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Showing posts with label Dentist. Show all posts
Showing posts with label Dentist. Show all posts

Thursday, 11 April 2019

Autism Polypill Version 5










Agnieszka's KetoForce and C8 are new additions, last time it was Tyler's Agmatine as additions to the Full Polypill

I recently updated my autism Polypill. It is now the fifth version, so it is becoming ever more personalized to one specific case of autism.  I added caprylic acid C8 and KetoForce Beta Hydroxybutyrate.
The full Polypill version 5 is here:


I do feel that I am getting near the final version. I already am pretty sure what is going to be added in the sixth version. There are one or two potentially clever ideas in this blog that I have not yet developed.
After my first year of autism research my doctor mother thought the result was good enough to stop, but I persevered and some further improvement did come. She was supportive of the concept but rather surprised it was possible. I think I have now achieved most of what is possible, which took an additional five years.
Having recently been reviewing the expected prognosis in longitudinal autism studies, including the one up to 22 years of age by Catherine Lord in the US, I think the result speaks for itself. In long term studies the remarkable improvement that rarely does occur, takes place by the age of eight. Verbal skills at the age of two is the best predictor of outcome at 19 years old.  I only started with my Polypill at the age of nine, when we were five years into trying to teach prepositions and maths was at the level of struggling with single digit addition and subtraction. Today at 15 years old, maths is at the same level as neurotypical 13-year-old classmates; so, we can say his maths age is 13.
I did suggest years ago to the French Bumetanide researchers that they measure IQ to show the impact of their therapy.
I think that in severe autism, and also Down Syndrome, huge strides forward are possible just by raising IQ.  We saw from the 15-year French study that the entire lower group, representing 80% of the total, had an IQ far less than 70 when they age out of school. An IQ of 70 is the threshold for MR/ID and affects 2.3% of the population.  Many of those French had IQs less than 40. 
Many parents do not like the term Mental Retardation (MR), so they made a nicer term Intellectual Disability (ID), which to me sounds like you might struggle playing chess, rather than dressing yourself and tying shoelaces.
Much MR/ID clearly is treatable.  That makes what is left of autism much easier to deal with. It makes the impact of any expensive 1:1 therapy much more substantial and therefore cost effective.
Recall we also have 81 other types of MR/ID that have been identified and are treatable.


As part of another project, I recently updated an old chart from this blog that shows the change in my autism index over time, including 6 years of the Polypill. I started treatment with Bumetanide on 17 December 2012. That was the sharp drop in the black line, followed rapidly by NAC and Atorvastatin. 


The big spike in the black line is the effect of the summertime allergy “stopping” the cognitive effect of bumetanide and producing the self-injurious behaviour of the same kind as the first big spike in the orange line.
The orange line after December 2012 is my forecast of what would happen, including a spike in bad behaviors likely to be triggered by puberty.
The spike in the black line at 13.5 years was a PANS-like episode that only lasted a couple of weeks, and was immediately treated using prednisone.
Heading towards 16 years old, Monty is still above the blue area, which we could call the “nerd cloud”. This is where you will find all those very mildly autistic, fully verbal people that now receive a medical or educational diagnosis of autism. Back in 1970s, 80s and 90s these were the nerdy kids at your school, who generally got by without any medical diagnosis/label. A small percentage will subsequently have attempted suicide.
On my chart typical development is not zero on the autism scale.
What is “normal” changes, typical kids develop their sense of “cool” group behavior before puberty and this continue until they become parents or just busy and fully employed. Then cool gradually fades and by 30 years old a socially awkward Aspie type really is not so different from a Dad who is juggling his job, commuting and his family obligations. There is no time to be cool.
I think around 18 is the peak difference between an NT young person and an Aspie.  Once the Aspie gets to College/University and meets more fellow Aspies life should get much better.  Find a job in a University or NASA and you will do just fine.
My therapy goal is just to keep heading towards zero on my scale. Entering the nerd cloud would be a great success; all that effort to reach the point many people with today's "autism" start from!
The IQ difference is already overcome. If you can do algebra, your IQ is way above 70.
Optimizing adaptive behaviour is the remaining goal. As the French longitudinal study and Catherine Lord from Cornell University highlighted in their studies, being fully verbal is a big part of enhancing adaptive behavior.  If you can be chatty, many aspects of life and functioning automatically get much easier.
So, in Monty’s case the emphasis has to be on expressive verbal communication, which is his weak point.
Fortunately, the additions in version 5 of the Polypill (Caprylic acid C8 and KetoForce BHB) and the expected additions in Version 6 will target this area. 
I did also write about critical periods and sensitive periods in the treatment of autism. It is clear that while it is never too late to start therapy, the sooner you start the bigger the effect will be. This is another reason why I doubt I will ever get to Version 10 - the clock is ticking.
Time is indeed a great healer, so even just Version 5 for another five years should continue to help Monty close the gap with typical people.
At another visit to the dentist last week when Monty had anaesthetic in his rear lower jaw, which apparently is the most difficult for a dentist treating a person with autism, the dentist was visibly relieved “it was exactly as you said it would be … he was better than my typical patients”.  That is the result of Polypills version 1 to 4 from 2012 to 2119; it is not down to parenting as the dentist believes. We did practise with a syringe and a drill at home, but it really was not needed. Monty understands why the process is necessary and what the steps involved are and so he is happy to sit back and open wide. Ten years ago this was not the case.

According to Catherine Lord at Cornell, based on her longitudinal studies from diagnosis up to adulthood, verbal skills at the age of 2 are the best predictor of outcome at 19 years old. Monty's verbal skills at the age of 2 were zero.

Unfortunately over 60% of the children she followed from 2 years old end up with a very poor outcome in adulthood - severe MR/ID, the adaptive skills of a four year old  and drugged up on psychotropic meds.  As in the 15 year long French longitudinal study of autism we looked at, the measured IQ falls over time. Anyone still think severe autism should not be treated? Perhaps they need their heads examining?

The optimal group of 10% do well, with an IQ shooting up to 111 (average IQ for typical people is 100) and OK with an adaptive functional age of 101 months (8.5 years old). Of them, 63% had a job and the great majority were not on psychotropic meds.  

It appears that in Lovaas' flawed ABA research he selected the kids that completed his trial from this Optimal 10% group. So yes, 50% did great, but they were already on track to do pretty well.  We learned from Dr Siegel that he weeded out the less able kids who did not respond to his therapy during the trial itself. You might think that all his research should now be rescinded.




LA ASD = less able ASD  (62% of the group) have IQ less than 70<70 div="">
MA ASD = more able ASD (38% of the group) with a subset called Optimal = the top 10%








Source: Catherine Lord's Presentation at UC Davis

I always wondered why American Psychiatrists decided to keep relaxing the boundaries of autism. There was no rational reason to do it, because it makes all the data incompatible and so comparisons meaningless. One good reason would be to hide the appalling outcomes of severe autism (DSM3 autism, Strictly Defined Autism etc), by adding more and more much milder autism the overall outcome looks quite acceptable.
Dr Lord is a psychologist and she comments in her presentation that today the prognosis results would look much better, as if that is a good thing. Being of logical engineer origin, I would counter that this is a nonsense. The results today would be exactly the same for those kind of kids; just that a sample in 2019 of 200 kids with newly diagnosed autism would include 100 who would not have been given a diagnosis 25 years ago when Dr Lord started her study. Nobody would have even sent those fully verbal quirky two year olds for evaluation.

For the final word on prognosis, we might recall from this earlier post

that 

"Autistic adults with a learning disability were found to die more than 30 years before non-autistic people."

Time to customize your personalized medical therapy for autism?  If your child was fully verbal at two years old, then you might not need to bother.

Conclusion
My conclusion is that after 480 posts, this blog is now giving a fairly complete picture of autism. The features provided by Blogger/Google make it hard to navigate this blog and the very useful index by label is no longer available. Only a few people have read the entire blog.
It could be reorganized as follows.
  • Prevalence of the many Autisms
  • Prognosis
  • Evidence from clinical trials and case studies that shows improvement is genuinely possible and so it is worth your while to commit serious time to the process
  • Lots of science blah blah 
  • Precision medicine leading to a personalized therapy 
Unfortunately the science blah blah does get very detailed and does lose many people.  Biology is not complicated like math, there is just an awful lot of it and it remains only partially understood, so it changes.  Most people can follow the science, if they are willing to spend enough time, but you need to know that genuine improvement is indeed possible.  Some people are lucky and find their type of autism is similar to someone else's who has already found an effective therapy.
At some point I will get someone to write the java script to make a better index to the blog, so at least I can find things. 
Hopefully Version 6 of the Polpill will include two steps forward.



Thursday, 14 March 2019

Dad ... where's the shaving foam? and Fun at the Dentist


Most of what you can read on the internet regarding autism is parents writing about their young children, or alternatively middle-aged Aspies with their very diverging views (either self treating on Reddit/Longcity, or campaigning for no treatment at all, for anyone).

I don’t delve into Facebook and its often closed groups, that some people now want banned. Google has closed Google+, which did carry this blog. 
Since teenagers and adults also have autism, you might expect them also to be a common topic. They are not.
Did all the young kids with autism “get better”? Sadly, not the case.
Did the parents just run out of energy?  Most likely the case.
Autism blogs do seem to just stop abruptly, rather than fade away gradually.

Hope springs eternal

The reason put forward for the mass use of ABA, but almost exclusively only in North America, is that parents really want to do “something”. ABA is "evidence-based", expensive, time-consuming and often you have to fight for it, so it ticks all the boxes.

As Agnieszka pointed out, it is shocking that all this ABA is based on much-quoted research that is well known to be fundamentally flawed.
But parents of toddlers want hope. Don't spoil it for them.
Over the next 10 to 15 years of parenthood, parents will adapt and get used to their new normal.
Along comes the next generation of parents and the story repeats.  You would hope that things are getting better, but did anyone bother to check?  By constantly broadening the clinical definition of autism since 1980, it is easy to paint a rosy picture that may be far from the reality. 

It would be great to hear the experiences of parents of adult children, diagnosed with autism when they were 3 years old in the 1980s and 1990s, particularly of those living in parts of the US where autism interventions were advanced (California, New England etc). Was ABA effective? What happened at school? What happened at the dentist? What about tying shoe laces, riding a bike - was it ever mastered? Who learnt to drive? Who got a job? What about supported/sheltered employment?  Who lives independently? Who lives in an institution? Who lives with parents? Dare I ask it, but what percentage are still alive? 
Severe autism continues to be seen as the childhood condition it genuinely was until the 1970s, when big State Mental Hospitals gradually stopped being the repository for young children with autistic behaviors. People entered as a child and never left. You could only encounter very young children with severe autism (then officially called childhood schizophrenia), unless you worked in one of these institutions, where older children and any surviving adults remained. In modern times adults with autism are again nearly always Aspies, the severely affected have again been hidden away.
In the 1970s physicians still had to apply DSM2, published in 1968, where there was still no autism category, it was considered childhood schizophrenia.
Autism first appeared as a diagnosis in 1980 in the first version of DSM3, you needed to satisfy all six points:
A. Onset before 30 months of age
B. Pervasive lack of responsiveness to other people 
C. Gross deficits in language development 
D. If speech is present, peculiar speech patterns such as immediate and delayed echolalia, metaphorical language, pronominal reversal 
E. Bizarre responses to various aspects of the environment, e.g., resistance to change, peculiar interest in or attachments to animate or inanimate objects 
F. Absence of delusions, hallucinations, loosening of associations, and incoherence as in Schizophrenia.

Outcomes in severe autism often are not good
It is much better to see things as they really are, from day one, not to have false expectations and realize that, while much is possible, it is up to you to make things happen, otherwise the result will not be pretty.

But, people do not want to hear sad stories, however real they are.
They want to read uplifting stories like the New York Times best-seller, "The Reason I Jump". This book is claimed to have been written by a young non-verbal Japanese boy, by pointing at letters on an alphabet chart. Many people, like Dr Siegel in California, believe it was really his mother’s work.

You can choose whichever version you prefer.

The Japanese handwriting system is extremely complex, with tens of thousands of characters, but all Japanese also learn Romanized Japanese which is used for computer inputs.

It would clearly be possible to establish if the author was Naoki Higashida, or his mother; most people would prefer to believe it was Naoki.
If today he writes his subsequent books alone in a room with his computer, or indeed a pad of paper, we would have the answer. If Mum/Mom has to be present in the room, I would have my doubts. 

Ten years ago I used to buy ABA books and resources from a company in New York set up by an Autism Mom, who had struggled to locate the resources her adopted daughter with autism had needed. It still is a great one-stop-shop and the Mom is still a big believer in ABA, but her daughter went from living at home to a group care home, not the result she or her eager Lovaas-evidence-based new customers were/are hoping for. 

The Mom does say that thousands of her customers have kids who were eventually "mainstreamed", but what does that tell you? I used to think that only quite functional kids were mainstreamed and only severely affected kids got special schools. In reality you have kids who cannot use the toilet mainstreamed and some very smart kids with Asperger's who have their own school.   Whether a child is mainstreamed or in a special school depends mainly on what the parents want and where they live; the child's severity of autism has remarkably little to do with it.

Our last ABA consultant told us that Monty, the client she sees the least, is the one who improved the most. That is of course a nice thing, but I wanted much more for Monty. Put another way, ABA was good and remains good, but it is not enough.

Lovaas grossly exaggerated the improvement that is likely in severe autism (DSM3 autism/SDA).  He excluded data from non-responders in his published results. This approach evidently continues to this day in some other autism studies I have read.

Kids with mild autism do not need intensive ABA with picture cards, it would be a huge waste of time and money. ABA principles can be applied to teaching emotions, empathy and other social skills to young Aspies.


Where do children with severe autism end up?


With all that Lovaas ABA behind them, these children were supposed to have become fully functional adults. Invest $200,000 in ABA in early childhood to save millions in future care costs; that still is the mantra in 2019.


Unfortunately, even after all this expense in childhood the end result still most often requires very expensive lifelong care provision, or the adult just stays at home with his aging parents.
Having closed the big State Mental Hospitals in almost all countries, there is often nowhere for many people to go. Some rich countries have some provision to live in supervised care homes or treatment centres; in the UK these are reported to be sometimes worse than the old State Mental Hospitals. Personally, I would reopen a limited number of State Mental Hospitals, much better than having mentally ill people living on the streets.

It is time to recognize that you need more than early intervention, or lifelong ABA therapy, you need to treat the underlying biology.  Ideally you would combine personalized medicine with early intervention.


“Dad … Where’s the Shaving Foam?”
An important take away point from Dr Siegel’s recent book (The Politics of Austism), that is not contentious, is that children with autism are often taught the “wrong things” during their 15+ years of education. Much time is wasted learning academic skills that are never mastered and not even useful, while basic life skills are neglected. Neglecting life skills is very easily done and this is why every family needs to have some outside input to their autism program.

Monty’s assistant at school in the mornings is currently teaching a group of older teenagers with autism how to tie their shoe laces. This is a skill that you really do need to eventually learn; if not at 16 then when?  Typical kids master tying show laces by the time they are about 5 years old.
I still get asked who brushes Monty’s teeth and who ties his laces. He is 15 years old now, he does.

Recently, I was asked who shaves Monty. He shaves himself, as I was reminded this morning when I heard a shout of:

“Dad … Where’s the Shaving Foam?”

A year ago that could only have been big brother, but now it is little brother himself.


Headphones
The stereotypical image for a boy with autism often seems to include fancy noise cancelling headphones or just ear defenders, now specially made for little heads.






Getting used to loud noises is just like getting used to tying shoe laces. It is a skill you need to practise and eventually you will likely master it.
We recently visited the noisy waiting room at a paediatric dental clinic and the two very nice dentists we came to meet immediately asked if Monty would prefer to wait outside, away from the noise. I said that years ago we might have needed that, but now it is not a problem, even screaming babies can be tolerated.

I recently  bought a new vacuum cleaner and this prompted our cleaning lady to recall how Monty used to hate her vacuuming and she had to do it when he was not at home.
Monty has learned to accept noise by being exposed to it. We did not hide him from noise, although the cleaning lady did. He does have sound sensitivity like many people with autism, but he has learnt to control it.

In a recent post I mentioned Monty’s new job washing cars.

He insisted at the weekend that he would clean the interior of my car, having already again cleaned the exterior.

“Dad’s car is a mess”
This translates to “now I want to clean the interior”.


Having carried the new vacuum cleaner to the garage, Monty turned to me and said -

“The vacuum cleaner will be very noisy”

Yes, but we don’t even think of walking over to where my power tools are kept and pick up the ear defenders. Noise is a part of life.

Autism friendly cinemas, theatres, even shopping

In developed countries there all kinds of adaptations being made to help people with autism. That is nice, but ultimately people with autism have to adapt to the world.

Testing limits and moving boundaries


We all have our limits and our comfort zone. Growing up typical people test their own limits and stretch their boundaries. This is one great benefit of sport, either team sport or individual pursuits.


Young children with severe autism have a very narrow comfort zone and will let you know the second you take them out of it. The natural caring reaction of parents ends up reinforcing these restricted boundaries.


Typical children are (sometimes literally) thrown in at the deep end and have to sink or swim, hopefully swim. This goes on through adolescence and the final result is a well rounded successful adult.

If you are allowed to stretch your boundaries, make failures, fall on your face only to get up and continue, you will achieve your potential. Just think about typical people you met growing up, or now see growing up, overly protective parents do not do their typical kids any good.

When you are an autistic child, with all the issues that brings, you start with very tight boundaries and a big effort is needed to widen them to engage with the world. If the boundaries are further reinforced by the upbringing, the child is losing their chance to engage with the world. 

These issues all apply to typical adolescents. They usually figure things out for themselves, but a lot does seem to depend on their peer group.


At the moment I am moving Monty's boundaries to accept a lengthy dental intervention by a very nice dentist. I am also trying to move the dentist's boundaries of what is possible, so she is not worrying too much about what might not be possible. We have found a good plan B, for what to do if it is not possible to complete the job with just local anesthetic.


In most of the world dentists are no longer allowed to give general anesthetic (GA), or even I/V sedation, unless they are within a hospital. This is because years ago too many serious accidents happened at the dentist. Ten years ago, the last time Monty has real dental work, it was under general anesthetic (GA) at a private dental clinical in a neighboring country, where they brought in an anesthesiologist just for him. When I was a child in the UK, there were one million general anesthetics administered by local dentists every year, this fell to 300,000 in the mid 90s and just 57,000 in 2000. In 2002 local dentists were banned from giving general anesthetic. From then on you had to do to your local acute hospital. The result may be less convenient, but people no longer die at the local dentist from mistakes with general anesthetic.

It looks like US dentists still make extensive use of sedation, I do not know about general anesthetic (GA). One common sedative used by dentists is intravenous Valium. That would not be a good idea in someone with bumetanide-responsive autism.

Our local University hospital offers dental work under GA, but you may need to wait 2 months for an appointment and they only do "radical" procedures, meaning they just pull out teeth.  They offered to make an appointment to extract Monty's tooth that I want to repair. Our plan B is a small local private hospital that also does some dentistry and offers general anesthetic. This is an option most local people were unaware of and is much cheaper than going abroad.

Having a plan B, means that proceeding with plan A is less scary for all concerned.  It is also scary for the dentist, which you might not have considered, but I think it is the reason that many dentists would not even try and treat a child with more severe autism.

I did discover 10 years ago a training program for dentists called D-Termined. It is available on DVD and the originator, Dr Tesini, now has a study to show its effectiveness.  Back then I could not find any dentist interested to learn how to treat difficult patients without general anesthetic.

The DVD used to be free, it has been updated but only the second part seems to be available to view online. Click the link below.

Familiarization and sequential tasking in Dentistry for patients with autism

The study is below.

Effectiveness of the D-TERMINED Program of Repetitive Tasking for Children with Autism Spectrum Disorder

In essence, it is step by step dentistry aimed at making children eventually treatable by a regular dentist, who has had no training. It is ABA applied to the dentist. You do need numerous visits to the dentist, getting comfortable with all the individual steps needed to complete a dental procedure.

Monty's new dentist is actually doing this, but based on applying her common sense.  She seems most worried about the local anesthetic causing a bad behavioral reaction. When you lose feeling in your mouth/jaw some people with autism can react very badly and then the dentist has to stop and take cover. That is why you need a Plan B.  I thought the injection and the drilling would be the problem.

We have now completed our first procedure that included local anesthetic, a fair amount of drilling and then filling. Strangely enough Monty enjoyed it; who else would have fun at the dentist?

Hopefully the rest of the work will go as smoothly.


P.S.

Where's the toothpaste?


This stopped being a question a few years ago, when Monty figured out what to do when he could not squeeze out any more toothpaste.  Go find a new one!






Tuesday, 22 April 2014

A Surprise at the Dentist



The dentist is probably the worst place you can imagine to have to take a child with autism.  The same is true with many typical kids and even some adults.
If you talk to older people about their childhood experience at the dentist, before high speed drills and the like, it was more like torture.  Times have changed, it is not just better equipment, but (some) attitudes have changed.
For someone with autism, going to the dentist should not have to be a terrifying experience; people with autism actually have a high pain threshold.  True they have lots of sensory issues, but it seems to be the fact that they do not understand what is going on, that is the real problem.

A better way
There exist some very child-friendly dentists who are more than a match for a child with autism.  They can achieve what seems impossible, a calm and cooperative dental patient, who will sit back and let the dentist do his work.
One such dentist has even made a training program for other dentists to show how to achieve this.  In effect, it is a very practical ABA lesson for dentists.  The dentist is called Dr Tesini and his program is called D-Termined and he is indeed determined to succeed.
Here is clip from Youtube.



 Dr Tesini even teamed up with an autism charity to make a DVD of his method.  It used to be free but now costs $13.
Here is a link to the foundation that funded the program.
I acquired the DVD 6 years ago, but could not find any local dentist interested to apply the method.
The method is great because once the child has got used to the nice friendly Dr Tesini and gone through all the steps, he is apparently then able to “tolerate” the less friendly regular dentists, for future dental visits.
In some special schools they have a dental chair for the kids to practice on, which as another great idea.

 
Monty at the Dentist Five years ago

We have a nice friendly dentist, but I think he felt from the start that working on a child with ASD was going to be too much.  We made a few very brief visits when Monty was four and five years old and even brought along the Dr Tesini D-Termined DVD,  but this really just showed how difficult a task lay ahead if any actual drilling and filling was required.
It was never really clear whether Monty had toothache or not, since he could not verbalize the problem.  So sometimes if he was behaving aggressively, we might think that he had tooth problems.  Later things would calm down and we would forget about teeth and dentists.
In the end I had to find a practical solution.  Were we live there seemed to be no good solutions;  generally people with ASD just have rotten teeth.  A State hospital clinic did in theory offer dentistry under full anesthetic, but it looks like the hospital block of a gulag and there was a three month wait anyway.  Private dentists are not allowed to give sedation or full anesthetic, for safety reasons, just local anesthetic.
Eventually I found a solution in a neighboring country where you could have dental work under general anesthetic, in surroundings that did not look like a prisoner of war camp. Aged five, Monty had his four fillings and one extraction under full anesthetic with a German dentist and a Hungarian anesthetist.  The first part involves an injection into a vein in the arm, even this little step involved a great deal of kicking and screaming (Monty and his Mum).
So as not to repeat this unpleasant, and very expensive, experience too often, I stopped Monty drinking so much fruit juice and came up with a special tooth brushing regime.
One of Monty’s first words, aged about 40 months was “juice” and so pleased were people to hear him use any word, that juice is what he got.  In fact when he said “juice” he really just meant he was thirsty, water would have been just fine.  The acidity of fruit juice rots milk teeth.  Also, at the start of an ABA program, or even PECS program, there are a lot of edible reinforcers (candies) involved; great for speech, but not your teeth.
The teeth brushing regime involved brushing first with a manual brush and then again with an electric tooth brush.  This way there is more chance of not missing anything.

Monty at the Dentist Five Years On

Having not had any dental work for five years and still not having found a dentist who wanted to learn how to treat a child with autism, I was faced again with the undesirable option of full anesthetic.  I hoped that in the subsequent five years there might be some options closer to home.
While it seems that only hospitals can give full anesthetic, one of the small private medical clinics that also do minor surgery, has started to offer dentistry.  So I thought that if they have an anesthetist available for the minor surgery, why can’t the dentist use him?
A few phone calls later, it did indeed seem to be possible.  It clearly was not something they usually did, but the dentist did not think it was a crazy idea.
So last week Monty, myself and his assistant, who teaches him at home in the afternoon, turned up at the clinic.  Expecting to see an older male dentist with a serious face, I was very surprised to see a small slim female dentist and her smiling assistant.  It was as if we had stepped in to Dr Tesini’s training video.
All happy, smiling and fun, the dentist let Monty play with all the buttons and bits of equipment.  She made balloons out of surgical gloves and generally made friends with her new patient.
Her attitude was “why would I need anesthetic to treat such a nice boy”.  She gave him an examination, with Monty being surprisingly compliant.  She concluded that his toothache was caused by his four rear permanent that have yet to emerge.  One of the five year old fillings in his milk teeth looks a bit poor, but the X-ray showed that it is far from the pulp of the tooth.  The tooth should fall out before the filling fails.
In fact the only intervention is protective fissure sealant on four permanent teeth and ultrasonic de-scaling his front teeth.
I say “only”, but this still needs him to keep still with a drill inside his mouth and not bite the dentist or her to cut his tongue.

So far so good
After six visits, three teeth have their fissure sealant and one more visit remains.
Monty is friends with the dentist and is dancing to the music in the waiting room as he leaves for home.
Who could have imagined such a surprise at the dentist?