Section I: Clinical Scenario and Dental Considerations

Clinical Scenario

A 64‐year‐old female presents to your clinic accompanied by her husband. She complains of increasingly mobility from a tooth in the upper left quadrant, which is affecting her ability to eat.

Medical History

  • Left‐sided stroke following percutaneous coronary intervention (formerly known as angioplasty with stent) 5 years ago; 4‐month stay in a rehabilitation unit; biannual reviews currently
  • Coronary heart disease
  • Stable angina
  • Type 2 diabetes mellitus
  • Mild chronic obstructive pulmonary disease – emphysema (GOLD 1)
  • Pneumonia 1 year ago
  • Allergy to penicillin


  • Aspirin
  • Clopidogrel
  • Trimetazidine
  • Carvedilol hydrochlorothiazide
  • Losartan
  • Vildagliptin/metformin

Dental History

  • Regular dental attender prior to her stroke; last dental visit 5 years ago; reports refusal of other dentists to provide care after her stroke
  • Now reports significant anxiety in relation to dentistry due to the length of time since her last visit
  • Brushes her teeth twice daily using a manual toothbrush
  • Concerned that she cannot swallow properly and hence uses a lower fluoride toothpaste so that she does not ingest too much fluoride

Social History

  • Lives with her husband and adult daughter
  • Worked in a corporate job before having a stroke; now receiving disability allowance
  • Care‐giver support daily
  • Reduced mobility; requires a wheelchair for long distances; able to transfer with assistance to the dental chair
  • Tobacco consumption: stopped 5 years ago after her stroke but previously smoked 20 cigarettes a day for more than 15 years
  • Alcohol consumption: nil

Oral Examination

  • Partially edentate (Figure 14.5.1)
  • #17, #15, #41 and #48 retained root fragments (Figure 14.5.2)
  • #25 grade III mobility with root caries and a cervical composite restoration
  • Cervical abrasion and root caries on all the mandibular anterior teeth
  • #37, #38 and #47 mesially inclined
  • Flabby mucosa overlying the maxillary alveolar ridge
  • Thin mandibular alveolar ridge
  • Generalised plaque deposits with associated gingival inflammation, particularly in association with the lower molar teeth
  • Food pouching in the right buccal sulcus
  • Xerostomia and healing ulcer left lateral border of the tongue (Figure 14.5.3)
  • Badly fitting upper removable acrylic partial denture (10 years old)
Photo depicts partially edentate; plaque-induced gingivitis.

Figure 14.5.1 Partially edentate; plaque‐induced gingivitis; root caries from #45 to #35; retained root #41.

Photo depicts retained root number 17, number 15; root caries number 24 (S).

Figure 14.5.2 Retained roots #17 and #15; root caries #24.

Photo depicts xerostomia and healing ulcer left lateral border of the tongue (S).

Figure 14.5.3 Xerostomia and healing ulcer left lateral border of the tongue.

Radiological Examination

  • Orthopantomogram demonstrates widespread interdental decay and multiple retained roots (Figure 14.5.4)
  • Cervical caries extending into the pulp of lower anterior teeth
  • Moderate to severe bone loss associated with several teeth
  • Significant resorption of maxillary alveolar ridge due to tooth loss

Structured Learning

  1. What are the potential risk factors for stroke in this patient?
    • Age (over 55 years old)
    • Coronary heart disease
    • Diabetes mellitus
    • Emphysema
    • Former smoker
    • Job‐related stress
  2. What are some of the features of a left hemispheric stroke that you may see in this patient?
    • Loss of function/paralysis on the right side of the body
    • Speech/language problems
    • Dysphagia
    • Memory loss
    • Slow, cautious behaviour
  3. The patient is concerned about the appearance of her broken teeth and reports that this is affecting her confidence and social interaction. What factors could have contributed to the deterioration in this patient’s dentition?
    • Stroke commonly affects the patient’s physical, psychological and social functioning
    • Physical factors
      • In the first few months during rehabilitation, the patient would have been highly dependent on others to brush her teeth (nursing staff, carers, family)
      • Limitations of the patient’s own mobility/dexterity on discharge are likely to have negatively affected her ability to brush her teeth effectively
      • Important to determine if she was right‐handed prior to her stroke; she may now have to rely on her left hand to brush her teeth which may not be as effective
      • Food pouching due to weakness of facial muscles
      • Access to dental care may be impaired due to reduced mobility
    • Psychological factors
    • Depression following a stroke can result in poor motivation to undertake self‐care and access help
    • Social functioning
      • Isolation due to loss of work and inability to attend social activities can cause further post‐stroke depression and make the patient less motivated to care for herself
      • Anxiety about healthcare‐related procedures such as invasive dental treatment can also contribute to dental neglect
        Photo depicts orthopantomogram demonstrating extensive interdental decay in relation to multiple mandibular teeth.

        Figure 14.5.4 Orthopantomogram demonstrating extensive interdental decay in relation to multiple mandibular teeth, retained roots #17, #15, #35, #41 and #48.

  4. The patient indicated that other dentists have refused to provide dental care as they considered her a high‐risk patient. How can you reassure the patient that dental treatment is safe?
    • The risk of recurrence of a stroke is highest during the first 30 days after the initial event
    • Elective and invasive dental treatment is ideally deferred to 6 months after a stroke; the patient’s stroke was 5 years ago; she is regularly reviewed by her physician and is also taking preventive medication
    • Patients with stable angina pectoris can be treated in the dental setting (see Chapter 8.2)
    • Dentists should be able to manage patients with mild chronic obstructive pulmonary disease (see Chapter 9.1)
  5. What may also be contributing to the patient’s anxiety?
    • Anxiety after stroke is common, affecting 25% of patients
    • She has not been able to access oral care for 5 years
    • It is important to have a detailed discussion regarding the best approach for anxiety management to enable delivery of dental care (see Chapter 15.1)
  6. The tooth #25 is hypermobile. She wants the tooth extracted but requests that the gap is immediately filled with a denture. What factors should you discuss?
    • Explain that an immediate denture requires dental impressions
    • The tooth is likely to become dislodged in the impression material when the tray is withdrawn; in view of this, it is advisable to administer a local anaesthesia infiltration in relation to #25 to avoid pain/discomfort
    • If #25 is inadvertently removed when taking the impression, this will result in a gap for a period while the laboratory constructs a denture
    • Discuss that an alternative approach is to electively extract #25, followed by removal of the other maxillary retained roots #17, #15 and #24 at subsequent visits; once the sockets have healed, impressions can be taken at a later date for an upper denture; this approach is more likely to result in a more stable denture
    • The patient may subsequently take some time adjusting to a new denture, particularly as she has some residual weakness of the facial muscles
    • She may require assistance placing and removing the denture
  7. The patient requests that #25 is removed urgently and accepts that replacement of her upper denture is best undertaken at a later stage. What factors do you need to consider in your risk assessment when planning dental treatment?
    • Social
      • Limited mobility
      • Dependence on an escort to be considered when setting up appointments
    • Medical
      • Dental treatment may elevate blood pressure and precipitate an episode of angina due to stress and anxiety (see Chapter 8.2)
      • Increased bleeding risk due to dual antiplatelet therapy (see Chapter 10.5)
      • Hypoglycaemia risk and potential for delayed healing related to diabetes mellitus (see Chapter 5.1)
      • Emphysema and the potential for hypoxia (see Chapter 9.1)
      • Anxiety (see Chapter 15.1)
      • Antibiotic alternatives due to penicillin allergy (see Chapter 16.1)
    • Dental
      • Poor oral health
      • Rampant dental caries
      • Poorly fitting denture
      • Food pouching persists on the right side, suggesting residual loss of function after the stroke
      • Challenges in denture construction and retention due to moderate bone loss, flabby mucosa and poor oral musculature control
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Nov 6, 2022 | Posted by in Implantology | Comments Off on Stroke

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