A Practical Approach to Special Care in Dentistry. Группа авторов

a 4‐year‐old child (supervised by the grandmother)

       Unstructured social environment (troubled and defiant)

       Unemployed

       Tobacco consumption: 20 cigarettes/day since she was 16 years old

       Alcohol consumption: 30 units weekly

      Oral Examination

       Generalised plaque deposits, covering a third of the tooth surfaces

       Gingivitis

       Abundant dental calculus

       Caries: #11, #12, #21, #22, #32 and #38

       Fillings: #16, #17, #26, #27, #37, #46 and #47

      Radiological Examination

       Orthopantomogram undertaken (Figure 5.2.1)

       Restorable caries in teeth #11, #12, #21, #22, #32 and #47

       Extensive and unrestorable caries in #16 and #38

       Impacted tooth #48

      Structured Learning

      1 What factors in this patient's medical history may be linked to the development of obstructive sleep apnoea‐hypopnoea?Hypothyroidism is thought to be a risk factor for the development of sleep apnoeaThe proposed mechanisms include increased mucopolysaccharide and protein deposition in the upper airway, altered regulatory control of pharyngeal dilator muscles from neuropathy, depression of respiratory centres and increased risk of obesityThe use of thyroid hormone replacement may reduce the symptoms of sleep apnoea; however, this patient is not compliant with her medical management

      2 The patient appears dishevelled and unkempt and her communication is limited. What factors could be contributing to this and what should you be alert for?Figure 5.2.1 Orthopantomogram: neglected mouth with unrestorable caries in tooth #38.The patient is not compliant with her medical management and hence the psychological and physical dysfunction associated with hypothyroidism is more likely to have an impact on her well‐being and quality of lifeSlowing of thought and speech, decreased attentiveness and memory, fatigue and apathy are more commonly observed with hypothyroidismRarely, this can progress to agitation and frank psychosisObstructive sleep apnoea‐hypopnoea syndrome (disrupted sleep, leading to fatigue)Depression/anxietyThere are also additional social factors which could have an impact as she is a young, single mother, unemployed, with no contact with her father, and has a high alcohol intakeAlthough the patient's 4‐year‐old daughter is principally looked after by the grandmother, it is important to consider if there are any child safeguarding concerns and raise these

      3 The patient has been told that her hypothyroidism is the reason for her hair loss. She believes that the hypothyroidism is also the reason for her teeth ‘breaking and falling out’. Is she correct?Hair loss may be related to hypothyroidism, as an adverse effect of azathioprine and/or due to alopecia areata (multifactorial autoimmune aetiology, but in some cases triggered by dental infections)The decline in dental health is more likely to be linked to poor oral care and limited access to dental care – these may be exacerbated by the generalised effects of hypothyroidism, namely fatigue, apathy, depressionHypothyroidism can also be accompanied by salivary gland dysfunction, regardless of the absence of Sjögren syndrome; this may be due to the effect of cytokines in the autoimmune process or because of thyroid hormone dysfunctionAdditionally, there may be a potential association between hypothyroidism and periodontitis due to the immunological and inflammatory markers found in both (evidence is very limited)

      4 You decide that the treatment of choice is to extract tooth #38. What factors are considered important in assessing the risk of managing this patient?SocialThe social‐cultural environment can jeopardise communication with the patient and the interest in any proposed treatment beyond resolving the painIrregular compliance with medical treatment is a predictor for limited compliance with postdental procedure recommendationsLimited compliance with treatment is also more likely due to depression/anxietyA suitable escort may be difficult to find as the grandmother looks after the patient's 4‐year‐old childMedicalBleeding tendency and drug selection due to liver damageSusceptibility to infections due to azathioprine‐induced immunosuppressionUntreated hypothyroidism is more likely to be associated with signs and symptoms, including impaired cognition/memory loss (impacts on capacity/consent)Myxoedema coma risk may occur; estimated prevalence around 0.1%, but may be higher as the patient is not compliant with her medical management and is additionally anxiousDentalAcute pulpitis that requires urgent treatmentDental treatment results compromised by heavy smoking, high alcohol intake and poor oral hygienePoor patient commitment to complex treatment plan and follow‐up visitsIncreased oral cancer risk due to tobacco and alcohol consumption

      5 Given that the patient has uncontrolled hypothyroidism, what should you do prior to extracting the #38?Liaise with the patient's physicianConsider referral to a hospital setting if the thyroid function is severely alteredRequest blood test resultsFull blood countHaemoglobin; anaemia may be induced by the hypothyroidism and/or by azathioprineWhite blood cell count; risk of leucopenia secondary to azathioprinePlatelet count; risk of thrombocytopenia due to the hepatic dysfunction or secondary to azathioprineCoagulation studyAutoimmune hepatitis can cause liver dysfunctionConsider pain and infection control in the first instance

      6 What sedation technique should be applied to this patient?Nitrous oxide may be employedBenzodiazepines are not recommended due to increased sensitivity; they compromise respiratory capacity and can also trigger a myxoedema coma

      7 If there is noteworthy bleeding during the surgical procedure, what could be causing it?Hypothyroidism causes vascular endothelial disorders that increase bleeding tendency (increased subcutaneous mucopolysaccharides, decreasing the ability of small blood vessels to constrict)Von Willebrand disease is associated with hypothyroidism and it potentially may have remained undiagnosed beforehandThrombocytopenia riskLiver dysfunction

      General Dental Considerations

      Oral Findings

       In children (cretinism)Thick lipsMacroglossiaDelayed tooth eruptionEnamel hypoplasiaRampant cariesMandibular retrusionAngle class II malocclusion

       In youths and adultsThick lipsMacroglossia (Figure 5.2.2)Burning mouthDysgeusiaXerostomiaLichen planusSusceptibility to cariesPeriodontal diseaseFigure 5.2.2 Macroglossia in a patient with hypothyroidism.

      Dental Management

       The dental treatment plan will be determined primarily by the level of hypothyroidism control and the presence of comorbidities (Table 5.2.1)Table 5.2.1 Considerations for dental management.Risk assessmentMyxoedema coma can be triggered under stressful conditions caused by dental treatmentAssess the presence of comorbidities such as hypotension, hypoadrenocorticism, anaemia, cardiac arrythmias, ischaemic heart disease and von Willebrand diseasePotentially increased bleeding riskPotentially delayed wound healing due to decreased metabolic activity in fibroblastsCriteria for referralControlled hypothyroidism: dependent on comorbidities, dental care can be provided in the local dental clinic settingUncontrolled hypothyroidism: delay elective dental treatment until the hypothyroidism has been controlled; if urgent procedures are required, a hospital setting is preferableAccess/positionIf goitre is present, there may be pressure on the airway; consider a semi‐reclined positionIf there is a bleeding risk, arrange appointments earlier in the day and weekCommunicationLiaise