Clinical Scenario

A 63‐year‐old male presents for a dental appointment complaining of pain from his upper left wisdom tooth (#28). It affects his eating and sleeping. Due to his dental anxiety, he has not seen a dentist for over 10 years.

Structured Learning

1. What is the most likely cause of the white lesions you have noticed on the patient’s palate?
   • Acute pseudomembranous candidiasis, commonly referred to as thrush
     

     

   • This is the most common type of oral candidiasis, accounting for about 35% of cases
   • The patient is using a steroid‐containing inhaler (fluticasone) which has an immunosuppressant effect and predisposes to the development of these lesions (exacerbated by a poorly cleaned denture)
   • It is characterised by a coating of pseudomembranous white slough that can be easily wiped away to reveal an erythematous mucosal base underneath
     

     

   • The white material is made up of debris, fibrin and desquamated epithelium and infiltrated by candidal hyphae (typically Candida albicans) to the depth of the stratum spinosum

2. What advice would you give the patient in relation to the oral lesions?
   • Oral candidal lesions are relatively common (studies vary widely in terms of stated prevalence due to the different diagnostic criteria used)
   • Preventive strategies
     • Review the use of inhaler to ensure that a deep breath is expelled before actuation – this ensures a subsequent deep breath in to draw the medication into the bronchi, rather than allowing it to accumulate in the mouth
     • Rinse the mouth and gargle with water after using an inhaler
     • Consider the use of a spacer to assist in drawing the inhaled medications into the lungs
     • Ensure that the denture is cleaned well, periodically disinfected and not worn at night (it can act as a reservoir for further candidal infection)
   • Therapeutic options
     • Oral candidosis may be persistent in the immunosuppressed patient using steroid inhalers frequently
     • Topical antifungal preparations of nystatin, amphotericin or miconazole are usually effective
     • Occasionally systemic medication, such as fluconazole, is required
3. You notice the patient has a continuous high‐pitched whistling sound when breathing. What may be causing this?
   • The sound is likely to be due to a wheeze
   • Wheezes are produced by the oscillation of the airway walls with fluid within the airway
   • It is most often heard on exhalation and is usually a sign of narrowing of the airway
   • In this patient it is likely to be caused by his asthma

4. What does the sound tell you about his asthma severity and what other observations may help to clarify this?
   • The patient’s asthma is likely to be moderate–severe
   • Other observations that may indicate severe asthma are:
     • Inability to complete sentences
     • Persistently breathless
     • Accessory muscles used to assist breathing (e.g. sternocleidomastoid and scalene neck muscle)
     • Tachypnea (>25 breaths/min)
     • Tachycardia (heart rate >110 beats/min)
     • Pulsus paradoxus (large decrease beyond 10 mmHg in systolic blood pressure during inspiration)
5. The patient requests urgent removal of #28 in your dental clinic. Apart from the patient’s wheeze, he has no other signs/symptoms suggestive of severe asthma. You contact the patient’s physician who confirms that the patient’s asthma is moderately well controlled and you can proceed. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Lives alone – lack of support/escort
     • Works shifts and hence may not be available during the day or may present for an appointment without having slept overnight
     • Dental anxiety may reduce co‐operation and increase the likelihood of an acute exacerbation of his asthma (however, dental extraction of #28 is unlikely to require the use of handpieces due to advanced bone loss)
   • Medical
     • Infrequent attendance for medical review of his asthma may impact on the control of his disease and increase the risk of an acute asthma attack
     • Chinese tonic used regularly instead of prescribed drugs and hence asthma control may not be optimal; although there are as yet no known absolute contraindications to Lignosus rhinoceros, it should be used as a complementary medication rather than as an alternative
     • Asthma is associated with an increased risk of other atopic reactions, including drug allergies (e.g. penicillin)
     • Ibuprofen and aspirin are associated with a risk of precipitating asthmatic attacks via hypersensitivity pathways (e.g. Samter’s triad syndrome)
     • Reduced mobility in relation to rheumatoid arthritis
     • A low BMI may indicate malnutrition, with an associated increased risk of anaemia and related reduced oxygenation (excessive tea consumption can also cause a deficiency of Fe and folic acid)
     • Visual impairment may impede communication
     • Steroid inhalers (high dose/frequent use) may be associated with adrenal suppression (see Chapter 12.1)
   • Dental
     • Removal of #28 may impact on the retention of his upper overdenture
     • Poor oral hygiene with associated oral health deterioration
     • Frequent cups of sweet tea and irregular mealtimes increase his caries risk
     • Inhaled beta‐agonist and steroid increase risk of dry mouth, caries and periodontal inflammation
     • Inhaled steroids may also delay postsurgical wound healing and increase recurrent oral candidiasis risk
     • Oral mucosal malignancy risk is higher in association with long‐term smoking and use of steroid inhalers
     • Gastro‐oesophageal reflux may cause dental erosion
6. Dental extraction of #28 is uneventful. He requests painkillers postoperatively as the area has been painful and he does not wish to miss more shifts at work. What should you consider?
   • Advise the patient that it is important to rest and allow the area to heal adequately, particularly as healing is likely to be delayed in relation to steroid use
   • Lack of rest may also exacerbate his asthma
   • Advise him of the risk of aspirin‐exacerbated respiratory disease, also known as Samter’s triad
     • This consists of 3 clinical features: asthma, sinus disease with recurrent nasal polyps, and sensitivity to aspirin and other non‐steroidal anti‐inflammatory drugs (e.g. ibuprofen) that inhibit the enzyme cyclo‐oxygenase‐1
     • A single dose of aspirin can provoke an acute asthma exacerbation, accompanied by rhinorrhoea, conjunctival irritation and flushing of the head and neck
     • Approximately 9% of all adults with asthma and 30% of patients with asthma and nasal polyps have Samter’s triad
7. The patient feels reassured after his experience of having #28 extracted. He is willing to return for regular care as he does not want to lose all his teeth. What are some effective ways to implement oral health prevention strategies for this patient?
   • An oral health prevention programme should take into account the patient’s shift patterns
   • With the alternating 8‐hour work cycle, he is unable to brush his teeth at regular times
   • It is important to reinforce that improving oral health can help to avoid further pain, distress and disruption to his work
   • Motivational interviewing may be helpful, where the patient is facilitated to establish his own methods in order to elicit the desired behavioural changes, which may include:
     • Rinsing his mouth after each inhaler use, which may not only reduce the risk of oral‐mucosal lesions, but can also freshen his breath
     • Mouth rinsing is easier to use during his work shifts, compared to toothbrushing
     • He may consider the option of a fluoride mouthwash to reduce caries risk (0.05% or 225 ppm sodium fluoride) and further reduce halitosis
     • Removing the denture and cleaning it before sleep may reduce smoke stains on the acrylic base and improve halitosis

General Dental Considerations