Saturday, May 23, 2020
Friday, April 17, 2020
Scottish Dental Show 2020
Inhalation Sedation.
A very brief introduction
This page is designed for delegates to the
Scottish Dental Show, Glasgow 2020.
In the light of the coronavirus pandemic
and the show's postponement,
the organisers have asked their booked speakers
to provide information, background and reading resources
on the topics they were booked to speak on at the show
on the 24th and 25th April 2020.
Please click the link below for my first short video.
More resources will follow
Monday, November 18, 2019
Dental Therapist updates Inhalation Sedation knowledge
Id like to share some interesting and very helpful
feedback from Dental Therapist,
Alex Middleton Dental Therapist from Sussex.
As an existing operator-sedationist,
utilising Inhalation Sedation, Alex attended our “RA”update day 2 years ago.
These days assume
attendees are currently or have recently utilised the technique having
previously received training and having been signed off as competent already.
Seeking another update recently and
since the date suited her better, Alex chose to attend day 1 of our accredited
3-day “New Starters” course on Nov 2nd 2019, designed to take dental
professionals from scratch to a point of readiness to undertake their first 10
cases under supervision.
In doing so, she joined dentists
from England, Ireland and Wales as well as an anaesthetist from Hungary in
Newbury, Berkshire.
Here are her comments, about which
she said : ” I am happy for you to use anything I have said and happy for you
to reword to suit”.
No changes have been made in fact.
“After completing the course today
(2.11.19) I feel that everyone should do this as a refresher!
“ I did the course
again (After 2 years) because I had a short break in practice but
felt today has consolidated
all of my learning. “
“I found that I was able
to understand it all completely compared to last time, which boosted my
confidence in my ability to practice safely.”
Yesterday, Nov 17th, she added ...
“I completed a very successful list on Thursday so thank you.” .
“More people should do
this training, is it the cost of the initial outlay that holds people back?”.
That last point will be
the subject of an entire opinion piece that I may look to get published.
Thanks so much Alex for
your valuable feedback and your food for thought.
Richard Charon
Saturday, November 16, 2019
The Scottish Dental Show 2020 - and for my next trick!
The Scottish Dental Show 2020.
where I will have 2 slots at the Scottish Dental Show 2020.
Date
Friday April 24th.
Time
9.30am and 12.30pm on
One talk is being designed for those (GDPs/DCPs) who might be considering introducing a new service to their practices.
The other offers a 1 hour eCPD Update to Dental teams already involved in offering Inhalation Sedation.
Come an say hello if you are there!
The RA Coach Website
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Tuesday, September 03, 2019
Inhalation Sedation A Golden Nugget: How to improve success with young children and very anxious adults
Richard Charon BDST/A The RA Coach
Inhalation Sedation
Accredited Course Provider and Trainer
IACSD (2015) RCS(STAC)2106 & 2018
Approved by The Dental Council of Ireland Dec 2017
(c)Inhalation Sedation
A Golden Nugget !
How to improve success with young children and very anxious adults
Unless the practitioner has already built
rapport with a patient, then it is asking
a lot, usually too much, to see a patient on referral and get on with a
sedation and treatment session and expect a successful outcome, more particularly for children, though this is
of course possible.
Much can be learned therefore from my
approach with
This approach would be my preferred way with very young patients, more particularly for patients referred to me and I believe greatly increases the chance of success and therefore reduce the risk of creating or exacerbating dental fear/anxiety or even phobia.
Each session can be quite short and would
incorporate the patient assessment, consent process , an acclimatization
session with “RA” and finally treatment.
Good communication, “Tell-Show-Do” and
positivity are all essential. Other strategies may be added according to the
practitioners capabilities, the age and cognitive abilities of the patient
Never over-promise and under-deliver BUT at
the same time the careful use of language and body language should be used to
suggest if not predict a very likely positive outcome.
“Let’s give this a try and see if it work”
is not the right approach.
An approach which is most likely to lead to
success, would be something along these lines.
“ What we have found is that other
children/people love the happy air, love the relaxation and
comfortable/cosy/floaty (choose your words) that it gives. Just imagine how
nice it would be if … (choose your words).”
Once the patient responds in a positive
manner then proceed to the next step:
Which would be a "Trial Run" with no treatment. This is a promise that
must not be broken.
More often than not I make another
appointment at this point with the promise of a quick try of the ”happy air”
(used for adults and children!) adding “
I don’t even want you to see your teeth next time” or “I’d like you to keep you
mouth closed next time” – is that OK?
If in the sedationist’s judgment the
patient’s level of dental anxiety is not too extreme, then ask at this first
visit that “when we have a trial run of the happy air, is it OK if I just count
your teeth just using a dental mirror - (Show them the mirror). If agreed, then
that will give the patient the opportunity to assess their own relaxed mouth,
reduced or absent gag reflex and “not minding a bit” about having a dentist’s
fingers or mirror in their mouth.
Assuming that session proceeds well and the
patient is positive at the end and can give you operator-sedationist the
thumbs-up then go on to book the treatment appointment, reminding them that
they will feel just as relaxed next time, before starting any treatment/ mending
your tooth or whatever is appropriate.
Expect the patient’s level of anxiety
to be lower on arrival for the treatment visit which normally proceeds very
successfully.
A word of warning.
Providing truly painless local anaesthetic
injections is also a key to success.
Do
not take liberties. The analgesic effects of
Nitrous Oxide can be overplayed. It will help but it will not “mask” a poorly
given LA injection.
I have witnessed GDPs for whom I was sedating
their patients, inflict (of course unintentionally) a painful injection because
they had assumed the patient would feel nothing.
The result on each occasion was a tearful
child, whose nasal secretions quickly prevented the required nasal breathing
and so of course the sedative effects of the nitrous oxide quickly wore off.
I would advise using topical L.A. and waiting long enough for it to take effect.
This can be applied soon after the initial
increments of nitrous oxide are given.
Once the Sedation-end point has bee reached
and the patient indicated they are comfortable, the mucosal surface will have
been anaesthetized or wait a little longer until it is deemed that the topical
will have taken effect.
Then very slowly inject one or two drops
only of LA and withdraw.
Wait a minute (be patient!) whilst the
patients breathing steadies and their sedation is maintained. Then return to
the injection site to very slowly give the appropriate dose for the patient and
the procedure.
Then wait an appropriate time again before proceeding with any operative treatment. If the patient shows any sign of sensation, stop, reassess and take whatever appropriate action is required to ensure anaesthesia.
I hope that helps.
Richard Charon
Richard Charon
#ISDAM2019 Congress
Richard Charon BDS
T/A The RA Coach
Inhalation Sedation
Accredited Course Provider and Trainer
IACSD (2015) RCS(STAC)2106 & 2018
Approved by The Dental Council of Ireland Dec 2017
The #ISDAM2019 Congress held at the royal College of Surgeons in Glasgow on 22nd & 23rd August 2019 is now behind us.
The speaker line-up and content was impressive but I must let others decide on whether my own contribution was of value.
I was honoured to be the 2nd speaker at the lectern on the first day following my colleague Roy Bennett (Dip. Sed.)
A
big thanks to Dr. Mike Gow
for his sustained hard work in creating this
first and very successful Congress of the International Society for
Dental Anxiety Management and to all the other insprational and
interesting speakers.
Saturday, August 17, 2019
Speaker at the ISDAM Congress Glasgow 2019
The final ISDAM Congress line-up at the Royal College of Physicians and Surgeons in Glasgow next Thursday and Friday, has been published. 2 days for like-minded colleagues to engage, exchange and for the speakers to deliver content aimed at opening the doors to 21st century dental care for those whose anxiety or phobia holds them back.
My Keynote has winged it's way to the organisers,
so 4 days of rehearsal should hone my 45 min. presentation!
Virgin 1st Class Euston to Glasgow.
Looking forward to it.
If you have a change of mind, I expect a few places are still available.
Friday, July 26, 2019
Welcome to my blog- for ISDAM Congress Delegates from Richard Charon
I am delighted to have been invited by Mike Gow to speak at the plenary session of this year's ISDAM Congress in Glasgow on Thursday August 22nd. at the Royal College of Physicians and Surgeons.
Like all of the speakers, I can but cover a few topics within my subject in the allocated time and I am aware that some in the audience, perhaps many, will have had no experience of providing Inhalation Sedation with titrated Nitrous Oxide and Oxygen or indeed have even witnessed its use.
So coming to any conclusion as to its place or usefulness may well be difficult for them.
For you perhaps.
So ahead of the Congress, I am providing links here to a number of unedited patient accounts/stories of their experiences, thoughts and feelings, having had the opportunity of benefiting at the receiving end of the "Happy Air".
I make no excuses but some of these are quite long, so perhaps make yourself a cup of tea of coffee, settle down and perhaps be interested, inspired and or even amazed!
Apologies if you have read these before but I suspect not.
I hope to have the opportunity to meet many of you on the 22nd -23rd of August.
Richard Charon BDS
Website
The RA Coach Blog
Linkedin
So coming to any conclusion as to its place or usefulness may well be difficult for them.
For you perhaps.
So ahead of the Congress, I am providing links here to a number of unedited patient accounts/stories of their experiences, thoughts and feelings, having had the opportunity of benefiting at the receiving end of the "Happy Air".
Apologies if you have read these before but I suspect not.
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It
is nice to be reminded that the work we all do has such a positive effect on patient's lives.
RA Coaching and Mentoring since 2003
Accredited Course Provider in Inhalation Sedation
IACSD Dec. 2015;
RCS(STAC) 2016 & 2018
Accredited Course Provider in Inhalation Sedation
IACSD Dec. 2015;
RCS(STAC) 2016 & 2018
Approved Dental Council of Ireland 2017
Please consider joining my RA Coach facebook group, for information, course dates, new recommendations, insights or cases to discuss with a group of interested people.
07884 230995:
Website
The RA Coach Blog
Sunday, May 12, 2019
Wednesday, November 28, 2018
Inhalation Sedation Testimonial for our eCPD Update Day 24.11.18
Yesterday I received this testimonial from Dr. Phil Loughnane BDS, DPDS, MJDF, PGCME, DipConSed. (Phil Loughnane BDS, DPDS, MJDF, PGCME, DipConSed
(Foundation Training Advisor), from the Stroud area of Gloucester, following his attendance with his 2 dental nurses, on Sat. 24th November at our eCPD Update day in Newbury.
I found this powerful, helpful and I must say gratifying too.
"Dear Richard
Thanks for sending the link to the PowerPoint - again really useful.
Many thanks for such a stimulating course on
Saturday. The three of us really enjoyed it and we all learnt so much.
Your experience and enthusiasm shone throughout the day and ensured that
we were learning relevant material the whole day.
You
are a natural educator and this led to a wonderful level of
participation from all delegates.
Please can I also request the audit logs that you mentioned we could adapt. ... as you were both so
available to talk before the course started & during breaks.
I found the course one of the best CPD events that I have ever attended.
... Great to meet a fellow Manchester graduate.
Phil
Phil and his team had to leave just before the "finale" photo - sorry Phil!
Do make contact if you and your experienced IHS team are due for an eCPD Update in this sedation technique.
Richard Charon BDS
Tuesday, October 30, 2018
David Craig at The Eastman 25th October 2018
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On Monday I attended an Advanced Dental
Sedation meeting at the Eastman mainly, it must be said, to hear what David Craig
had to say on his view for dental conscious sedation for the next 5 years.
David as most will know, was a committee
member for IACSD and a past president of both SAAD & the DSTG and has
always been very supportive of my activities in relation to IHS training.
David was clear to point out that the
points he was about to raise in his talk
were his personal views only.
As far as possible these are my verbatim contemporaneous notes.
I have occasionally added a comment of my own in Italics.
His aim was to cover 4 areas:
·
Clinical techniques and service
·
Training
·
Research
·
Guidelines
He notes that Guidelines were “Guidelines NOT
“tramlines”!
Bearing in mind the audience were
anaesthetists or sedationists involved in polypharmacy/advanced techniques,
David re-stated the line that the
·
“vast majority of treatment
under sedation could be achieved with single drug, Midazolam or Nitrous
Oxide/Oxygen using IHS.
Midazolam included, IV, Oral and
Intra-nasal. The latter two in particular for special needs whose management
had been transformed this way.
Nevertheless there was a need for the small
% not adequately covered by these methods to receive additional drugs such as
Fenatnyl with an increase in the use of Propofol for those with dementia and
ambulatory problems. The use of these
drugs have given rise to training availability.
David regretted what he saw as an arbitrary
division or compartmentalization
(my
term not his) into “Basic” and “Advanced”
techniques.
Giving the impression that the former were
ultra-safe whereas the latter were ultra dangerous. The truth is that there is
a continuum.
The
commissioning document (2017) pulls together various guidelines.
·
Sedation for under 12s could
be/would be limited to Inhalation Sedation within 5 years.
·
Patient Assessments would/should
include an airway assessment – including for sedation in medical disciplines,
when this was often not done.
- This needed to be a formal airway assessment regimen to ensure the possibility of using BVM (bag, valve,mask) in an emergency rather than intubation in the dental surgery. The latter not being normally relevant in general dental practice
He mentioned in passing the system used by
Australian and NZ anaesthetists and I thought I heard him say “BONES” – in fact
it looks like the mnemonic is M.O.A.N.S.
This look to be a very comprehensive review: 63 pages on Airway assessment! ANZCA.
My assumption from his comment is that advice on formal airway assessment is likley to be contained within this publication.
This look to be a very comprehensive review: 63 pages on Airway assessment! ANZCA.
My assumption from his comment is that advice on formal airway assessment is likley to be contained within this publication.
·
IACSD Standards are due for
review. Since there is no new evidence nor any new problems, he saw no reason
for any changes to be made.
·
There is the prospect of a new
Intravenous drug on the horizon which he could not say more about other than
its half life was very short, so suitable for quick interventions with a rapid
recovery.
Capnography: Within 5 years in acute Trusts.
·
No help for ASA1 & 2 cases (those sedated with Midazolam in general
practice).
·
In ASA3 cases, it could be very
useful. Further research was needed but the warning of lowered respiratory function
was very much faster compared to pulse oximetry – in fact a 240 secs faster response time.
Outcomes
and Audit:
Keep it simple. The guidelines mention logs
and Audit but he stressed the importance of recoding the outcomes. Was the sedation a success, was the planned
treatment completed, were there difficulties or problems?
As far as audit was concerned he mentioned
·
The patient journey (no more added)
·
Did it meet their expectations?
·
Was the patient satisfied with
the sedation?
·
Was the treatment able to be
carried out?
Training
(A topic
close to my heart!)
The basic techniques were easy to train and
to find trainers.
There were now 50 accredited courses and
about the same number of independent (RCS
STAC approved) supervisors now.
There were gaps for training in the use of
Propofol and hands-on supervised clinical experience was very hard to find. So
he felt the use of Propofol would not increase in the next 5 years.
“Mentors” as listed by SAAD and the DSTG
had been done away with since some may not have been competent.
David raised the question of the “Transitional Arrangements” (put in place
by IACSD in 2015) and how long they would be in pace and that they might to be
“tightened up” but then again unlikely as these were likely to be extended in the
next 5 years. (I am unsure of what that
might mean, since they were put in place to allow people already using sedation
to continue without further training.
However
by now, anyone returning to sedation I would think would need to be retrained
or mentored again before restarting).
David said that “Thanks to Richard here. We
were able to get things up and running with course accreditations” and …
·
We were unlikely to see a
register of conscious sedationists
·
The eCPD requirements (over the next 5 years) were likely to
remain the same.
Research
Needed
·
Fasting: Evidence needed but not for Nitrous
Oxide or Midazolam
·
Capnography: needs to be
studied in a dental setting to be appropriate.
·
Propofol: Proven efficacy in dentistry but the
algorithm in special care doesn’t work.
·
NEW Short-Acting BDZ: Work underway
– he cannot say what – with a drug with very short alpha and beta half-lives,
allowing rapid recovery and so NO ESCORTS!
·
Ketamine: Introduced to the UK
by Prof. James Roelofse
·
Dexmedetomidine: No respiratory
depression but longer recovery than
Midaz?
·
Nitrous Oxide/Oxygen with
Midazolam: (An idea he likes).
Initiate sedation with Midazolam and finish off with N2O/O2.
As
an example, at the end of a treatment session with scaling/perio Tx in the last
phase, which the patients often dislike.
A standard technique in Canada. It avoids adding more Midazolam to the total
dose whilst keeping the patient sufficiently sedated, allowing Midazolam to
“wear off”.
·
CBT a very useful technique but
not for acute cases.
He returned to guidelines etc.
He thought that NICE might look at under 19s
but there was no new evidence/ nothing new and NICE were only supposed to make
changes with evidence not expert opinion, though they do.
The Academy of Medical Royal Colleges 2013
guidelines would be reviewed
As well as IACSD. He hoped it would not be
re-opened again stating no new evidence,
no new problems.
The Scottish SDCEP guidelnes had been accepted
for all “New Starters”
Wales recently published their own
guidelines.
Northern Ireland are still on the 2013
guidelines (news to me !)
All guidance was now aligned including that
from the Royal College of Anaesthetists.
That's all Folks
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This short opinion piece suggest it is indeed safe.
The authors state: "In the absence of clear evidence with regard to the potential of IHS to generate an aerosol, a decision should be made locally as to its safe use. We have adopted a precautionary approach and provide IHS using level 3 PPE as for an AGP. Further research is urgently needed however."