Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 19

1 The #48 is painful on palpation and you suspect periapical periodontitis. The patient's temperature is not elevated and there is no associated lymph node enlargement. What emergency management would you propose and why?It is important to treat the dental infection urgently to reduce the risk of significant morbidity and life‐threatening sequelae, including Ludwig's anginaHowever, within the last 20 years, antimicrobial resistance has become a significant issue with prescribed antibiotics/dosages being ineffectiveHence it is important to remove the source of infection, establish drainage and prescribe analgesicsFurther effective antibiotics may also enable successful dental intervention at a later date, namely effective local anaesthesia followed by removal of the infected pulpal contents or by extraction of the toothDrainage of an associated abscess should also be considered if swelling develops

2 The patient has received appropriate and high‐dose antibiotics and requests that you attempt to extract the tooth the same day. Although she has no previous experience with local anaesthesia, she appears to be co‐operative and has capacity. What would you discuss with her?Extraction of #48 is the preferred treatment option as:The use of rotary instrumentation for caries removal is associated with increased risk due to the posterior position of the tooth, uncontrolled movements and increased gag reflexThere is limited access to allow for endodontic treatment (e.g. due to difficulties accessing the posterior sections of the mouth)The patient struggles to access her posterior teeth for cleaningAs this is an urgent procedure, the dental extraction can be attempted in the dental chairGiven her considerable dental treatment needs, this can be followed up by the provision of non‐urgent procedures (e.g. restorations) provided in a hospital setting under general anaesthesiaProsthetic rehabilitation and subsequent follow‐up/treatment sessions should be performed in the dental clinic, if possible

3 What factors are considered important in assessing the risk of managing this patient?SocialLack of available escortTransport difficulties when attending dental clinic/hospitalLimited financial meansMedicalNeck position compromised by the dental chair and by problems in the cervical spine; consider the option of treating the patient in her wheelchairRisks associated with general anaesthesia may be increased in patients with cerebral palsy (hypothermia, hypotension)Adjustment disorder may reduce compliance and manifest as increased anxiety/tearfulnessDentalLocal stimuli and stress can increase involuntary movementsGag reflexLimited access to the oral cavitySialorrhoea compromises operatory field isolationPoor self‐cleansing of the oral cavityUnsupervised oral hygiene habits

4 The patient requests premedication/sedation. What do you need to consider when selecting the correct approach?The patient is already taking oral benzodiazepinesHence, a medical consultation is required before proceeding, given the risk of synergy with some of the drugs the patient is taking, i.e. the effects can be increased when midazolam is combined with bromazepamGiven the absence of chronic respiratory problems, nitrous oxide may be used

5 The patient requests oral prosthetic rehabilitation after her teeth are extracted/stabilised. What options would you discuss?If oral hygiene improves:Removable prostheses can be difficult to insert and, with oral dyskinesias, are more unstable, potentially causing injuries to the mucosa/obstruction of the airway if dislodgedFixed implant‐supported or tooth‐supported prostheses are preferable; these can be limited to the anterior/aesthetic zones to allow for improved appearance and easier access for cleaningThe cost of these options needs to be consideredIf oral hygiene remains poor and the dental caries risk remains high:It may be preferable to accept the gaps rather than compromise further teethAlternatively, a removable dental prosthesis may be attempted as this is reversible and can be removed to allow access for cleaningFurthermore, teeth can be added to the partial denture, if further dental extractions become necessaryThis may be better than implant‐supported measures if there are financial limitations

6 Drooling (sialorrhoea) is a common consequence of cerebral palsy among patients with difficulties swallowing saliva. What medication is this patient taking that could be of benefit?Trihexyphenidyl hydrochloride is an anticholinergic drug and hence reduces saliva productionThis medication may also be effective for reducing dystonia or improving upper arm function in patients with cerebral palsy

7 What are the most widely used therapeutic modalities for sialorrhoea?Physiotherapy for swallowing and postural re‐educationDrugs: anticholinergic agents (scopolamine, atropine, glycopyrrolate) or botulinum toxinSurgery: Wharton's duct relocation, excision of a submandibular gland or selective neurectomy