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The effect of remimazolam on a Parkinson’s patient

S. Madaan*¹ BDS (Lond), MFDS RCS (Ed), General dentist with a special interest in restorative and surgical dentistry, St Johns Dental Practice, Oxford, OX1 2LH.
A. Harris² BDS (Lond), DPDS, General dentist, visiting sedationist and SAAD accredited mentor, London, The Dentist Salisbury, SP1 2LH.
*Correspondence to: Dr Sita Madaan
Email: drsitamadaan@gmail.com
Madaan S, Harris A. The effect of remimazolam on a Parkinson’s patient. SAAD Dig. 2024: 40(II): 124-127 

Case Summary

A 63-year-old lady who is 5 ft 4 in and weighs 66 kg was diagnosed with Parkinson’s disease in 2016. Sedation with remimazolam was used with the aim of alleviating the patient’s fears so that we could remove her poor prognosis teeth and perform socket preservation in the upper left quadrant with the view to placing dental implants in the future. We found that using remimazolam enhanced her involuntary movements due to Parkinson’s disease, with each dose administered.

Patient details
Gender: Female
Age at start of treatment: 62 

Pre-treatment assessment

The patient presented with a left-sided swelling of the buccal space relating to two upper retained roots, not affecting the eye, and a toothache of two weeks. The patient stopped caring about her dental health after she was diagnosed with Parkinson’s disease in 2016 and started to neglect her dentition. She has started to feel self-conscious of her teeth but is extremely nervous of the dentist and has only presented because she had been suffering with pain for two weeks and had developed an abscess relating to some retained roots.

Relevant medical history

The patient is an ASA II. She was diagnosed with Parkinson’s disease in 2016. The patient also suffers from epilepsy and has been diagnosed as having grand mal seizures, although she had experienced a petit mal seizure in the last year. She has also been diagnosed with hypothyroidism. Overall, the patient is mobile, but says she is stiff in the morning and ok with stairs.

Medications

• Co-careldopa 50mg: primarily used to manage the symptoms of Parkinson's disease, however, it does not slow down the disease or prevent it from worsening
• Ropinirole 100mg a day: used to treat the symptoms of Parkinson's disease and restless legs syndrome - it can improve symptoms like shaking (tremors), slowness and stiffness
• Epilim 4mg bd: for epilepsy
• Levothyroxine 100µg od
• The patient also has a codeine allergy.

Previous sedation history

The patient has never been sedated before and has a BMI of 25. Her alcohol intake is 18 units per week with no history of taking benzodiazepines or recreational drugs. Her pre-operative blood pressure was 120/78.

Dental history

Irregular attender, has not attended for over 10 years.

Clinical examination

The patient had some trismus, not relating to dental infection. Several fractured teeth were seen with heavy evidence of parafunction and her muscles of mastication were tender because of this. There was evidence of heavy palatal erosion due to dietary acids, which the patient was unaware of. Calculus, plaque, and gingivitis were present throughout the mouth.

Bitewings and an OPG were taken for a full assessment of the patient’s dentition which showed:

LR7 is fractured and requires vitality testing and then cuspal coverage.

LR6 is a root filled tooth which has been prepared for a crown and will require a new crown.

LR5 is fractured with deep caries and has been recommended for extraction.

LL5 retained root recommended for extraction.

UR6 is a root fragment and requires extraction.

UR2-UL2 are fractured. Wear and exposed dentine can be seen clinically.

UL4 is a metal post crown with a questionable long-term prognosis.

UL6 and UL7 are root filled retained roots with signs of periapical pathology around UL7.

UL8 LL8 are unerupted.

There is mild generalized horizontal bone loss with vertical bone loss around the UL6 retained root.

Pre-treatment photographs

Diagnostic summary

1. Mild periodontitis (Stage 2 Grade A), which is active at present, with poor oral hygiene due to demotivation to look after oral health since onset of Parkinson’s disease.
2. Buccal caries on the lower premolars.
3. Retained roots which will require extraction. Multiple fractured teeth requiring cuspal coverage.
4. Palatal wear of the upper anteriors and fractured upper and lower incisors due to erosion, attrition and tooth position.
5. Post-extraction spaces which will require fixed, long-term space replacement to keep the bone stimulated and prevent bone loss from occurring in these areas.

Aims and objectives of treatment

1. Stabilisation of oral hygiene and gingival inflammation
2. Strengthening of enamel to reduce the risk of future decay and prevent tooth wear with high fluoride toothpaste
3. Elimination of any causes of disease, and to bring about a state of health, function and self-confidence
4. Alleviation of dental anxiety using treatment under IV sedation.

Treatment plan

1. Prevention advice: oral hygiene to be reinforced with emphasis on motivating the patient to introduce interdental cleaning into her regime. To discuss use of plaque disclosing tablets to aid removal of biofilm. Duraphat toothpaste to be prescribed to strengthen enamel against decay and prevent further tooth surface loss, which is of multifactorial origin (attrition and erosion)
2. Oral hygiene stabilisation with hygienist and periodontist involvement
3. Extraction of poor prognosis teeth and socket preservation in the upper left region as the patient would like to consider fixed space replacement, in the form of dental implants, if her oral hygiene permits this in the future. The patent is aware of the risks associated with dental implants including peri-implantitis. This phase of treatment will be carried out under IV sedation using remimazolam, due to the better sedative profile than that of the current drugs, including rapid onset and offset of sedation and a predictable duration of action
4. Caries stabilisation of lower premolars which require filling cervically
5. Fractured teeth to have cuspal coverage restorations and post crown to be monitored
6. Fractured anterior teeth and palatal exposed dentine to be repaired
7. Patient is also a heavy bruxist and will need some form of protection at the end of treatment. 

Treatment undertaken

• The initial presentation was as a new patient at an emergency appointment in February 2023 during which an assessment was carried out, a periapical radiograph (PA) was taken and referral for full mouth Orthopantomogram (OPG) made. Antibiotics were prescribed to prevent the further spread of infection and the patient was advised to return for a full mouth detailed clinical examination. Even though there were no signs of septicaemia or cellulitis, the patient’s reduced co-operation and compromised oral hygiene until this point was taken into consideration as a risk factor for further spread of infection.
• The patient then saw the periodontist and had multiple sessions with the hygienist every three weeks where disclosing tablets were used to aid oral hygiene instruction.
• She expressed her concerns about undergoing dental treatment and explained that she was nervous. We discussed the possibility of sedation, and she filled out an Indicator of Sedation Need form. Her pre-operative sedation score was 21 indicating a very high Modified Dental Anxiety Scale (MDAS) score. Given her underlying medical health and considering the treatment complexity this gave a score of ‘very high need’ for sedation.
• We elected to use remimazolam due to its superior properties over midazolam such as rapid induction, rapid recovery, and less respiratory depression.¹ The patient then attended in May 2023 for extraction of all retained roots, UR5, UL6, UL7, LR5, LL5 and socket preservation in the upper left quadrant (ULQ). At this stage the drug was in its infancy for use in general dental practice sedation cases, as remimazolam was approved for use in dentistry in the UK in January 2023.

Treatment findings

A total of 17.5 mg of remimazolam was administered over the course of 1 hour 15 mins. An initial 5 mg dose was administered. With every subsequent 2.5 mg increment given the patient demonstrated jerky movements and signs of un-cooperation. Her legs started to jerk, and her jaw would clamp down which would impede the procedure but then she would settle down. A brief timeline of events is as follows:

11.54: Rapid induction of remimazolam (5 mg over 2 mins)

11.58: The patient did not like the administration of local anaesthetic

12.06: 2.5 mg administered, patient became unco-operative and was very jerky during the upper left quadrant extractions

12.28: 2.5 mg administered. The patient reported ‘this is a great experience’.

12.32: 2.5 mg administered. Bone grafting of the upper left quadrant.

12.36: The patient was much more relaxed.

12.42: Sutures placed and collagen plug.

12.53: Patient is relaxed during further suturing

13.00: 2.5 mg administered, patient is unco-operative again

13.10: Patient is more aware of what is going on

13.13: 2.5 mg administered

13.20: Patient did not like local anaesthetic (LA)

13.35: Patient was co-operative for extractions

13.49: Patient settled down and was more co-operative but was aware of treatment

13.55: Remaining lower surgical extraction was completed

14.00: Procedure finished

Long term treatment and future considerations

 In future, we could consider giving a reduced dose over a longer administration period. However, reducing the duration of the drug use would make it unsuitable for long surgical types of procedures. It is worth considering that now that she has been reintroduced to dental work after several years, she may have a lower sedation score in future and may not need treatment under sedation going forward. Her next phase of treatment would be restorative and only when we come to implant placement may she feel a need to revisit the idea of sedation.

We could consider trying to manage her pre-operative anxiety using other relaxation techniques such as deep relaxation with diaphragmatic breathing or hypnotherapy². We could also consider the use of midazolam as there are case reports to support the use of this drug to ease the symptoms of Parkinson’s disease.²

At present the patient is still mid-restorative phase due to a fall and subsequent hip injury, causing a delay in the completion of her treatment. The anterior restorative work which has been carried out so far was unremarkable and was undertaken under local anaesthetic with ease.

Discussion and reflection about case presented

As remimazolam was only approved for use in dentistry in UK in January 2023, the seditionist had limited experience of practical cases with this drug. In hindsight, she could have started with a lower induction dose and could have given lower top-up doses, as the patient swung from being co-operative to unco-operative immediately after top-up increments.

On a follow up phone call the next day, the patient reported that the sedation was ‘fabulous’, she didn’t remember anything about the treatment apart from the tail end of the appointment and the patient was much more co-operative at this point. She felt normal upon leaving the practice and was delighted with the outcome.

Oral surgery can be difficult in patients with chorea-like dyskinesia (involuntary movements) which is common in those on long-term levodopa medication for Parkinson's disease,³ and we know of no conclusive evidence to indicate whether conscious sedation with midazolam is effective in such cases. However, there are case reports of a patient in whom levodopa-induced chorea-like dyskinesia disappeared when midazolam was given intravenously for conscious sedation, so this drug could be preferred in such patients.³

References

1. Kim K M. Remimazolam: Pharmacological Characteristics and Clinical Applications in Anaesthesiology. Anesth Pain Med (Seoul) 2022; 17: 1–11.

2. Wang R, Huang X, Wang Y, Akbari M. Non-pharmacologic approaches in preoperative anxiety: a comprehensive review. Front Public Health 2022, 10: 852673.

3. Shibuya M, Hojo T, Hase Y, Fujisawa T. Conscious sedation with midazolam intravenously for a patient with Parkinson's disease and unpredictable chorea- like dyskinesia. Br J Oral Maxillofac Surg 2018; 56: 546-548. 

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A synopsis of articles of interest from the last twelve months to inspire further reading 

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 Interview with Yi Loo
President of SAAD
Manni Deol (Honorary Secretary)

How long have you been connected with SAAD?
My first introduction to SAAD was in 2009 when I was working as part of a wonderful sedation team under the guidance of Paul Averley. He was a SAAD Trustee and pioneer in primary care-based research in paediatric conscious sedation. Shortly after this, I became the first SAAD member to join the society online and was elected to the Board of Trustees in 2015.

Since that first Board meeting, I have had the true privilege of contributing to SAAD’s charitable aims, not only through the Board of Trustees but also through the Training Board, the Teaching Faculty and as Assistant Editor of the Digest. The projects over the years have resulted in many close collaborations with the dedicated people on the SAAD Board of Trustees, Editorial Board, Training Board and Faculty who are truly an inspirational group of people, committed to excellence in our field.

It has been humbling and inspirational to meet and work with so many established sedationists from all round the UK whilst at the same time helping to guide those starting out on their sedation journey through the SAAD course. This has really driven home the importance of sedation for our patients and the privilege it is to be leading an organisation which supports so many caring and professional people.

Had you always wanted to be a dentist?
My first dream job was to become a vet. I was inspired by James Herriot’s incredibly humorous depictions of life as a country vet and was captivated by his compassion and the genuine care he showed for animals and their owners. As I read and chuckled along to Herriot's stories, he made me appreciate the unique bond between a caregiver and their patients and that sense of connection and empathy became a driving force for me. Over time, however, I realised I would be utterly hopeless in the fields of modern Yorkshire as a born and bred Londoner and that dentistry would allow me to bring that same level of dedication and care to people in a hands- on, meaningful way. Dentistry has turned out to be the perfect path for me, but I suspect that Herriot’s influence is still close to my heart!

What would your alternative dream job be?
For a long time, I envisioned life as an architect, driven by the idea of creating spaces inspired by the many that I love: the Getty Museum in Los Angeles, Penang’s Peranakan Mansion and far too many incredible buildings and spaces in London to list now. They each induce calm and invite their visitors to spend time and think beyond the immediate vistas. In many ways, it is an extension of what we do as dentists. We create environments that bring people together from different backgrounds and perspectives, to ground us and help us to make meaningful impacts in daily experiences.

Where was your last holiday?
We were very fortunate to have a family holiday to Greece in the October half term. It was a real treat to savour those last rays of sunshine before we headed into the Christmas countdown.

Which dental school did you attend and when?
I spent five incredible years in ‘the Toon’ as a dental student at Newcastle University from 2002 to 2007.

How much sedation, pain and anxiety management were you taught at that time?
I was very fortunate to train in a dental hospital with such a brilliant reputation and passion for patient care and sedation. John Meechan was, at the time, carrying out trials on willing students, such as my housemates. He was comparing lidocaine with what was the new kid on the block, articaine, so the concept of advancing analgesia was being nurtured from the outset of my dental education. From him, however, I learnt that the real skill in helping dentally anxious patients was not the drugs, but compassion and care...and a shared dedication to supporting Newcastle United!

After gaining my BDS, I completed further House Officer jobs in departments such as oral surgery, sedation and paediatric dentistry. This is where I delivered my first dental treatments under inhalation and intravenous sedation and gained an awareness of the work of the sedation department, the basis of my experience prior to completing the Diploma in Conscious Sedation at the University of Newcastle upon Tyne.

What is your favourite food?
My favourite foods are a mix of nostalgia and comfort. I have a soft spot for homemade Chinese dishes from my childhood: flavours and textures that bring back memories of family meals and traditions. Then there’s apple crumble, which has been a favourite ever since my very first cooking class as a 7-year-old; learning to make it sparked my love for that warm, cosy feeling that comes with eating it. And, of course, I can’t resist a good scoop of gelato, specifically liquorice gelato, something I’ll happily enjoy any time!

Who or what were the main influences which led you towards an interest in sedation?
The first time I truly saw the therapeutic power of sedation was when I shadowed Kathy Wilson at a community clinic in Tyneside as an undergraduate. It was like watching David Copperfield at work. Her skill was more than evident as she coaxed a man through his dental treatment under inhalation sedation with such apparent ease. I now realise that it was made to look a lot easier thanks to her incredible skills in patient management.

After this, I was fortunate to work under the guidance of Paul Averley and his team providing sedation for adults and children who were referred from throughout Teesside and County Durham. Unbeknownst to me at the time, Paul was instrumental in helping to design the initial SAAD Safe Sedation Practice Scheme, the SAAD quality assurance programme to benchmark sedation services. He was also working with bodies such as the Standing Dental Advisory Committee and the National Institute of Health and Care Excellence (NICE) to develop national guidance alongside his pioneering work in primary care sedation research. I was immersed in a ‘lived and breathed’ translation of the sedation guidance of the day, surrounded by innovation and a large, skilled, sedation team with one goal in mind: delivery of safe, efficient dental care under sedation.

In what way did your sedation training change your career and clinical practice?
My initial sedation training and Diploma in Conscious Sedation helped me secure a post providing oral, inhalation and intravenous sedation for children at King’s College Dental Institute, London. Alongside other roles as a clinical tutor and general dental practice associate positions, I learnt the importance of really listening to children’s experiences alongside those of their patients to try to unpick their concerns and expectations.

The clinics treated the full diaspora of children who live in London, many with high levels of socio-economic deprivation, and complex psycho-social and / or dental needs. I soon learnt how to appropriately assess medically unwell patients and it honed many oral surgery skills.

The need for sedation touches children from every corner of society. I gain such satisfaction from trying to understand each child’s journey and take joy in helping to build a solid foundation for future oral health care, so much so, that I then decided to take on specialty training and became a specialist in paediatric dentistry.

What changes do you intend to make at SAAD over the next three years?
Dentistry in the UK is constantly evolving with innovations across the sector resulting in a highly dynamic dental landscape. Although technology and societal changes reinforce some of the movements, I hope to ensure that SAAD continues to support existing members whilst meeting the needs of the new generation of dentists. The Society has some fantastic initiatives which we will continue to encourage and develop. We will promote innovation and research, not just by those in established research centres, and hope to inspire more dentists and their teams to add sedation and further anxiety management skills to their skillset.

Alongside this, I intend to grow SAAD’s reputation as the leader in sedation, pain and anxiety management and ensure that it continues to be respected as the voice of reasoned, evidenced and unbiased sedation advice. 

You seem to have had a varied and interesting career in dentistry. Can you tell me which has been your favourite job or role?
I have a lot of admiration for various people in different roles. However, one aspect that stands out is watching team members grow and develop. I particularly enjoy seeing the progress of those you've trained, like dental nurses or other dentists, as they advance in their skills and careers.

Do you have any regrets?
I try to learn from the past and not dwell and regret!

What one thing do you think would improve NHS dentistry?
Improving NHS dentistry is a complex challenge, but one impactful change could be increasing funding and resources to allow for more comprehensive and preventive care under sedation. 

What is an average week like for you at the moment?
Each week brings consistent variety. I currently work at Guy’s and St Thomas’ Hospital and St George’s Hospital providing consultations for referred patients, treatment under sedation and general anaesthetic and much more!

What about interests outside of dentistry?
Outside of dentistry, my life is all about family and friends, exploring and staying active. I love spending quality time with my husband and our two boys: they keep me grounded and always on my toes! We’re big on making memories together, whether it's exploring new places or simply enjoying family time. I’m also energised by playing netball; it’s a great way to stay fit, unwind, and embrace a little competitive spirit with some fellow mums and old friends.

What is your guilty pleasure?
I do enjoy savouring a good quality hot chocolate on a cold day or singing along to the Les Misérables (original London cast recording) to dust off the cobwebs! There is something so powerful about the story and the interpretation of the score which produces shivers despite having listened to it countless times.

What three pieces of advice would you give a young dentist with an interest in sedation?
Firstly, I would recommend joining SAAD to access the membership perks such as access to our webinars and the Digest.

Secondly, attend a SAAD course to meet sedationists from a range of dental backgrounds and other delegates who may be in the same position as you.

Finally, the old adage of practice makes perfect! Find what works for you!

What is the most important lesson life has taught you?
I think one of the most important lessons is to embrace the beauty and promise of what’s around us, to appreciate the present and not just hope for what is beyond us. It’s wonderful to dream big, to look to the horizon and imagine new possibilities; just like watching the sunrise and sunset and wondering about the lands that lie beyond it. But even more meaningful is savouring the view right under our noses: the sand, the sea and the beauty in the people around us. Make time for true compassion, show moral integrity and consider others’ perspectives. That is what brings real fulfilment.

 Ronan Lee

Dentistry has been a winding journey for me, one that started with challenges but has led to an incredibly fulfilling career. Initially my path wasn’t the smoothest, having been rejected from dental school due to my A-levels, so I spent three years at the University of Nottingham before reapplying successfully onto the graduate entry programme at King’s College London and qualifying in 2022.

During my time at King’s, I was honoured to win several awards including the Jose Souyave Prize and the Peter Lunt Prize. However, it was the Harry Radin Prize for Special Care Dentistry that sparked my interest in working with anxious patients and conscious sedation.

After my foundation training, I completed a Dental Core Training (DCT) post at the Royal London Dental Hospital. During this time my interest for managing complex cases through conscious sedation flourished thanks to the incredible mentorship I received from colleagues in the Special Care Department. I went on to gain accreditation in both intravenous and inhalation sedation techniques. I also undertook a sustainability quality improvement project aimed at raising awareness of the environmental impact of nitrous oxide and more environmentally-friendly techniques. Presenting my findings at several national conferences was both rewarding and eye-opening, and I was fortunate enough to go on to win SAAD’s Drummond Jackson Essay Prize as a result of this work.

In my practice, I incorporate sustainable sedation techniques whenever possible. From non-pharmacological methods such as theta waves and calming scents to reduce anxiety, to reducing reliance on nitrous oxide, I work to ensure that my approach balances effective patient care with environmental responsibility.

I currently divide my time between Leicester Square Dental Clinic and The Park Dental Practice in Stanmore, providing general dental services. Alongside my clinical practice, I am pursuing an MSc in Implant Dentistry at Eastman Dental Hospital, while also offering peripatetic sedation services.

Beyond clinical work, I am passionate about giving back to the dental community. As a trustee for the Tom Bereznicki Dental Education Foundation, I am focused on supporting the growth of newly qualified dentists.

As a new Trustee at SAAD, I’m excited to bring new ideas, particularly in making the charity more accessible to younger professionals. I know first-hand how impactful sedation can be for anxious patients, and I believe that with the right mentorship and education,more young dentists can incorporate this invaluable skill into their practice.

Outside of dentistry, I am training for the Bologna and London Landmarks Half Marathons. Cooking is another passion of mine, and I love sharing my food on Instagram under the handle @ronanleefoodie.

Simon Chaplin-Rogers

I qualified in December 1979 at University College Hospital Medical and Dental School (UCHMS). Post qualification there followed six months as a Dental House Surgeon at UCH, before being awarded a medical place qualifying in Medicine in 1984. Then followed a medical rotation training for the next five years, my last year being as an SHO /Registrar in anaesthetics / intensive care based on the Middlesex Hospital rotation.

In 1990 I moved from London to join a medical partnership in Hampshire, working three and a half days a week as a general medical practitioner (GP) and one and a half days in Putney, London as a general dental practitioner (GDP) with a special interest in sedation. As a GP in the early years, I maintained my interest in medical anaesthetics, working with Hampshire Ambulance in the scheme then known as BASICS (British Association of Immediate Scheme Doctors) assisting ambulance teams at trauma and big incidents. This has been superseded by the paramedic teams that we see today plus more formally trained trauma anaesthetists.

Then followed a period of a year’s attachment to the Eastman Dental Hospital before purchasing and forming a dental partnership group and developing two sites in Winchester. It was an NHS dental practice, a teaching practice and provided private care. I was one of the Vocational Trainee trainers, sedation teachers and providers of care. In the wider dental community, I served on the executive of the Hampshire, Dorset and Isle of Wight Local Dental Committee, including periods as vice Chair and Chairman and still do have a special interest in supporting colleagues and practices in difficulty. In 2015 I undertook the diploma course in conscious sedation course run by Newcastle Hospital: this was a time to undertake a focussed revision period in this aspect of care.

On the medical side, I went on to become the senior partner of the medical practice based on two sites in Chandlers Ford, Hampshire. We were an eight partner practice looking after 17,000 patients. I retired from the practice in May 2022 and now work as a GP advisor to urgent care services in University Hospitals Dorset (Royal Bournemouth, Poole, Christchurch Hospitals).

I have always worked in large dental and medical partnerships and have found them rewarding both in clinical focus and peer engagement, the ‘support’ around the many business issues is invaluable: especially now in these challenging times as demand and expectations have to be met.

With that passion around partnership in mind, over the past four years we have started to build up a group of partnership-led practices. We number twelve practices with a staff of 56 GDPs, 32 hygienists and therapists, 200+ reception and nursing team. We have an active sedation training programme across all the practices.

On a personal note, I was born in April 1955, am married with four, now adult, children and we have a smallholding farm that is a hobby and a carry on of ‘The Good Life’.

I hope I can bring to the role of Trustee a business-based clinician with a broad experience of primary care provision of service. I would like to describe myself as someone who comes to the ‘table’ with solutions not problems and is always thinking ‘where do we need to be in five years?’

Stephanie Fenesan

My journey into dentistry began at King’s College London, from where I graduated in 2012. It was here that I first got hands-on experience with conscious sedation, particularly in the paediatric and special care dentistry departments. I loved these early opportunities to connect with patients and help ease their anxiety, setting the foundation for my career.

After graduating, I moved to the beautiful south coast to complete my dental foundation training. I then spent two years in Dental Core Training, focusing on special care dentistry and oral and maxillofacial surgery. This period was incredibly rewarding as I provided a wide range of care for patients with additional needs. Each patient brought a unique set of challenges and I enjoyed the unique problem-solving skills needed to formulate individual, tailored treatment plans for providing their dental care. The variety of patients and range of dental treatments we provide in this field keep my work exciting and engaging.

In 2019, I started specialty training in special care dentistry at Guy’s and St Thomas’ Hospitals. This experience allowed me to deepen my knowledge of conscious sedation techniques and during this time I completed my master’s at King’s College London. My thesis, which was a systematic review on intravenous sedation with midazolam, not only enhanced my understanding of evidence-based practice but also highlighted the importance of continual learning in our field.

I currently work in the special care dental service across London and Hertfordshire, where I have the privilege of caring for a diverse range of patients from those with dental anxiety to individuals with learning disabilities and complex medical conditions. Each day presents new challenges, and I enjoy the sense of achievement that comes from overcoming them. Knowing that I can make a positive difference in someone’s dental experience is incredibly rewarding. 

In addition to my clinical work, I mentor new starters providing sedation and am a clinical supervisor for specialty trainees. Being involved in teaching has reinforced my commitment to providing high-quality care while also ensuring that the next generation of dental professionals is well equipped with the knowledge and skills they need to provide safe and effective dental care. Teaching keeps me connected to the evolving landscape of dentistry.

Outside of work, I enjoy spending time with my husband and our two young children. We love exploring together, and my daughter’s recent fascination with the Tudors has led us to visit the Tower of London multiple times this year! Each visit turns into a mini-history lesson, complete with tales of weddings and beheadings.

Richard Kerr

I am a Londoner originally and trained at United Medical and Dental Schools of Guy's and St Thomas' Hospitals (UMDS) qualifying many years ago.

I relocated to beautiful Devon shortly after qualifying and started my career in oral surgery. I have practised intravenous (IV) sedation for many years in both primary and secondary care oral surgery settings, having started my training in sedation with SAAD.

I am an Associate Specialist in the department of Oral & Maxillofacial Surgery (OMFS) at the Royal Devon University Hospital. I also have a primary care oral surgery (OS) contract and work in a local dental practice.

Despite being exempt from the new requirements to practice sedation, I decided to undertake a diploma in conscious sedation at Newcastle dental hospital seven years ago: an excellent course that I would highly recommend.

I am a sedation supervisor for nurses and dentists training in sedation. I also teach sedation for the MSc Oral Surgery course run by the Peninsula Dental School.

I have recently been able to introduce an inhalational sedation service for patients in the OMFS unit. I am honoured to become a Trustee for SAAD.

Outside of work I am a keen runner and also trying to complete walking the southwest coast path.

 The Lord Colwyn
President of SAAD 1993 – 1998

Lord Tony Colwyn was born Ian Anthony Hamilton-Smith on New Year’s Day 1942, the elder son of the second Baron Colwyn of Colwyn Bay. He went to school at Cheltenham College where he excelled at swimming and rugby. He did his dental training at Barts and the old Royal Dental Hospital. On graduation in 1966 he returned to Cheltenham and worked firstly as an associate and then in a successful partnership with Goeff Hind. However, he wished to return to London and for some years worked as an associate for Stanley Drummond-Jackson, the founding father of SAAD, in his Wimpole Street practice. While he was taught anaesthesia for dentistry at the Royal it was his time with ‘DJ’ that gave him both the enthusiasm and practical skills that would shape his future career. While with DJ he became involved with SAAD, as a tutor at the ‘big’ courses at Gower Street and with the administration of the Society. He was president of SAAD from 1993 to 1998. In 1983 Tony and I formed a partnership at 53 Wimpole Street. We had been friends for many years and on occasions worked together but the abolition of the operator / anaesthetist suggested an amalgamation of our two practices (I had taken on No 53 on the death of DJ in 1978). We enjoyed 20 years of a wonderful partnership and remained close friends in our retirement. Tony gave a great deal back to dentistry. He advised the GDC and the BDA when they sought advice on parliamentary matters. He was a non-executive director of the Medical Protection Society and later Chairman of Dental Protection from 1995 to 2001.

Tony inherited the title on his father’s death in 1966. From the first he was a conscientious and regular attender at the House of Lords.

He survived the Blair reforms of the upper house of 1999 and was one of 92 hereditary peers to retain their seats. He sat as a Conservative, served on numerous Lords’ committees and was elected Deputy Speaker in 2011. In 1989 he was appointed CBE for his services to Parliament. He continued to cycle to the House, after surgery in Wimpole Street and then from his home in Chelsea, until ill health forced his retirement in 2022.

From his youth he was an enthusiastic and talented jazz musician. At college he teamed up with Jim Beach to play and while Jim went on to manage Queen, Tony formed the 3B Band. It was hugely successful. They played society gigs, fancy weddings, hunt balls, the Albert Hall and the late Queen’s ruby anniversary party. And my 60th. He was a founder of Jazz FM radio with Johny Dankworth. He was a member of the Parliamentary jazz group with Ken Clarke and others. He always maintained the 3B Band made very little but they certainly had a whale of a time.

Sadly, Tony contracted Lewy body dementia some four years ago and died of complications on 4 August 2024. He is survived by his wonderful wife, Nicky, who cared for and nursed him at home; by his son, Craig, who inherits the title and by his beautiful daughters Jackie, Kirstie and Tanya. 

What a wonderful life. I will miss him. 

Ian Brett

Meg Skelly (1947 – 2025)

BDS (Hons), FDS RCPS (Glasgow), MDS, FDS RCS (England)

Ann Maureen (Meg) Skelly was born on 18 February 1947. Meg had considered becoming a dentist but instead began her career as a student nurse at St. Bartholomew’s Hospital in 1965. On qualifying, she undertook further training at the Radcliffe Infirmary in Oxford in anaesthetic nursing. Following a period in Canada and Norway, she returned to the UK and became an anaesthetic sister at Dulwich Hospital, London. This experience would later lead to her interest in dental sedation. In 1973 she became a dental student at Guy’s Hospital Dental School, eventually fulfilling her earlier interest in dentistry.

Following her graduation Meg held house officer, demonstrator and lecturer posts at Guy’s before being appointed as Senior Lecturer and Honorary Consultant in Dental Sedation. This was a groundbreaking appointment, supported by the Department of Anaesthetics, which led to the establishment of the UK's first Department of Sedation and Special Care Dentistry at United Medical and Dental Schools (UMDS) / Guy's Hospital in 1996.

Meg led the teaching of sedation techniques for dentistry in the UK. She was responsible for training thousands of dentists who went on to provide safe and effective care for large numbers of anxious patients. Many of Meg’s colleagues and trainees went on to establish novel training programmes in procedural sedation for dentists, doctors and nurses. Meg also made a significant contribution to sedation-related research and training published in peer-reviewed journals, book chapters and textbooks.

In addition to her clinical and teaching roles, Meg was Student Admissions Director at UMDS (later Guy’s King’s and St Thomas’ Dental Institute [GKT]) for ten years from 1996 and in 1992 she was elected President of Guy’s Hospital Dental Society. In 2007 GKT recognised Meg’s outstanding achievements by conferring upon her the Distinguished Service Award.

Meg was a conscientious, effective and popular head of department. She led her team by personal example and established excellent working relationships with colleagues in the hospital and school. Meg’s vision and high standards ensured that the department would continue to develop long after her retirement in 2007. Meg will also be remembered for her kindness, patience and mischievous sense of humour.

Meg died on 31 January 2025 at the age of 77, following a long illness. She will be greatly missed by her family and all those whose life she enriched.

David Craig
2 February 2025