Clinical Scenario

The husband of a 29‐year‐old female presents at the dental clinic, concerned about the oral health of his wife. He requests a home visit as his wife is unable to attend in person due to a relapsing episode of multiple sclerosis and they do not have access to appropriate transport to bring her to the dental clinic. You arrange a domiciliary visit. The patient reports that her teeth are brittle and break easily, with additional intermittent pain in the upper right quadrant, especially when food gets caught.

Radiological Examination

• Long cone periapical radiographs taken using a portable x‐ray machine during domiciliary visit (Figure 14.3.3)
• #16: extensive mesial caries extending into the pulp
• #14, #15, #36 and #47: multiple retained roots
• #23: periapical radiolucency

Structured Learning

1. Why is domiciliary care particularly suitable for the first dental assessment of this patient?
   • Domiciliary care is offered to patients who are unable to access dental clinics due to their physical or medical condition, as is the case for this patient due to her MS relapse/exacerbation
   • Initial oral hygiene advice can be given (e.g. removing the denture at night, obtaining help when brushing her teeth, considering an electric toothbrush, using a higher fluoride toothpaste)
     

     

   • It is also useful as the patient is symptomatic and dental screening allows a provisional diagnosis to be made
   • Radiographs can be undertaken using a mobile device in order to determine which teeth are in need of immediate treatment
   • If a clean environment can be achieved in a part of the residence, simple dental extractions can be carried out after taking radiographs, and with proper lighting and a portable suction system
   • Denture fitting and construction or simple relining of dentures can also be undertaken during domiciliary visits
   • If the patient will need more extensive treatment, a dental clinic visit can be planned with the family and transport arranged if needed
2. What factors could be contributing to the poor oral health in this patient?
   • Patients with multiple sclerosis, especially during periods of relapse, may stop brushing their teeth regularly due to fatigue, low mood and poor motivation
   • Tremors and rigidity make moving difficult and thus she may have inefficient toothbrushing techniques due to reduced dexterity and restricted access to the bathroom
   • Poor social support system – the patient has no additional carers to assist her in daily activities; unable to access dental treatment since her husband is working and she has small children to care for
   • Due to difficulty in chewing and swallowing, the patient chooses softer high‐carbohydrate food/drink (for extra energy) which increases dental caries risk as well
   • Xerostomia as a side‐effect of medication
   • Suboptimal fluoride concentration of the toothpaste
   • Denture being left inside the mouth for prolonged periods and not removed at night
   • Decreased sensation in the oral cavity can cause food packing and retention

3. What impact does the patient’s daily dose of prednisone have on the delivery of dental treatment?
   • Prolonged glucocorticoid steroid therapy can cause multiple side‐effects such as immunosuppression, delayed wound healing, decreased glucose intolerance, fluid and electrolyte imbalance, adrenocortical suppression and psychological effects (see Chapter 12.1)
4. What other factors do you need to consider in your risk assessment?
   • Social
     • Availability of escort (husband works)
     • Taking care of young children at home
     • No regular carer support
     • Reduced mobility
   • Medical
     • Currently in a relapse stage of MS when tolerance of medical/dental interventions is reduced
     • Assessing the need for steroid cover for invasive and stressful dental procedures (see Chapter 12.1)
   • Dental
     • Poor oral health
     • Cariogenic diet
     • Poorly fitting denture which is worn
     • Food pouching
     • Loss of posterior occlusal support
     • Rampant caries
5. Following discussion with the patient and her husband, an upper dental clearance with construction of a replacement full upper denture is agreed as the best way forward when the patient’s MS is more stable. What would be the specific risks you would need to discuss with her?
   • A further relapse may be triggered by the planned dental extractions as it is known that stress/infections can trigger an exacerbation
   • The dental extractions are likely to require a surgical approach due to the extensive dental decay/loss of coronal structure
   • There is an aspiration risk due to dysphagia
   • Wearing a full upper denture can be difficult due to uncontrollable spasms and xerostomia, although use of denture retention pastes may help
   • Putting the denture in and out of the mouth may also be difficult due to tremors
6. What is likely to be causing the erythematous area on the hard palate and what risk factors does the patient have for its development?
   • The chronic erythematous appearance of the palate corresponds to the fit surface of her upper denture and is suggestive of denture‐induced stomatitis
   • This is caused by a candidal infection and is usually asymptomatic
   • Risk factors for this patient include poor oral hygiene, xerostomia, failure to remove the denture at night, a poorly fitting acrylic denture, poor diet (possible anaemia)

General Dental Considerations