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.