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!).
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).
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
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