Vaseekaran Sivarajasingam
Cardiff and Vale University Health Board
There is substantial unmet need (estimated 10,200 adults; 2021) for dental care under sedation among adult patients in CAVUHB. Aims of the project are:
- To develop a Sedation Service and Training Centre, University Dental Hospital (UDH), CAVUHB. In so doing, UDH will offer LA and sedation for anxious and special care patients, relying less on GA. Existing Dental GA waiters will be revalidated and sedation considered for appropriate patients.
- To provide training opportunities for trainees, and (upskilling) primary care dental teams in Wales – indirectly leading to reduced referrals to secondary care.
A whole systems approach will be taken with new sedation patient care pathways linked with primary care. Currently, there is a lack of NHS General Dental Service providers of sedation in CAVUHB and in Wales. A well-trained, well-led sedation service will enable appropriate assessment of referrals and patients, so care is provided in the most cost-effective and appropriate setting.
Sedation training centre would provide the home for a national conscious sedation course for Wales developed collaboratively with HEIW – HEIW would QA the course through its Deanery role. The service would be able to train Dental Core Trainees from across Wales as part of the dental workforce planning. As a training centre the opportunity exists to bring income from cross-charging other health boards for training dentists, nurses and dental therapists, or from primary care dental teams wishing to provide sedation to their patients.
Development of the Sedation Service and Training Centre in collaboration with primary care and HEIW will lead to a change in the landscape of how dentistry is delivered in secondary care (with less reliance on GA) and have real diffusion of benefits (CAVUHB).
Why now?
- Recognition that CAVUHB has a large unmet need for dental treatment under sedation and currently patients, practitioners and services are over-reliant on general anesthetic for dental procedures in secondary care.
- Lack of training facilities in Wales to upskill primary care dentists/Teams, and dental therapist so they can provide dental care under conscious sedation in the community.
Venue for the envisioned sedation service and training centre, UDH
There are two General Anesthetic theatres in University Dental Hospital, CAVUHB, which are underutilised for a number of reasons including that all Children’s General Anesthetic surgeries have migrated to The Noah’s Ark Children’s Hospital for Wales. This has given us an ideal opportunity to maximise the utilisation of existing resources in UDH.
Funding and Equipment
The Project Lead has submitted a funding request (CAVUHB) under the National Integrated Medium-Term Plan (IMTP) for the following, totalling £266,040.
- Consultant Lead for Sedation (Dental Directorate)
- Band 5 sedation nurses x 2
- Band 4 sedation nurse
- One day Anaesthetic time for propofol sedation support
In addition, the following equipment has been identified for the sedation service and training centre (with guidance from the Lead Anaesthetist) and costings sought.
- Airvo/ high flow nasal O2, Fischer and Pykel
- PK pump x4 2per theatre
- Bis monitor
- Remimazolam (byfavo) by Paion
- Sufentanil (Dzuveo)
- Operating chair to table, x4
- Oxford Help pillow x 1
- C-mac videolaryngoscope
- IV injection arm for training x2
Sustainability
Nitrous Oxide (N2O) use in Dental Sedation, UDH, CAVUHB
N2O is a greenhouse gas with a global warming potential 300 times greater than CO2. N2O persists in the atmosphere for 114 years and associated with B12 deficiency, neurological damage and infertility. N2O is used commonly in children to reduce pain and anxiety during dental treatment.
Currently N2O is delivered via manifolds
CAVUHB purchases 1.18 million litres of N2O per year (equivalent to 679 tonnes of CO2). Only, 27,000 litres reach patients, with the system efficiency of 2.5%, i.e., 97% of N2O bought in CAVUHB never reaches the patient, being lost in manifolds. Portable cylinder N2O supply efficiency is approximately 74%.
Switch to N2O portable cylinders, UDHA questionnaire survey of dental sedation users, UDH, has been developed for feedback on N2O manifold decommissioning. We have teamed up with Elaine Lewis, Pharmacy, to explore decommission N2O manifold, and to use cylinders instead. This work is in partnership with pharmacy, dental clinicians/nurses, anaesthetists, managers and estates.
Support for the project
Andrew Dickenson, Chief Dental Officer, Wales
‘It is a significant development for dentistry and aligns with the current policy direction.’
‘Welcome development, especially in light of the dental reform programme and the recovery of services post-pandemic.’
‘This would provide an opportunity to include sedation training into the HEIW training programme….. and serve as an attraction to bring new dentists into Wales.’
‘It could support MCNs and the upskilling of dental teams, their staff and establish more interest for offering enhanced services in primary care.’
