Clinical Scenario

A 17‐year‐old female presents to an emergency hospital department following facial trauma experienced during an epileptic seizure (Figure 1.2.1). She complains of pain and mobility in the maxillary central incisors. Your dental opinion is sought.

Structured Learning

1. The decision was made to undertake a detailed examination and deliver any required dental treatment under general anaesthesia in a hospital setting. Why?
   • The patient’s epilepsy is not under control
   • The patient’s degree of co‐operation is limited due to intellectual impairment
2. What factors are important to consider when assessing the risk of managing this patient?
   • Social
     • Availability of escorts/family to accompany the patient (younger sibling requires supervision)
     • Capacity assessment required: if the patient is assessed as lacking capacity in relation to the proposed procedure, a best interest decision will be required; this should involve family members, social services, any health and social care professionals involved with the adult’s care, carers
     • Deprivation of Liberty standards cannot be applied if the patient is admitted as she is below the age of 18 years old
     • Financial means (insurance coverage) to cover the costs of treatment in a hospital setting under general anaesthesia (varies between countries)
   • Medical
     • Increased risks in general associated with general anaesthesia
       

       

       

     • High risk of seizures perioperatively due to the refractory epilepsy; hence inpatient bed and neurology support needed during admission
   • Dental
     • Urgency of dental treatment (due to pain/mobility of anterior teeth) – cannot be delayed until the patient may be more stable after the vagus nerve stimulator is placed
     • High risk of further dental trauma
     • Risk of caries related to the oral dryness induced by the anticonvulsant drugs
     • Limited efficacy of brushing exacerbated due to the gingival enlargement (secondary to ethosuximide, sodium valproate, lamotrigine)
     • Potential bleeding tendency (sodium valproate)
     • Difficulty following up the patient due to her lack of co‐operation
3. You determine that it is likely the displaced incisors will need extraction. Why is a full blood count and coagulation test advisable prior to this?
   • Routine preoperative full blood count testing for patients undergoing general anaesthesia is mandatory in most countries
   • The patient is taking sodium valproate: this can cause blood dyscrasias, including thrombocytopenia, aplastic anaemia, pure red cell aplasia, macrocytosis, neutropenia, and bleeding disorders (coagulation defects)
4. During the best interest discussion, the patient’s family insists that prosthetic rehabilitation is performed during the same general anaesthetic session as any dental extractions. Why is this not recommended?
   • There is a high risk of dental prosthetic fracture due to further trauma
   • It is advisable to delay this procedure until the epilepsy is controlled (at least wait until the efficacy of the vagus nerve stimulator has been observed)
   • It is also preferable to wait until the remodelling of the bone crest is complete and to rule out damage of the contiguous teeth
5. During the intraoperative examination, a comminuted fracture of the external table of the maxillary bone is discovered. What is the ideal approach?
   • Attempt to preserve the alveolus and maintain the integrity of the bone crest
   • Consider applying bone regeneration techniques (with bone or filling biomaterials and barrier membranes) (Figure 1.2.3)
   • The risk of delayed healing and exposure of the membrane should be assessed prior to proceeding
6. What antibiotic should be prescribed after completing the surgical procedure?
   • The recommendation is for beta‐lactams, lincosamides and macrolides
   • Metronidazole and quinolones should be avoided (risk of triggering seizures)

General Dental Considerations