Case Presentation Flashcards
(40 cards)
Why was your patient not concerned about his appearance until now?
He has a complex home life and his appearance wasn’t his priority. Being promoted to a managerial position at work has made him more conscious of his appearance and his partner has also been pushing him to take better care of his oral health and appearance.
What was wrong with the immediate denture provided 3 years ago?
The denture was fitted on the day of the extractions. The patient felt that the dentist fitted a denture that didn’t actually fit his mouth. He was unable to seat it or tolerate it. At the time, the spaces didn’t concern him and he was still able to function so did not return to have this resolved.
Why does the patient want a denture now?
He is now more aware of his appearance and wants to improve on this. He is also aware that he is in need of further treatment including extractions and wants to be able to wear a denture rather than be left completely edentulous.
What does the patient expect from a new denture?
Mainly aesthetics. He wants a denture that he will be able to tolerate in public to improve his appearance and replace missing teeth. He is aware that tolerating a denture will be difficult but is keen to persevere. He is happy to wear a denture outwith his home, and can function without a denture at home for meal times if he does find them too uncomfortable
Why does the patient take omeprazole?
He takes it for prevention of gastric ulcer relapse. He has a history of gastric ulcers but is currently asymptomatic. He has no history of reflux and doesn’t remember when he last had gastric issues.
What is omeprazole and how does it work?
It is a proton pump inhibitor.
It inhibits gastric acid secretion by blocking the proton pump system of the gastric parietal cells
Are there any side effects of omeprazole that could impact the patients oral health?
Dry mouth is listed as a common side effect, however the patient has not had a dry mouth on examination and does not complain of any side effects.
Nausea and vomitting are also common side effects, but the patient does not complain of having suffered this.
Will the patients’ allergy to penicillin affect your treatment?
No changes will have to be made to the treatment plan. However, if a script for ABs was needed, I would prescribe metronidazole instead at 400mg 3 x daily for 5 days
what are the signs and symptoms of anaphylaxis?
*Flushing
*Sweating
*Nausea and abdominal pain
*Possible rash
*Swelling of soft tissues
*Swelling of throat and tongue
*Wheezing
*Difficulty breathing
*Increased heart rate
What actions should be taken in the event of anaphylaxis?
*Reassure the patient
*Carry out A-E assessment
*Dial 999 for ambulance
*Administer oxygen at 15 litres per minute
*Raise patients legs to help restore their BP
*If symptoms are life threatening, administer IM injection of adrenaline into outer aspect of thigh
*Can be repeated after 5 minutes on opposite thigh
*0.5ml adults, 0.3ml 6-12years, 0.15ml 6mo-6yr
*Continue to assess and reassure patient
What is the pack years of your patient?
20 pack years = 20 cigs per day for 20 years
Did you offer smoking cessation advice to your patient?
Yes, initially offered cessation advice in the format of the 3 As
Ask - establish and record smoking status
Advise - on personal benefits of quitting in light of findings in the mouth
Act - Offer help and sign post to local stop smoking services
Patient declined advice. Has never quit, is not interested in quitting.
Advised patient that a referral can be made if he changes his mind, he can also approach me or a pharmacist in the future if he changes his mind. Also advised him that I will revisit his smoking status at future appointments
What are some oral side effects of tobacco use?
* Smokers are 2-4 x more likely to develop potentially malignant lesions
* Smoking is an independent risk factor for periodontal disease (relative risk 2-6 x that of non smokers)
* Smoking increases dental treatment risks and problems ie dry socket following extraction
* Smokers have significanly greater medical risks, compromised health and more days of illness
* Tobacco and alcohol are the main determinants of oral cancer, if both are present, the risks are synergistic
Name two potentially malignant lesions that can present in a smoker
Leukoplakia
Erythroplakia
What is the connection between smoking and periodontal disease?
* Smoking associagted with increased rates of alveolar bone loss, attachment loss and pocket formation
* 40% of chronic periodontitis is attributable to smoking
* Smoking demonstrates a dose response with periodontal disease
* Smoking has a masking effect on gingival symptoms of inflammation
List some other tobacco related oral lesions
* Staining of teeth, restorations and dentures
* Halitosis
* Nicotine stomatitis (smokers palate)
* Smokers melanosis
* Black hairy tongue
* Extractions take longer to heal
What are some systemic risks of smoking?
* Stroke
* Cancer of lips, tongue, throat, larynx, oesophagus
* Heart attack
* COPD
* Chest infections
* Lung cancer
* Stomach ulcers
* Delayed healing
What are some benefits of stopping smoking?
* CO returns to normal within 48 hours
* Nicotine leaves the body within 72 hours
* Breathing improves within 2 weeks to 3 months
* After one year, the risk of cardiovascular disease is half that of a smoker
* Financial benefits
What is the link to smoking and alcohol consumption to oral cancer risk?
Smoking and drinking in combination can increase oral cancer risk by up to 30%
There is also a link between oral cancer and poor diet. This is not something I have discussed with my patient. This is something I plan to visit with him on the return of the diet diary
Was your patient prescribed duraphat? What concentration?
I did consider the prescription of duraphat and it was a discussion I had with my supervising clinician. As the patient has not been very engaging, and due to oral hygiene being so suboptimal, it was decided that prescribing high fluoride toothpaste would have minimal benefit.
The patients home life was also taken into consideration, the risk of his daughter having access to the duraphat.
However, if it were to be prescribed, it would have een 5,000 ppmF
What impact could the patients social history have on his oral health?
The patient has a high stress home and work life.
He often works 7 days per week, and although he genuinely enjoys his job, it means he spends long hours away from home.
As the manager, his time and attention is in high demand.
He is expected to be the first person to arrive and the last person to leave.
He has frequent coffee and cigarette breaks and food is usually bought out of convinience.
At home he lives with his partner and their teenage daughter. His daughter is autistic and is currently home schooled. This is a responsibility his partner has taken on and so it falls on him to provide for the family financially.
This also means that time spent at home is not relaxing, after working hours he takes on his share of the household tasks too.
He is a very dedicated father and is often doing things to please his daughter such as DIY to make home and garden improvements as well as taking on responsibilities as a pet owner. The family currently have two adult dogs and two of their pups (but recently had all 7 pups until the others found homes). They also have ginuea pigs
What preventive advice was given to your patient?
* Tooth brushing advice. Patient states he brushes 2 x daily with colgate toothpaste. Reassured patient that this is ideal, and to ensure he is spending 2 minutes twice daily. Discussed and demonstrated brushing gums as well as teeth, and emphasised the importance of brushing before bed.
* Advised pt to spit excess toothpaste and not rinse.
* Recommended the use of disclosing tablets
* Advised pt that manual toothbrush is adequate with good technique but offered advice on the use of an electric toothbrush also.
* Sized and demonstrated the use of interdental brushes. Patient given a variety of brushes to try at home. States he is using the brushes severeral times per week (not always daily) but evidence of this lacking.
What is the BPE?
The BPE is a screening tool employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis or periodontitis, irrespective of historical attachment loss and bone loss. As such, the BPE guides the need for further diagnostic measures prior to establishing a definitive periodontal diagnosis and appropriate treatment planning
