Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 91

1 What factors may have contributed to the high caries rate?Lack of access to regular dental careHigh sugar content of foodStill using a children's toothpaste – fluoride content not optimal for an adultOral dryness secondary to medication (levomepromazine and biperiden)

2 What could be the cause of the incisal/coronal dental fractures in this patient?BruxismSelf‐harmPica (e.g. lithophagy/ingesting stones)Figure 2.2.1 Oral examination was carried out with the help of pictograms.Figure 2.2.2 (a) Fracture of the incisal edge of the crown of tooth #11. (b) Multiple cusp fractures.

3 What factors are considered important in assessing the risk of managing this patient?SocialCommunication challenges (non‐verbal and verbal)Limited co‐operation which can be worsened by unfamiliar environments or loud noisesSelf‐harmMedicalAortic stricture corrected should not impact on delivery of dental treatmentVomiting/nausea as a potential side‐effect of biperidenDizziness, lightheadedness, headache as a side‐effect of haloperidolDentalUrgent dental treatment required for #47Local stimuli (e.g. rotary instrumentation noise) and stress can negatively impact behaviourPain tolerance unknownTooth surface loss/bruxismIncreased likelihood of further/recurrent caries due to the highly cariogenic diet and suboptimal fluoride levels in the toothpaste

4 Following a course of antibiotics to manage the acute infection associated with #47, the patient returns for extraction of this tooth. What would you consider?Although this patient has no previous experience with local anaesthesia, it may be possible to attempt more urgent procedures (e.g. extraction of #47) in the dental clinic; acclimatisation visits should be arranged, with appropriate adjustments in place (minimise loud noises, use pictograms)Given the considerable dental treatment needs and depending on the patient's ability to co‐operate with treatment under local anaesthesia, this may be followed by comprehensive dental treatment under general anaesthesia session in a hospital setting where available – this will avoid the repeated trigger of vibration/noise from the dental drillSuccessive follow‐up/treatment sessions should be attempted in the dental clinic to ensure regular dental reviews are in place

5 What should you consider when arranging dental visits for assessment and acclimatisation?It may be helpful to create a story book with pictograms to anticipate what's going to happenKeep the appointments in the same time slot/day of the week, ensuring that they do not interfere with the specialised centre visits or important activities for the patient (e.g. going to the swimming pool)Always implement the same study routine (e.g. meeting place, progressive exposure to the setting and instrumentation)Do not change dental treatment rooms or dental chairsAlways recruit the professional team (both dentist and support staff)Do not change attire (e.g. work uniform colour)

6 If the patient needs to be sedated, what technique would you use?Patients with autism often do not tolerate the nasal facemask for applying nitrous oxide/may not accept physical contact on parts of their face (although this can be trained in some cases)Due to the risk of synergy with the antipsychotic drugs the patient is taking, a medical consultation opinion should be accessed if sedatives (e.g. benzodiazepines) are being consideredParadoxical reactions to drug sedation are common

7 After completing the extraction, you note that there is extensive purulent discharge from the socket and prescribe an analgesic and an antibiotic. Which should you avoid?Any nonsteroidal anti‐inflammatory analgesic may be prescribedDo not administer opioid analgesics (e.g. codeine or tramadol) due to potential interactions with the antipsychotic drugsAvoid azithromycin because of the interaction with levomepromazine (risk of QT interval prolongation)