u003c/strong\u003e - Poor access to NHS services for anxious patients were reported as an incentive to using OBZs to facilitate care in general dental practice:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;L\u003cem\u003eong waits for sedation on NHS, so think it\u0026rsquo;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.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOther factors\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrescribing by GPs\u003c/em\u003e\u003c/strong\u003e - 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).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The problem comes when the GP has prescribed and [the patient] has taken the medication without my knowledge. One patient I believed was drunk.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eMakes it difficult and challenging: the consent process is compromised. Patient safety was compromised as did not always have an escort.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDrug-seeking behaviour\u003c/em\u003e\u003c/strong\u003e - 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%).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlternative approaches to anxiety management\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany dentists reported avoiding the use of OBZs, with most preferring behavioural management techniques (see Table 2).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eProportion of dentists using each of the other anxiety management techniques\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eChoice\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eProportion\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eConfidence Interval (95%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBehavioural management techniques\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84.7\u0026ndash;92.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntravenous Sedation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.3\u0026ndash;37.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSystematic Desensitisation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.4\u0026ndash;28.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInhalation Sedation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.5\u0026ndash;22.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCognitive behavioural therapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.4\u0026ndash;14.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHypnosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.5\u0026ndash;11.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.5\u0026ndash;11.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.8\u0026ndash;8.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAcupuncture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.6\u0026ndash;6.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eA general lack of confidence about OBZ prescribing exists, together with a desire for further training in prescribing anxiolytics, even amongst 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 Intercollegiate sedation guidelines in 2015 introduced confusion for many, including whether additional qualifications are required for prescribing anxiolytic pre-medication.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDiazepam was the preferred OBZ among respondents, consistent with routinely collected NHS prescribing data.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e However, it is more prone to interactions and has a longer half-life than temazepam.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e For these reasons, the British National Formulary (BNF) recommends temazepam as more suitable when it is important to minimise any residual effect the following day.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e By contrast, Scottish Dental Clinical Effectiveness Programme (SDCEP) drug prescribing guidelines recommend only diazepam as pre-medication.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e These sorts of discrepancies between the two documents are examples of the lack of clear guidance for dentists on OBZ prescribing.\u003c/p\u003e \u003cp\u003eHowever, 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).\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e 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.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Various additional legal requirements for prescribing CDs exist, including the requirement to specify \u0026lsquo;for dental treatment only\u0026rsquo;.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConfusion was also expressed in the study about whether dentists without additional qualifications can prescribe OBZs. Whilst the Intercollegiate Standards for Conscious Sedation in the Provision of Dental Care and the SDCEP Conscious Sedation in Dentistry guidelines both cover pre-medications, some ambiguity is clear.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e These inconsistencies and ambiguities within current guidance could be a contributing factor in dentists self-reported lack of confidence in prescribing OBZs. US guidelines are much more explicit on the requirements that a dentist must satisfy before prescribing OBZs at anxiolytic doses.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Further research is indicated to produce clear UK guidance about pre-medication, including doses and the need for additional qualifications.\u003c/p\u003e \u003cp\u003eThis 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\u0026rsquo;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.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e 3\u003c/sup\u003e 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.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e 20\u003c/sup\u003e Displacement of anxious dental patients to GPs may help explain the significantly lower OBZ prescription rate found in England compared to the US and Australia.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e 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).\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e A further patient safety concern relating to the prescribing of OBZs was the lack of access for dentists to a patient\u0026rsquo;s complete medical history. Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e 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.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e 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.\u003c/p\u003e \u003cp\u003eThe 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\u0026ndash;40 years old vs 48% of GDC registered dentists).\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e 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% confidence intervals 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.\u003c/p\u003e \u003cp\u003eThe 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.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Whilst 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.\u003csup\u003e\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e 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.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA lack of confidence in prescribing OBZs for anxiolysis exists among UK dentists. Diazepam was preferred by dentists despite its residual effects lasting longer when compared to temazepam GPs are prescribing OBZs both with and without dentists\u0026rsquo; input to alleviate patients\u0026rsquo; dental anxiety. This impacts on both patient safety and ability to provide valid consent during dental appointments. In view of these findings, guidelines for dentists and GPs should be clarified and training provided to enhance patient safety, reduce the burden on GPs and broaden access to dental care for anxious patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclaration of interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflicts of interest\u003c/p\u003e\n\u003ch2\u003eAuthor contributions statements\u003c/h2\u003e\n\u003cp\u003eThe authors were involved as follows: Conception - WT. Design of the Work \u0026ndash; All authors. Data collection \u0026ndash; KF and WT. Data analysis and interpretation \u0026ndash; KF and WT. Drafting the article \u0026ndash; KF and WT. Critical revision of the article and final approval of the version to be published \u0026ndash; all authors.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWith thanks to those who piloted the questionnaire and those who participated in the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNuttall N, Freeman R, Beavan-Seymour C, K H. 8: Access and barriers to care - a report from the Adult Dental Health Survey 2009 [Internet]. The Health and Social Care Information Centre; 2011\u003c/li\u003e\n\u003cli\u003eArmfield JM, Stewart JF, Spencer AJ. The vicious cycle of dental fear: exploring the interplay between oral health, service utilization and dental fear. BMC Oral Health. 2007;7(1):1.\u003c/li\u003e\n\u003cli\u003eCope AL, Wood F, Francis NA, Chestnutt IG. Patients\u0026rsquo; reasons for consulting a GP when experiencing a dental problem: a qualitative study. Br J Gen Pract. 2018;68(677):e877-e83.\u003c/li\u003e\n\u003cli\u003eSamorodnitzky GR, Levin L. Self‐assessed dental status, oral behavior, DMF, and dental anxiety. J Dent Ed. 2005;69(12):1385-9.\u003c/li\u003e\n\u003cli\u003eHarding A, Vernazza CR, Wilson K, Harding J, Girdler NM. What are dental non-attenders\u0026apos; preferences for anxiety management techniques? A cross-sectional study based at a dental access centre. Br Dent J. 2015;218(7):415-21.\u003c/li\u003e\n\u003cli\u003eJoint Formulary Committee. Hypnotics and anxiolytics,. . In: \u003cem\u003eBritish National Formulary \u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eIntercollegiate Advisory Committee for Sedation in Dentistry. Standards for Conscious Sedation in the Provision of Dental Care 2015. Available from: https://www.rcseng.ac.uk/-/media/files/rcs/fds/publications/dental-sedation-report-2015-web-v2.pd.\u003c/li\u003e\n\u003cli\u003eFinn K, Kwasnicki A, Field EA, Randall C. UK Dental Medicines Advisory Service - questions asked by dentists: part 3 - prescribing of anxiolytic medications in dental practice. Br Dent J. 2021;231(9):556-61.\u003c/li\u003e\n\u003cli\u003eTeoh L, Thompson W, Hubbard C, Gellad W, Finn K, KJ S. Comparison of dental benzodiazepine prescriptions from the United States, England and Australia from 2013-2018. Am J Prevent Med. 2021; 61(1):73-79.\u003c/li\u003e\n\u003cli\u003eMaguire WS, Lewney J, Landes DP. A comparison of the sedation provision of NHS dental services 2014-2016 for local authorities throughout England. Br Dent J. 2019;227(6):497-502.\u003c/li\u003e\n\u003cli\u003eNHSBSA Freedom of Information Requests, FOI 10426 Available at: https://opendata.nhsbsa.net/theme/freedom-of-information-disclosure-log..\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic Analysis: A Practical Guide: SAGE Publications; 2021.\u003c/li\u003e\n\u003cli\u003eTeoh L, Thompson W, Hubbard CC, Gellad W, Finn K, Suda KJ. Comparison of Dental Benzodiazepine Prescriptions From the U.S., England, and Australia From 2013 to 2018. Am J Prev Med. 2021;61(1):73-9.\u003c/li\u003e\n\u003cli\u003eScottish Dental Clinical Effectiveness Programme. Drug Prescribing For Dentistry: Dental Clinical Guidance 2016. Available from: https://www.sdcep.org.uk/media/2wleqlnr/sdcep-drug-prescribing-for-dentistry-3rd-edition.pdf.\u003c/li\u003e\n\u003cli\u003eThe Misuse of Drugs Regulations 2001. Available from: https://www.legislation.gov.uk/uksi/2001/3998/contents/made.\u003c/li\u003e\n\u003cli\u003eAmerican Dental Association. G U I D E L I N E S for the Use of Sedation and General Anesthesia by Dentists 2007. Available from: https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/publications/cdt/anesthesia_guidelines.pdf.\u003c/li\u003e\n\u003cli\u003eCope AL, Wood F, Francis NA, Chestnutt IG. General practitioners\u0026apos; attitudes towards the management of dental conditions and use of antibiotics in these consultations: a qualitative study. BMJ Open. 2015;5(10):e008551.\u003c/li\u003e\n\u003cli\u003eBater MC, Jones D, Watson MG. A survey of oral and dental disease presenting to general medical practitioners. Qual Prim Care. 2005;13(3).\u003c/li\u003e\n\u003cli\u003eCope AL, Chestnutt IG, Wood F, Francis NA. Dental consultations in UK general practice and antibiotic prescribing rates: a retrospective cohort study. Br J Gen Pract. 2016;66(646):e329-e36.\u003c/li\u003e\n\u003cli\u003eBritish Medical Association. Patients presenting with dental problems 2020. Available from: https://www.bma.org.uk/advice-and-support/gp-practices/gp-service-provision/patients-presenting-with-dental-problems.\u003c/li\u003e\n\u003cli\u003eIpswich \u0026amp; East Suffolk Clinical Commissioning Group NEECCG, West Suffolk Clinical Commissioning Group,. Do not prescribe - medicines or preparations for Dental Conditions on FP10. Available from: https://www.westsuffolkccg.nhs.uk/wp-content/uploads/2021/02/Dental-medicines-prescribing-policy-January-2021.pdf.\u003c/li\u003e\n\u003cli\u003eNHS Digital. Summary Care Records (SCR). Available from: https://digital.nhs.uk/services/summary-care-records-scr.\u003c/li\u003e\n\u003cli\u003eGeneral Dental Council. Registration Statistical : Report 2021. Available from: https://www.gdc-uk.org/docs/default-source/annual-reports/gdc_registration-statistical-report-2021-22-final-accessible.pdf?sfvrsn=78d3f4e_3.\u003c/li\u003e\n\u003cli\u003eSchmitz A. Benzodiazepine use, misuse, and abuse: A review. Ment Health Clin. 2016;6(3):120-6.\u003c/li\u003e\n\u003cli\u003eGordon D, Heimberg RG, Tellez M, Ismail AI. A critical review of approaches to the treatment of dental anxiety in adults. J Anxiety Disord. 2013;27(4):365-78.\u003c/li\u003e\n\u003cli\u003eAppukuttan DP. Strategies to manage patients with dental anxiety and dental phobia: literature review. Clin Cosmet Investig Dent. 2016;8:35-50.\u003c/li\u003e\n\u003cli\u003eFreeman R, Humphris GM. Dental anxiety, communication and the dental team: responses to fearful patients. J Calif Dent Assoc. 2019.\u003c/li\u003e\n\u003cli\u003eDailey YM, Humphris GM, Lennon MA. Reducing patients\u0026apos; state anxiety in general dental practice: a randomized controlled trial. J Dent Res. 2002;81(5):319-22.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"british-dental-journal","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bdj","sideBox":"Learn more about [British Dental Journal](http://www.nature.com/bdj/)","snPcode":"41415","submissionUrl":"https://mts-bdj.nature.com/cgi-bin/main.plex","title":"British Dental Journal","twitterHandle":"@the_bdj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2203925/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2203925/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOral benzodiazepines can facilitate treatment of dentally anxious patients and are widely used in countries such as Australia and the United States. Dentists in the United Kingdom (UK) prescribe them much less often.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eTo examine oral benzodiazepine prescribing by dentists in the UK, including patterns of practice, barriers to use, and alternative anxiety management strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn online mixed-methods survey was conducted utilising Qualtrics\u0026trade;. Participants were recruited via the Facebook private group: For Dentists, By Dentists during April to June 2021. Quantitative data were analysed with descriptive statistics and qualitative data with thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e235 dentists participated, with 91% being general dentists. Only 18% were confident in their use. Half had previously prescribed oral benzodiazepines, of which 36% were in the last year. Diazepam was the anxiolytic preferred by respondents. Two thirds of dentists who had never prescribed anxiolytics were interested in doing so in the future. Concerns about managing anxious patients with benzodiazepines included: inadequate training, confusion about guidelines, medico-legal risk, and issues of GPs prescribing anxiolytics to dental patients unbeknown to their dentist.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA lack of confidence prescribing oral benzodiazepines for anxiolysis exists among UK dentists. Guidelines should be clarified, and training provided.\u003c/p\u003e","manuscriptTitle":"The Use of Oral Benzodiazepines for the Management of Dental Anxiety: A Web-based Survey of UK Dentists","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-17 19:49:14","doi":"10.21203/rs.3.rs-2203925/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2023-01-09T17:40:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2022-12-19T12:36:26+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2022-12-13T11:16:58+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2022-12-05T15:10:49+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2022-11-18T09:03:58+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2022-11-14T11:38:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-10-26T08:23:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-10-26T08:23:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"British Dental Journal","date":"2022-10-25T23:36:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"british-dental-journal","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bdj","sideBox":"Learn more about [British Dental Journal](http://www.nature.com/bdj/)","snPcode":"41415","submissionUrl":"https://mts-bdj.nature.com/cgi-bin/main.plex","title":"British Dental Journal","twitterHandle":"@the_bdj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a4685462-a714-4fc5-92a2-3710b71e7337","owner":[],"postedDate":"November 17th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":16948263,"name":"Health sciences/Health care/Dentistry/Dental pharmacology"},{"id":16948264,"name":"Health sciences/Health care/Dentistry/Special care dentistry"}],"tags":[],"updatedAt":"2023-01-23T11:21:51+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-17 19:49:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2203925","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2203925","identity":"rs-2203925","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}