Clinical case scenario assignment

The impact of oral conditions on an individuals’ quality of life can be profound, more so when they are increased risk patients such as the elderly or those with Down syndrome. These individuals experience the same dental problems as the general population; however, poor oral health may add an additional burden, whereas good oral health has benefits in that it can improve general health, social acceptability, self-esteem and quality of life (Fiske, Griffiths, Jamieson, & Manger, 2000).

When formulating an oral health care plan for higher risk patients, it is valuable to have a general knowledge of how to treat such cases. This assessment will explore two clinical case scenarios and the process through which each treatment plan is developed. Furthermore, the importance of providing a patient with quality care, rather than merely treatment, will be explored.

CASE 1

Appointment 1:

Complete Initial Assessment

Take medical history

According to Duggal, Hosy, and Welbury (2005, p.42), taking a comprehensive case history is an “essential prelude to clinical examination, diagnosis, and treatment planning”, and also plays a role in establishing a relationship with the patient.

In this case the patient is a thirteen year old female with Down syndrome, a genetic disorder that ranges in severity with unique characteristics that can influence dental care (Pilcher, 1998). It is associated with physical and medical conditions such as cardiac defects, compromised immune system, and upper respiratory infections (MacDonald & Avery, 2000).

Dental consideration

The history reveals that the patient received surgery for a cardiac abnormality at birth, and does not require antibiotic cover for dental treatment. The National Heart Foundation of New Zealand (2009) state that antibacterial cover is given as a prophylactic measure to prevent endocarditis; a serious and potentially fatal infection that affects the endocardium when bacteria is transported through the blood stream from the mouth because of dental work. Although prophylaxis is not necessary, consultation with the patient’s physician is crucial to determine any underlying medical conditions that concern her dental treatment.

According to Pilcher (1998) the eruption of teeth in persons with Down syndrome is usually delayed, may occur in an unusual order and there is an extremely high rate of missing teeth in both the primary and permanent dentitions. Therefore, it is important to maintain the primary dentition for as long as possible. Additionally, The National Institute of Dental and Craniofacial Research (NIDCR) (2010) state that patients with Down syndrome can experience rapid destructive periodontal disease thought to be a result of their lowered host immune response. Other related factors include abnormal tooth morphology with an increased likelihood of smaller or conical roots, bruxism, malocclusion, and poor oral hygiene (Boyd, Quick, & Murray, 2004).

Therefore, good homecare is vital to manage periodontal disease and carious lesions. The mental capability of people with Down syndrome can vary widely (NIDCR, 2010), which is why as a health professional it is important to perceive how much information the patient is able to comprehend. Education should be given to the family and caregiver to ensure optimal homecare is provided.

Plaque index

Taking a plaque score is a quick and useful way for a dental provider to assess oral hygiene by estimating the tooth surface covered with debris and/or calculus (Wilkins, 2009). The patient has plaque deposits along the gingival margins of many tooth surfaces and calculus deposits on the lingual surfaces of the lower anterior teeth indicating poor oral hygiene.

Periodontal probing

It is described that the patient has red and inflamed gingival tissues with the worst area associated with the upper anterior teeth. This is likely to be a result of mouth breathing which is common in patients with Down syndrome due to a small nasal airway and incompetent lips (Pilcher, 1998). Periodontal charting will determine whether the condition is gingivitis which is reversible or periodontitis. If there are periodontal pocket depths greater than 3mm, bone loss and root surface involvement, a more extensive treatment will be required (Wilkins, 2009).

Record examination and dental charting

– Upper permanent lateral incisors appear to be absent

– Upper deciduous canines show no mobility & permanent canines not visible

– Mesial marginal ridge of 75 broken down as a result of dental caries and is symptomless

– Fistula buccal to 74

– Permanent incisors and first molars show signs of mild to moderate hypoplasia

Radiographs

Bitewing radiographs should be taken to check for bone levels, calculus, overhangs of restorations, and carious lesions in the posterior teeth. An orthopantomogram (OPG) will determine the presence and position of permanent teeth and assess growth and development as well as other pathology (Cameron & Widmer, 2003). Additionally, a periapical radiograph will be necessary for pre-operative assessment of tooth 74 and 75 to determine the origin of the fistula.

Diagnosis

– Abscessed tooth (74 or 75 depending on radiographs)

– 75 has dental caries with pulpal involvement

– Periodontal disease (depending on pocket depth)

Differential diagnosis: – Severe plaque-induced gingivitis or

– Chronic periodontitis

– Mild to moderate molar incisor hypomineralisation hypoplasia

Oral health education and instruction

The patient has poor plaque control and therefore should be taught brushing and flossing techniques using the tell/show/do method so the dental provider can see how well the patient and parent or caregiver understand what is being instructed. She should be advised to brush at least twice a day and floss daily, as well as brush the tongue and gingiva.

The use of an electric toothbrush and floss holders should be recommended as those with Down syndrome often have limited manual dexterity (Sacks & Buckley, 2003). Additionally, a high concentration of fluoride such as Neutrofluor 5000 Plus toothpaste is recommended for daily use by patients with high risk of dental caries which Wilkins states will promote remineralisation and help strengthen the teeth (2009).

Dietary advice

Diet should be discussed with a focus on finding if the patient has a lot of sugar in her diet and educating her on the effects of cariogenic foods, perhaps using Stephan’s curve to explain depending on her level of understanding. The patient should be encouraged to eat cheese, unsweetened yogurt, milk and other dairy products as they contain calcium, phosphorous and magnesium which helps protect dental health (The Dairy Council Digest, 2000). Moreover, sugary and acidic drinks should be minimised as they can cause enamel erosion. It is vital the parent or caregiver receive this information as they may have a significant influence over her diet and pamphlets taken home to serve as a reference or reminder.

Formulate a treatment plan

Cameron and Widmer (2003, p. 6) state that treatment should be performed in the following order: (1) Emergency care and relief of pain, (2) preventive care, (3) surgical treatment, (4) restorative treatment, (5) orthodontic treatment, (6) extensive restorative or further surgical management, and (7) recall and review.

Once this has been completed it should be discussed with both the patient and her parents or caregiver and informed consent must be given.

Appointment 2:

The amalgam restoration in the 74 is described as appearing sound but there is a fistula present buccal to the tooth. A fistula is a channel allowing excess exudate to drain from an abscess (Ibsen & Phelan, 2004). Although this can be painless, it is considered an emergency and should be dealt with before any dental treatment.

It is likely that the fistula is related to the 75 which is broken down due to dental caries. When the marginal ridge of a primary molar is broken down due to dental caries, the pulp is consistently exposed (Cameron & Widmer, 2003). Although the 75 is described as symptomless, this may be because the drained exudate is relieving pressure from inside the tooth meaning it is less likely to be painful. If the PA radiograph confirms that the carious lesion on tooth 75 has pulpal involvement, it will be treated with either pulpectomy or extraction.

Pulpectomy: If tooth 35 is not present, the 75 should be preserved and a referral to a dentist to perform root canal therapy will be given. It is advised that a stainless steel crown be placed as according to Cameron and Widmer (2003) this is the strongest possible final restoration following pulpectomy and will be necessary to preserve the 75 for as long as possible.

Extraction: If 35 is present, the 75 should be extracted. However if 35 is not ready to erupt, a space maintainer is recommended to preserve the gap after extraction of 75 to prevent the adjacent teeth drifting into its space. This will enable the 35 to erupt in the proper position and prevent malocclusion in the future and will require a referral to an orthodontist.

The amalgam restoration on tooth 74 appears sound and depending on radiograph results, if there is no abscess on tooth 74 and 34 is present, no treatment is needed on this tooth. If there is abscess on 74, the same treatment for abscessed 75 is indicated.

Appointment 3:

Reassess oral hygiene: Reinforce good behaviour and make necessary recommendations for continual improvement.

Scale and polish: The aim of this is to remove as much bacteria from the oral cavity as possible and have a healthy mouth to perform restorative work in. According to Stefanac and Nesbit (2001), when planning treatment, it is sensible to put the least invasive treatments first when possible so that the patient can familiarise themselves with the dental setting and feel comfortable. (Pilcher, 1998) states that having a patient with Down syndrome that is relaxed and at ease can assists with cooperation in the chair and useful for future appointments.

Hypoplasia: The permanent incisors and first molars are described as having mild to moderate hypoplasia. Enamel hypoplasia is a deficiency in quantity of enamel that results in a defect of contour in the surface (Cameron & Widmer, 2003). This defect can cause tooth sensitivity, may be unsightly and more susceptible to dental caries. A compromised immune system is a characteristic of most individuals with Down syndrome which contributes to a higher rate of infections (Pilcher, 1998) and it is possible that the hypoplasia is related to the patient’s condition. Because of the teeth involved, this is likely to be Molar Incisor Hypomineralisation (MIH) which is defined as a hypomineralisation of systemic origin of one to four permanent first molars frequently associated with affected incisors (Weerheijm, 2003).

It is important that MIH be treated as soon as identified to minimise the heightened risk of dental caries and prevent the patient from experiencing tooth sensitivity. Treatment options depend on the severity of the hypoplasia and the symptoms associated with it (University of Iowa, n.d.). It should be noted that the worst area of inflamed gingival tissue is associated with the upper anterior teeth which could be a result of the patient avoiding these as they are sensitive or painful to brush. It may be useful to ask the patient about this so that education can be given on the importance of brushing all areas and the problem can be addressed.

In this case scenario, the most effective treatment would be the application of a fluoride varnish to the hypoplastic areas followed by resin-based sealants. Alternatively, if ideal moisture control cannot be achieved, glass ionomer sealant can be used. According to Subramaniam, Konde, and Mandanna (2008), the retention of resin sealant is seen to be superior of that of the glass ionomer which should be treated as temporary only. Cameron and Widmer (2003) explain that localised defects may be restored with composite resin and pitting defects may require stain removal with either rotary instruments or some sort of bleaching system. Furthermore, if there is sensitivity, the use of tooth mousse products should be advised to assist with remineralisation and desensitisation of the teeth (Walsh, 2007).

Appointment 4:

Remove IRM: Although the temporary restoration on tooth 65 is sound, it should be replaced with a permanent filling as Mount and Hume state that zinc oxide eugenol hydrolyses in time and should not be used for over six months (1998). Additionally, composite should not be used because the release of eugenol will inhibit the polymerisation of the composite resin (Mount & Hume, 1998). Therefore, an amalgam restoration should be placed on tooth 65 if the radiograph shows tooth 25 is present. If the permanent successor is not present, the temporary restoration should be replaced with a permanent restoration like a stainless steel crown and may require pulpotomy depending on how far the carious lesion has progressed in the tooth.

Recall:

A three month recall should be arranged as the patient is high risk for caries and periodontal disease. It is essential that optimal oral hygiene is maintained and well monitored by the dental practitioner.

CASE 2

The human needs of each older adult must be assessed individually and not based on preconceived stereotypes as the healthcare needs of elderly persons can vary from health to severe illness (Darby & Walsh, 2010). According to Fiske et al. (2000) there is a general trend for a reduction in edentulism and an increase in the retention of natural teeth. This attitude leads to more people wanting to understand how to best maintain good oral hygiene and it is the role of the dental provider to assist these individuals with appropriate educational instructions.

In this clinical case scenario the patient is an 81 year old man who comes to the clinic for dental hygiene care.

Appointment 1:

Complete Initial Assessment

Take medical history

The patient shows early signs of Parkinson’s disease; a progressive neurodegenerative disorder of neurons that produce dopamine (Little, Falace, Miller, & Rhodus, 2008). Loss of these neurons results in characteristic motor disturbances including a resting tremor, muscular rigidity, bradykinesia and postural instability. It is common for those with Parkinson’s disease to also experience xerostomia as a result of polypharmacy and is significant as this increases the risk of periodontal disease and coronal and root surface caries (Wilkins, 2009).

It is described that the patient has mild congestive heart failure which The American Heart Association (2011) state is the inability of the heart to supply sufficient blood flow to meet the needs of the body and can be a result of myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy. As the heart failure is mild, he will not require antibiotic prophylaxis for dental treatment however it is wise to confirm this with his physician.

The patient is taking nitroglycerin tablets under the tongue to relieve chest pain several times a week. It is taken sublingually for immediate relief of chest pain by reducing the oxygen need of the heart and may cause dizziness, light-headedness and fainting and may cause xerostomia (Medline Plus, 2011).

The patient has stiffness in the fingers of his dominant right hand due to arthritis; an inflammatory or degenerative process which involves the joints (Arthritis Foundation, 2011). Patients with arthritis may experience pain, swelling, limitation of motion and deformity of the joints and may find it difficult to keep an open mouth for long dental procedures.

Oral hygiene assessment

The patient has poor oral hygiene. It is likely that due to his arthritis which affects the fingers in his right hand, he is not adequately brushing quadrants 2 and 3. It should be noted that there are signs of abrasion lesions on the buccal surfaces of quadrants 1 and 4. Abrasion is the mechanical wearing away of tooth substance by forces other than mastication (Wilkins, 2009, p.272) and this is likely to be a result of the patient vigorously brushing horizontally. Furthermore, he has heavy plaque deposits on the lower lingual and all interproximal which indicate interproximal plaque removal methods must be instructed.

Periodontal probing

All periodontal pockets measure 1-3 mm except for 26 mesial with a probing depth of 4mm indicating generally good periodontal health.

Record exam and dental charting

– 27 moderately filled teeth present with tooth 25 lost due to a fractured root

– Gingival recession is present with 1-2 mm areas of root surfaces exposed on most teeth. A couple of theses surfaces present with light brown marks that are soft to touch

– Tooth 26 shows sign of periodontal bone loss palatally as well as tipping and drifting forward into the space left by 25

– Heavy plaque deposits on the buccal surfaces of quadrant 2 and quadrant 3 as well as lower lingual and all interproximal surfaces

– Very light plaque deposits on the buccal surfaces of quadrant 1 and quadrant 4

– Some surfaces with light plaque show signs of abrasion

Radiographs

To complete the initial assessment, bitewing radiographs and an OPG should be taken. This can give the dental provider information on alveolar bone levels, plaque retention factors, interproximal and secondary caries, furcation defects, subgingival calculus and additional pathology (Tugnail, Clerehugh, & Hirschmann, 1999). A periapical radiograph of tooth 26 is taken to examine bone loss and to check for subgingival calculus and root surface caries.

Risk assessment

The patient is at high risk of developing dental caries and moderate risk for periodontal disease due to his medical history. His lack of manual dexterity associated with Parkinson’s disease and arthritis, makes adequate plaque removal difficult to achieve. Moreover, due to medications, he is more likely to have xerostomia which will increase his risk of periodontal disease and dental caries, especially root surface caries (Wilkins, 1999).

Diagnosis

– Moderate plaque-induced gingivitis

– Localised moderate chronic periodontitis on tooth 26 due to tilting

– Generalised gingival recession

– Toothbrush abrasion

– Areas of root surface caries

Oral health education and oral hygiene instruction

Perhaps the most important treatment a dental provider can give is that of oral health education, information, promotion and counselling. This enables the patient to maintain good oral hygiene themselves and prevent further disease processes. In this clinical case scenario it is vital to advise the patient on homecare which will address his risks of dental caries and periodontal disease.

According to Darby & Walsh (2010) caries control and prevention activities must address three interrelated factors: (1) removal of bacterial plaque and biofilm, (2) reduction of refined carbohydrates and snacking in the diet, and (3) use of topical fluoride.

The patient’s oral hygiene activities are compromised due to the arthritis in his right hand and in the future will be further affected by his developing Parkinson’s disease. His poor oral hygiene should be addressed firstly by recommending the use of adaptive devices. Using a powered toothbrush and modifications of handle size, width, and grip, will provide assistance for the patient with thorough plaque removal. It should also be suggested that the patient use floss holders to ensure the effective removal of interproximal plaque or alternatively, interproximal brushes can be recommended if the patient is able to use them effectively.

Poor dietary practices involving the over consumption of soft, retentive refined carbohydrates and frequent snacking patterns are common among older adults (Darby & Walsh, 2010). The dental provider has an obligation to educate the patient on optimum food choices and nutritional patterns to promote oral health. It could also be beneficial to speak with any caregivers regarding the patient’s diet and make suggestions to prevent further carious lesions. Replacing sweet snacks with cheese and crackers or substituting sugar-free hard candy for mints are examples of two specific dietary interventions that may be more easily and realistically implemented for older adults.

Furthermore, the frequent use of topical fluoride products for home use should be encouraged. A high fluoride toothpaste (5,000 ppm) will help to strengthen enamel and aid in the prevention of dental caries and will cause little change in the routine of the patient.

For management of xerostomia, the patient is advised to take frequent sips of water and avoid the consumption of alcoholic drinks which will further dry out the oral mucosa. Sugar-free chewing gums will help stimulate the saliva but if the patient experiences difficulty in chewing because of arthritis, this may not be advisable. Additionally, tooth mousse should be recommended to provide lubrication and assist in preventing root surface caries (Walsh, 2007).

If the patient is unable to provide adequate home care, alternative solutions should be provided, such as the introduction of the Collis curve toothbrush, assisted brushing, or chlorhexidine rinses (Little et al., 2008) These aids facilitate self-care and hence self-determination for the patient. The patient may suffer from mild dementia and due to his age may have difficulty remembering everything discussed at the initial appointment therefore all instruction should be written down and passed to him or a caregiver.

Formulate a treatment plan

Appointments should be kept short and scheduled in the morning or early afternoon when patient is less tired or whenever suits his needs best. Once a care plan has been completed it should be discussed with the patient and informed consent must be given.

Appointment 2:

– Re-assess oral hygiene

– Quadrant scaling is recommended in case a full debridement cannot be completed in one appointment

– Reinforce good oral hygiene

Appointment 3:

– Re-assess oral hygiene

– Complete scaling and full mouth polish

– Reinforce good oral hygiene

A referral letter to the patient’s dentist is to be written and given to him regarding the restorative work required on the root caries present in his mouth. The importance of treatment should be explained to the patient and if necessary his caregivers should also be advised of the work required. As a preventive method, fluoride varnish should be applied to the other receded areas to help remineralise the enamel and reduce any sensitivity the patient may be experiencing (Wilkins, 2009).

Recall:

Upon completion of treatment for this patient, a three month recall should be arranged as his medical history indicates he may require regular maintenance in the future. This is also a good chance to evaluate the outcome and effectiveness of the previous treatment.

According to Stefanac and Nesbit (2001) an oral health care plan is about balancing the ideal with the practical, and emphasis should be placed on the patient and their needs which ought to drive the treatment planning process. There has been a shift in treatment given by dental providers, where the focus is now on not only restoring the problem in the clinic, but educating the patient on how they can best achieve optimal oral health themselves.

This assessment has investigated two different clinical case scenarios and discussed oral health care plans for each. In addition, it has examined the importance of treating each patient as an individual with specific needs and the significance of providing them with methods or self-care.