Saturday, November 16, 2019

The Scottish Dental Show 2020 - and for my next trick!

The Scottish Dental Show 2020. 

I'm delighted that I can now confirm that I have been booked for another trip to Glasgow, 
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 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

(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





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#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.

It is nice to be reminded that the work we all do has such a positive effect on patient's lives.

Richard Charon BDS
RA Coaching and Mentoring since 2003
 

Accredited Course Provider in Inhalation Sedation  
IACSD Dec. 2015; 
RCS(STAC) 2016 & 2018
Approved Dental Council of Ireland 2017

07884 230995:
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.

Website

The RA Coach Blog

Linkedin

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

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.

Thanks for sending the link to the PowerPoint - again really useful.

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.

·      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