Sedation in Daily Dentistry – A Guide – PDP136

Jaz’s Introduction:
And what about deciding whether inhalation station, AKA gas and air versus intravenous sedation is best for your patient, and what is the correct path you have to take to be able to safely provide sedation in practice? These are all the questions we’ll be covering in today’s episode. Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast.

It’s not often we do an episode on sedation. It’s quite a niche thing, but it complements some of the previous episodes we’ve done such as the one about hypnosis with Mike Gow. You have to listen to that one. And Mike and Roy, today’s guests are actually really good friends, and it makes total sense. You know, Roy was a fantastic calm communicator. I would feel very safe in his hands as a patient. And that’s what we all want. We all want our patients to feel safe around us, and that come from how we communicate to our patients. So, before we start on this episode about sedation, all those things that I just discussed, let’s get to the Protrusive Dental Pearl.

Protrusive Dental Pearl:
So, if you’re new to the podcast, every main episode, every PDP episode, I will share a Protrusive Dental Pearl. One tip that you can apply straight away. And this one is about communication. I very often like to do well communication one and this is not because I am some sort of master of communication.

This is far from it. This is just something that I’ve been very much in tune with myself. I try to reflect on my communication skills and try to improve, and I try to look at other clinicians when I shadow them or when I see them in practice. What can I learn from them? So, the example I’m gonna share with you today is I had a dentist shadowing me recently, and I like to ask dentist, what did you learn today?

What did you gain from today? And she said to me, ‘Jaz, I like the way that when you were explaining risks to a patient, you just slowed down. You just really slowed the pace down and emphasized certain words.’ And through doing that, I think you are a more impactful communicator and patients will remember.

And I’m very intentional when I do this, in fact, after a deep restoration or a really nasty crack, and I take a photo with my intra or camera and after the procedure. I’ll sit the patient up and I’ll say, wow, that was really tough, Mrs. Smith, or make some sort of comment and I’ll also compliment them, ‘Well done. You stayed open really well and I appreciate how still you were.’ Or something like that, and then I’ll say, ‘I’m happy with how everything went, but you do have quite a nasty crack in there. I’m hoping that your nerve will survive, and you won’t need something called a root canal treatment, but in case you do, here are the things that you’re looking out for.

I want you to get in touch with me, if you get a severe throbbing ache, any sleep disturbance due to toothache or just sensitivity that doesn’t settle.’ And of course, I’ll show them on the big screen the photo of their crack, and now the patient has owned their problem is their crack. I’m just the communicator.

I’m just passing on this message. I’m just showing them what I’ve found in their tooth. And I know that in 99% chance that they’re not gonna have any issues. They’ll think, ‘Wow, you know, this is amazing! Jaz, a great dentist.’ I didn’t get any of that horrible pain that you described. But equally, if they do get irreversible pulpitis or get into trouble from this tooth because of the crack, they remember that part of the episode.

In fact, it takes me back to a really good episode we did, which called Consent is Like An Onion, with Shaun Sellars and Zak Kara, do listen to that because Shaun summarized something called the Peak End Rule. What parts of the consultation do patients remember? What parts of an appointment do patients remember and they remember the peak?

The most significant thing of that appointment and the end. So, if you end on a high, and if you’re nice and calm in your approach and you slow down and emphasize and be a visual educator to the patient, you show them the crack, for example, in this example I’m sharing with you, then I think that’s a really good way to communicate risks to your patient.

Main Episode:
Now let’s join Dr. Roy Bennett. Talk about sedation for the wet fingered practitioner, Dr. Roy Bennett. Welcome to the Protrusive Dental Podcast, my friend. How are you?

[Roy]
Yeah, really good, thanks. How are you?

[Jaz]
Yeah, great. And it’s great to have a rare sedation speaker. It’s not something we’ve covered that well on the podcast or on that much depth.

So, I want to cover it in a way that’s gonna, those burning questions that we have around the world as dentistry. As I do believe, and I’m sure you’ve seen as trends, and we’ll talk about it, is that. The USE OF SEDATION is perhaps UNDERUTILIZED in various countries, and it’s only gonna go high and higher, but you are the expert in that.

For those who are unfamiliar with you, Roy, please tell us a little bit about yourself as a practicing dentist and yourself as a sedation.

[Roy]
Okay, so I’ve been in practice about 34 years now. I’ve spent about 15 years of those with special care dentistry at the university background. And then I set up my own teaching facility back in 2011 to teach a postgraduates around the country sedation.

Cause as you said, there’s an absolute need for that. And I teach IV sedation. Okay. So, I’ve actually do a little bit of oral sedation, bit of inhalation sedation. And also, I’m quite a holistic practitioner, so I do off hypnotherapy as well.

[Jaz]
Brilliant.

[Roy]
So quite a well-rounded sort of sedation if you like.

[Jaz]
You showed me some videos of someone who, I believe for some reason you couldn’t use IV sedation, but then you were using hypnotherapy and you showed me how relaxed that patient was and so that was really cool to see. So I’m sure we can, even for those practitioners who aren’t using drugs of any sort or gases of any sort to sedate, there are some things that we can perhaps share to help put their patients at ease a bit more. So I’m very excited for today’s chat and so it’s great to hear you’ve been teaching dentists about this kind of stuff. So I’m gonna start with my basic level question before we then escalate to IV and whatnot, is oral sedation. A lot of my patients in the past have obtained Temazepam like oral from their GP.

Prior to the appointment with me, and that made me feel awkward because I was a little bit uncertain about where that puts me in terms of, okay, a patient is technically under sedation, I’m not sedation trained. How could something go wrong? Okay, so I wanna know from you, medical, legally, what are the rules and the laws in terms of me being able to, A) give out Temazepam?

And then what level of training do I need or what are the requirements? And B) that goes along with that. What if the GP gives Temazepam? Am I in still some way responsible for the sedation during the dentistry? Interesting, isn’t it?

[Roy]
Okay. Okay, so let’s go back to basics. Basically, the temazepam is a benzodiazepine, right? It’s one of the family of the drugs, quite traditional in the sedation world that I work in. But you know, things like Temazepam is a premedicant, so it’s pre-medication. It just takes the edge off people that when they’re slightly anxious, okay? Now I prefer my patient to be open with me and as they’ve been with you to let you know that they’ve taken that.

But one thing you’ve gotta know about that is one thing you’ve gotta know is that your consent process then is not valid. If you wanna change a treatment plan when a patient on Temazepam, then you have to go back to when they’re not on Temazepam. So you can’t then launch into a different treatment profile once they’re slightly sedated. If we’re doing sedation on site, we wouldn’t give Temazepam, we’d use oral sedation. So to me, Temazepam, to be clear or  Diazepam given by a GP or prescribed by you, would be just to take the edges of somebody. It’s just to relieve the pre-treatment anxiety.

[Jaz]
And do you think it’s a useful thing to- You’re not a fan. Okay. Just coming onto that.

[Roy]
No, I think it’s an adjunct. I think if you’ve got somebody who’s particularly anxious, sometimes they’ll double up on the dose. They may take alcohol with that, but you’re not in control. And I’m a guy in sedations likes to be in control. So when you take a pre-med, you’re sort of fixed into gear.

You can’t go through the gears, you can’t titrate the drug. The Temazepam is a one fixed dose, as it were. And then it’s also dependent on what they’ve eaten, how they’ve slept. what their demeanor is. So it’s, a lot of clinicians will use this, but I’m not a fan because you’re not in control. You’re not controlling the sedation now. So medical legally, I’m not a fan, I have to say.

[Jaz]
Okay. That’s useful to know.

[Roy]
It has its place to give the patients a reasonable night’s sleep the night before. But to be honest, when you get a very anxious, it’s not gonna hit the side that controllability is not-

[Jaz]
So it’s not enough of an anxiolytic it sounds like. And also it does mess up your consent process. So for those listening who do have a patient who didn’t know was taken Temazepam and they come to you and say, ‘I just, I was so nervous my GP gave me Temazepam and they’re kind of drugged up in your practice, then a great point made by Roy that actually you gotta be really careful about changing the course of treatment.

[Roy]
And also if you go outside the remit of what a GP does, which is usually about, you know, two to five milligrams of Diazepam, or 10 to 20 milligrams of Temazepam. You’re really straying into more high sedation levels. So pre-medication, before the procedure or going to sleep, it’s quite low doses. So really those low doses are just gonna just take the edge off people. If they’re really anxious when they come in to see you, that anxiety will still be there in some way. So you might be disappointed as a clinician that hasn’t done what you thought it would do.

[Jaz]
Okay. You’ve done a good job of pulling me off Temazepam. What is the level one, so you know, what is the next level up from that, that you think that GDPs who may be entering the world of sedation could start to do that you feel has its place a more widespread in clinical dentistry?

[Roy]
So one of the important things is to assess the patient correctly. So I use a pre-visit questionnaire, which I send out to the home address. They fill that in. I get a level of the anxiety that they have through the modified dental anxiety score. We get a score, which is more valid, and then I can work out what kind of approach that we’re going to do with that patient.

Now it might be inhalation sedation. It might be a little bit of hypnotherapy. It might be the language you use with the patient. We’re gonna put topical on. We’re gonna look after you. It’s the language that’s really important. It’s a bit like NLP language. Okay. So we don’t use the words obviously, pain, injection, excavator.

We talk about things like comfort, how comfortable you are. We’ll put cream on that will make you feel more comfortable. And then we’ll present the treatment plan and decide which route we take the patient down, whether that’s inhalation, sedation, or just sort of normalistic programming you like. Or we’ll go down the IV sedation route.

[Jaz]
Okay. So it sounds like really in terms of lowest anxiety to highest anxiety, like level one, we’re talking just really good care in terms of communication and being selective of your words and creating a nice calming environment. One level up from that, which might need a bit more investment in the practice.

We’re talking about scavenging and stuff like inhalation sedation. The level up from that would be intravenous. Are all of those that are used in general practice by general dentists or are there any others?

[Roy]
Well, you could use intranasal sedation if somebody’s quite phobic, and you could use some oral sedation, which is onsite sedation.

Not outside the practice, really take a tablet. So they come in the practice and then you would mix an elixia or a drink of benzodiazepine, Midazolam, and that would then calm the patient. Now, if you are gonna go down that route of them having a drink of oral sedation, then they do need to be cannulated.

So you’ve gotta have the know-how and the core of knowledge to be a IV Sedationist to give all sedation. Does that make sense?

[Jaz]
It does. And is it a myth that inhalation sedation is just for children?

[Roy]
Correct. Absolutely. So, I’ll do a myth bust here for you.

[Jaz]
Please.

[Roy]
So basically, I do inhalation sedation right from sort of five-year-olds right up to 95-year-olds. Okay. It’s a really, really good system. It’s a really safe system. When we do inhalation sedation, we’ve always got 30% oxygen flowing through in that background, which is even better than the 21% air that we breathe. Isn’t it? So very safe system, titrateable. So, you can go up and down. As with IV sedation, which is what I like Titrateable, we can dose it to the end point and the reaction of the patient.

So I’m going through my gears, going through the inhalation sedation of percentage of the drug, the sedative of nitrous oxide that we would give so you are safe. Underused in the UK, 50% of American GDPs use it in the states which is amazing, isn’t it? When you go, when you visit the states, you’ll notice every practice or every other practice has an insulation sedation unit.

And why is that? Because the public expect it. They expect that kind level of option or care when they need the treatment. Okay. So it’s an expectation of the American public. So inhalation sedation absolutely underused in the UK shouldn’t just be used in community care or special. So it’s a really good thing.

Sometimes I don’t want to sedate an elderly patient or they’re on certain medicines. We’ll just use a little bit of inhalation sedation to take that impression. If we’re not doing a digital scan, whatever, or they’re just little bit phobic, it’s limitations, if you like, are probably where the patient is extremely phobic or extremely anxious.

And then the inhalation sedation, the nitrous won’t be enough to get them from A to B. So we really do have to go back to what I said at the start, which is to be, let’s assess this correctly. Where does that patient lie in their anxiety score?

[Jaz]
I’m gonna ask you a tough question now, Roy. Assuming all things being equal with a patient, patient A, and patient B, that their medical health history is that they’re ASA grade 1 fit and healthy but they’re slightly different in the anxiety level in terms of MDAS, is there a magic score in terms of, okay, after 21, I consider inhalation sedation not to be effective. Is there a magic score or is it still an art form? Is it still arts and crafts?

[Roy]
Yes. Yeah, it’s a good question. Sedation is an art form. It’s bringing the science together with your personality on the demeanor and the personality of the patient as well. So absolutely, as we always said, in any kind of sphere of dentistry, whether it’s implant dentistry or whatever, there is an art form. It’s that discussion which is pre sedation discussion with the patient, which is critical.

So I’ll always book 20 minutes. I’ll sit down with the patient, not in the dental chair. We’ll sit together, we’ll go through it and we’ll find out what ticks the box for that patient. Where do they lie? Because some patients who are controlled type patients type a behavior probably might resist the sedation and it might be a bit of a sedation failure for you.

So we have to see that patient has to trust you and they have to be on board with the sedation, we’re not gonna do the sedation of the patient because we’re ticking an MDAS score. We need the patient to follow us on that journey as well.

[Jaz]
Got it. So there’s no, yeah, I mean I expected that to honest. I know there’s no magic answer. Magic number.

[Roy]
Yeah.

[Jaz]
In terms of the level of training medical legally required, and if you know about the US and Australia, cuz got lot of listeners from US, Australia, and New Zealand around the world, but obviously I’m sure you know about the UK, but if you know about the world as well, it’d be great to know from you what is the level of training that you need to be able to provide inhalation sedation in practice?

[Roy]
Okay. So, you need to basically do a core of knowledge over one or two days, like the 12 hour CPD, which is didactic teaching, and then you’ve got to be supervised through your 10 cases of mixed variety inhalation sedation. If you are gonna do that, then you would do some assessments as well, just so you’ll have a supervised colleague standing next to you, and then they’ll go through the 10 cases.

So you might take one or two or three days to do that if you’ve got all your cases together or over a matter of weeks or month, and then you will revisit those cases and discuss that with your supervisor. So IV sedation a little bit more in depth. Again, a two day beginner course, core knowledge. And then we need to do 20 courses-

[Jaz]
20 cases, yeah.

[Roy]
20 cases of mixed ability. Again, so from extractions, fillings, or whatever. Okay, so you do need that 20 cases. Now, that just gives you a basic sort of understanding in my view. Then you really start learning as all things in dentistry. You start, you have some failures, you have to accept that, you have to revisit that.

So, but basically, the ISCD, the Intercollegiate Advisory Committee of Sedation in Dentistry 2015, revised 2020. The standards, and that’s what we follow and what the lawyers follow is 20 cases, logged cases.

[Jaz]
Mm-hmm.

[Roy]
Now, when you carry on as Sedationist, you must keep your log cases, the log book in case the CQC ever decide to walk in and say, ‘Oh, tell me about your sedation cases.’

[Jaz]
Oh, that just makes sense. Fine. That’s the lovely, nice, clear guidelines to follow in terms of being able to implement this. I remember doing some restorative cases and then I essentially, I hired a sedation to come to just manage the sedation cuz I had so much on my plate.

I was raising the vertical dimension. It was my early days. I was still, very much engross in my restorative density. There’s no way I could expect to do anything beyond what I was doing in the mouth. Now I’m at a point where I’m a lot more comfortable with my restorative dentistry could I, is it naughty if I’m doing the restorative entry and the sedation at the same time? Or should there be someone else doing the sedation always? How does that work?

[Roy]
Okay. So, my philosophy is if it’s a straightforward thing that you’re doing in dentistry, if it’s a simple thing, if it’s a straightforward extraction, if it’s straightforward restorative, if your head space is not too overused as it were, then go ahead and be the operator sedationist, and that’s the term that you were mentioning there, operator sedationist. Now, if it’s not simple and it’s not straightforward, or the patient is challenging or the patient has some medical comorbidities, or the general situation is a bit more stressful for you as the operator, then I’d always get a dedicated sedationist.

[Jaz]
Got it.

[Roy]
Okay. And that’s what the standards say actually, if things are a bit more challenging, step back, take two steps back. Well, I’m gonna concentrate on my occlusion today. On the restorative, I’ll be placing the implants. My head’s gonna be pretty full. And this patient’s a bit challenging actually. So do you know what?

I’m gonna have a good team member with me. I’m gonna have a dedicated sedationist in who’s gonna take that pressure off. And also that’s best care for the patient as well because we need a dedicated sedationist at the other end of the chair who’s just gonna monitor the patient, look after the patient while you, you can do your excellent dentistry.

[Jaz]
Brilliant. Now, if we dentists start thinking about sedation training, and let’s say they get some cases under their belt, they build their portfolio, they get their 20 cases, and we’ll talk about the end, about how to go about doing that. I’m sure you have a great help that you can give us all. When dentist, maybe your delegates or a dentist that you’ve trained run in trouble, cuz everything’s got some failures. Just like you said, you know, we get failures, I get restorative failures. You get sedation failures and that kind of stuff. What are the most common lessons to be learned for those starting in sedation that you could share with us?

[Roy]
Okay, so I think the first hurdle that most people sort of have to leap over, if you like, is on their first few cases when they are giving the drug. Okay, so giving the drug is via cannula, obviously in the back of the hand or in the arm, and actually cannulation skills is a big hurdle for most people.

So it’s a learned skill. Bit like when we’re trying to find a, you know, second MB canal and a molar. It’s a learn technique, okay? So cannulation. The more we do, the more we learn, the better we become. So that’s a little bit of a hurdle. Second hurdle that we come across is we administer the drug under supervision with our colleague.

But then we say to our colleague, when do you think I should start to numb the patient up? When do you think the patient’s ready? And that’s where the art form from. You’re looking at the patient and saying, ‘Right. I’m gonna say to the patient now, are you okay if we numb up now? Are you ready to proceed?’

And the patient may go, oh yeah, nod or not, and we know we’re at the right level of station. Then what we don’t want to do is jump the situation and the patient be under sedated and then start numbing the patient up and that can dissipate the good effect that we’ve achieved already. So it’s the timing.

The timing of numbing up, the timing of administration, the drug. So that takes a learning curve of sort of five to 10 cases to see that-

[Jaz]
It’s turning that knowledge into wisdom, isn’t it really, Roy?

[Roy]
Yeah, absolutely. And then keeping that patient, you’ve taken the patient to a nice level of sedation and as I say, cruising altitude. We want to keep the patient nicely, comfortable and it might be a long procedure. It might be 2, 3, 4 hours, implants, whatever. So we want to maintain that patient at a nice level of sedation, let the patient learn and become to a nice recovery and a safe discharge. So it’s like taking that patient on a sedation journey.

[Jaz]
One question I’ve got already, Roy, cuz you’ve sparked my interest now, is I had this another myth busting, let’s call it then a misconception that I had. But previously when I asked you about inhalation sedation for adults, that was a previous myth that I had that was corrected and me and Mike Gow many episodes ago discussed that and then we confirmed that. So if you guys haven’t listened to that, Mike Gow episode, it’s brilliant. Roy, you and Mike are good friends as well, so that is nice to hear. Hello Mike if you’re listening. And so another misconception I had with sedation is that, I dunno where I read this, but like the golden hour, the golden 45 minutes once you start IV sedation, you’ve gotta get everything done in 45 minutes. And I actually remember doing restorative cases being like, okay, I’ve got 45 minutes. Prep, prep, prep. Oh, so you’ve actually just busted that myth. So what is the truth there? How can we, how long can you safely go for?

[Roy]
Okay. Okay. So if we think about the drug that we are using, that can have an effect. So if we are using the basic drug that we use in the UK, which is Midazolam currently, okay? Benzodiazepine then, and we titrate to effect and we get the patient in the first sort of three or four minutes at the right level of sedation. We probably, and I agree with you, we’ve probably got a window of about 30 to 45 minutes of peak sedation.

If we want to extend that, then we need to have a bit of experience, and then we need to, I don’t like the word topping up, but we need to add some more Midazolam after about 30 minutes. Okay. So we’re topping up. We’re topping up. But what we have to understand is that patient’s gonna have a longer recovery then.

[Jaz]
Mm-hmm.

[Roy]
Because we’ve added more drug than what we started with. Okay. So now the drug profile is changing. Some of the things that we have to think about is how long can I keep the patient titrated at that level? Okay. Now some clinicians will use maybe a different drug that we can touch on, but which is appearing in the UK, which will give you that top of level continually.

Okay? So there’s different drugs out there, and there’s a anesthetist that use different drugs like propofol, and that’s the continuous infusion, which sort of gets around this problem of the drop up after 30 or 40 minutes. But that’s advanced sedation.

[Jaz]
Got it. Now we’ll talk about this new drug because I see you’re doing lots of lecturing about it, so it’s worth touching on at the end in terms of some nitty gritty details and making it tangible for the dentist.

What this podcast is all about is when dentists are starting out implementing sedation in their practice, what are the hurdles that they have to jump through? Like I’m thinking it’s such a useful thing and I’m thinking already. In my practice, we don’t have anyone that provides sedation and we always have to reach out to someone.

So I think it’ll just make business sense and also how much more we can serve our patients. If every practice had one dentist who was trained in sedation. So what are the hurdles? Like one automatic one I’m thinking of Roy, is that perhaps our nurses then also need to be sedation trained. Is that a hurdle?

[Roy]
Yeah, that’s correct. So there are two route you can go down in the practice. One is that you’ve just mentioned, you’ve touched on, which is you bring in a dedicated Sedationist and that sort of complies with all the regulations and the standards. They would be purely administering the drug and monitoring the patient.

So it’ll be nice for your team to have some core of knowledge, but it’s not absolutely required. So that dedicated Sedationist will take all of that sort of paperwork and sort of administration off you. Okay. The other route is that you actually become the operator sedationist and treat some of your patients. And yes, you would need to have a dedicated nurse who you pick out of your team who you think would be suitable to become the monitoring dedicated sedation nurse.

And she would need exactly 20 cases core of knowledge, and that’s what you’d need. So you’d need, I tend to, if I’m doing operating sedationist in my practice, I’m having me as a clinician treating, and then I’m having my sedation nurse who does all the monitoring dedicated, and then I’ll have my four handed nurse next to me. So I have a good three member team. Okay.

[Jaz]
Got it.

[Roy]
So the minimum is having an operator sedationist and a dedicated sedation nurse, but that then stresses because you haven’t got your 400 nurse as well. So I always say have three in the room if you are the operator sedationist.

[Jaz]
That’s a good rule actually. Yeah. Rule of three. I like it. It’s also same in crown lengthening. Rule of three. But that’s another time to tackle. Roy, is there a ideal personality trait or an ideal type of dentist that lends himself to being a operator sedationist or doing sedation training? Like me personally, I love the idea cuz I like getting people out of pain.

I like making ’em feel at ease. I like to learn new tips from people like you to make my dentistry calmer experience. So I love all that, but equally, I am like, when I’m doing my dentistry, I am like in seven and a half magnification. I’m so engrossed on every enamel prism and every retraction cord and I’m loving it, right? I worry about then splitting my attention to something else. So is there an ideal candidate?

[Roy]
So I think, well, let me take you back in time. The reason I got into sedation was a little bit of self-preservation room. I’m quite an empathetic guy, but in life you’ve only got such petrol in the tank and you can be so empathetic and that can, if you’re being caring individual, you need sort of systems in your practice. You need-

[Jaz]
Need drugs.

[Roy]
Well, not always drugs, but it’s useful to have, isn’t it? So, yeah, so I just needed a toolkit into my bag to sort of approach these very anxious patients that would find me to get referred from colleagues. Go and see Roy Bennett, you know, we don’t wanna do this sedation case, you know, Roy, you can use short.

[Jaz]
It’s a great practice builder.

[Roy]
Absolutely. And we became a referral hub for doing the cases that nobody really wanted to do. So I had to build a very experienced team around me. So it’s not just me, it’s my visiting anesthetist. It’s my sedation nurses that I’ve trained over the years. It’s the receptionist.

Everybody in the team is really important. It’s a holistic thing. It’s a whole team that’s important in giving that patient that journey from being very phobic to being accepting the treatment. Okay. So my mission really is to take them off the drugs. It’s not to be a sedation dentist. It might be of the first few appointments, but if I follow the standards, it’s doing the simple way, simple things for patients.

So it might be to wean a IV sedation onto inhalation sedation, and then hopefully one day just by talking to them. Okay, so that’s the mission. It’s not always about one tick. Everybody gets IV sedation. That’s not the way to do it.

[Jaz]
Well said, and I love that. That’s really good. An individualized approach. And I like, a bit like endodontists, they always tell me, oh, preventive endodontics, we want to do pulpotomies.

You wanna preserve the pulp, you guys you want to, yeah. Get them off the sedation, which is very admirable and very good. I like that very much. Before we talk about the new drug and then how we can learn more. And actually for those whose interest has been peaked by learning, wanting to learn sedation, which I think is such a great thing to offer.

Any other key points that you think GDPs, wet-fingered GDPs out there right now should know about sedation and our patient base and how either something scientific you want to share, or a top tip.

[Roy]
Okay. So, I would all say that I think any new patient that comes to me, we get a proper sort of prequestionnaire profile, a good assessment, and then decide what anxiety levels they might have.

Okay. I think the advancements in sedation will probably be on the monitoring. So for me, for the last 10 years, I’ve sort of always looked at those advances and most of sedation now we use a pulse oximetry. We check the blood, we check the blood pressure. I’ve always wanted a bit more than that. So I have a entitled carbon dioxide monitoring as well, which is five stream monitoring, which is on the nasal.

And that can assess the ventilation of a patient because in primary care you’re not in a hospital setting. And it gives you a little bit more confidence of safety. I’m all about safety in the safety aspect of sedation. If I was saying to somebody starting out in IV sedation, like, is that something you really want to do?

Cuz it’s not suitable for every practitioner. It depends on your mindset as well. And is it something cuz you will attract certain patients that will be challenging? And difficult, so I think, I’m very like Mike Gow. I look at the whole patient. Is this patient suitable for sedation? Okay.

It’s not just a tick box mentality. Okay? So it’s very important to use good language. I think hypnotherapy really helped me in my career, and that’s just using some words and relaxing the patient. And I’ve been on some courses for, just to help with that, to use the right language and speak to psychologists and hypnotherapy because as we know, dentistry is, you know, there very lots of anxious patients out there, about 50% unless of those patients that are gonna need maybe inhalation or IV or oral sedation. So, it’s finding out really going back to basics from what the patient is.

[Jaz]
What really struck a chord with me there, Roy, is be careful of what kind of patients you would attract and make it a considered thing for you. So I don’t actually advertise directly to patients that I treat TMD I quite like doing that, but if I advertise, I know that my diary would be booked up six miles. I still get people driving hundreds of miles to see me, which is great, you know, very flattering. I’m very happy to help them. I loved this field, but I still want to get rubber dam on. I still want to do my restorative density so I don’t advertise. But if you invest in a skill like sedation and you want to go in to be able to offer that to your patients, then if the word gets out and then you start seeing more challenging cases, then yeah, you have to be kind of prepared for that as well. So I think that’s a excellent point there that I can definitely relate to. Roy, yes, please.

[Roy]
So I would say, you know, a good mentor once said to me many years ago, you know, if you’re about to sedate a patient, always expect the unexpected, okay?

[Jaz]
Mm-hmm.

[Roy]
So it’s like going on stage. You never know what the audience is gonna be like to, so you’ve got to be ready and you’ve gotta have a team of people ready and what’s my plan B? What’s my plan B if the sedation is a failure or I didn’t complete the treatment, what am I gonna do? So you need to think ahead a bit and think about, okay, my plan B is, I’ve got some colleagues that can come and help me who do advanced sedation. So that’s my plan B of plan A, which is the simple plan fails.

[Jaz]
Mm-hmm.

[Roy]
So I’m just always one step ahead and I’m thinking, okay, this patient may be challenging. But I’m surprised we get through it with just basic, safe sedation. Everybody’s happy, but I can let you into a statistic. About 4% of my cases end up being sort of a dance sedation where I’m having to use different team members or different drugs or so 96% of the time, we’re following straightforward techniques in most of my career in 34 years.

[Jaz]
Excellent. I’m thinking of two. I mean, based on our chat now, I really enjoyed this, by the way, Roy, of two qualities. I think then just what I’ve interpreted, this is my artistic interpretation of what you’re saying. Two good qualities that a sedation operator or someone who wants to start doing sedation should have is, A) emotional intelligence or stroke, a good communicator, and B) is leadership skills, Roy, because you gotta be quick to think on your feet and then you’re managing and you’re leading a team and you need to instill confidence in your team when you’re doing this. Any other attributes or anything you wanna add to that?

[Roy]
So I would say, well, let me tell you a story. A practitioner rang me up a few weeks ago and said, look, I’m interested in starting it in my private practice. I’ve converted to private practice. I really don’t want to refer the patients out. I’ve thought about sedation. I’m not sure whether it’s for me or not.

Okay? So I said, okay. So what we’ll do is I will come to the practice, I’ll show you the systems, we’ll do the management, we’ll give you the leadership, but here’s the thing. Why don’t you bring in a dedicated sedationist who you’re comfortable with and you can interview them, that they fit in with your practice and that in your ethos.

But why don’t you sit in with those cases and watch the dedicated sedationist do that and then get a feel for it and see if it’s for you. Because all this guy ever had was some just experiences, an undergraduate, you know, he’s only done about 10 cases from over the last 10 years. So, and those cases might been challenging.

Why not experience that before you commit a lot of time and energy to a course that what we don’t wanna do, like in dentistry, and I’ve done myself, you’ll go down into a course, you’ll go off left center and you’ll make. I must do that and then end up maybe not using that.

[Jaz]
I hate that so much, Roy. And what this podcast has become is a constant reminder to implement and therefore be very careful about your next educational move. Do the education. It’s amazing for fulfillment from your career, but have that mindset that you’re gonna go all in.

[Roy]
Absolutely. So, you need to sort of pace it really. I would get somebody in, is this gonna work in my practice? Is this for me? It’s quite a commitment for a principal to do that.

[Jaz]
Well said. And that new drug. Before we talk about how we can learn from you, just tell us about that new drug. How new are we talking? Is this something that’s been around in other countries and now just been introduced to UK? Or tell us more about it.

[Roy]
Okay. Yeah, so, this is a benzodiazepine, very similar to Midazolam that we’ve used over 40 years, but to me it’s a bit of a game changer. So I’m quite excited about this new development. It was patented in about 2020. It’s been authorized in the UK 2021. I’m using this drug now. I’m still using Midazolam, but this drug is called Remimazolam , okay? Not to be confused with anaesthetist drug called Remifentanil. That’s a completely different drug. Okay, so this is Remimazolam. It took me a while to learn to say it.

[Jaz]
Who comes up with these names. Just pick something more catchy, you know.

[Roy]
Ah, so the trade name is by Favo, B-Y-F-A-V-O. And so, so why do I think this is useful? Why do I think this drug is useful? Okay, so this, the onset and offset of this drug.

So how quickly comes on board and how quickly it wears off much faster than Midazolam. So this enables us to have a quicker induction for the patient. The patient will sedate more quickly, so we’ll then be putting the local in much more quickly. But the thing that we have to watch is that the drug then profile is offset is much quicker.

For example, after about eight minutes, for 10 minutes of me giving the last in increment of this drug, the patient will be up and about recovered, walking safe discharge. Okay? Now why is that good? Because in my experience over the years, some cases midazolam, the patients be quite groggy. The discharge has taken a while.

We’ve had to book a full hour. To make sure that the patient recovers well. So we might have finished a straightforward extraction phase that took me 10 minutes, but we’ve had to make sure with the drug profile that the patient was safe to leave for an hour. So with this drug, I can, if it’s straightforward procedure, I can be done and I can be inducted, treated, and finished within, say, 30 minutes.

[Jaz]
Mm-hmm.

[Roy]
And as safe patients leaving the premises in a safe way. Okay. They still need an escort. Still need a chaperone. I, like I term it as a soft drug, a clean drug. Its profile to me is really exciting because compared to, say, Midazolam have the occasional patient who will have a aggressive, idiosyncratic odd reaction to Midazolam, and I’m sure people out there may have had that in their careers. We don’t tend to get that through this drug. It seems to be metabolized slightly differently. And also with obese patients who are overweight and sleep apnea, they worry me when we have to do sedation. So this will seem to get better outcomes with.

So all in all, I’m about safety, so I like the safety aspects of this drug. I like the pharmacology of this drug, so it’s gonna be in my repertoire. Definitely. Yeah.

[Jaz]
Is this the future of sedation?

[Roy]
I think it is going to be one of the mainstays. I don’t think Midazolam is going to disappear. I don’t think some of the anesthetic drugs gonna disappear like propofol. That’s all gonna be there, but isn’t it nice? For a dentist to be able to go, ah, well for this case we’re gonna choose. We’re gonna use that because we know it’s safer. We’ve got an elderly patient in, we don’t want it to be confused at the end of the sedation.

Cause that’s quite frightening for them. Whereas with this drug within eight minutes, 10 minutes, it’s like clearheaded recovery. Good discharge. So I think it certainly, I wish I’d have had it 25 years ago, I think.

[Jaz]
Well, it sounds very promising. Roy, thank you so much for this really educational episode. Please tell us, for those who, who may be interested in learning more, who are implementing sedation into their practice, you’ve been doing teaching for years, how can we learn from you, which association are you attached to? How can we find out more?

[Roy]
Okay, so I’m attached with the two associations. One is my own web training site, which is mellowdental.co.uk and you can find me on there. But I’m also a senior clinical advisor to UK Sedation and we’re doing webinars and presentations. So be on to uksedation.com, and we’ll be presenting at the Royal Society of Medicine on the 15th of February. Next on the new drug that we just talked about so you can come and learn about that and be excited about that.

[Jaz]
Please send me the links, Roy, and I can put them in the show notes so people can jump on to learn more. And guys, even if you don’t, even if you decide it’s not for you, but someone in the practice may benefit, please send them this episode. But equally, I’m sure you gained something of value in terms of maybe you had this misconception about sedation or one of those myths that we busted. So I, it certainly helped me, Roy, I love your clear, calm communication style. Thank you so much.

[Roy]
Thank you. And thank you for inviting me.

Jaz’s Outro:
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