All patients, legal guardians, persons with parental responsibility or Power of Attorney consented for using fully anonymized information for educational purpose only.
Child, lack of cooperation, high caries rate
Child, below 5 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.
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.
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.
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.
Unexplained discomfort/pain upper uadrant, edentulous arch.
Extra- and intraoral did not reveal any obvious pathologies, also nothing radiologically suspicious on intraoral radiograph. To consider OPG full mouth radiograph, advice from patient’s GP with the view of likely maxillary chronic sinusitis and second opinion from specialist in oral surgery with regards to: neuralgia, TMJ problem, sinus polyp, tumour, displaced root into sinus.
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.
Patient on prolonged use of cortycosteroids due to pituitary gland disfunction
Non-urgent extraction of carious, unrestorable and currently asypmtomatic molar tooth, with radiological symtoms of chronic periapical inflammation. Furction involvement. Potential source of odontogenic infection. Action: referral letter to patient’s GP requesting information about the need of additional steroids dose before elected non-surgical extraction.
Alcohol misuse, referral from rehabilitation centre
On examination: advanced generalized chronic periodontitis, pocketing more than 5.5 mm, mobile anterior teeth, gross sub and supragingival calculus acumulation. Smoker. Smoking cessation and advice. Discussion about aetiology of perio disease. Long term treatment plan: OHI, Perio US scaling and deep FMD, OH review, perio stabilisation, multiple extractions, provision of partial acrylic dentures.
Adult with learning disability, wheelchair bound.
Capacity to consent, able to consent, understand, maintain and retain information. Attended with carer, carers brushes his teeth with previously prescribed high fluoride toothpaste. Substantial amount of calculus mainly lower anteriors. Able to transfer into dental chair with the carer assistance. ‘Turn table’ very useful. Good cooperation, but difficult adaptation while changing a dentist. Prefers to see only one operator who has seen for a long period of time as ‘feels comfortable’ with this dentist. Gradual confidence build up, lots of explanations and reassurance. Good sense of humour desirable. To start with a simple, non-invasive procedure, eg. scaling and OH demo.
Homeless resident of care home.
Carers and social workers were not aware that patient wears upper denture which was discovered during initial dental examination. Explained thoroughly the importance of regular denture hygiene, stressed that acrylic denture should not be worn at night time.
Substance abuse, including alcohol
Usually ‘unstable’ life, dental health is a less priority, very irregular attendee, emergency dental visits mainly due to dental pain. Pain can be masked by prolonged use of analgesic opioid drugs. Liver disfunction, to avoid erythromycin and tetracyclines, lower doses of metrinidazole and clindamycin, lower dose of midazolam if IIV sedation. Local anaesthesia preferably with articaine (non-liver metabolism), bleeding tendency due to liver disfunction, clotting screen, blood clotting status, liver function test, always prothrombin test. Always ,socket packing, after extraction to prevent from excessive bleeding, check glucose level before invasive procedures. Sweeteners can be toxic towards liver.
Undiagnosed mandible fracture
Unco-operative, disable patient, unable to express and indicate and express dental problems. Recurrent extraoral swelling, brief exam revealed loose molar lower tooth. Obligue lateral radiograph taken instead of OPT (biomolar technique) as other types of radiographs were not possible. Findings: mandible unilateral fracture, trauma origin.
Patient with learning disability who requires regular non-dental procedure under GA (blood test sample, radiographs, botox injection, ear/eye investigation, minor surgerye)
This procedure can be carried out along with and in combination with dental care under GA (EUA, dental treatment)
Agitated and violent patient, mental health issue
Oral premedication with midazolam solution (diluted in orange juice as v. unpleasant taste) prior dental treatment.
Difficult endodontic treatment due to root canal obliteration. Patient declined to attend specialist endodontist appointment as suffers from severe anxiety.
Best possible solution in this case: to get a second opinion from specialist before attempting RCT completion within primary/community care. ‘Never give up’ rule – if the first attempt not successful – try again, use a special modalities, techniques and/or materials, eg. EDTA gel/cream, special files (C-Pilot, C+ files) with small diameter (10, 0.08 ISO) and ultrasonic dedicated endo tips for root canal negotiation.
Adult patient with severe/profound learning disability.
Had two episodes of dental treatment under GA. Still the same poor cooperation formany years, nothing improved. Additionally, mental health problems. Patient on resperidone. Reluctant to enter dental office, stayed in waiting room for a long time, loud and hyperactive. No dental problems reported by carers. Dental assessment with difficulties, only a brief exam carried out with lots of reassurance. Patient was standing up in the corner of dental office all the time, did not sit on dental chair, fearful and anxious, agitated. Management: very gentle but methodological approach, no unnecessary action, lots of smiling and ‘use of body language’, quiet nice tone of voice. Gradual acclimatisation. Kneeing down and quick assessment with plastic mirror as unpredictable patient reaction. Spotted broken/worn molar tooth, defected amalgam s signs of clenching/grinding. no signs of acute problems. Clear and obvious lack of capacity. Capacity assessment carries out. No need for best interest meeting as patient has got relatives. Discussion with carers re: justification for full dental examination under IV sedation or GA. Referral sent for OPT prior elective dental treatment, if necessary. Options: to monitor or to sort out of existing asymptomatic problems.
‘Uncertain’ vital signs readings
Patient on “strong” anti-psychotic medications who requires simple root extraction. Feels fine and seems to be generally ok. Mentioned about some ‘heart issues’ in the past associated with ‘slightly leaking valve’. Hypertension, patient does not take anti-hypertensive tablets regularly. Abnormal vital signs results, confirmed: BP measured: 110/105 RR, HR 105, Saturation 89%. Decided to postpone extraction
Extremelly low O2 saturation level
Patient with chronic condition affecting lungs – COPD, patient on oxygen at home. Oxygen cylinder left in the car. Routine denture work as requested by pt. Initial pulseoxometer recording: low O2 % between 80-90%. During 3rd stage of denture work, O2% -70%, short of breath, needs long recovery after getting to surgery from her car. Oxygen supply via nasal mask.
Unpredictable special needs patient’s reaction. Overenthusiastic approach.
Special needs patient, moderate learning disability, requested extraction of uppper front tooth as ‘it is hurting a lot’. Speach impairement. UR2 TTP++. Radiograph not possible as pt having severe gag reflex. Mental capacity assessment, pt has got capacity to consent. Options provided: RCT, AB course or extraction. Pt opted for xla, seems to be pretty coop, very chatty indeed. Attempted xla – failed as pt feels like “lots of pressure inside”. Extraction abandoned. Initial stage of RCT instead. AB prescribed. Adv NSAID Ibuprofen and chlorhexidine mouthwash.
Non-surgical extractions and eye minimally invasive procedure (intraocular injections).
Second opinion from consultant ophtalmologist: extraction can be carried out a week after eye injection under antibiotic cover
Patient with dementia, consused, good cooperation, no co-existent medical conditions.
Advanced generalized periodontitis. US scaling FMD with carers consent, Form 4 completed for any other ‘invasive’ procedures.