Clinical cases

Child, lack of cooperation, high caries rate

Child, 4 y.o., MH fit & well, uncooperative and phobic, despite of acclimatisation visits. Pain, local swelling, grossly carious deciduous molar teeth in more than 2 quadrants, pulpally involved, multiple carious cavities, unrestorable, poor prognosis. A few courses of antibiotic in the past. Routine treatment under LA not possible. Tx plan:  multiple extractions during GA session in hospital setting, following options discussion, GA assessment, valid consent protocol, check list and and pre- post-operative advise. Prophylactic programme implementation including topical fluoride 22600 ppm varnish, dietary advice and OHI. Recall intervals 3/12

Acute trauma, inhalation sedation

Young patient age 7 years referred by GDP due to limited cooperation. MH clear. Presenting with acute trauma injury of upper anterior mixed dentition. Right deciduous incisor mobile, intruded and overlapped slightly visible and partially erupted permanent incisor (intact), pain. Tx plan: to attempt URA extraction under local anaesthesia using inhalation sedation.

Anxiety, wisdom teeth, intravenous sedation
Patient, 25 y.o. , MH not significant, high level of anxiety, bad dental experience. Dgn: partially erupted wisdom teeth 18, 48 (UR8, LR8), symptomatic, Pericoronitis episodes three times in the past, antibiotic taken, with associating oedema and trismus. OPG – mesially inclinated, proper eruption impossible.  Tx plan: surgical removal under intravenous sedation, following options discussion, IV assessment, pre-op. advise.

Elderly, house bound, periodontal disease, root caries

Elderly patient 70 y.o., homebound, mobility restrictions. MH complex medical problems. Intermittent slight pain, dental origin. Sub-optimal oral hygiene, deep root caries lesions. Chronic periodontal inflammation, gingival bleeding. Tx plan: domiciliary visit, periodontal treatment with S&P, debridement, topical irrigation with antiseptic wash, caries stabilisation with fluoride-releasing GIC as a long term solution. Ambulance transport to be arranged to see patient in clinic next visit.

Medical condition, biphosphonates, extraction

Medically compromised patient taking alendronic acid (Fosamax) due to non-malignant disease who have taken bisphosphonates > 3 year. Currently asymptomatic roots remains of lower molar toot. Occasional pain and discomfort, inflammatory exacerbation within the region of tooths rests. Patients with possible osteochemonecrosis (ON) are advised to refer the patient to an Oral and Maxillofacial consultant for advice on management of the case. Tx plan: the risk of ON is very low and no changes should be made to routine dental care. If extraction required in future, should be performed as atraumatically as possible. To be referred if chronic exposed bone. Periodontal surgery, apical surgery and implants are not contra-indicated, but should be avoided if possible. Immediately prior to and following surgical procedures involving bone, the patients should rinse with a chlorhexidine mouthwash.

Learning disability, cerebral palsy, poor oral hygiene

Adult patient with mild learning disability (cerebral palsy), partially cooperative. Problems with fluids swollowing. Clenching and grinding. Difficult and challenging examination. Substantial amount of supra and subgingival calculus and soft debris, generalized gingivitis, otherwise no obvious caries detected. Full permanent dentition, Tx plan: initial hand scaling and debridement with the use of soft&safe mouth rest. Chlorhexidine mouthwash 0.2% topically applied with cotton swabs. Highly concentrated fluoride toothpaste advised (non-foaming toothpaste) twice daily, thorough oral hygiene advice given, prophylactic advise regarding particularly ‘sugary’ medications (anti-epilepsy syrup), electric toothbrush recommended. Second appointment arranged for review, full S&P and further perio treatment.

Autism, partial cooperation

Young patient with autism and ADHD diagnosis, impatient and nervous but cooperative partially. Not in pain at present, but episodes of short pain to mainly cold in past. Large carious cavity in molar upper tooth (occlusal surface). Tx plan: to attempt to take radiograph, acclimatisation visit, avoidance of distraction inside surgery, calm and friendly atmosphere. Gentle step excavation with hand intrument to build up pt confidence. Temporary sedative dressing. If asymptomatic – to try permanent filling under LA naxt visit.

Dementia, Alzheimer’s disease, poor denture fit

Late stage of dementia, patient still having capacity to make a consent about the dental treatment. Old set of complete dentures, poorly fitted and movable, decreased vertical dimension, general horizontal bone loss, particularly within mandibule. Insufficient muscle control. Tx plan: to construct a new uper denture only, with the additional support of clinical lab technician.

Immunocompromised patient (HIV positive)

Patient with diagnosed AIDS (HIV carer), in pain for a few days due to pulpally involved tooth (irreversible pulpitis). Unrestorable tooth structure (gross caries).  No obvious local swelling present. Short-term outcome: first stage of endodontic treatment under LA (pulp extirpation), letter for second opinion from hospital consultant regarding patient immune level and any contraindications for invasive dental procedures. Long-term outcome: extraction under LA following the opinion of consultant and additional blood tests results, including CD4 count, platelet count, white blood cells, liver enzymes, etc. Atraumatic xla, local haemostatic  measures, post-operative observation. Antibiotic cover not recommended routinely as risk of opportunistic fungal infections and/or gastro-intestinal side effects.

Mental health issue patient

Patient with diagnosed bi-polar disorder, on medications (long-term pharmacotherapy). Agitated and anxcious. Routine dental examination revealed a need of substantial treatment (fillings). Tx plan:  conservative treatment under LA with additional oral sedation with the use of anxiolytic drugs (benzodiazepine – Temazepam). Request for a professional opinion sent to Psychiatry consultant re: any interactions with current medications.

Bariatric dentistry

Self-referred patient with high BMI score and cardiovascular problems, including high blood pressure (unstable). Needs non-surgical extraction of single tooth. Currently receiving p.o. anticoagulant therapy (Warfarin) anti-hypertensive treatment.  Tx plan: arrangement of bariatric chair facilities, BP monitoring and check prior procedure, INR check the day before extraction or in-office (CoaguCheck), extraction under LA with the use of local anaesthetic agent without vasoconstrictor. Atraumatic extraction and the use of local haemostatic measures (eg. Haemocollagen sponge).

Dry mouth syndrome (post-radiotherapy, head & neck cancer)

Patient who received the course of radiotherapy due to oral cancer treatment (finished).  Impaired saliva secretion, disturbed quality and quantity of saliva. Oral mucosa lesions. Tx plan: Prescription of saliva substitute spray/gel/mouthwash, antiseptic, alkohol-free spray of Benzydamine hydrochloride, and antiseptic (healing) toothpaste (Corsodyl). Soft linining of existing dentures.

Medically compromised patient: asthma (controlled), prolonged anxiety, mild depression

Patient complaining of ‘gums’ problems: gingiva bleeding, swelling. On medications: Ventolin, Prozac, Diazepam. Sporadic, well-prevented athma episodes, one per months. Dental phobia, first dental visit for several years. Clinical diagnosis: chronic periodontitis, periodontal abscess. Treatemnt plan: consultation with patient’s GP re: asthma and mood disorders, appointments for OH, S&P, full debridement and subgingival curretage under inhalation sedation to reduce patient fear and anxiety and prevent respiratory problems. AB protocol if indicated to eradicate gingival inflammation.

 Severe physical disability, wheelchair user

Patient requires routine dental treatment. Difficult access to general dental practice due to mobility problems. Special arrangements: ambulance transport, hoist use/sliding board/wheelchair recliner. Additional head-rest and back-rest (cushin) used. Toothpaste dispenser and extra toothbrush grip advised.

Teenager with diagnosed eating disorder (reoccuring episodes of anorexia/bulimia)

Clinical diagnosis: multiple erosive cavities (enamel loss) due to prolonged exposure to endogenic and extrinsic acids. Proceeding: thorough explanation of possible etiology of tooth surface loss. Advice re: diet change, oral hygiene advice re: the use of additional prophylactic measures: mouthwash, highly-concentrated toothpaste and remineralising agent (ToothMousse, CPP-ACP), letter sent to patient GP. Direct restorations with the use of A/E composite. Recall 3/12 with patient oral health status monitoring.

Medically compromised patient with congenital immune disease.

MH: leucocytopoenia, systemic immune deficiency. No current medications taken. Non curable condition. Patient requires extensive and advanced periodontal treatment due to localised aggressive periodontitis. Tx plan: referral to specialist in periodontics for second opinion re: long term prognosis of molar teeth. Antibiotic cover before full debridement with subgingival scalling, application of topical agent (chlorhexidine 0.2%) Advised to use intraoral irrigator, antiseptic toothpaste and antibacterial mouthwash (Corsodyl daily). Recall 6/12

Medically compromised patient with hormone disturbances (corticosteroids imbalance, risk of adrenal crisis)

Patient on long-term pharmacotherapy due to GCC disturbances. HBP, cardiovascular problems. Requires semi-surgical extraction of symptomatic lower third molar (NICE guidelines met). Treatment plan: consultation with hospital consultant re: any contraindications for invasive procedure (and distressed circumstances) which may trigger adverse systemic effects. Consultant recommended to postpone extraction till the safe ‘hormone-related window’ occurs. Pharmacotherapy supplemented with additional medications. Extraction to be carried out in hospital settings.

Granuloma sarcoidosis of the lungs, auto-immune respiratory condition

Patient permanently on oxygen (carring oxygen cylinder on the car) and long term steroids pharmacotherapy (acting as immunosupressant). Consultation before any invasive procedure recommended. Often need of double dose of steroids pre-operatively. No special precautions necessary however second opinion from patient’s GP or specialist always needs to be considered.

Multi-drug resistant oral candydiasis.

Learnign disability patient suffering from prolonged, multi-drug resistant oral candydiasis. Denture wearer. Positive lab tests re: candida albicans, c. glabrata (+++). Multiple intraoral mucosal lesions. Nystatin, miconazole, fluconazol, itraconazol are ineffective. New denture work and non-standard, evidence-based approach – decision to use ozonated water for regular mouth rinse and candida eradication. Significant local conditions improvement after 4 weeks time of using ozonated water.

Fibromyalgia case.

Adult patient in chronic generalized pain. Prolonged use of NSAIDs, including opioids. Anxious and phobic. Needs ‘gentle’ approach, gradual confidence build -up and acclimatization. May need an increased dose of LA’s before dental procedures. In selected cases, for total mouth clearance, GA shoud be taken into consideration.

Chronic alcohol-dependence

Patient under care of  rehabilitation unit. Highly phobic, increased anxiety as he has not been to dentist for a long time. MH revealed mild epileptic seizures due to prolonged alcohol intake. On Epilin. GP opinion re: proper liver function. Capacity assessment performed. Patient fully able to consent for dental procedure, ie. to understand, to retain, to weight and to communicate information provided. Consent signed. Extraction performed uneventfully.

 

Chronic TMJ problems

Patient reported repeated problems (pain, trismus, blockage) related to TMJ’s following dental procedures. No obvious causative factors. Pre-preparation with the manual training, masticatory muscles relaxation technique preoperatively, NSAID Ibuprofen 400 mg an hour before procedure. Non complicated, simple extraction of decoronated and asymptomatic UR8, prolonged procedure, a few breaks during procedure with mandible movements training. Adv to used NSAID 200 mg tds for 3 days after XLA. No clinical indication for AB course. Advised periodical mouth opening and trainig re: TMJ function and mobility, adv a warm pack since the next day. Patient turned up 2 weeks later complaining of slight blockage RHS and unable to open mouth as it was before procedure. Intraorally mouth opening up to maximum 2.5 fingers. Patient c/o some ‘obstacle’ on RHS at the last stage of mandible movement down. No obvious signs of TMJ disfunction re: clicking, dislocation. Laser biostimulation applied 8 minutes, 5 cycles. every 2 days. To consider further investigation of TMG and functional therapy if necessary.

Bariatric patient, post-LA complications

Obesity, high BMI score > 45. Patient immobile, bed bounded for years. Regular domiciliary care. PDH: non-eventful dental procedures. MH: mild, well controlled asthma, occasional breathing problems, mild anxiety, prolonged depression. No underlying heart conditions. On antiasthmatic medications. Needs non-surgical extraction (non-urgent) of mobileUL5 (grade 2 mobility. Risk assessment re: potential complications related to LA or xla. Following administration of LA (4%articaine with adrenaline 1:100000, 3/4 cartridge, buccal/palatal infiltration) patient has become unwell, dizziness, warm sensations on the LHS of the body. Observation for 30 minutes. Symptoms gradually subsided. Extraction abandoned. Patient expects carers in an hour. Alarm buttom available by patient’s bed and easy to access. Thorough clinical notes regarding incident. Phone call to patient an hour later to find out how is feeling. Recovered fully after 2 hours. Latter to patient’s GP describing the clinical situation and requesting further investigation.