Clinical Scenario

A 28‐year‐old patient presents to your dental clinic due to self‐injury to the palate using a fork; he is accompanied by his mother. She suspects toothache as the trigger, as her son had previously been putting his fingers into the corner of his mouth and slapping his face on the right side.

Structured Learning

1. What factors may have contributed to the high caries rate?
   • Lack of access to regular dental care
   • High sugar content of food
   • Still using a children’s toothpaste – fluoride content not optimal for an adult
   • Oral dryness secondary to medication (levomepromazine and biperiden)
2. What could be the cause of the incisal/coronal dental fractures in this patient?
   • Bruxism
   • Self‐harm
   • Pica (e.g. lithophagy/ingesting stones)
     

     

     

3. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Communication challenges (non‐verbal and verbal)
     • Limited co‐operation which can be worsened by unfamiliar environments or loud noises
     • Self‐harm
   • Medical
     • Aortic stricture corrected should not impact on delivery of dental treatment
     • Vomiting/nausea as a potential side‐effect of biperiden
     • Dizziness, lightheadedness, headache as a side‐effect of haloperidol
   • Dental
   • Urgent dental treatment required for #47
     • Local stimuli (e.g. rotary instrumentation noise) and stress can negatively impact behaviour
     • Pain tolerance unknown
     • Tooth surface loss/bruxism
     • Increased 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 drill
   • Successive 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 happen
   • Keep 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 chairs
   • Always recruit the professional team (both dentist and support staff)
   • Do not change attire (e.g. work uniform colour)

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