Case Histories Nos 2-514th Dec 2003

Here are three cases completed over the last few days Cases 2 & 3

These next cases involve a mother and her 5 yr old twins boys. Both twins have moderately hypoplastic 2nd deciduous molars. Twin No 1 had had a small occlusal amalgam filling at LLE completed at another practice. This had been completed without RA or LA and no further remarks were made to me concerning that procedure by his mother. He now required a slightly larger restoration in the LRE.

Using an airmotor-driven speed increasing handpiece I attempted to prep this tooth without RA or LA. He was very cooperative, from which I presumed he had had a pain-free experience for his first filling, however and this came as no real surprise to me, he very soon objected to me proceeding further.

At this point I stopped, explained the idea of RA to his watching mother, obtained her consent and completed the procedure using RA alone, but only just. Well we all make mistakes and learning from this, I treated his twin’s LRE with RA and LA and this proved so successful that mother requested RA for her own dental restorative treatment. Another success!

Cases 4 & 5 Both had very different clinical requirements but both have some similarities from a management point of view. Both are highly intelligent businessmen aged 45-55.

Case 4 is moderately anxious adult and he "doesn’t do pain". This would include gentle use of a BPE probe for example and over many years has been successfully treated using RA and LA. He sedates readily at a relatively low N2O level. He recently required more extensive treatment including a difficult crown prep and core build up in an upper second molar and opted for IV sedation. However he is needle phobic and with his very low pain threshold, I used RA first to enable the venepunture procedure. Even then he yelped but at least kept quite still so the rest of the sedation and dental procedure proceeded smoothly.

Case 5

I feel that an entire book could be written about the second case, so I will resist the temptation. Suffice it to say he is a true dental phobic in the psychiatric sense and has oral sedation just to get through the front door. He required a major restorative rescue of his upper anterior dentition as a provisional measure to tide him over the next few months until a permanent solution is found as he is a severe gagger. Yesterday he attended for a long IV session. I prescribed Temazepam tabs as a pre-med, which he forgot to take the night before and only took one dose, too close to the appointment to be effective – a lesson to learnt here! He is so anxious that his pre-op BP was something like 210/118 (pulse rate 116)

Here I used RA to reduce his BP and allow the venepuncture successfully. After 6 or 7 minutes on RA, his BP had reduced to about 160 /100 and pulse of about 85. He claims to have no known hypertension problems BUT I will be referring him to have this checked. At this point I was able to undertake his IV sedation although he is difficult to maintain over a long session. The dental procedure was completed as planned (4 upper anterior root fillings, 4 crown preps and two 3-unit temporary bridges). He recovered uneventfully .

As an update , after two and a half years he has never returned to complete the planned bridgwork. Probably a testament to my temporary bridge work and/or his deep seated phobia preventing him from returninng. This case proves the point that patients sedated by IV drugs have amnesia so never lose the intial fear. Their behavious cannot be modified whilst they are unaware that the dentistry they feared so much was nothing like as unpleasant as they had imagined it would be.