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

Monday, October 15, 2018

The RA Coach - Background information

A Little Background for You
 
 
I qualified in Manchester in 1975 and went directly into GDP.  By 1977 I had undertaken manufacturer’s training and as an Associate in an NHS practice, introduced a “Relative Analgesia (RA)” service – having invested in the equipment myself!

I owned my own practice in Newbury Berkshire from Jan 1989 - October 2012, remaining as a part-time Associate until August 2014.

In 2001 I had a brief conversation with well-known Dental Business Coach  -  Chris Barrow, during an advanced and very intensive, 1-year dental practice management course.

The subject of the conversation was – Why should I come to your dental practice? What makes you stand out?
What is your USP?

Sitting around a boardroom table with about 6-8 other dental practice owners and being the last to be asked the question, it soon became clear that I was not the only one enhancing the standard of my Aesthetic Dentistry – having gained a “Full Membership” of B.A.A.D. in 1999 and not the only one introducing dental implants (having started to study the topic in the mid-1980s) – so how could I differentiate myself from my colleagues at that table?

Well I had been utilising “RA” since 1977 to the great benefit of many patients and something that possibly only 2-5% of GDPs then were able to offer.

Chris asked me whether it was a subject I could teach, dubbed me the “RA Coach” and gave me permission to pursue this idea.
By Jan 2003 I had developed a course, sufficiently different from what was then on offer by SAAD for example was ready to offer this to interested colleagues.
There has been much water under the bridge since then. The much favoured US and UK terminology of “RA” has waned in favour of “Inhalation(al) sedation” - shortened to IS or IHS.
Several iterations of Dental Sedation guidelines starting in particular in 2003, 2011 then importantly in 2015 and again in 2017 has changed what and how I have been able to pass on my experience and the requirements of  Dentists, DCPs and Dental Nurses involved

A one-day course with practitioners able to self-determine their own competence in 2003 has changed into a 3-day course to include me supervising candidate’s first 10 cases around the UK and since 2017 in Ireland too with what has become a well-tried 2-day structured program – even delivered to one GDP in Cyprus!

So to the name. “The RA Coach” has effectively become my brand. However what I do in fact is not really coaching at all but to act as a didactic teacher, a one-to-one mentor (before, during and after the 3-day accredited courses) and finally as an assessor to appraise candidates with the aim of signing off their competence, feeding back and reporting to them. 

It remains open to me to decline to sign off a candidate if I am not satisfied that they have demonstrated their professional approach and that they can safely and successfully assess and provide inhalation sedation for a range of patients and complete all of the required clinical governance record keeping.

So despite the fact I am not technically coaching I will retain the brand name for the time being.

Richard Charon

Friday, October 12, 2018

Many congratulations to Samantha Cawsey



 Many Congratulations to Samantha Cawsey - Dental Therapist



 

 ... who today became the third Dental Therapist from the same Bristol practice, to have completed accredited Inhalation Sedation training with me very ably assisted by her terrific dental nurse. Together with practice owner Dr. Neil Gerrard and one of their Associates, that made 5 Dental professionals from the multi-award winning practice, https://www.facebook.com/CliftonDentalStudio now able to offer this excellent dental sedation technique to their patients. 

Here is some feedback from the Dental Hygienist and Therapist Network on Facebook :

  
Thoroughly enjoyed the course as well as feedback from patients “life changing” an excellent dose of job satisfaction!   Thank you again Richard 🎉 looking forward to treating many more patients with RA sedation, starting with my first patient tomorrow morning!

If you or your practice would like to bring the many benefits of IHS to you patients, 
my next accredited course is booking now

Sat. April 6th 2019 in Newbury, Berks


Thursday, September 06, 2018

Wand Workshops Autumn 2018.

Hope you have all had a great summer. Now the work begins for us all - so are you ready to innovate? Not using the Wand yet? Your patients will thank you and so will your back, shoulders, arms, wrists and finger joints! 


I'll be running a Wand Workshop day with Daniel Pinder of Dental Sky Ltd at 
 C.A.D.E. 
( THE CENTRE OF ADVANCED DENTAL EDUCATION)
163 Ashley Rd, Hale WA15 9SD
NEAR ALTRINCHAM, CHESHIRE 

Friday 28th Sept. 2018. 

 Just time to book your places!

I Have personally used The Wand for LA injections given to all patients for 10 years. 
I look forward to sharing my experience and knowledge with you in Hale in September!

Otherwise why not come to London and make a weekend of it?
Devonshire Place W1 in October and November


Wednesday, May 02, 2018

Become a Wizard with your Wand


Mother said we had change their lives!


From time to time I look back on some of my facebook posts.
You may find this story helpful...
"And this, in part, is why I do what I do it... 
"Yesterday we saw an 8 year old on referral from another practice about 8 miles away for the removal of a carious ULd,  with inhalation sedation.

Her parents were very anxious since their older daughter had had to have a GA last year for several extractions and the family found this to be a very traumatic experience.

We saw her for a trial run of the happy air last week and she was well behaved and cooperative.

So yesterday she attended for the extraction and as expected the whole procedure went very smoothly. She did not react at any time during the procedure including the palatal infiltration using The Wand and the extraction, despite the tooth having most of it's splayed roots intact.

She recovered beautifully and dad, who was of course witnessing everything, was bowled over.
Mother was concerned she would need to have a day off school today. We reassured her that her daughter would be fine.
Mother called the practice just now to say ...That we were right, her daughter could have gone to school today. She said her daughter had chatted happily all the way home unlike her sister who had cried for hours after her general anaesthetic to have teeth removed.
Mother said we had change their lives!"

So if you or your practice would like to be able to provide this level of care, please feel free to contact me. 


Learn about or re-visit the benefits of utilising The Wand® 







Friday, April 13, 2018

The Wand® Academy

Dr. Richard Charon BDS commenced work with Dental Sky Ltd as a 
Clinical Consultant for The Wand (STA) local anaesthetic system in Jan. 2018. 


 

This appointment was underpinned with 10 years of continuous use of The Wand from 2004 in my private dental practice in Newbury. I abandoned standard L.A. syringes within a week of my new acquisition! I used it as a stand-alone technique for all patients and of course as an an adjunct to inhalation sedation for anxious dental patients treated with "RA". 





 "The Wand Academy"

He is  currently involved in developing this programme with their Dental Sky team which will focus on new Wand Workshops which are now planned in England and Scotland throughout 2018 to cover the theory and practical to bring this revolution in local anaesthesia.

Dates have just been set for WAND training days in London, Manchester(Hale,Cheshire) and Bristol, monthly between now and the end of the year.
 
Relaxed posture using The Wand for an ID Block

Sat. June 2nd Hale, Cheshire 
Sat. June 23rd Bristol 
Fri. July 20th Londec centre  
Sat. Sept. 29th Hale, Cheshire 
October 5th & 6th London at the ExCeL Centre as part of the Dental Showcase, onboard The Sunborn yacht-hotel moored alongside the ExCeL. 
Thurs. October 18th Devonshire Place
Fri 7th December Londec centre

THE WAND IN USE FOR A STANDARD ID BLOCK
Mike Gow is looking after the workshops in Scotland. 
Please feel free to get in touch if any of these venues and dates are of interest. 

If you have a Wand unit which is under-utilised or if The Wand might be your next practice-building acquisition, these dates are not to be missed.

WARNING: USING OF THE WAND MAY GROW YOUR PRACTICE!


Dr Richard Charon BDS - Clinical Consultant  

richard.charon@dentalsky.com
Dental Sky Website
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Dental Sky Wholesaler Ltd, Unit A Foster Road, Ashford Business Park, Ashford, Kent, TN24 0SH
Telephone: 01233 502 605 | Mobile: | Fax: | Website: www.dentalsky.com










Tuesday, March 20, 2018

Dental and Needle Phobia - Managing the situation.



Here is a success story from yesterday I feel is worthy of sharing using combining standard Inhalation Sedation with Nitrous Oxide and Oxygen (IHS) & The Wand STA® to overcome a common problem.

I do declare an interest since I have recently been appointed as a clinical consultant by 
Sky Dental, the UK’s sole distributor/supplier of The Wand® and I do provide accredited eCPD courses in Inhalation Sedation.
However I would have used the same approach had this not been the case, since I had been a Wand user for almost 10 years prior to retiring as a GDP in 2014.

Case history

The patient: “A difficult 13 year old female patient who was “Dental & Needle phobic”.

Her background:
This is the core of the e-mail I received from a practice manager just before Christmas:

“… we have a patient I’m hoping you can help us with. She is 13 years old and both dental and needle phobic, the latter is the worse of the two. She is due to have fixed orthodontic appliances but requires fillings beforehand.

She has had a session of private hypnotherapy which has not been successful. We have referred her to the community dental service but she is too old for them to treat her. A subsequent referral to our local NHS sedation clinic resulted in an ok consultation but she unfortunately panicked at the treatment appointment, became hysterical and they have refused to see her again.

Her mother has had to cancel her brace placement appointment, and is of the belief inhalation sedation is the way forward, but I have no idea who does this locally, hence me contacting X.
Mother cannot afford private sedation, which we could have provided, nor a referral to Toothbeary in Richmond for paediatric dentistry.

I am now at a loss! Are you able to help or advise in any way?  I look forward to hearing from you, and offer my thanks in advance.”

She had contacted a highly experienced IV sedationist who generally utilizes polypharmacy techniques on a peripatetic basis, someone I know well.

Knowing my own area of interest/expertise he gave the PM my name as a possible better option for the patient.  So she approached me to see if IHS could be the solution in Jan. The patient was not yet having pain with these teeth so we had some time in hand.

I no longer work in practice but I do offer a visiting sedation service from time to time to local GDPs.  Each appointment involved me in a 1 hour round trip plus loading and unloading and setting up/breaking down all of the equipment and gas cylinders.

However alarm bells rang in this case, as I teach that whilst IHS is excellent for many cases, if a patient is truly phobic, it is unlikely to work by itself.  Indeed I would often refer for hypnotherapy, for example, to be used alone or indeed in combination with sedation for true phobics.

 
My chosen approach:

I can only offer my sedation services on a private basis. I explained this at the outset and provided a step-by-step quote for the patient with the idea of proceeding no further at any stage if the patient refused to continue.
Her mother was happy to accept my private fee quote which included a mileage allowance.

I offered the patient’s mother to refer her daughter for a second attempt at CBT/hypnotherapy with a different practitioner who might have more success than the first.
As an alternative I could try to overcome her anxiety/phobia (not certain which at that stage) but it would have to be done on my terms.

The 3-step plan offered was simple enough but would require cooperation of the mother and daughter.

Step 1: Feb 14th: To meet & greet, assess, to explain my idea of how to move forward utilizing IHS with a full explanation and Q&A session to gain Montgomery consent to provide an “RA trial” at the next visit.

If accepted move to Step 2:
Outcome: Mother was very sensible and the patient, though evidently anxious was quite sensible too given her history and previous experiences.  They were prepared to move to step 2 of my plan.

Step 2: 8th March:  The visit was designed to assess the patient’s willingness to sit in the dental chair, and acceptance nasal mask (Porter-Brown) and all being well, to move onto an “RA trial”-(mouth closed & no Treatment).

The patient was also new to the GDP at this practice and he only had one BW radiograph and needed to take 2 new BWs for up-to-date information. The patient was quite cooperative for these and they were taken before we moved ahead with the “RA trial”.
The RA trial went very well, she was quite happy with the idea of using this “new technique” to help her at her next treatment appointment but it was clear that the patient’s main issue was having a local anaesthetic injection.

The rads. showed 2 grossly carious but potentially salvageable 6s at UR6 and LL6. That being the case, I did not want to risk the chance of either:
1       Refusing to accept sedation because she felt it was a cover-up as an injection would be used which would still upset her or
2      Achieving sedation with nitrous oxide and oxygen, (which although very effective, does allow patients some awareness of what is happening) and then just at the point the dentist raised the syringe to give the LA she might see it and still object/raise her hand or try to turn away. 
3    Reacting to a standard LA injection as it was being carried out because it was given too quickly (as I have seen more than once before!).

So my decision with agreement from the treating dentist was that
1        I would give the LA (to be sure of getting the timing just right too) but
2       That I would try to arrange for a one-off loan of The Wand® for me to use (as I no longer have one of my own). That way the patient would not see a syringe and the LA could be provided totally painlessly.

I contacted Daniel Pinder of Dental Sky who is their product specialist for The Wand® and he agreed to help me (and the patient).

Step 3 The plan was to treat one tooth under IHS and to assess the patient’s acceptance.
The decision was to tackle UR6 first. Yesterday Daniel very helpfully delivered and set up a unit at the practice shortly before I arrived and then returned 2 hours later to collect it.

Technique details
We proceeded to re-gain patient consent and moving to the treatment room then very smoothly and without any fuss of any kind, proceeded (while mother quietly watched) to sedate her using IHS. Next as the patient’s sedation began and with her knowledge a fine brush was used to apply topical anaesthetic gel into the gingival crevice buccally.

The Wand® was used in it’s STA mode and a short “handpiece/wand”.
Starting at the disto-buccal aspect of UR6, I obtained a positive feedback (Green zone LED display) from The Wand® Dynamic Pressure Sensing® technology feature, giving assurance of correct delivery of LA in the correct place (½ cartridge Lignocaine 2% with adrenaline).

Moving to the mesio-buccal aspect, the feedback from the Wand was less positive (indicating operator error!) and so to be certain at this point of fully anaesthetizing this tooth with a very deep cavity, I chose to change to the mid-length (Brown colour-coded) Wand, turn off the STA mode and deliver a standard Bucc. Infiltration over UR6.  The patient was unaware of any of the above.
  
The initial STA site disto-buccally (possibly in addition to the analgesic added effect of nitrous oxide) meant that on testing the palatal gingiva with a BPE probe she reported feeling nothing.

I then stepped back and the GDP took over, applying a rubber dam without hindrance and proceeded to prepping the deep cavity and restoring it very nicely with composite.

Dr. Hitesh Chandegra of Gipsy Lane Advanced Dental Centre, Reading



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Note the combination of Inhalation Sedation,, personal music & Dental Dam. 
Complete relaxation and detachment from procedures following injection with The Wand® for a "needle and dental phobic" patient. The patient remained responsive to verbal communication at all times.
Sedationist: Richard Charon BDS


Patient Feedback 
The Sedation recovery was fast and uneventful and the patient feedback was excellent.

The session took 54 mins to complete including sedation & recovery and the patient remained in verbal contact throughout.

She said "It seemed very quick","... remembered very little,", "... very happy" " .. will do this again next time".  She was quite happy to go ahead and book the next appointment which has been done.

Other equipment
I use an MDM RA flowmeter on a mobile stand with Miniscav unit from RA Medical Services and Porter-Brown active scavenging nasal masks (my preferred option by a margin).

Discussion:
There could of course have been other avenues to explore to overcome this patient’s needle phobia and indeed my first preference, given her history, was to try once again with a non-pharmacological method. However this was not acceptable to the patient/her mother.

As the potential sedationist at the early stage, it was for me to take over the full management and not just arrive on the day and go ahead and “gas” the patient.
This approach with a patient who has never met me and with whom I have not had a chance to develop any meaningful rapport or insight, though not doomed to failure, will increase the chances of failure in my experience.

Would it have been possible to achieve the same result using a tell, show, do approach and the Wand only? Quite possibly/probably but there would always have been the chance that if the patient had a deep needle-phobia she might have reacted negatively to any suggestion of an injection, however small the needle and however  the method had been “dressed-up”. There is no knowing for sure but I wanted to avoid any failures at any step which would then have been more difficult to recover from.

Concusion
In this case the combination of

1)    The promise of doing everything “quite differently” from her previous dental experiences and
2)    The detachment and analgesia provided by the inhalation sedation and
3)    The absence of a shiny, threatening metal syringe and ability to provide a totally painless and non-threatening LA experience using the Wand
succeeded in overcoming all of the patient’s anxiety/phobia and allowing her to receive the treatment needed in a relaxed and straightforward manner.

If you, your practice and your patients might benefit from using either Inhalation Sedation and/or The Wand®, please do get in touch to find out more about the accredited training (for IHS) and practical training for The Wand® that I am able to provide.

Accredited Inhalation Sedation training for “new starters” (GDPs and DCPs):

For The Wand® information and training opportunities:

Full consent given to use photos