Clinical Scenario

A 76‐year‐old male presents to you complaining that he is unable to eat with his removable lower denture and only wears it for aesthetic reasons when leaving the house. The patient reports that he has been unwell due to heart problems and hence has not been to see a dentist in the last 5 years. He now feels able to tolerate dental treatment.

Structured Learning

1. The patient informs you that his previous dentist alerted his doctor and cardiologist regarding the possibility of a potential problem with the left carotid artery. What could have made the dentist suspect this?
   • In patients undergoing orthopantomogram examination for dental diagnostic purposes, approximately 10% will have evidence of carotid artery calcification
   • It is estimated that 1 in 7 patients with carotid calcification on an orthopantomogram is likely to have a carotid stenosis ≥50%, compared with 1 in 20 patients without carotid artery calcification visible on an orthopantomogram
   • Carotid artery calcification is confirmed by an experienced dental radiologist who should advise the dentist that further evaluation is required, especially if there are any symptoms suggestive of cerebral ischaemia
     

     

   • This patient had a TIA; the dentist may have linked the symptoms to the orthopantomogram findings and referred the patient for urgent medical review, leading to a stent being placed

2. The patient asks about the feasibility of prosthetic rehabilitation with osseointegrated dental implants and whether they would be less successful given his medical problems. What would you discuss?
   • In carriers of coronary stents, the placement of implants is not contraindicated, and there is no evidence that their long‐term prognosis is jeopardised
   • Potential complications may occur during the dental procedure and include prolonged bleeding and the onset of a cardiac ischaemia episode
   • A number of antihypertensive drugs may even promote new bone growth (e.g. beta‐blockers have been shown to improve bone mineral density in some studies and this patient is taking bisoprolol)
   • The level of diabetes control can determine the success of the implants
3. What could be contributing to the patient’s bradyphrenia (slowness of thought)?
   • Health comorbidities, particularly cardiovascular risk factors, are well known to pose risks for cognitive decline in older adults
   • Hypertension has been suggested as a risk factor for subtle executive and memory deficits, above and beyond that conferred by diseases such as Parkinson’s
   • Although by definition, symptoms of a TIA subside completely within 24 hours, it is known that there can be more prolonged impairment of cognitive function
4. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Limited availability for dental clinic visits (requires a companion)
     • Bradyphrenia may make it difficult for the patient to process the information on risks and benefits of any proposed procedure and to obtain informed consent (the presence of his son may be necessary at this stage)
   • Medical
     • Risk of a recurrent ischaemic heart episode triggered by a stressful situation in the dental setting (see Chapter 8.3)
     • Increased risk of a hypertensive crisis and bleeding tendency due to arterial hypertension (see Chapter 8.1)
     • Hypoglycaemia, hyperglycaemia, increased risk of infection and delayed wound healing related to diabetes (see Chapter 5.1)
     • Tendency to bleed due to the antithrombotic drugs (see Chapter 10.5)
     • Drug interactions
   • Dental
     • There is evidence of oral disease elsewhere in the mouth which must be stabilised prior to dental implant planning
     • Placement of dental implants will require commitment to a complex treatment plan with multiple appointments and long‐term review
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