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DH 152: Special Patients Case Study #1

DH 152: Special Patients Case Study #1. By: Amanda Nickelson 1120, Ouiza Yahiaoui 1129 & Carmel Aronian 1103. Patient History. Patient Profile: Patient is a 52 year old African American female. Chief Complaint:

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DH 152: Special Patients Case Study #1

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  1. DH 152: Special PatientsCase Study #1 By: Amanda Nickelson 1120, Ouiza Yahiaoui 1129 & Carmel Aronian 1103

  2. Patient History • Patient Profile: Patient is a 52 year old African American female. • Chief Complaint: “My gums bleed like crazy and I'm concerned with this red blister in the front.  I've also been having a lot of pain lately back here on the bottom.”

  3. Medical History Uncontrolled hyperthyroidism: Graves' disease, diagnosed 12 months ago.  Patient admits to being inconsistent with medications. Depression: Diagnosed 4 yrs. ago; tried different prescription medications; saw no results and discontinued meds Infective endocarditis: Caused by childhood rheumatic fever.  Allergy to amoxicillin Last physician visit: 6 mo ago Medications: Methimazole- Pt takes it sporadically- once or twice a week when she remembers.   Aspirin Clindamycin     • Social history: • Patients admits to drinking 3-4 drinks per week • Patients' son died 5 years ago

  4. Methimazole For palliative treatment of hyperthyroidism; last dose 10 days ago Pharmacologic Category:antithyroid  Local Anesthetic/Vasoconstrictor Precautions:Non e Effects on Dental Treatment:abnormal taste and salivary gland swelling. Effects on Bleeding:None  Dosage:5 mg/day

  5. Aspirin For pain on her LR side; last dose this AM Pharmacologic Category: Salicylate Use: Pain, inflammation,  & fever Local Anesthetic/Vasoconstrictor Precautions: N/A Effects on Dental Treatment: Bleeding/ inhibits platelet aggregation 

  6. Clindamycin Pharmacologic Category: antibiotic Use:pre-medication/ alternate oral antibiotic for prevention of IE in individuals allergic to penicillins or ampicillin Local Anesthetic/Vasoconstrictor Precautions: N/A Effects on Dental Treatment: N/A Effects on Bleeding: N/A Dosage: 600 mg

  7. Dental History • Pt. admits that sometimes she goes 2-3 days without brushing; does not floss or use interdental aids at all • Medium- heavy to heavy calculus. • Eight years since last dental prophy & exam • Pt. complains: pain & sensitivity on LR post teeth for 6 months. 

  8. Medical Assessment • Patient presents with: • stage I hypertensive blood pressure • depression (assumed based on patients unkept appearance, lethargic demeanor, and poor oral hygiene) • uncontrolled hyperthyroidism • past history of infective endocarditis • Vital Signs:  BP: 156/92; P: 90; R: 23    • ASA III because of the systemic effects of uncontrolled hyperthyroidism & uncontrolled depression.

  9. Dental Assessment • Possible carious lesions: M #4, D #5, O #12, #13, #20, #21, #28, & #31, and M #29 • Last dental visit: 8 years ago; Reason: Recare appointment  • Current FMX and Intra-Oral Photographs:  • Missing Teeth: 1,2,3,16,17,18,19,30, 32 • No evidence of any past restorations • Supra-eruption of 14,15, 31 • Mesial drift of 31

  10. E/I Assessment Extraoral exam: • The patient presents with enlarged thyroid gland on the left side of neck; area is firm to palpation.  • Patient is sweating excessively.  • TMJ is within normal limits. • Maximum opening is 45 mm Intraoral exam: • Bilateral mandibular tori. • Tooth #8 presents with an erythematic, shiny, 9 mm diameter bulla, bullbous, compressible; resembles pyogenic granuloma. • Salivary flow is poor. • Gross caries on tooth #29. • Possible facial recession based on extraoral photos: 2 mm on 6, 11, 21, 27-29. 1 mm on 10 & 22.

  11. Slight midline deviation to the right. • Molar relationship can not be classified because first molars are missing.  • Cuspid relationship: left side is class I; right side is class I with tendency for a class II. • Overbite and overjet apear within normal limits. Occlusion

  12. Gingival Description Maxillary: • Free gingiva:  Erythematous, shiny, irregular, rolled borders, blunted and bulbous papilla.  • Attached gingiva: red, pigmented, smooth, edematous, hemmorrhagic. Mandibular: • Free gingiva: loss of architecture, blunted, punched-out  papilla, irregular rolled borders, generalized erythematous. • Attached gingiva: smooth, shiny, red, pigmented. 

  13. On radiograph: evidence of generalized horizontal bone loss and calculus buildup on  #4, 8, 9, 23-26. 

  14. Periodontal Assessment • PFI: 15% • MBI: 100% • BOP: 96%  • OH: Poor • Mobility: unknown • Furcations: unknown • Probing depths are generalized 4-5 mm posteriorly and 2-3 mm anteriorly with localized 7-9 mm on tooth # 8. • Evidence of either calculus or periodontal involvement with suppuration on #4.  Radiograph shows distal ledge of calculus and radiolucent alveolar bone between #4 and #5, suggestive of a possible periodontal abscess.

  15. Dental Hygiene Assessment • WLAC calculus Code: 5 medium-heavy to heavy • AAP Classification:Generalized chronic moderate periodontitis with localized severe, perpetuated by dental plaque and calculus,  missing teeth, and modified by systemic conditions. 

  16. Depression • Affects of depression on oral health: •    Periodontal disease due to • neglect of oral hygiene • altered immune system • clenching & grinding •     Rampant dental decay due to • carbohydrates diet/sweets • decrease in salivary output. •     Halitosis •     Chronic facial pain

  17. Depression • Dental management requires: • Current medication regimen • Any history of alcohol/substance abuse • Preventive dental education • Anticaries agent with fluoride • Saliva substitutes/ increase water intake • Special precaution when administering local analgesics • Positioning upright in dental chair/ orthostatic hypotension • Precaution related to low blood pressure • Decrease length of dental visits Friedlander, A., & Mahler, M. (2001). Major depressive disorder: Psychpathology, medical management and dental implications. The Journal of the American Dental Association, 132(5), 629-638.  Retrieved from http://jada.ada.org/cgi/content/full/132/7/629

  18. Hyperthyroidism • Affects of hyperthyroidism on oral health: • Increased susceptibility to caries • Periodontal disease • Presence of extraglandular thyroid tissue • Accelerated dental eruption • Burning mouth syndrome • Dental management requires: • Monitor vital signs during procedure • If uncontrolled, consult physician & avoid epinephrine; only emergent procedures should be performed • Minimize stress- appointments should be brief • Use precaution with NSAIDs; avoid aspirin Pinto, A., & Glick, M. (2002). Management of patients with thyroid disease. The Journal of the American Dental Association, 133(7), 849-858. Retrieved from http://jada.ada.org/cgi/content/full/133/7/849

  19. Infective Endocarditis The American Heart Association guidelines emphasize that maintaining optimal oral health and practicing effective daily oral hygiene are more important in reducing the risk of IE than is taking preventive antibiotics before a dental visit. Preventive antibiotics before a dental procedure are advised for patients with a history of infective endocarditis.  The American Heart Association (2007). Antibiotics and your heart. The Journal of the American Dental Association, 138(6), 920. Retrieved from http://www.ada.org/sections/publicResources/pdfs/patient_75.pdf

  20. Dental Hygiene Care Plan We suggest a total of five appointments: • Appointment 1: Initial health history exam • Appointment 2: Comprehensive exam • Appointment 3: UR & LR SRP  • Appointment 4: UL & LL SRP • Appointment 5: Reevaluation appointment (completed one month after 4th appointment) *Every appointment will begin with the following:  RMH, Vital Signs, E/I Exam, a pre-procedural rinse with 10 mL of .12% chlorhexidine gluconate, and OHI. Document patient has premedicated with 600 mg of Clindamycin. 

  21. Appointment 1:Initial Health History Exam • Discuss with patient that she cannot be seen until her hyperthyroidism is under control due to the fact that the uncontrolled disease can lead to an increased risk of hypertension, angina, MI, congestive heart failure and severe arrhythmias.   • Provide referral to medical doctor for medical evaluation and treatment of hyperthyroidism, hypertension and depression.  • Advise the patient of the potential relationship between dental treatment and infections of the heart and her increased risk due to past history of infective endocarditis. • Make sure patient knows to premedicate with Clindamycin 600 mg, one hour prior to any invasive dental procedure.   • All assessments and dental treatments will be postponed until patient has been seen by her medical doctor and her hyperthyroidism becomes controlled. 

  22. Appointment 2:Comprehensive Exam • Confirm with patient's physician that hyperthyroid condition is stable • FMX and intraoral photos • Full mouth probing and periodontal assessments • CAMBRA assessment • General exam with dentist to create patient treatment plan. DDS and hygienist will coordinate periodontal therapy with restorative work; this will reduce number of times patient has to premedicate.   • Appointments will be condensed to avoid excessive use of premedication antibiotics. • Appointments will be scheduled in the morningto create the most comfortable situation for the patient.  • Give oral hygiene instructions and assess patient physical skills and motivation.  Instruct patient in the modified Bass and roll technique and flossing using show-tell-do method.  Encourage patients use of xylitol gum and NaF rinse.  Send patient home with 1.1% NaF prescription strength toothpaste. • Advise patient to stop taking Aspirin aproximately 10 days prior to SRP to control bleeding.

  23. Appointment 3: UR & LR SRP(Two weeks after appointment 1) • Provide patient with N20 sedation • Scale and Root Plan on LRQ & URQ with anesthesia; Epinephrine will be limited to two carpules.  • Reinforce toothbrush and flossing instructions. • DDS will possibly perform restorative procedure on tooth #29. • Send patient home with a 3 day food diary.  • Send pt home with 12% Chlorhexidine to be used 2x a day for two weeks.  

  24. Appointment 4: LL & UL SRP(Within 1 week) • Provide patient with N2O sedation.  • Assess tissue response on UR & LR quadrants.   • SRP on LLQ & ULQ with anesthesia with limited epinephrine.   • Reinforce toothbrush and flossing instructions.  • Review food diary and discuss possible modifications to improve health, such as limiting sodium & carbohydrate intake and including 30 minutes of exercise.  • Encourage patients continued use of xylitol products for dry mouth. 

  25. Appointment 5: Reevaluation(Four weeks later) • Assess tissue response on FM. • Check patients OH with disclosing solution- give positive reinforcement, review OHI.  • Inquire about nutrition modifications.  • Perform selective polishing as needed.  • Scale and root plane if necessary.  • Assess for Reduced Gingival Bleeding BOP<75% and a reduction in pocket depths.   • Switch to 10 mL clorhexidine rinse for 1 minute daily for 1 week each month.  • 5% NaF fluoride varnish application on FM. 

  26. Three Month Recare Appointments: • Periodontal maintenance. • Fluoride varnish application.   • Reinforce OHI and nutritional modifications.  • Take bitewing radiographs every 6-18 months or until no cavitated lesions are evident.  Prognosis: • Poor  • Rationale:  • Pt. is depressed, so compliance will most likely be minimal • Pt. has not played an active role in staying healthy. • Poor outcome following periodontal treatment due: • Overwhelming/ not compliant with tx recommendations • Impair immune system = low body response to infection

  27. Referrals • Periodontist regarding localized probing depth: #8- 9 mm & pos. pyogenic granuloma • Medical doctor for uncontrolled hyperthyroidism & depression

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