Protaper Next Endodontic evening

Many thanks to Professor Phil Lumley, John from Denstply, Neesha from Henry Schein and Dr Manju Kumar for an excellent evenings CPD course.

We’ve enjoyed a short lecture on Protaper Next and current Endodontic theory, food and coffee and an extremely well organised and fully stocked hands on session. Certainly lots to think about and new things to introduce tomorrow morning.

Ive got to admit, it’s a superb endo system, even for complex cases, simple to use and great results. Very impressed!

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What if you can’t find a vein?

My experience of treating patients under sedation has been that once the venous access has been achieved, the session becomes easier from that point. The patient is relaxed, the team is relaxed and all is well. But finding that elusive vein can be very stressful!

At the initial consultation, the patient may be more relaxed and the vein obvious. But when then come for treatment for the first time, everything shuts down and the nice vein you noted previously has disappeared! What you really dont want is to be straggling around puncturing holes which will only increase the patients stress levels and reduce their confidence in your skills!

There are some great techniques that Ive come across over the years to help find decent access.

One of the simplest ways is to get venous pooling. Using a manual blood pressure cuff (still my favourite), hold the pressure between systolic and diastolic. The blood will pool and the veins will become engorged and therefore much more obvious.

If that fails, there are some great devices (gadgets) out there to help find the decent veins in the first place, even deep in the forearm. I love the VeinLite EMS, sold by Medisave. More details can be found at https://www.veinlite.com/.

This fantastic tool allows not only visualisation of the venous architecture, but when turned around, will hold the skin firm and anchor the vein down, so you cannulate through the access window in the device itself.

It costs around £160 but saves so much guesswork, feeling around for veins and failed access situations. I have used it several times on patients who have said “good luck finding a vein!”

How do you treat the Needle Phobic Dental Patient? An introduction to Intranasal Sedation

My name is Dr Rob Endicott and I have been carrying out IV and RA sedation for over 10 years. I have been blessed over that time to have helped over 1000 patients achieve healthy mouths after years of neglect.

I have talked before about the “Guilt Spiral”, where nervous patients develop a dental problem and try to ignore it, knowing it needs to be sorted out. The problem worsens, develops into an infection and regular antibiotics seem to keep it at bay, but the patient still knows it needs to be sorted out. But this time, a lot of people are embarrassed and are are scared that the dentist will say or think “How can you let yourself get into this situation?”

So it is ignored again until the tooth breaks. The patient is left with stumps of teeth, recurring infections and pain and thinking, “not only am I going to be a bollocking from the dentist but it will be difficult and painful to get the tooth out.” So, the situation is ignored still further until a breaking point is reached, a cosmetic disaster, a life threatening swelling or inability to eat anymore.

This pattern is something we see an awful lot in Sedation / Phobia Dentistry. If only patients got to us sooner, trusting us not to tell them off and believing us when we say the treatment is going to be painless!

Its one of the reasons why Dentistry for nervous patients is so rewarding. We can see lives turned around, patients smiling again, routine maintenance dentistry easier to handle, depressions lifted, diets improved, personal care improved, relationships improved to the point of finding Mr or Mrs Right!

I often say to patients that getting them through the door, in the chair and talking about solutions to their dental problems is the hard bit. One they are passed that, the dentistry, especially with sedation, ends up being the easy bit.

But how do we cope with patients who have a fear of needles? IV sedation involves needles and so often we find that if patients dont want needles in their mouth (which we know we can do without hurting them) then possibly more uncomfortable injections in their skin can be an even worse fear.

We can try Relative Analgesia (or what Dr Richard Charon calls “Happy Air”). This is a great needle free way to relax patients and make their dentistry easier.

But so many of these severely phobic patients want to be “asleep” and be completely unaware of whats going on.

A few years ago, I started using Intranasal Sedation. Intranasal involves spraying a fine mist of concentrated Midazolam up the nostrils using an attachment on a 1 or 2ml syringe.

After about 10-15 minutes, the patient is experiencing similar effects to IV midazolam. You can then cannulate without the patient being aware, for top up and more importantly, for reversal.

There are many useful features of Intranasal uptake of Midazolam.

It has a slower absorption rate than IV so it is difficult to get a spike in the serum levels commonly associated with over-sedation. This makes the administration very safe.

It can provide the same depth or sedation and often topping up is not required. Because of the slower uptake curve of serum levels, and the subsequent slower half life, topping up with IV is a little unpredictable, as one dose is dropping off, another quicker one is being introduced. I often find there is no need to top up.

It is simple and cheap to provide. The Mucosal Atomisation Device that fist on the syringe is readily available, low cost and comfortable for patients. The Midazolam is made to special prescription by Guys and St Thomas’ Pharmacy and comes in a pack of 5 for around £60.

The half life, whilst slightly longer than IV, is still suitable for good safe recovery and fits in with the dental diary well. I often need to schedule just an additional fifteen minutes for recovery.

Patients are unaware and do not remember the cannulation!

Drawbacks

As with everything is life, IN sedation is not a magic bullet. There are some important things to know:

The recovery is not as clean as IV, the patient can feel “heavy headed” for longer than normal, but as most of my patients go home and then sleep for a few hours, that doesn’t seem to be a problem.

It is not an alternative for IV. It is important for safety reasons to be able to reverse it with Flumazenil so cannulation is always needed.

It is not an alternative where you can’t be certain of venous access. Where no vein is available and therefore access will be difficult to achieve once sedated, it should not be used. If there is difficulty finding a vein, then see my other post for some great tips.

It doesn’t taste that great. The vial does contain lidocaine topical anaesthetic which can reduce the unpleasantness, but even that tastes pretty foul. The taste and slight burning sensation can be reduced greatly by giving the patient either pure Orange Juice or Cherryade.

I have to admit though that these issues have never prevented me from using IN sedation with patients who are needle phobic. They seem like minor problems in comparison to the trauma of IV.

If you are interested as a practitioner on getting involved with IN, speak to your sedation mentor, SAAD, or email me at rob.

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For more information visit http://www.intranasal.net

http://en.m.wikipedia.org/wiki/Midazolam

Calling all hygienists who work unassisted, Free audio software to first ten users

coming soon, EasyMedRecord is a hands free simple way of quickly dictating notes and perio charting for processing later. I am giving away 10 free copies when it is released for hygienists to test.

You know how difficult it is to do periodontal charting if you work unassisted. Quite often you need to call in a nurse to help you but would it help if there was a low cost hands free way of recording your charting?
I know colleagues who set up an iphone on the bracket table, go into Voice Memos, record, edit the title of the recording and play it back later. but we’ve come up with a way of doing this on your existing computer, using a simple foot switch. One tap for record, One tap for save. no finger pressing required.

The software sits in the system tray, running in the background, waiting for a key or foot switch press. A microphone on the desk, table or chair mounted will pick up your speech clearly and the file automatically saved for you.

Full perio charting, including pocket depth, recession, bleeding , furcations, PRFs, suppuration can be read out in real time as you examine, for you or an assistant to process later that day when time allows.

Its the little things that can make a difference.

The software is in development now and should be ready by the end of october. I am on the lookout for BETA testers so I am giving away 10 copies of the software to hygienists who fancy giving it a go, as long as they provide some feedback. If you are interested in helping, drop me a line at rob@phobiadentist.com.

with best wishes
Rob

EasyMedRecord – a crazy easy to use Windows Audio note recorder for Dentists

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Announcing the upcoming release of this new Audio note recorder I have been developing. Its something that sits in your Windows 7 System Tray, running quietly in the background waiting for you to press a simple shortcut key on the keyboard. It then records up to 5 minutes of audio and when you hit the key again, it autosaves it in a predesignated folder. All you need to make an audio note, with just two clicks.

It can also be controlled with a foot pedal or separate wall mounted keypad. The computers own microphone can be used, or a separate lapel mic or desktop mic can be supplied, even a wireless bluetooth mic for mounting on the dental chair.

Why did I invent this?

Being a dentist is stressful, running your own practice on top of that just adds to the stress and for years I have been very interested in ways to make the routine non-efficient things in our daily lives much simpler.

Its the simple solutions in life that make the big difference. Every day as dentists / hygienists / therapists we are examining patients, making more and more copious notes, dictating letters, making to-do lists so we don’t forget to action something.

Most of us have an assistant who can help write the notes and make base charting but sometimes there is too much to write there and then and its hard to keep up. Some hygienists and therapists work without a nurse and when it comes to complex pocket charting, its really useful to have some help by recording the data quickly in audio format and then transferring that to the records in their own time.

I wanted to make this all really easy so I have come up with EasyMedRecord.

I wanted a ridiculously easy way of making and storing audio notes. I had a vision of having a foot pedal that when I clicked it, a recording would start and when i clicked it again, the recording would stop. I wouldn’t then need to touch my keyboard or mouse to save it, i wouldn’t have to break the cross infection barrier.

To start with, we are developing a simple keyboard shortcut so the assistant or operator can start and stop a recording. I am developing a foot pedal to do this as well, along with a wall mounted USB keypad that can do it, along with other automated tasks.

Possible uses for this product include:
Rapid base charting
Rapid in depth note taking
Rapid extensive Periodontal charting
Unassisted note writing
Dictation of letters
Note taking during surgical and implant procedures
Real time audio notes to send to other operators or receptionists (in conjunction with a free practice dropbox account and IFTT alert system for PCs and iPhones/iPads) locally or remotely
To-do lists
Rapid autoreminders (oo, I must do this while I remember)

We are currently in software design stage which looks to be ready in October with a launch in November. I am also planning a KickStarter campaign because I believe this product is useful across all areas of healthcare and has a worldwide market.

If anyone has any suggestions or feedback at this stage I would love to hear from you. If there are any features you would like to see, I really want this product to be open and commented on and regularly fed back so I can make it better and better over the years.

Will keep you updated!
With best wishes
Rob

Excellent oral medicine update from Mrs Judith Stocker last week

Many thanks to our local Oral Surgery and Medicine consultant, Judith Stocker for an excellent talk on “Red Flags in Oral Medicine”. It was fascinating to hear what she sees in a referral letter and the sort of cases she faces every single day.

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It was great as well to get an update on bisphosphonates in Oral surgery, interesting to hear that the cases of ONJ (osteonecrosis of the jaw) often come with oral bisphosphonates and often appear months after the procedure. The risks of ONJ can carry on for decades after cessation of the medication so we need to be aware not only of follow up in these cases, but also in our medical histories to discover any previous history of bisphosphonates use and prescribe penicillin post op to help cover the patient.

Another excellent talk from the Warwickshire Dental Training Institute with great feedback.

Apple TV for the dental office part two – patient demonstrations

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In part one of this series, we looked at using Apple TV to set up a wireless second surgery monitor right in front of the patient, in order to show the patient radiographs, photos or anything you want from your primary surgery monitor. This saves laying cables under floors, expensive pole mounts from dental chairs, a second graphics card or video splitter and surgery disruption.

In this second part, I am going to cover the use of Flickr to build a library of patient education photos.

A quick example, I saw a lady yesterday who wanted to know her options for a retainer. I went into AppleTV, clicked on the Flickr button, opened up my library of ortho photos and showed her what fixed and removable retainers look like. It was very quick and easy and appeared on a nice big screen in great detail.

You can build libraries (called “sets”) of different aspects of dentistry and fill with as many photos as you need. The free account on Flickr gives you lots of storage so you aren’t in danger of running out of space.

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When you need to explain to the patient what different treatment options there are for replacement of a missing tooth, you can have a set of photos showing bridges, dentures or implants.

You could as well couple this with some PowerPoint or Keynote slides. In both software packages you can export slides as JPG photos.
This is a great idea for a robust consent procedure. If you wanted an implant consent process for yourself or your implant coordinator, you could quickly design a set of slides to run the patient through, in the proper order, safe in the knowledge that you haven’t missed anything. We have so much to remember as dentists, so many things to remember to write down, so many processes to go through, this can really help as an Aide Memoire.

So, firstly create your slides in PowerPoint or Keynote. Export the slides as graphics and upload them to a set in Flickr.

Flickr is really easy to use, you can even do all this on an IPhone or iPad. Apps are available for both to upload your photos to the right sets. You can even create you slides using Keynote for iOS.

The only thing to watch is that other people may be able to see your photos, so watch the confidentially thing.

If you’ve any questions about this great use of AppleTV, or any top tips, just email me at rob@phobiadentist.com.

Apple TV for the dental office – Part one, use as an easy wireless second surgery monitor

If you are gadget driven dentist, please share this!

Sometimes a dental gadget purchase deserves shouting about so I have decided to write a series of articles extolling the usefulness of the AppleTV, one of the best sub £100 gadgets I have ever purchased for my dental surgery.

About 6 months ago I mounted a large flat screen on the opposite wall in my surgery, facing the patient. It was an idea I totally stole from a good friend, Coventry Perio and Implant guru Mr Matthew Perkins. The idea was to take the video signal out of my surgical microscope and have it displayed on the wall, in high definition. Works a treat and I will blog about that more specialised setup soon.

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However, I had a spare Apple TV at home so I plugged it in in my office, wondering what it could do for me in my workplace. It’s been so revolutionary that I have been moved to write a series of articles about it.

1 – Airparrot (http://www.airsquirrels.com/airparrot/)

Users of Apple TV and iPhones and iPads may well be familiar with Airplay, which allows the user to display the iOS screen remotely onto a television. This means that videos, pictures and music can be wirelessly transmitted from iOS gadget to the telly with ease and speed. With modern versions of iOS, a user can even mirror the whole small screen onto the big screen.

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Airparrot is a $9.99 download that allows you to mirror your home or work computer onto another screen. There is a version for PC and Mac and is really easy to install.

What this means for me as a dentist is that at a touch of a button, I can display the patients X-rays or digital images that are on my surgery computer onto the big screen in front of the patient, without the need to run wires everywhere. This is remarkable! Operating over the wifi network, the speed is phenomenal, the mouse moves smoothly and the quality is crystal clear.

Of course if I am mirroring my PC monitor (and audio by the way), I can display anything I want, CAESY patient education stuff, slides, videos etc.

What this means as well is that I have a low cost solution to a second monitor in the surgery. Retrofitting a second screen in a fully working surgery is extremely difficult. Mounting the screen on the chair with the right bracket, getting power to it from the chair, running cables under the floor from the desk. Trust me, I’ve tried it and I wished this had been invented 10 years ago.

With the AppleTV setup, simply mount the flat screen on a suitable wall, plug in the AppleTV with a simple HDMI cable, connect it to your wireless (or wired) network, install the Airparrot software on your PC or Mac (as long as your computer is either wired in to same network via Ethernet like mine, or wifi enabled) and then when you want the patient to see your screen, a simple right click on the icon in the system tray and Voila! Up it comes on the big screen.

I think that’s worth the cost of the AppleTV alone, but we’ve bearly scratched the surface. I need to write up the use of ICloud, IMovie theatre, Radio, Airplay, displaying intraoral images from Memory cards and Flickr. So much more to be done – will keep you posted.

With best techie wishes

Rob