RA Today Case Histories

Case No. 20: RA for endo. in a 14 yr old

2004-10-15T21:21:00.000-07:00

Today I undertook an endo treatment for a 14 yr old in an upper 2nd pre-molar. She has been a patient since she was about 5. She is a very pleasant young lady who is just a tad over-protected and is at the awkward teenage stage.During her fixed ortho. (Carried out on referral to an orthodontist) she dropped out of regular attendance and re-appeared with pulpitis from a deeply carious cavity a few weeks ago.

I used RA then to undertake a vital pulpotomy without problems. On titration, she took a little longer to become adequately sedated and a slightly higher % of N2O than I would have guessed. However this first session gave us a datum level to work at for the next session. She returned today for the Endo at UR5.

We quickly established sedation at the previous O2/N2O level. During induction, topical was applied and once sedated, the LA was given with no response from her. We waited a few minutes, applied a rubber Dam and the endo was completed without any reaction from her at any time. This included application of rubber dam clamp, Hawe- Neos clear Matrix and a wedge to complete a composite filling with a glass ionomer base.

The composite was placed with a compression instrument to achieve a good contact. On removal of the rubber dam clamp I noted it had compressed the unanaesthetised palatal gingival margin somewhat. Again this had elicited no response from her and will recover quickly I am sure. 2 intra-oral peri-apical films were taken with digital sensors and holders, which are generally quite uncomfortable for many, again without reaction from her.

RA can achieve this for you and your patients too!

Case No 19 Extns in a heavy smoking diabetic

2004-10-14T19:21:00.000-07:00

One of today's RA cases has been an irregular attender over a number of years.
He is a nice chap, but with poor dental health. A teacher aged about 55 and a heavy pipe smoker (an inhaler). He sounds "chesty". 2 years ago he was diagnosed diabetic, (controlled with oral mediaction). He Required a clearance of his remaining severely periodontally compromised upper teeth. (5 of them) and fitting a F/- Immediate denture.

Implants are not an option for him. He has had RA before but asked about IV sedation. I did explain the small risk with IVS due to his restricted lung capacity possibly resulting in a rapid drop in SaO2 as his breathing slows and becomes shallower. Also a possible, but difficult to quantify, risk of blood glucose levels being adversely affected. So he happily agreed that with the high level of oxygenation available with RA, that this would be his preferred option.The whole procedure was completed without any problems – Oh and the denture looks great too!

Case No.18THE perfect advert for Relative Analgesia!

2004-10-12T22:06:00.000-07:00

Today I was back on on cloud nine, never mind the patient. I completed a case that would have been THE perfect advert for Relative Analgesia

A young girl of 11/12 yrs of age required the extraction of 6 deciduous teeth for ortho.All were moderately firm. They were:

Upper e/cde and

lower e/e

She is a "bit of a madam" and came into the surgery with Mum, who is a sensible type." Is this going to hurt?” she says........... You get the picture! After a little banter careful explanation and reassurance she easily accepted the nasal mask.Then, under the influence of RA, titrated, in her case to 50% N2O: 50% O2 (remember every case is different) she became very well sedated. Topical was applied during the induction on CWRs to all 4 quadrants. Mother was happy to leave the room at this point.

Buccal infiltrations for all 4 quadrants plus lingual infiltrations for lower e/e plus bilateral palatal infiltrations for the upper teeth and not a murmur or a blink from her. (Yes, that is 8 x LA injections).All gingival margins probed to ensure adequate LA and all extns. carried out without so much as twitch from her.Recovery, as always was swift, mother returned to the surgery during O2 recovery phase and she left the surgery 31 minutes after entering.

Brilliant, it really made my day. I only wish I had video'd the case. There will be others.

Welcome to the Case History Section

2004-10-10T14:34:00.000-07:00

Just three more cases to upload to this site to make the promised 20 !

Case No 17. A True Dental Phobic

2004-10-10T14:11:00.000-07:00

Earlier this week I saw a adult male patient with extreme anxiety, verging on a true phobia. I had seen him only once before when he attended with an abscess arising from a previously root-filled LL3 (#33) about 18 months ago. On that occasion we treated him under IV Midazolam and re-treated the tooth, which has been symptomless since.

He arrived, perspiring profusely through fear, though he is otherwise an entirely pleasant chap, he has had a very adverse previous dental experience(s) as a child. His hair and shirt were soaked before he sat in the dental chair ! On this occasion, he was unaccompanied, had a mechanical # of the ML cusp of LR6 ( #46) and had gross supragingival calculus and staining anteriorly. Oh yes , and he was getting married in a few days time!

Isn't it always the way !

After all the necessary explanations and duly signing a consent form, we were able to administer RA ( inhalational sedation) there and then, provide a temporary dressing and using an ultrasonic scaler, smarten him up for his wedding. He may well not permit more than this level of treatment without I.V. sedation. This remains to be seen in the future.

This case illustrates nicely, 3 key benefits of Relative Analgesia.

It can be used "in an emergency" situation when an escort is unavailable.
In some cases it can be used to allow simple palliative treatment in otherwise fearful patients, pending an IV session at a later date.
That patients who get used to IV as a sedation method, never conquer their fear, since they have little recall of the fact that the dentistry could have been or was pain free. They may well become indefinately dependant on IV sedation.

Legal and Copyright notice

2004-10-06T15:12:00.000-07:00

Thank you for taking the time to read this RA "Blog" website. Are you convinced of the benefits yet? If you feel that you would like to be able to offer RA to your patients, please contact me for details of my Hands-on RA training courses.

Richard Charon is a Dental Practitioner serving Dental Practitioners in their desire to provide the benefits Relative Analgesia (Inhalational Sedation) to their patients. His One day Hands-on teaching courses are currently delivered from his Private Dental Practice at St. Mary’s House Dental Practice, Newbury, Berkshire SL6 6HF.

You may copy or distribute “RA Today “as long as this copyright notice and full information about contacting the author are attached. The author is: Dr.Richard Charon Contact him at richard.charon@ntlworld.com or at St. Mary’s House Dental Practice, Newbury, Berkshire SL6 6HF. Tel: 01635 47757 Please forward this e-newsletter to your friends and colleagues.

Your recommendation is how we grow awareness of our one-day Hands-on RA course. To change or cancel your email address, e-mail me directly at richard.charon@ntlworld.com We will never release, sell or give a subscriber's name or email address to any other party or organisation. Course attendees or those making enquiries will only receive email messages that contain requested information, new articles or newsletters or announcements of new services

SITE IN DEVELOPMENT

2004-10-05T13:32:00.000-07:00

THANK YOU FOR NAVIGATING HERE

OVER 20 RELATIVE ANALGESIA CASES WILL BE POSTED HERE IN THE NEXT FEW DAYS.

IN THE MEANTIME THEY CAN BE FOUND BY SCROLLING DOWN THE SCREEN on www.the-ra-coach.com

THANK YOU FOR YOUR PATIENCE

Cases 15 & 16- Two Anecdotes

2004-07-18T20:49:00.000-07:00

These next two are really short anecdotes. Both involving the use of Relative Analgesia for children.

Case 15

This youngster was one of my RA Course demonstration cases, who attended with her mother last Saturday and whose treatment under RA was video- relayed to my course participants. She is a small 7 1/2 year old who has had several restorations from the age of about 5 with Relative Analgesia (RA) and LA. Towards the end of her 20 minutes session (to place a medium sized Glass ionomer in LRd with LA ), I told her she was " breathing fresh air now" and that she "would soon be on her way home". She said she didn't want to go home because the happy air was fun and she went on to tell me that " I am the only one in my class who likes going to the dentist. I think I want to be a dentist when I grow up"! Mother was delighted at the result and quite rightly very proud her offspring too.

and in a similar vein ( no pun intended)

Case 16

We saw a thirteen year old with retained , though moderately mobile upper Es today for routine examination. Both teeth has small distal cavities which required temporary fillings to await their exfoliation in the next few months. I bgan to remove her breakfast from these areas and she asked if she could have Relative Analgesia (RA), to which I replied that there was really no need this time for sedation. " Well then can't you take them out, then I can have the happy air" she said.

Children volunteering for extractions ?!

Needless to say she didn't get her wish but left cheerfully anyway !

Relative Analgesia (RA) is a practice builder - you'd better believe it !

Case No.14 20 yr old gagger

2004-05-19T21:37:00.000-07:00

A lady in her late twenties attended today. She was moderately anxious with a tendancy to gag. UL7 was grossly carious though only slightly sensitive. A PA showed the caries to be very close to the pulp. But the tooth was salveagable.

She was booked today for an exploration and temporary dressing. Proceeding incrementally, good sedation was, unusually, only acheived initially at 30% N2O/O2. LA was acheived using The Wand Plus TM The Nitrous Oxide ratio was reduced to 40%/60% Oxygen.

Without detailing the detailed clinical stages from here, the net result, was a vital pulpal exposure , needing intra-pulpal LA and a vital pulpotomy.

She was delighted with the result and has promised a testimonial. She was clear that she would not have tolerated treatment "that far back" without the assistance of RA. I am sure you all see patients like this on a regular basis.

RA makes life so much easier for everyone and the patient is sure to return and be a source of referrals.

Case No 13. 20 Year-Old ReportStill Worthy of Repeating

2004-05-14T23:21:00.000-07:00

This case report is a bit of a cheat. I actually undertook it nearly 20 years ago!!

It is no less valid today. A cheeky 4-5 yr old boy with a mop of red hair had a number of carious teeth to restore. He was full of beans and not overly keen on cooperating. We introduced him to RA using a simple "tell,show,do" approach. First the nasal hood (without being attached to the tubing) to play with and try out.

Then checking it out on his nose " to make sure he could breathe through it" Then attaching the tubing and providing a few minutes trial run, with no treatment- indeed making sure that he DIDN'T open his mouth. This was very effective and well accepted and he returned for 2 or 3 visits to complete the required work.

At the end of the last session and having had his 2+ minutes on 100% O2, he sat up and uttered the priceless words.

" Mum, will you buy me one of these" !

A great success and words I have recalled and re-told regularly since then. If you would enjoy your day's work more with reactions like that, perhaps it is time you considered introducing RA into your repetoire.

Contact me for more information : richard@the-ra-coach.com

Case No 12. RA can be ideal for short notice problems

2004-05-06T22:14:00.000-07:00

Today we saw a patient who was so anxious that he had failed to attend two previous appointments. He had arrived at the front door and THEN TURNED AWAY thorough fear. Today he booked himself in under a pseudonym because he thought we would refuse to reserve an appointment for him a third time ( he may have been right !).

So what was his dental problem?

1) He is a commercial pilot

2) He was flying tomorrow and would be away for 3 weeks

3) He was worried about a LL7 which had had a composite placed elsewhere about a year ago and hadn't settled. Having had several root fillings before he assumed he would need the same again.

4) Recent treatment had been carried out under IV sedation.

Given that he was booked in as an "emergency" we were not in a position to offer IV sedation at short notice and with no escort. The tooth was vital but not especially hyperaemic, slightly TTP, no buccal tenderness and with a normal perio condition. The composite filling was reasonably satisfactory externally but was an occlusal with a long buccal extension. A P.A. radiograph revealed no pathology and the filling appeared relatively shallow. I provisionally diagnosed post-composite sensitivity , probably as a result of setting contraction. I advised this was unlikely to get worse in the short term but he was keen for me to "do something".

Using RA we needed to go to a 35% Nitous oxide/ 65% oxygen level to achieve sufficient sedation. I also used the "WAND" for an ID block with no reaction from him. Effective LA was swift and removal of the composite revealed a clean, well prepped ,shallow cavity. I placed a glass ionomer and he recovered uneventfully. I expect that this will have settled his problem . He booked a full New Patient consultation and paid for this in advance before he left today. Another happy patient & another source of referrals. I will ask him to write a testimonial at his next visit. We didn't have time to begin to discuss the reason for his dental anxiety, but RA was the right tool for the job for him today.

Case No 11Patient almost speechless with delight at the outcome

2004-02-05T22:06:00.000-08:00

This lady attended for the first time some weeks before Christmas. She takes good care of her appearance BUT her fear of Dentistry has kept her from seeking care for many years. She has a moderately advanced chronic periodontal status and some failed old restorations.

We introduced her to the benefits of RA before beginning any treatment and now have made very good progress in improving her periodontal condition, using RA to allow her to cope with the necessary operative first phase treatment. A few days ago I completed 2 extensive composite restorations, replacing leaking/failed amalgams. In addition to RA, I used my newly acquired Wand Plus (TM) LA machine and of course, rubber dam. The synergy of a sense of detachment created by the RA and the entirely painless LA procedure and the sense of "separation" created by the use of the dental dam left the patient almost speechless with delight at the outcome.

Quite simply, she could hardly believe how easy & pleasant this dental experience had been compared to her previous experiences.

I am confident that she has now turned the corner and will become an excellent dental patient with all the benefits that flow from that for her and for us in terms of growing our practice reputation. So I am looking forward to a testimonial and referrals of new patients from her.

Would you like to be able to offer your patients these benefits? See below for details of my Hands-on RA courses or e-mail me at richard.charon@ntlworld.com

Case No 10. RA & The Wand(TM) A Win-Win

2004-01-30T21:47:00.000-08:00

Well here we are again back on cloud nine. This case combined my newly delivered Wand Plus LA machine and RA. Yesterday's case involves a 12/13 year old. She was seen for the first time recently with a deep carious cavity in # 46. X-ray and symptoms indicated a likely pulpal exposure. #47 was in position and #48 was present on radiograph.

At her first treatment visit , she easily accepted RA and we proceeded with normal ID block. Very careful caries excavation produced an evident vital exposure. This was dressed and a discussion with mother followed re endo or ext and ortho to move #47 mesially keeping it upright. She attended about a week later requesting Ext.

We went ahead with her RA sedation and acheived adequate levels within 2-3 minutes. Using the Wand and the single tooth technique . #46 was individually anaesthetised -NO ID BLOCK was used and the tooth ext painlessly about 1-2 minutes later.

Result. Relaxed happy patient and mother ( who watched the entire procedure- her choice not mine !). Her Mother , also a new patient has recently had RA for her treatment too. Will I use this combination again- why certainly ! Would it have worked with conventional IDB - why certainly but the wand meant no numb lip for hours afterwards and a rapid and predictable anaesthesia. I have yet to review her regarding healing and her experience of the post op period. I'll let you know when I do.

REVIEW
Case History Case 10- REVIEW We reviewed our case 10 ,young lady, treated as described below. She and her mother were absolutely delighted with the result. The healing was quite uneventful, and the patient in question had some further restorative treatment under RA which was starightforward too. Result: Happy patient ~ Happy Dentist - Win- win with RA !

Case No 9RA is not for every patient

2004-01-20T22:40:00.000-08:00

Well, in truth , probably not. However in my opinion the success rate is in the high 90% in terms of being able to successfully complete a planned procedure.

In Case 9 I have included a touch of honesty ! Today I examined an adult male in his mid 40s. He attends irregularly as he is a moderate gagger. His perio condition indicated the need for a number of periapical radiographs. He managed the first but then began to gag. In the past he had had RA for treatment. Unusually he requires a maximum dose to have a worthwhile effect. He agreed to using RA for the rads. Despite sedating him to a max 70% Nitrous : 30% oxygen, he had some difficulty in permitting the radiogrphic examination.

However we eventually succeeded with he minimum of gagging. In all probabliity, he was mouth breathing, at least for some of the time and so did to gain the full benefit.

So was he fully sedated? - No.

Did the RA negate his gag reflex? - Partially.

Did I manage to take the required x-ray images? - Yes

Was this a success?- Partially.

Will he return for further treatment? - I expect so.

There you have it. Is RA always the answer. No.

This afternoon I interviewed a prospective patient in need of some major dental treatment. It took her 20 minutes to cross the road to enter the practice. I have no doubt that the depth of her anxiety means she is more suited to IV sedation and intend to offer her this form of sedation.

Case No. 8. Composite @ #46 with No LA

2004-01-19T13:21:00.000-08:00

This afternoon I treated a 10 year old with a carious DB fissure in tooth 46 (LR6). The cavity was into dentine though only a little wider than the fissure. She has had RA before. She was easily sedated and I completed the cavity prep without LA. acid etched. bonded and 3 layers of composite. She was ready to leave about 12 minutes after coming into the surgery and no numb lip.

Are you interested in being able to treat youngsters as easily as this? If so, read on and discover what RA could do for you and your practice.

Contact me for course details richard@the-ra-coach.com

Case No7. One of my youngest RA cases

2003-12-16T13:59:00.000-08:00

Today I saw an 11 year old for a routine inspection. Her father has given permission for this report. I first saw Helen at the age of about two and a half when she presented with carious lesions. Over a period of time, (several years) and despite dietry and other preventive attempts, dental interventions became necessary. We treated her ( and occasionally others since, too) by lying her in a supine position on top of Dad reclined in the dental chair, with her head on father's right shoulder. Father is a very sensible sort who trusts us implicitly. The RA mask was applied over Helen's nose and the tubing draped over father's shoulders. A good level of sedation was acheived and the dentistry completed with or without LA as appropriate The experience has left Helen a completely relaxed patient at the age of 11 and today we completed 4 fissure sealants including a newly erupted 2nd molar on a completely relaxed child without RA. The likelihood is that if she ever did needed a filling, RA would not be needed for her.

Case No 6.First visit referral from a colleague

2003-12-14T13:44:00.000-08:00

A new patient was referred by a local practitioner. A nice enough lady of about 50- something. She was very anxious with fear "in her eyes" in the waiting room. There was much wringing of hands and perspiring. We began with an after hours chat about her fears, with a promise beforehand, that no treatment or even examinations would occur at this visit. Amongst other things we discussed the pros and cons of RA or IV options for her since she was a severe gagger.

She attended a few days ago for a second visit to give her a trial run (and titrate her) of RA and carry out a routine examination (though no intra-oral rads at this stage). I asked her during the early moments of induction, as I often do, how many gin and tonics (glasses of wine etc) it would take to get her "tiddly". This can be an important and revealing question. Teetotallers, tend to sedate at lower levels of Nitrous Oxide.

She told me that she drunk beer and would down 12 pints at a sitting!! Well to me this sounded preciously close to alcoholism, however at that stage I just took it on board and continued, as expected to a relatively higher proportion of Nitrous than Mr and Mrs average, achieving a good level of relaxation. Her demeanour visibly changed, she stopped sweating and shaking and allowed a full examination, charting, BPE scores etc. She commented during the session how different she felt, how much better. At the end of the session, she returned to her shaky self but could not get over the difference the RA had made to her.

She subsequently became a regular patient of the practice accepting routine dental care.

Case Histories Nos 2-514th Dec 2003

2003-12-12T14:56:00.000-08:00

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.

Case History No.114th Dec 2003

2003-12-11T14:47:00.000-08:00

A new patient referred by a local practitioner. A nice enough lady of about 50- something. Very anxious, fear in her eyes in the waiting room. Much wringing of hands and perspiring. We began with an after hours chat about her fears, with a promise beforehand, that no treatment or even examinations would occur at this visit.

Amongst other things we discussed the pros and cons of RA or IV options for her. She was a severe gagger. She attended a few days ago for a second visit to have her trial run of RA (and titrate her) and carry out a routine examination (though no intra-oral rads at this stage). I asked her during the early moments of induction, as I often do, how many gin and tonics (glasses of wine etc) it would take to get her "tiddly". This can be an important and revealing question. Teetotallers, tend to sedate at lower levels of N20.

Her demeanour visibly changed, she stopped sweating and shaking and allowed a full examination, charting, BPE scores etc. She commented during the session how different she felt, how much better. At the end of the session, she returned to her shaky self but could not get over the difference the RA had made to her.