Clinical Scenario

You are contacted by the palliative care physician responsible for the care of an 80‐year‐old woman who is currently residing in a hospice. The physician is concerned that the patient has a mobile lower incisor which poses an aspiration risk and asks that you undertake an urgent domiciliary visit.

Structured Learning

1. What could be causing the coating on the palate?
   • The coating consists of a dehydrated mix of secretions from minor salivary glands in the palate and exfoliated epidermal or mucosal tissues
   • These can coat the oral mucosal surfaces and the occlusal surfaces of teeth
   • Contributing factors include:
     • Xerostomia (mouth breathing)
     • Poor hydration
     • Reduced oral cleansing due to reduced oromuscular function
     • Lack of oral care provision in the hospice
2. What is the significant risk associated with the palatal debris?
   • Microbial colonisation can occur
   • The debris can dislodge and obstruct the airway
   • Despite placement of the nasogastric tube to aid feeding, the patient remains at risk of aspiration of fragments of the debris, increasing the likelihood of aspiration pneumonia

   

3. What factors would have contributed to the inability to obtain radiographs?
   • Avaliability of a portable X‐ray device
   • Limited co‐operation (dementia)
   • Limited access (stroke)
   • Bruxism/clenching
   • Possibility of displacing #14
4. What other factors do you need to consider in your risk assessment when planning to extract #14?
   • Social
     • Non‐ambulatory
     • Fully dependent
   • Medical
     • Multiple comorbidities, ASA IV (severe systemic disease that is a constant threat to life)
     • Dementia resulting in limited co‐operation and capacity
     • Significant dysphagia/aspiration risk; related pneumonia risk
     • Dental treatment may elevate blood pressure and precipitate an episode of angina due to stress and anxiety (see Chapter 8.2)
     • Increased bleeding risk due to antiplatelet therapy and hypertension (not clinically significant; see Chapter 10.5)
     • MRSA positive
     • Double incontinence (require facilities to change pads as required)
   • Dental
     • Risk of aspiration of the mobile tooth
     • Neglected oral health/poor oral hygiene
     • Chronic complications of radiotherapy, including osteoradionecrosis of the bone
     • Inability to open mouth
     • Limited co‐operation
5. The decision is made to extract the hypermobile #14 urgently at the hospice with sedation provided via the nasogastric tube and close monitoring by the palliative care physician. Why is this particularly appropriate given the patient’s MRSA status?
   • Arranging to see the patient in her hospice room avoids transport, thereby minimising further environmental contamination/exposure of additional persons to MRSA
6. What additional precautions would you take given that the patient is MRSA positive?
   • Standard recommendations for disease control and prevention are generally adequate for preventing the transmission of MRSA and include:
     • Minimise the number of dental staff attending to essential members only
     • Use of personal protective equipment is essential and should be donned before entering the patient’s room
     • Strict hand hygiene protocols should be in place
     • Appropriate handling of contaminated equipment, materials and surfaces is essential
     • Safe handling of sharps and safe injection practices should be observed
7. Three weeks later, you are contacted by the hospice again as the patient has developed a painful swelling on the side of her face. The concern is that this may be due to a dental abscess. What would be your approach?
   • Confirm that the patient has received pain control and antibiotics have been prescribed given the likelihood of infection
   • Confirm if the patient is still MRSA positive
   • Discuss whether further sedation can be administered by the physician to allow improved access to the mouth to visualise the teeth/deliver urgent dental treatment
   • Domiciliary care:
     • Portable handheld/wireless x‐ray radiation devices can be useful to obtain intraoral radiographs
     • Undertake required dental treatment if this can be provided safely in the hospice setting (e.g. simple dental extraction of a mobile tooth where the tooth can be fully visualised/the airway protected)
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