By Theo Batistas, DDS Prepared by DOCS Education Having just turned 60—and facing deferred care after postponing routine dental visits—this patient knew substantial work lay in store. But the woman was determined to bring her oral health under control. Among her complaints were moderate crowding, looseness, and flared U/L anterior teeth. She found the prospect of sedation especially attractive because the notion of undergoing numerous visits was simply not palatable. The patient reported a number of adverse health habits, including heavy smoking and alcohol use. Her dental history entailed periodontal treatment, root canals, crowns and extractions. A comprehensive oral exam was conducted involving a full mouth series of X-rays and inter-oral photos, study models, and bite record. Diagnosis & treatment plan The patient was found to have Type III periodontal disease. Numbers 8, 9, 14, 29 and 30 were determined to be periodontally involved and hopeless. Decay was discovered under existing crowns. New crowns were recommended for numbers 4, 5, 11, 12, 13 and 28. The patient’s treatment plan was divided into multiple phases and spread across several years. We devised the plan to address all of the oral disease as well as cosmetic needs. The patient would have restorative matters addressed immediately followed by a period of stabilization. She would undergo ortho for approximately one year. The patient would follow ortho with implant placements and additional restorative work. We decided to conclude with the placement of permanent implant crowns. Prior to the first sedation appointment in November 2006, pre- and post-operative instructions were reviewed with the patient who also provided written consent. Sedation protocol The patient took 10 mg diazepam the night before her initial appointment. Between 6 a.m. and 10:45 a.m. she was given 3.5 tablets of 0.25 mg triazolam. Nitrous oxide was administered throughout. Between 8:45 a.m. through 11:30 a.m. 5.75 cartridges Lidocaine® 2 % 1:100,000 epi were used and 2 cartridges Carbocaine® 2%. 1:100,000 eip. She responded extremely well, achieved a good level of sedation and reacted to doctor’s prompts every five minutes. Subsequent treatment The next phase of treatment consisted of finishing additional restorative work—again under oral conscious sedation—together with Invisalign™ treatment for approximately 13 months. Another phase of treatment was completed in December 2006. This appointment addressed the lower left area of the patient’s mouth. The treatment included root canals, post, buildups and crowns, and the patient tolerated it extremely well. The patient’s Invisalign™ treatment extended from Spring 2007 to Spring 2008. Smoking decreased during implant process A 3D cone beam scan was completed prior to the patient’s implant consultation appointment in September 2008. Due to the fact that the patient is a heavy smoker, the risks and possibility of implant failure were discussed at length. The patient acknowledged that she understood this consequence and accepted all risks for continuing smoking. The patient did significantly decrease her smoking during the implant process while also adding vitamins daily. The final oral conscious sedation appointment for this patient was scheduled for October 2008. The patient had five implants placed as well as some bone grafting at this appointment. The same oral conscious sedation protocol was followed as earlier. All five implants were placed successfully and the patient came back for her post-op appointment. She stated that she tolerated the procedure very well and doesn’t remember much about the appointment. The patient had an additional restorative procedure done in November 2008. In February 2009 the patient was scheduled for her implant crown appointment. The impressions were taken on this day and the patient received her implant crowns in April 2009 completing her dental treatment plan. The patient was overjoyed at the final results and stated that she felt like a new woman.
