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

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).

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.

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

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