Clinical Scenario

A 6‐year‐old girl presents to your dental clinic with her foster mother who requests management of the patient’s dental crowding.

Structured Learning

1. Why is the hypoacusis/loss of hearing in this patient particularly significant?
   • The patient has mixed bilateral deafness (which implies sensorineural impairment)
   • The auditory threshold is very low in one ear and severe in the other
   • The onset of the deafness was prelingual
2. What other factors impact on the ability to communicate with this patient?
   • Does not tolerate her hearing aids (often removes them)
   • Additional visual deficit which will impact on her ability to:
     

     

     • Engage with other communication management techniques such as pictograms and ‘tell–show–do’ (Figure 3.2.2)
     • Ability to lip read or use sign language effectively
   • No prior dental experience so unable to relate to surroundings, including the feel and smells associated with a dental office
   • Learning disability
     

     

   • Behavioural issues which may be worsened by heightened anxiety

3. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Lack of spoken language
     • Limited co‐operation
     • Potentially aggressive behaviour
   • Medical
     • Auditory deficit
     • Visual deficit
     • Intellectual deficit
   • Dental
     • No previous experience of dental visits and hence limited co‐operation; will require acclimatisation
     • Certain behavioural control techniques are not applicable (e.g. tone of voice)
     • Delayed dental development, malocclusion, tooth agenesis and high arched palate in relation to the foetal alcohol syndrome
4. The foster parent explains that the child is being bullied at school because she looks different. What would you do?
   • Discuss that improving the appearance of the child’s teeth may not stop the bullying as the child may have other distinctive facial features of foetal alcohol syndrome which may appear different (small eyes, thin upper lip, short, upturned nose and a smooth skin surface between the nose and upper lip)
   • Explain that the child is too young for dental extractions, orthodontics and/or orthognathic surgery to be planned (she is in the mixed dentition stage)
   • She also has limited co‐operation
   • The most important focus is to acclimatise her to visiting the dentist regularly so that her oral health can be maintained and enable more invasive treatment at a later stage
   • Encourage the foster parent to discuss the bullying with the school and social services

5. Tooth crowding in anterior sectors has promoted the localised accumulation of dental calculus. What factors would you need to consider when choosing the appropriate technique for removal of these deposits?
   • Manual instruments (curettes) may be preferable to minimise the background noise
   • Ultrasonic instrumentation can cause interference with hearing aids
6. The patient is not co‐operative for calculus removal. What factors are important to assess prior to the adjunctive use of inhalational sedation?

• The nasal hood may not be tolerated or may have a further negative impact on communication
• Sedation itself may further impede communication
• The patient has developmental delay – it is important to consider her weight and height before deciding on the appropriate concentration
• Risperidone and nitrous oxide both have CNS depressant effects

General Dental Considerations