Clinical Scenario

A 47‐year‐old female attends your dental clinic asking for replacement of her lost teeth. The appearance of her mouth is contributing to her low self‐esteem. She no longer smiles and avoids leaving the house. She appears unkempt and is extremely thin.

Oral Examination

• Vertical dimension loss
• Palatine torus
• Dry tongue/mouth
• Generalised soft and hard deposits
• Generalised periodontitis
• Partially edentate (Figure 15.2.1)
• Retained roots: #17, #24, #27 and #41(Figure 15.2.2)
• Extensive caries: #15, #23, #34, #32, #31, #43 and #44 (Figure 15.2.3)

Structured Learning

1. What could be the connection between the patient’s depression and her low body mass index (BMI)?
   • Depression and eating disorders have a bidirectional relationship
   • An additional diagnosis of anorexia nervosa should be considered
   • This will have a further impact on the social, medical and dental risk factors when planning care
2. What factors have contributed to the poor dental status of this patient?
   • Self‐neglect
   • Irregular dental attender
   • Cariogenic diet
   • Fluoxetine can cause a dry mouth and hence increase the dental caries risk further
   • Cocaine use can also result in a dry mouth
   • Binge drinking can lead to further oral neglect
   • Asthma medication oral side‐effects (see Chapter 9.2)
3. The patient is convinced that improving her dental appearance will help her find a job and hence cure her depression. Is she correct?
   • Loss of teeth and unattractive smile can have an impact on the patient’s psychological state, increasing low self‐esteem, withdrawal and isolation
     

     

   • Although improving the appearance of the teeth may be a positive action, it will not cure her depression
   • The patient’s expectations need to be realistic

4. What factors do you need to consider in your risk assessment for the management of this patient?
   • Social
     • Irregular attender, poor compliance and tolerance
     • Associated habits (see Chapters 15.4 and 15.5)
     • No telephone contact number
     • No escort or next of kin
     • Financial constraints (irregular income)
   • Medical
     • Asthma (consider patient’s triggers) (see Chapter 9.2)
     • Low BMI; poor diet (risk of deficiencies/anaemia/delayed healing)
     • Potential increased bleeding risk (side‐effect from fluoxetine)
   • Dental
     • Deep overbite
     • Reduced denture retention (mandibular ridge resorbed posteriorly; palatine torus; dry mouth)
     • Poor dental status
     • Managing expectations
5. The patient wants dental treatment to commence immediately. What would you need to ensure in relation to her depression?
   • Ideally, a course of dental treatment should be scheduled when the patient is actively accessing support for their depression
   • This will increase the likelihood of a successful dental treatment outcome
   • Some simple dental procedures (e.g. retained root extractions) can be provided to stimulate the patient and help change attitudes and habits
6. Given that the prognosis of her remaining teeth is poor, you advise a dental clearance followed by provision of complete denture. What would be the challenges in relation to construction of a denture?
   • Construction of an immediate denture is not advisable due to the loss of multiple teeth and gross caries in the remaining teeth
   • Healing after the dental extractions may be delayed
   • Multiple visits required to construct the denture
   • Retention may be reduced in relation to xerostomia and the presence of a palatine torus
7. The patient fails to attend the dental appointment booked to commence dental extractions. What would you do?
   • This may be a safeguarding concern, particularly if the patient reports suicidal ideation
   • As the patient has no next of kin/family or telephone number, contact the doctor to register your concern

General Dental Considerations