Case No.14 20 yr old gagger

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

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

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

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

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

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

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

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

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

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

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.

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.