New avenues

Hygienist/therapist Amy Workman recommends a pathway which may take you places in this review of an inhalation sedation course

As  DH&Ts, we have been able to treat patients under inhalation sedation as the ‘operator’ with the dentist working cooperatively as the ‘sedationist’. In 2006, the GDC revised the scope of practice, allowing DH&Ts to act as both operator and sedationist for the first time. This posed an exciting new challenge to all DH&Ts who had been working co-operatively and to those who wished to expand their skill base. Logically, the next step was to find a place on a reputable course, which meets all the criteria set by the GDC for verifiable CPD… not an easy task, until 2010, when SAAD ran its pilot course for DH&Ts.

The SAAD national course in conscious sedation offers an introduction for dental and medical professionals with no previous experience of conscious sedation and an update on new developments and changes in legislative framework for those who have been using sedation techniques for many years.

Being only the second cohort of DH&Ts to participate in the SAAD course, it was with much anticipation I headed to London for the weekend (some sedation for the flight would have been useful!). From the start, it was expressed that all the teaching would be completed in conjunction with the dentists and dental nurses as the curriculum was the same for everyone, with more emphasis on inhalation sedation for DH&Ts.

The programme kicked off with a comprehensive review of anatomy, physiology and pharmacology. It is especially important for the sedationist to have a working knowledge of the normal anatomy in order to appreciate the changes made to the cardiovascular and respiratory systems when using inhalation sedation. Patient assessment and treatment planning followed, emphasising the importance of a satisfactory first visit/assessment to ensure success of sedation. Fact-finding as to why the patient requires sedation eg: anxiety, medical complications, gagging, etc is essential, as is taking a thorough medical, dental and social history.

The remainder of day one was spent on the theoretical and practical implications of using inhalation sedation (IS). Nitrous oxide is a colourless, odourless gas at room temperature that is 1.5 times heavier than air. When stored for use for IS, it is compressed at 800psi. Compressed, it is a liquid and sublimates to a gas on delivery. In therapeutic doses, it has virtually no side effects. However, it does produce mild analgesia, muscle relaxation and reduction in anxiety and gagging. There are relatively few contra-indications that make it suitable for a wide range of patients, however disadvantages such as severe anxiety, inability to breathe nasally and psychological disorders related to nasal hood must be taken into account.

There is a vast range of equipment available for IS encompassing portable and piped delivery systems. Key safety features were discussed as most current machines have several design features that ensure nitrous oxide cannot be over-delivered and cannot be delivered in the absence of oxygen. Scavenging – active and passive – is essential to prevent nitrous pollution to both the operator and the appropriately trained assistant. The IS theory was then converted to clinical technique with demonstration and participation of equipment checks and set-up.

Practical

We were then fortunate enough to be able to undertake IS on each other under the close supervision of the course tutors, which was a nerve-wracking experience for the seditionist but a thoroughly pleasant one for the patient. At each point, the course tutors instilled confidence in the operator/sedationist ensuring confidence and competence in all the pre-sedation equipment checks, pre-sedation assessment and during the procedure. Day one was closed with management of complications of IS, basic life support with airway adjuncts (fantastic for verifiable and core CPD) and review of the day’s learning.

Legal talk

‘Keeping away from the Lawyers’ opened day two with a discussion about risk management and the importance of keeping up to date with all aspects of the frequently changing medico-legal framework especially in the area of sedation where the patient is more vulnerable. Controlling risks by following a high quality and robust consent process, good patient care systems that fulfil patient needs, high quality contemporaneous record keeping, clear protocols for emergencies, complaints, training and maintenance, requirement of competent adequately trained chaperone and knowledge of local rules were all emphasised.

Practical and written assessment were also a key part of day two, demonstrating to the course tutors (and the GDC!) that a high level of competence had been achieved by the DH&Ts. Further to the practical and written assessment, a record of experience is also to be achieved, made up of 10 supervised cases with the DH&T acting as the sedationist or the operator/sedationist. This record of experience must be completed before full SAAD certification is issued. IS technique was also compounded by use of a videoed treatment session with a patient, which was incredibly useful in seeing the sequential steps of undertaking treatment as an operator/sedationist. Also highlighted was the importance of having an appropriately trained chaperone/assistant when settling the patient into treatment.

Other techniques of sedation (eg: intra-venous and oral) were discussed. IS is not the most suitable option for every patient and, especially for those with anxiety, it is important that, where possible, the correct form of sedation is selected in the first instance. Correct selection should help to prevent aggravating the anxiety and build confidence and rapport between the patient and operator. For the DH&T, this may mean referring the patent for I.V. or having an appropriate sedationist whilst acting as the operator.

Sedation for medically compromised patients was covered, this included assessing risk and the classification of medical fitness. It was emphasised that patients who have significant medical complications are best treated by appropriately trained and experienced sedation teams, this may mean referring to a hospital/community-based setting. Following this, a question-and-answer session saw the conclusion of day two.

The SAAD course in inhalation sedation for DH&Ts was an interesting, thorough course with various, appropriate teaching methods. It offers a new avenue for further training unlike any postgraduate course currently available for DH&Ts. High quality teaching to the same standard as dentists appeared to be one of the core values of the course, along with complying with GDC standards in professional practice. I found the entire weekend engaging and left with the knowledge and confidence to start my supervised cases straight away. Overall, I would say that this course is invaluable for those who have access to IS and wish to use it.

‘Next step’ essentials

• A working knowledge of anatomy

• A satisfactory first visit/assessment

• A knowledge of why the patient requires sedation

• An awareness of medical, dental and social history

• An awareness of a patient’s severe anxiety, inability to breathe nasally and any psychological disorders

• Basic life-support knowledge

• An understanding of what sedation suits which patient

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Amy Workman DipDHDT RCSEd graduated from the Royal College of Surgeons Edinburgh (Glasgow Dental Hospital and School) with diplomas in Dental Hygiene and Dental Therapy in 200. Amy has spent the past four years working in both private and NHS practice and has completed further training in facial aesthetics in 2010. Currently working in Millersneuk Dental Practice and Dentistry on the Square, Amy has a keen interest in paediatric dentistry, sedation and facial aesthetics.

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