Newsletter 2002
Sedation Teaching: Symposium
London May 2002
Over 120 delegates met at the Royal College of Physicians in London for the annual Dental Sedation Teachers Group Symposium.
John Lowry President of the Royal College of Surgeons opened the meeting by describing the role of the Royal College of Surgeons in sedation training, and refreshed our knowledge of the history of sedation in dentistry. He discussed the ongoing problems of funding for teaching, and the development of new sedation Guidelines by the Standing Dental Advisory Committee SDAC.
Representatives from different hospital teaching departments and the Community Dental Service then highlighted the specific problems they had encountered in establishing undergraduate dental school courses in sedation. The recurring theme was identifying curriculum time, appropriate funding and suitable patients. More on these presentations inside.
Later Jane Little who has successfully gained the GKT Diploma, gave us some feedback from a Diploma students' perspective. ( see page 5 )
Lunch followed the Annual General Meeting and then Michael Wood described his successful use of intranasal midazolam for children in general practice. He found it a rapidly effective, reliable technique with minimal side effects.
Kevin Fairbrother entertained us with his experiences of the challenges of establishing an undergraduate course in sedation, as a newly appointed Consultant. Alistair Speirs followed with a description of multifaceted role as a Restorative Consultant.
Ash Patel and Gerry Flaum summarised the duties of the new SHO posts in Pain and Anxiety Control that have been created in Birmingham. Perhaps another answer to the problem of sedation training at a postgraduate level?
An informative meeting ended with Margaret Wilson challenging us to find an acceptable, user- friendly format for the DSTG Standard Teaching Document which is now well under way.
Derek Debuse: Chairman's Update
This, the second issue of the DSTG Newsletter, aims to keep the membership in touch with what is happening in the world of sedation for dentistry, and more particularly, its educational aspects. Dentistry is at the forefront of training for sedation, something that the Royal College of Anaesthetists and other medical colleagues readily acknowledge. DSTG is in a position to ensure that this is carried forward.
The Committee was delighted with the meeting at the Royal College of Physicians last May. It had an upbeat, optimistic feel to it and was very well attended. Congratulations to Carole Boyle for the impeccable organisation.
Members of the DSTG Committee have been involved in directing the work of other committees, enabling the National Sedation Course to make progress, and influencing the content of "The First Five Years" which directs the teaching of conscious sedation to undergraduate students.
At the AGM in May, the Committee was expanded in order to encourage the general membership to apply for election to the Committee. We hope that the membership will take advantage of this. The Committee is eager that the new Dental Nurse Representative will encourage involvement in the activities of the Group.
Clinical Teaching - Problems and Solutions
Meg Skelly, head of the department of sedation and special care dentistry at GKT, started the presentations by explaining students at GKT attend a polyclinic type set up in their final year for an introductory course and patient treatment using RA and IV sedation. Undergraduates have had some experience of IV in oral surgery but the polyclinic extends this with a variety of procedures and patients, who are phobic. Students work in pairs taking turns to be the operator/sedationist or assist. The clinic is open plan, good for supervision but noisy and cramped. Patients and treatment need to be screened for suitability for undergraduates, which can conflict with the need to provide a service. Teaching is given by dentists supported by dental nurses. A mix of primary care and specialist skills is required, including experience in behaviour management. Clinic space is limited, separate recovery and assessment areas would be better. Dr Skelly raised the difficulty of assessing students and whether they are measured against defined criteria.
Paul Coulthard, Senior Lecturer in oral and maxillofacial surgery at Manchester, spoke about the sedation course he organises. There are a large number of patients but they are a specific group, requiring largely IV sedation. Staff training is needed to encourage more RA in adults. Students work in pairs and with a nurse, one operator the other sedationist. Again there is difficulty in selecting suitable procedures and arranging treatment for medically compromised patients. The course affords an opportunity for sedation teaching but it would ideally be integrated into the whole undergraduate program to include sedation for restorative dentistry. Marie Terese Hosey, Senior Lecturer in pediatric dentistry at Glasgow said the most common reason for referral is anxiety. It is reported that 60% anxious children can be managed with behavioural management alone, the course aims to show undergraduates where sedation fits in. There are many patients, some difficult for qualified dentists to treat: irregular attenders with multiple caries. It is stressful for the students who need to master operative skills as well as sedation. There is a high student turnover so little continuing care. There is considerable interest in sedation for children, there are many experienced specialists and it is valuable in teaching treatment planning, consent and links to GA. There are student outreach schemes in the CDS clinics. In the future collaboration with the adult and surgical departments for holistic care would be ideal.
Christine Arnold, Senior Dental Officer in special needs and sedation in Chester NHS Trust, spoke about the student placement scheme. Students in their final year gain hands on experience by attending clinics, supervised by a CDO led by an SDO. Problems are insufficient number of staff using IV sedation and selection of patients without complex medical problems. Surgical SDO clinics are therefore used for IV experience. Students may find it difficult to get to clinics and there is no continuity of patient care.
For postgraduate clinical teaching Derek Debuse spoke about mentoring in General Practice. Many dentists gain experience this way, finding a mentor locally through the DSTG list, SAAD, approaching course lecturers or by word of mouth. A prerequisite is that the dentist and dental nurse attend a relevant course, then they may observe, assist and treat patients in either practice. A mentor can advise on documentation and equipment. 10-12 cases are required to be considered competent but it is useful to maintain contact for continuing advice and attend update courses. The MDU recommend a written agreement to show the mentor is responsible for the sedation during supervision but the trainee for the dentistry. The patient must be aware of the arrangement.
David Craig spoke about the Diploma course at GKT which has run for 5 years. Attendance is one day a week for six months. It is heavily oversubscribed. The course components are underpinning knowledge (introductory course, study days, self-directed learning); patient management (assessment, sedation, treatment, recovery, consent, complications, failures) and continuous assessment (essays, MCQs, logbooks). There is a final assessment with a written paper, MCQ, project and clinical management The aim is to create a pool of dentists with substantial training and experience who may go on to train others.
Following the presentations there was a lively discussion with other teachers sharing their experiences. The medicolegal issues associated with mentoring where also discussed
Diploma: The Verdict
A study was carried out among past Diploma students of the Department of Sedation and Special Care Dentistry, GKT Dental Institute. The aims of the study were to provide an evaluation of the Sedation Diploma Course by past students and to investigate the sedation practice of those students including their current involvement in the sedation training of other dental staff.
All 30 past Diploma students from 1997 - 2000 were sent a postal questionnaire. 100% response rate was achieved after further repeat questionnaires and follow up by telephone.
Eleven out of thirty students felt that there were some areas not covered adequately or at all by the course. These included: sedation for special needs; other techniques such as propofol, intranasal sedation and hypnosis; paediatric sedation; advanced life support; medico-legal aspects and project planning. Three people felt the project was unnecessary. Four students would have preferred a longer course to include more theory and/or practical or for project completion and with respect to the balance of theory against practical, comments were based around wanting more theory in the form of more lectures/tutorials but not at the expense of the practical input.
When asked for suggestions to improve the Diploma Course, the inclusion of many topics already mentioned in previous answers were reiterated such as sedation for special needs, alternative techniques, more theory support. One other suggestion was to be able to gain a Certificate in Sedation rather than a Diploma if a project was not done. The other major comment was disappointment that it was not a registrable qualification.
Turning to their sedation practice, twenty seven out of thirty felt the course had changed their clinical practice. The remaining three were not practising sedation due to constraints in their current working environment. The change in sedation practice was greater for those working in the CDS than the GDS with all those in the CDS practising both inhalation and intravenous sedation and only CDS staff practising intranasal sedation. A wide range of treatment was being provided under sedation with most carrying out routine conservation and extractions and two thirds providing minor oral surgery, root canal therapy, crown and bridgework and periodontal treatment. All but one of those currently practising sedation accepted referrals with all CDS accepting mainly local referrals and less GDS staff accepting referrals but from a wider area.
Twenty nine of the thirty students expressed interest in a sedation update day covering topics which had been previously highlighted. Eighteen were involved in the sedation training of other dental staff and of the remaining twelve, eight were prepared to be involved in future.
Almost two thirds of the group thought there may be a place for an alternative course aimed somewhere between a two day SAAD course and the Diploma and a wide range of suggestions were made.
Overall, the Diploma was thought to be an extremely valuable course that had changed the clinical practice of the students. The main recommendations included: finding ways to include the areas thought to less well covered and more theory either into the main course or in the form of update days; looking at the possibility of an alternative course at a lower level than the Diploma and continued evaluation of this course including comparison with other similar course.
Postgraduate Sedation
Following the success of the undergraduate teaching guidelines a small subcommittee comprising David Craig, Tom Cripps, Chris Holden and Derek Debuse chaired by Nigel Robb has been set up. The task of this group is to produce guidance on training in advanced conscious sedation techniques for adult patients.
Advanced techniques include multiple intravenous drugs, continuous intravenous infusion techniques, transmucosal sedation and mixed route techniques. The entry requirements to advanced sedation training are described and recommendations made for the appropriate amount of clinical training.
The document will give guidance to course organisers and to those who want to extend the range of their sedation skills.
It is hoped that the document produced by the sub-committee will be discussed at the next committee meeting in November for publication next year.
DSTG Meeting 2003
The 10th International Dental Congress on Modern Pain Control is to be held at the Edinburgh International Conference Centre, Edinburgh, Scotland from 5th-7th June 2003. There will be an exciting and controversial scientific programme, including plenary sessions from prestigious international speakers, free papers sessions, symposia and a trade exhibition. There will also be pre-congress workshops on 4th June. The contents of the conference will be finalised on the basis of submitted abstracts, taking into account both quality and thematic balance.
Edinburgh is one of the world's most beautiful cities, renowned for its unique heritage, architectural grandeur and cultural vibrancy. During the Congress, the scientific programme will be complimented by a varied social programme to suit participants or those just on holiday, beginning with the Welcome Reception in the magnificent setting of Edinburgh Castle.
At present DSTG is liasing with the organising committee and it seems likely that DSTG will chair a session and that the Annual General Meeting will take place in Edinburgh. The committee felt that it was appropriate that DSTG should have a presence at this important international meeting and that members would find much of interest. Further details will be sent to DSTG members early next year.
For further information go to www.saaduk.org (right click to open in a new window) and follow the links to IFDAS
Thanks to contributors to the newsletter
Nicole Dunning
Mary Burke
Jane Little
Derek Debuse
Any suggestions for future newsletters to the Editor
Carole Boyle
carole.boyle@kcl.ac.uk
Department of Sedation and Special Care Dentistry
Floor 26 GKT Dental Institute
London SE1 9RT