Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 127

1 Although the patient's blindness is likely to be a sequela of the surgery, what other causes should be excluded in liaison with the patient's physician?Following detection of the cleft palate, it is important to consider the presence of an underlying hereditary syndromeUnderlying syndromes are identified in ~20% of cases of cleft lip and ~40% of cases of isolated cleft palateFurthermore, an associated syndrome, such as polymalformative syndrome, may be responsible for some of the patient's other conditions, including visual impairmentFigure 3.1.1 Thickened upper labial frenulum.Figure 3.1.2 Cone beam computed tomography showing a considerable isolated cleft palate.

2  The patient's mother insists that her daughter's midline diastema should be corrected. What should you determine when deciding whether to proceed?Is the patient aware of the diastema (in view of her visual impairment) or is it more of a concern to her mother who is very involved in her care?What are the patient's wishes – although she is 9 years old, any elective/cosmetic treatment should be discussed with her to determine her viewThe patient's age: she is still in the mixed dentition stageThe size of the diastema and if it is increasing in sizeTreatment options in relation to the patient's compliance (frenectomy, orthodontics, restorative treatment)

3 What dental considerations are there for this patient in relation to her underlying diabetes insipidus?Diabetes insipidus and diabetes mellitus are different entities; although both can present with constant thirst and polyuria, central diabetes insipidus is an antidiuretic hormone deficiency caused by damage to the hypothalamus or, as in this case, the pituitary glandSome patients can present with dental fluorosis (due to excessive intake of fluoride in drinking water) and/or dry mouth (due to excessive fluid loss)These patients are susceptible to episodes of orthostatic hypotension

4 What factors are considered important in assessing the risk of managing this patient?SocialImpaired communication due to loss of vision; may be further impaired due to the cleft palate (can lead to unclear speech, hearing problems due to middle ear infections)Potential for overprotection due to the mother's professional backgroundMedicalAcute complications resulting from panhypopituitarism and diabetes insipidus (e.g. hypoglycaemia, hypotension, agitation)The congenital heart disease has resolved and hence does not require further consideration in relation to planned dental treatmentDentalCleft palate may be associated with malalignment of the teeth and/or nasal regurgitationComplexity of orthodontic treatment and surgery necessary to address the cleft palate

5 You decide to undertake the dental fillings before attempting a frenectomy. After an injection of local anaesthetic, the patient begins to cry and becomes anxious. What would be your approach?The pain threshold for children with blindness can be significantly lower than that of children without blindnessStop and undertake acclimatisation appointments, allowing the patient to feel and touch equipment (with sharp components/needle removed)Ensure you explain what you are going to do at each stage of treatment and acknowledge that this is necessary for all steps as the patient is blindConsider adjuncts to reduce the discomfort associated with local anaesthesia infiltrations (e.g. computer‐controlled local anaesthetic delivery)Consider the use of sedation

6 When attempting restoration of the #85, the dental caries is more extensive than previously thought. The tooth is not restorable and requires extraction. The patient is taking 20 mg of hydrocortisone a day. What corticosteroid supplementation regimen should be administered to prevent an adrenal crisis (see Chapter 12.1)?Hydrocortisone is a short‐acting glucocorticoidThe equivalent dose for 20 mg of hydrocortisone is 5 mg of prednisone or prednisolone (intermediate‐acting)Therefore, no supplementation regimen is needed