Clinical Scenario

A 38‐year‐old female presents to you requesting replacement of her upper denture as the current denture fractured 6 months ago and now keeps falling out. She does not want any other treatment and appears agitated, anxious and unkempt.

Structured Learning

1. What characteristics of this patient are likely to be linked to the use of recreational drugs?
   • Self‐neglect
   • Agitated state
   • Close association with other psychiatric illness (e.g. depression), social issues and dangerous behaviours (e.g. previous sex worker, heavy alcohol consumption)
2. What additional information about the recreational drug use would you need in order to carry out appropriate risk assessment for the management of this patient?
   

   

   • Most recent recreational drug use consumption, i.e. is the patient still under the influence of these drugs when she presents for treatment?
   • Further detail regarding the type, frequency, quantity and modality of drug consumption
   • Confirm if she is receiving active support and treatment for her recreational drug use (identify physician/specialist involved in her care)
   • Social history (including other risk behaviours, dependants, suitable escort)
   • Presence of other comorbidities, including blood‐borne viruses, cardiac valve damage/infective endocarditis (intravenous drug use; more commonly involving the tricuspid valve), liver injury (viruses, alcohol, drugs)
3. What characteristics of this patient’s borderline personality disorder may impact on dental management?
   • This disorder is a mental illness characterised by severe mood instability, impulsive behaviour and lack of emotion control
   • The patient has associated features of paranoia and depression (see Chapter 15.2)
     

     

   • Features of this disorder may be misinterpreted as signs of recreational drug use
   • It is likely to be associated with a negative impact on her interpersonal relationship and self‐identity, with further impairment of her personal life

4. Despite the presence of retained roots, carious lesions and periodontal disease, the patient insists that she only wants her denture replaced and does not want to return for multiple appointments. What are your options?
   • Refuse to proceed as you do not want to leave untreated dental disease – risk is that the patient is lost to care and will never return
   • Temporarily repair the existing denture on the same day using a cold cure acrylic material; gain patient’s confidence and arrange a review to follow up denture when you can rediscuss the untreated oral disease – risk is that the repair is unstable; the patient will not return and/or may lose confidence
   • Take impressions for an immediate denture and use a copy technique if the current denture fits reasonably well (duplicate horseshoe design to avoid palatine torus); gain patient’s confidence and attempt acclimatisation to care when the patient returns for this to be fitted. If the patient gains confidence and sees the benefit of dental care, stabilise the remaining dentition and construct a definitive replacement denture
5. Following replacement of the upper denture, the patient agrees to proceed with extractions and fillings as required. What factors do you need to consider in your risk assessment for the management of this patient?
   • Social
     • Difficulties finding suitable escort (i.e. the partner of this patient also uses recreational drugs and suffers from depression)
     • Additional unhealthy habits (tobacco, alcohol, poor diet)
     • Recreational drug use likely to be uncontrolled as she has recently also started using intravenous heroin
     • Currently unemployed – cost of dental treatment may have an impact
     • Capacity/consent impaired by recreational drug use and alcohol excess – if the patient is unable to comply with abstaining for 12 hours, you will not be able to obtain informed consent
     • Likely to have issues with trust due to physical/sexual abuse when younger; may prefer a female dentist
   • Medical
     • Fatty liver, likely to be linked to excess alcohol consumption; depending on the extent, may result in impaired liver function (see Chapter 6.1)
     • Iron deficiency and anaemia are common after bariatric surgery (see Chapter 16.4)
     • Increased risk of hypertensive crisis and orthostatic hypotension (see Chapter 8.1)
     • Asthma – risk of an acute presentation increased by general anxiety (see Chapter 9.2)
     • Eating disorder (history of excess weight) – still consuming excess sweet foods
     • Intravenous drug use (more recently using heroin) – associated with the risk of infective endocarditis and parenterally transmitted infections (e.g. HBV, HCV, HIV)
   • Dental
     • Dental anxiety – may further impact on compliance and attendance
     • High caries risk: highly cariogenic diet, poor oral hygiene habits, hyposalivation (secondary to cocaine/heroin use, methadone treatment and other psychoactive drugs), possible sugar content in methadone
     • Increased risk of tooth surface loss due to attrition/bruxism, secondary recreational drug use, erosion from dietary acids and reflux secondary to gastric surgery
     • Caution with epinephrine‐containing local anaesthesia as cocaine use is associated with a risk of arrhythmias, hypertension and cardiac failure

6. What preoperative investigations would you consider for this patient?
   • Full blood count: risk of anaemia (related to malnutrition)
   • Coagulation profile: due to the liver disease and additional risk of thrombocytopenia (linked to heroin use)
7. The patient asks for medication to help control her dental anxiety. Why would you have concerns regarding providing this?
   • The patient may be attempting to access further opioid/benzodiazepine medication to supplement her recreational drug use
   • Risk of interaction between prescribed medications and recreational drugs
   • Methadone can interact with benzodiazepines and cause severe respiratory depression

General Dental Considerations