Challenging Cases

Disclaimer: All patients or legal guardians with parental responsibility consented for using  fully anonymized information for educational purpose only.

Challenging cases, beyond standard clinical approach:

‘Borderline’ individuals with special needs – patients who seem to be able to consent for treatment, but only partially capable to understand and gather necessary information related to individual dental treatment plan. Often patients with mild learning disabilities who are living independently. Capacity assessment necessary.

Shared parental responsibility – eg. foster mum/dad (or grandmother/grandfather) according to court statement and biological mum/dad. Valid consent needs to be obtained from both sides for any dental intervention, particularly invasive procedures: dental treatment under general anaesthesia. If biological parents ‘unavailable’ – at least verbal consent has to be given from biological mum/dad via eg. phone call.

Patient with cranial malformations required dental treatment under general anaesthesia. Neurological consultation may be needed. Intraoperative extraoral radiographs should be considerd – close cooperation with Department of Radiology at the hospital.

Patient with severe learning disabilities receiving eg. regular Botox injections for muscles spasms under GA. Multidisciplinary approach dealing with eg. extractions and ther medical procedures combined the same time under GA.

Combination of eg. dental treament under general anaesthesia and another operation indicated for medical reason. Close cooperation with hospital staff required.  To avoid tonsils removal and multiple extractions uder GA in children as not well tolerated.

Patient who reports that is “allergic to everything” (“panallergy”). Epizodes of sudden allergic reactions to different types of medications, including antibiotics, local anaesthetics, food, chemicals, etc. Emergency Drugs kit checked and available. Close cooperation with anaesthetic team in case of dental treatment under general anaesthesia. Special precautions required if sedative drugs ae going to be administered IV (propofol, midazolam). To avoid post-operative AB cover following multiple xga’s under GA as patient can get allergic reaction to eg. amoxicillin infusion administered via IV way.

Unusual orthodontic treatment plan for a phobic child referred to community dental clinic for pain and anxiety control. Example: request of multiple extractions of eg. permanent second molars or permanent canines. Another second orthodontic opinion may be needed.

Patient with a rare and not fully diagnosed medical conditions. Example: Sinus Syndrome – arrythmia with changeable heart rate up and down, epizodes of faints, extremely low or extremely high heart rate. Pacemaker fit is considered. Cardiologist consultation is required regarding use of local anaesthetic with or without adrenaline.

Multiple deciduous teeth gross decay which are unrestorable and pulpally involved. Parents unable to make a decision and undecisive, not happy with treatment plan which includes multiple extractions under general anaesthesia.

Elderly, wheelchair bound patient with mental and/or physical disabilities (dementia, Alzheimer disease) who requires complex dental work.

Disable patient with constant tremor and involuntary head movements. Risk of accidental injury.

HIV-positive patient who requires multiple extractions due to eg. periodontal disease and who is medically stable, however platelets count is reasonably low (< 100 000). Second opinion from consultant recommended.

Extremely severe gag reflex. Very cooperative patient who requires extensive restorative work. Dental assessment not possible. OPG taken with difficulties. CBT and pre-medication with diazepam (?) for proper full examination, then to consider IHS/IV sedation. Dental treatment under GA may be the only option. Second opinion from ENT specialist, to search underlying physiological/pathological condition.

Needle phobic young patient (teenager) who requires multiple extraction due to purely orthodontic reason. Would not tolerate extractions under LA. Is there a justification for orthodontic extractions under GA ?

Very young child (4 y.o), rampant caries, all deciduou teeth, apart from deciduou canines. Most of them not restorable. Has been on antibiotics a few Times as having recurrent swellings/odontogenic abcesses. Not compliant with treatment under LA. Parents would not consent for multiple extractions under GA. Safeguarding issue, concern needs to be raised.

Patient with severe learning disabilities. Gross calculus accumulation and deterioration of gingivae condition. Patient would not tolerate routine USS scaling. Is there a justification for full dental assesssment under GA and USS scaling/FMD under GA ? To consider IV sedation first.

Patient with lack of capacity to consent for dental treatment. Capacity assessment necessary and subsequently best interest meeting, involving patient’s relative(s). Family members of the patient who is not capable to consent must be always informed about the planned dental treatment and involved in patient care (legal requirement).

Parents requested impant installations under GA to replaced avulsed central incisors in 15 years old, lost due to epileptic seizures. To consider prons and cons, resources, clinical indications. Temporary removable denture would be the option until final decision will be made about the age 18-19 (completed oro-facial development).

Parents requested multi stage RCT under GA for their special needs child. To consider long-term prognosis, predictability, resources, clinical indications.

Complex medical conditions, patient ressusscitated 6 month ago due to heart failure. Multiple retained roots to be extracted. On dual combined politherapy: antiplatelet (2x) and NACOs anticoagulant (2x) drugs. Consultation with pt’s GP and haematologist. To consider referral to oral surgery department as a most safe environment for invasive procedures.

Patient, who requests a sigle dental procedure (eg. extraction of symptomatic tooth) and declines the other urgent dental care. Unable to accept different sedation options provided. Changes his/her mind. Multi-stage approach, encouragement, consensus regarding final decision following explanation to patient and signed consent.

Haemophilia A, severe, < 1% factor VIII. Patient requires only restorations and RCT. Consultation with haematologist re: factor VIII cover before procedure (local anaesthetic), second opinion re: ID block LA. Patient may be able to self administer factor VIII 1 hour before procedure. Additionally should start taking tranexamic acid 3x daily since a day before procedure and continue for 5-7 days.

Patient on permanent oxygen therapy due to respiratory failure (lungs disfunction, eg. sarcoidosis). Careful treatment planning, to avoid prolonged procedures.

Patient on prolonged steroids medications (hydrocortisone and prednisolone) 20-30mg hydrocortisone and up to 10mg prednisolone per day who require elective surgical removal of buried root lower molar toooth. Not in pain. Patient’s GP unable to provide advice regarding the ‘steroids cover’, ie. increased, additional dose of steroids on the day of dental procedure. Decision about referring patient to oral surgery department to get extraction carried out in sefe hospital setting as risk of adrenal crisis

Severely phobic 11 y.o. patient. Planned multiple extractions of all 6’s with LA. GA not possible due to medical condition. Ideally IV sedation, since the age of 12.

Severely phobic (needle phobia mainly) 15 years old patient. Need of single extraction of pulpally involved upper molar tooth with recurrent symptoms of odontogenic inflammation. Suitable to for extraction under local anaesthesia but strongly declined as feels, he/she would not cope with a standard procedure. No indications for treatment under GA (XGA). Long waiting list to get IV sedation. To try behavioural management and CBT, gentle approach and acclimatization, gradual confidence build up. Lots of explanations and chats about what it is going to involve, demonstration of topical gel, the use of ultra short needle initially and then standard short for infiltration. Ideally The Wand if possible.

Obesity, very high BMI score. Patient immobile, bed bounded for years. Asthma, breathing problems. Needs extraction. Risk assessment re: potential complications related to LA or xla.

Patient with factor VIII deficiency required fillings with LA (infiltration) and surgical extraction of wisdom tooth. Letter to Hemophilia and Haemostasis Center re: pre- and postoperative advice/cover. Referral to Oral Surgery department for extraction of wisdom tooth.

Mother has diagnosed malignant hyperthermia. Her son has not been tested yet due to his young age. General anaethesia is strictly contraindicated till obtained results from specialist tests. “A rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anaesthesia — specifically the volatile anaesthetic agents and succinylcholine, neuromulscular blocking agents.

Elderly patient with dementia, lack of capacity and severe underlying medical conditions.  No next of kins or family members. Need of best interest meeting arrangement.

Medically compromised patient on anticoagulat politherapy. Multiple anticougulant medications, including antiplatelet drug and new oral anticoagulants.

Patient who recovered following drugs misuse and addiction. On methadone therapy. High sugary oral solution, kariogenic syrup. Rampant caries, multiple retained roots. Phobic, might tolerate minor, non-invasive treatment under LA (fillings) but would not tolerate extractions. Needs referal to sedation clinic for multiple xla’s or GA’s.

Medicaly compromosed patient with recurrent oral ulcers. Needs blood test and thorough investigation of potential underlying problems.

Pregnant woman, second trymester, multiple symptomatic roots. Ref to oral surgery as compromised pregnancy and risk of complications.

Different and opposing consultants/specialists opinions about pharmacological ‘cover’ prior to invasive dental procedure (extraction). How to establish ‘goldemn medium’ between these two specialists points of view ?

Elderly patient with early signs of dementia, sadly rapidly progressing condition. Dental problems seems to be currently manageable, restorative work would be the best available option at the moment (carious cavities, no pulpal involvement). However, patient’s cognitive dysfunctions are likely to significantly and markedly deteriorate ever the next few years time. Is radical approach, eg. multiple extractions justified in order to prevent problems in future ? Is exodontia, full/partial clearance and denture work the reasonable option to consider as well?

Severely phobic patient, generally healthy, medical history non-contributory. Demanding dental treatment under general anaesthesia.

Multiple oral mucosa lesions, mixed white patches and erythematous areas: floor of the mouth, tongue, cheeks and palate. No obvious ulcerations. Non smoker. Referral to specialist in oral medicine and adv to use ‘neutral’ toothpaste, sodium laurate free.

Uncontrolled epilepsy

Frequent epileptic seizures, grand mal fits frequently, on multiple anti-convulsive medications, poorely controlled seizures, clenching tendency. Patient in pain, periodontally involved central incisor, extremelly mobile, unsavable. High risk of tooth aspiration/inhalation. Can extraction be carried out in primary care setting or patient should be referred for this procedure to be completed in secondary care setting (safe hospital settting)? Main precaution: buccal midazolam 10mg has to be ready to be used in case of epileptic attack as an emergency drug.

Severe learning disability, patient partially co-operative. Fluctuating co-operation.

Patient had two episodes of full dental assessment and major dental treatment under GA as would not tolerate any other way of dental care. Parents made a requests to attempt a routine full dental examination withount any other special tachniques. Desite a few attempts, gradual desinsitisation and acclimatisation, patient was not happy to get the mouth/teeth assessed. Parents were informed that GA needs to be considered as a last resort and conscious sedation, particulary IV sedation can be very heplful to provide a full mouth examiantion.

Incoherent consultants second opinions

Patient with inherited heart condition. Two cardiologist consultants, two different opinions: a) AB cover necessary for ultrasonic deep scaling and the opposite statement b) AB course definitelly not relevant. Balanced decision and common sense with regards to best patient interest.

Severe/profound learning disability.  Is IV sedation justified for a full dental assessment?

Patient confined to wheelchair, no verbal communication, however able to understand partially. Lack of cooperation, would not allow even a brief assessment, could not open mouth. Carers do not report any dental problems, patient do not express/indicates any dental pain/discomfort. Next of kin mentioned about ‘pretty lose lower front tooth’ which has been like this for a long time.  Episodes of aspiration pneumonia from time to time. Carers find brushing very difficult. Prescribed high F 5000ppm TP, adv to use intraoral irrigator with chlorhexidine mouthwash for plaque control and reduction of oral bacteria. Review in 1/12 and to try full dental exam next visit (patient can be potentially in a better mood). IV sedation for dental exam and scaling to  be considered nv.

Severe LD, very lose upper incisor, risk of swollowing/aspiration.

Lose tooth catching constantly lower lip, recurrent lower lip ulceration/crack. Already referred for multiple XGA’s. Lack of capacity to consent, however patient partially understand and weight provided information, but unable to retain them. Seems to be fine with LA and simple xla. Has got nominated formal Power of Attorney.  Plan: to chase up the original referral and double check when the hospital appt. will be arranged for GA, to contact LPA and make the decision about urgent extraction under LA of very mobile incisor, acting in the best patient interest (risk of swallowing/aspiration).

Visually impaired patient (Glaucoma)

Vitally important to stay on the front of the patient face.

Potential acute odontogenic infection

Severe learning disability, non -verbal patient, indicates some acute dental problems by banging his face on one side. Full dental assessment not possible due to lack of cooperation. No obvious external swelling o facial asymmetry. Potential diagnostic measures: temperature measurement, tenderness to cheeks/lips/chin palpation, bimolar radiographs,thermal scan of facial area (thermal camera), CRP blood test?