Clinical Scenario

You are contacted by the local community services regarding a 64‐year‐old man temporarily residing in one of their lodgings. The man is complaining of persistent pain in the region of left maxillary sinus, with discharge from his nose.

Structured Learning

1. The patient is unable to recall the reason why the metal mesh on left orbital floor was placed. What factors could be responsible for his lack of recall?
   • Excess alcohol consumption can affect the ability to recall past events; this can be temporary or permanent, i.e. Wernicke encephalopathy (see Chapter 15.5)
     

     

   • The patient has a history of recreational drug use which may impact on his ability to recall previous events
   • Social stigmatisation may make the patient reluctant to divulge the details of a past event which may be related to abuse, assault or trauma due to incapacitation (drugs/alcohol)

2. Following liaison with the patient’s social and medical team, you confirm that the patient had an orbital blowout fracture 6 years ago due to blunt trauma related to an assault. Titanium mesh, together with a bone graft, was used for reconstruction of an orbital floor fracture. What could be a possible explanation of this patient’s symptoms?
   • As there are no maxillary teeth, and no observed oroantral communication, a dental cause is unlikely
   • Chronic sinusitis and allergic rhinitis may be contributing to his symptoms
   • Infection of the mesh is a plausible cause of the nasal discharge
   • Although this complication is generally uncommon (~2%), the patient’s medical comorbidities considerably increase the risk of infection
   • Shortly after the orbital reconstruction surgery, the patient was imprisoned, hence was lost to surgical follow‐up
3. The nasal discharge appears purulent. What are important considerations when prescribing antibiotics and pain relief for this patient while you arrange a surgical review?
   • Avoid drugs that are metabolised in the liver due to the history of hepatitis C and continued excess alcohol consumption (see Chapter 4.3)
   • The analgesics of choice are paracetamol and COX‐2 inhibitor; however, consider the hepatotoxic effect of paracetamol (dose adjustment and minimising the dose/duration)
   • The antibiotics of choice are amoxicillin and penicillin V
   • Clindamycin and metronidazole may be prescribed at reduced doses
   • Quinolones are a fairly safe option and do not require dose adjustment
   • In view of the high alcohol intake, avoid non‐steroidal anti‐inflammatory drugs as they can increase the risk of gastric erosions and intestinal bleeding
   • Do not prescribe metronidazole (disulfiram effect)/cephalosporins due to the interaction between these antibiotics and alcohol (see Chapter 15.5)
   • Opioids enhance sedation and should be avoided, particularly as the patient has a history of recreational drug use and prescribing opioids can trigger a relapse
4. What factors may make this patient more likely to mouth breath?
   • Chronic rhinitis/asthma
   • Chronic sinusitis
   • History of trauma to the facial structures may have also caused a compromised nasal airway (e.g. deviated septum)
   • Chronic obstructive pulmonary disease
5. What factors could be contributing to this patient’s poor oral health?
   • Poor oral hygiene habits, including not using fluoride toothpaste
   • Poor awareness regarding the importance of oral care
   • Lack of motivation
   • Poor access to dental services (previous prison dental service only provided dental extractions; homeless)
   • Comorbidities including asthma and gastro‐oesophageal reflux disease

6. The patient returns to you asking for removal of all his remaining teeth and a set of dentures to improve his appearance. He feels that his improved dental appearance will help him find employment. What factors do you need to consider in your risk assessment for the management of this patient?
   • Social
     • Vulnerable adult
     • Currently homeless/unemployed – cost of dental treatment may have an impact
     • Capacity/consent impaired by alcohol excess
     • Attendance may be erratic due to alcohol excess, lack of permanent housing, cost of transport
     • Unable to reliably contact the patient
     • Lack of family support/suitable escort (need to liaise with social services)
     • Ex‐offender with a history of violence – ensure a chaperone is present as per the local lone worker policy
     • Unrealistic expectations that a new set of dentures will enable him to find employment
   • Medical
     • Alcohol‐related liver disease/comorbidities (see Chapter 6.1)
     • Caution when prescribing drugs due to increased likelihood of impaired liver function/side‐effects and interaction with alcohol
     • Malnutrition, lack of regular meals commonly associated with iron deficiency (anaemia)
     • Impaired respiratory function in relation to tuberculosis and chronic obstructive pulmonary disease/asthma (see Chapters 4.1 and 9.2)
     • Reactivation of latent tuberculosis
     • Asthma is associated with an increased risk of other atopic reactions, including drug allergies (e.g. penicillin)
     • Ibuprofen and aspirin are associated with a risk of precipitating asthmatic attacks (see Chapter 9.2)
   • Dental
     • Poor oral hygiene habits and poor oral health
     • Increased risk of xerostomia (mouth breather, alcohol excess)
     • Tooth surface loss in relation to use of a hard toothbrush, gastro‐oesophageal reflux disease (increased due to alcohol excess)
     • Requirement to attend multiple appointments for dental extraction and subsequently for denture construction
     • Delayed healing (alcohol excess, malnutrition)
     • Steroid inhaler use is associated with an increased risk of oral candidiasis
     • Oral cancer risk – higher due to alcohol excess, tobacco use and malnutrition

General Dental Considerations