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In Praise of RA
With the demise of GA in a GDP setting, relative analgesia or RA (conscious inhalational sedation) offers a real alternative for the management of anxiety. Here, Richard Charon, BDS, offers a personal view backed up by almost 25 years’ experience

The current use of RA in general practice seems to be very limited. According to one supplier of RA equipment, about 80-90 per cent of their sales are to health authorities. This seems such a wasted opportunity for GDPs. The technical details of administration and an overview of equipment are well documented in the article by Graham Roberts et al in Dental Update, April 2000.

Offering RA to your patients can, amongst other benefits:

¨ Revolutionise your patient's dental experience
¨ Provide a safe and viable alternative to GA for ortho extractions.
¨ Add value to the service you provide
¨ Help build your reputation
¨ Build goodwill for your practice
¨ Reduce the stress of your working day

RA is effective, easy, pleasant and safe. I have successfully used it to help build my practice and I believe I have, in my own small way, made some contribution to helping change public perceptions of dentistry for the better. Patients love it and I love its effect on them and on my ability to complete decent dentistry in what would otherwise be difficult or impossible circumstances. What is more, with the usual provisos, I never need worry about patient safety or discomfort during administration.

Patients leave happy and parents of children are amazed. Patient selection is paramount, as with all modes of sedation. However, any doubts as to the patients’ suitability is easily assessed by providing a ‘trial run’.

The Trial Run

Most first-time patients benefit from a trial run and one could argue that it might be essential for some. There are three main benefits. Firstly, since both operator and patient know that no treatment is to be undertaken, all concerned are entirely at ease. Secondly, a slow titration against response, assessed by direct verbal communication with the patient, provides a pre-operative ‘dose’ assessment. This reassures the patient that you are in control of the situation and, yes, the ‘happy air’ does work. Thirdly, the patient has had a brief but pleasant experience, which positively reinforces the operator’s story.

R.A. One Technique - Many Uses

RA has proven to be an invaluable tool for orthodontic extractions.
Simultaneous extraction of four premolars in a ten to thirteen year-old using LA with RA has, in my hands, been 100 per cent successful. The patient is ready to walk out of the surgery by the time any packs are removed and the post-op instructions have been given, plus their experience has been a positive one.

The Non-Attender

Many cases of dental neglect in the non-attender are founded on the problem of
a gag reflex. Gagging is an anxiety-driven response. I would estimate that for 95 per cent of these cases, RA provides a level of sedation that is sufficiently anxiolytic to subdue the gag reflex and allows almost all routine dental operative procedures to be carried out. The patient becomes accustomed to pain-free and anxiety-free dentistry and a virtuous circle is set up.

A Dream Combination

To achieve a real sense of detachment from the procedure for the patient, it is hard to beat the use of RA with rubber dam. It is essential for endodontics and most authorities would say for adhesive dentistry and amalgam removal.

I have heard it said that when undertaking procedures for upper anterior teeth, RA is difficult to use because of the nasal mask. I have never hesitated to use RA for this area. A recent complex multidisciplinary case was only made possible by the use of RA. It involved advanced periodontal treatment including localised surgery and placement of a bioglass GTR procedure, several endodontic procedures, including the surgical repair of a lateral perforation of a lateral incisor followed by six crowns for the upper anterior teeth.

The crowns required two sets of laboratory-made provisionals to perfect occlusion especially her anterior guidance, assess phonetics and aesthetics and to permit successful interdental papilla downgrowth. Multiple sets of impressions were needed over three years. I am certain that I would not have achieved the same result without the assistance of RA.

If you are interested in learning this technique in a Private practice setting please e-mail me at Rwcharon@btinternet.com for details of courses to be run later in 2001.