Clinical Scenario

A 9‐year‐old girl attends your dental clinic for an oral examination. You observe that she has low insertion and thickening of the upper labial frenum in the interincisal region. This is associated with a midline diastema which the patient’s mother wants corrected.

Structured Learning

1. Although the patient’s blindness is likely to be a sequela of the surgery, what other causes should be excluded in liaison with the patient’s physician?
   • Following detection of the cleft palate, it is important to consider the presence of an underlying hereditary syndrome
   • Underlying syndromes are identified in ~20% of cases of cleft lip and ~40% of cases of isolated cleft palate
   • Furthermore, an associated syndrome, such as polymalformative syndrome, may be responsible for some of the patient’s other conditions, including visual impairment
     

     

     

2. The patient’s mother insists that her daughter’s midline diastema should be corrected. What should you determine when deciding whether to proceed?
   • Is the patient aware of the diastema (in view of her visual impairment) or is it more of a concern to her mother who is very involved in her care?
   • What are the patient’s wishes – although she is 9 years old, any elective/cosmetic treatment should be discussed with her to determine her view
   • The patient’s age: she is still in the mixed dentition stage
   • The size of the diastema and if it is increasing in size
   • Treatment options in relation to the patient’s compliance (frenectomy, orthodontics, restorative treatment)
3. What dental considerations are there for this patient in relation to her underlying diabetes insipidus?
   • Diabetes insipidus and diabetes mellitus are different entities; although both can present with constant thirst and polyuria, central diabetes insipidus is an antidiuretic hormone deficiency caused by damage to the hypothalamus or, as in this case, the pituitary gland
   • Some patients can present with dental fluorosis (due to excessive intake of fluoride in drinking water) and/or dry mouth (due to excessive fluid loss)
   • These patients are susceptible to episodes of orthostatic hypotension
4. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Impaired communication due to loss of vision; may be further impaired due to the cleft palate (can lead to unclear speech, hearing problems due to middle ear infections)
     • Potential for overprotection due to the mother’s professional background
   • Medical
     • Acute complications resulting from panhypopituitarism and diabetes insipidus (e.g. hypoglycaemia, hypotension, agitation)
     • The congenital heart disease has resolved and hence does not require further consideration in relation to planned dental treatment
   • Dental
     • Cleft palate may be associated with malalignment of the teeth and/or nasal regurgitation
     • Complexity of orthodontic treatment and surgery necessary to address the cleft palate
5. You decide to undertake the dental fillings before attempting a frenectomy. After an injection of local anaesthetic, the patient begins to cry and becomes anxious. What would be your approach?
   • The pain threshold for children with blindness can be significantly lower than that of children without blindness
   • Stop and undertake acclimatisation appointments, allowing the patient to feel and touch equipment (with sharp components/needle removed)
   • Ensure you explain what you are going to do at each stage of treatment and acknowledge that this is necessary for all steps as the patient is blind
   • Consider adjuncts to reduce the discomfort associated with local anaesthesia infiltrations (e.g. computer‐controlled local anaesthetic delivery)
   • Consider the use of sedation
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