Clinical Scenario

A 55‐year‐old female presents to your dental clinic complaining of pain in an upper left first molar tooth.

Radiological Examination

• Patient unable to tolerate intraoral radiographs due to limited space/access in the mouth
• Difficulty with orthopantomogram due to tissue mass around shoulders obstructing movement of emission tube and cartridge frame (wider machine required; accessed in another clinic) (Figures 16.4.1)
• Orthopantomogram confirms distal caries in #26 and generalised bone loss (10–30%) (Figure 16.4.2)

Structured Learning

1. What does the raised BMI of this patient indicate?
   • This patient has a BMI of 46.9 kg/m², which is classified as morbidly obese
   • She has an ‘extremely high risk’ of cardiovascular diseases, stroke, diabetes and also weight‐related diseases
2. The patient asks that you only recline her slightly in the dental chair as lying flat makes her feel breathless. What could be contributing to this feeling?
   • Obesity can be associated with compressive effects of the excess abdominal weight which prevents the lungs from inflating fully, particularly when lying down; patients should be seen in a semi‐upright position
   • Other factors which may exacerbate her shortness of breath include her underlying dental anxiety, asthma, pulmonary hypertension and ischaemic heart disease
3. The dental chair fails to move upright at the end of your examination (Figure 16.4.3). What is the most likely reason for this?
   • Most standard dental chairs have a safe working limit (SWL) in the region of 140 kg/22 stone
   • The dental chair will not reposition as the maximum weight limit has been exceeded
4. The patient bursts into tears. She is embarrassed and apologises that her weight is the likely reason the dental chair does not move. How would you respond?
   • Apologise and reassure the patient that she is not at fault
   • Explain it is a legal‐ethical duty of service providers to make ‘reasonable adjustments’ to enable equitable access to dental care regardless of any disability
   • Advise her that it is possible for her to access dental care with suitable and safe facilities, practices and equipment – inform her that you will attempt to make these available for her next visit (e.g. access to a bariatric dental chair/bench and platform; SWL 203 kg/32 stone) (Figures 16.4.4 and 16.4.5)
   • Reassure her that the staff will have specific training on bariatric handling and transfer to optimise safety
5. The patient consents to extraction of the carious #26. What other factors do you need to consider in your risk assessment?
   • Social
     • Identifying a suitable escort; essential if sedation is being considered to manage her dental anxiety
   • Medical
     • Airway compromise/respiratory distress due to obesity
     • Increased risk of hypertensive crisis and orthostatic hypotension (see Chapter 8.1)
     • Acute presentation of angina‐related chest pain (see Chapter 8.2)
       

       

       

     • Hypoglycaemia, infection risk and delayed wound healing due to diabetes (see Chapter 5.2)
     • High risk of thromboembolic events (see Chapter 14.5)
       

       

     • Risk of an acute asthma attack (see Chapter 9.2)
     • Stress from the dental environment can trigger an anxiety crisis (see Chapter 15.1)
     • Polypharmacy

   • Dental
     • Dental anxiety may reduce compliance for dental treatment
     • Unable to recline the dental chair
     • It may not be possible to place the forceps on #26 in the correct position due to the buccal adipose tissue
     • Limited access for further radiographs, operative dentistry/instrumentation and oral hygiene practices due to increased adipose tissue
     • Tooth surface loss likely to be secondary to gastro‐oesophageal reflux disease and bruxism
     • Poor oral hygiene (increased incidence of dry socket)
6. The patient asks for sedation due to her dental anxiety. What factors should you consider?
   • The abundant adipose tissues act as a ‘reservoir’ for the sedatives, attenuating the active drug concentration in plasma; therefore, the sedative available to the central nervous system is reduced
   • The effect of sedation agents is often prolonged; this is due to the fat‐soluble molecular structure of benzodiazepines and propofol
   • Concomitantly, available plasma sedative to the liver or kidneys is also reduced, slowing down elimination rate and recovery
   • Furthermore, benzodiazepines (e.g. midazolam) cause respiratory depression
   • The patient also has multiple medical comorbidities
   • If sedation is being considered, this should be undertaken in a hospital environment with the support of an anaesthetist; a presedation assessment will be required to assess the airway and impact of the concurrent medical condition
   • Propofol, ketamine and nitrous oxide have a less airway‐depressive effect and may be preferred to benzodiazepines
   • Titration induction is essential
   • Prolonged recovery is likely; access to an inpatient bed is advisable

General Dental Considerations