CASE 2:

1.0 A 59-year-old male with intellectual disability and hearing impairment

presents to your dental surgery for a dental assessment. He has difficulty
walking and is using a single point walking stick. He is awaiting a hip
replacement. He wears a hearing aid and communicates with simple gestures,
body language and lip reading.

1.1 Medical History: Mild intellectual disability, Hypertension, hearing

difficulties, Depressive anxiety disorder.
Intellectual disability (ID) starts any time before a child turns 18 and is characterized by problems with
both:

 Intellectual functioning or intelligence, which include the ability to learn, reason, problem
solve, and other skills
 Adaptive behavior, which includes everyday social and life skills

Characterised by:

 Deficits in mental abilities (Criterion A); reasoning, problem solving, planning, abstract thinking,
judgment, academic learning
 Impairment in everyday adaptive functioning in comparison to individual’s age, gender and
socio-culturally matched peers (Criterion B)
 Onset during the developmental period (Criterion C)

All individuals with intellectual disorders have a developmental disorder, but not vice versa.

Hypertension: Last reading, when diagnosed, well controlled etc, medications - xerostomia

Hearing difficulties – using hearing aids?

Responds better to visual communication – through images, tell show do etc

Depressive anxiety

 Depression and anxiety at same time

 Depression

o Major depressive disorder represents the classic condition in this group of disorders. It is
characterized by discrete episodes of at least 2 weeks’ duration.
 A diagnosis based on a single episode is possible, although the disorder is a
recurrent one in the majority of cases
 o Diagnostic features include depressed mood, disinterest, weight loss, insomnia,
fatigue, feeling of worthlessness and suicidal thoughts which persist for at least 2
weeks
 Increased caries risk – sweet cravings; impaired taste perception
 Poor Oral Hygiene
 Medication related
o Tardive dyskinesia and clenching due to SSRI
o Xerostomia due to anti-depressants, more evident with TCAs compared with SSRI
o Stomatitis, glossitis, gingivitis

Anxiety

 Anxiety disorders include disorders that share features of excessive fear and anxiety and
related behavioral disturbances. Fear is the emotional response to real or perceived imminent
threat, whereas anxiety is anticipation of future threat.
o Anxiety consists of a range of thoughts, feelings, and behavior
o Anxiety may be defined as a psychophysiological phenomenon experienced as a
foreboding dread of threat whether the threat is generated by internal, real or
imagined dangers
 Diagnostic features:
o Excessive anxiety and worry (apprehensive expectation), occurring more days than not
for at least 6 months, about a number of events or activities (such as work or school
performance).
o The individual finds it difficult to control the worry.
o The anxiety and worry are associated with three (or more) of the following six
Symptoms: restlessness, being easily fatigued, difficulty concentrating, irritability,
muscle tension, sleep disturbance

Combination of pharmacological and psychological interventions (cognitive behavioral therapy), but CBT
is commonly first line as opposed to pharmacological management

 CBT: therapy based on the fact that cognitions control feelings and behavior, behavior affect
thought and pattern
 Pharmacotherapy – SSRIs, SNRIs, TCAs, Anxiolytics

Social History: Lives in supported accommodation with 5 other residents. He attends a day program on
working days and stays at home on weekends. Despite this, he relies on carer for support with ADLs
including oral hygiene. His sister has medical Power of Attorney. He is not able to consent for himself.
He is a non-smoker.

Previous dental history: Its current state is the result of years of neglected oral health. The few remaining
teeth are in various states of disrepair. He is currently on a full liquid diet.

Extra orally: He developed bilateral angular cheilitis. His lips are very dry. He is a mouth breather.

Intra orally: Teeth 35 and 43 were very mobile (class III). He has generalized bone atrophy
Reason for presenting: He has pain and discomfort anteriorly.

Radiology report – OPG: No aggressive lesion of the bony mandible.  Dentition is shown.

Questions:

1. What information can you draw from the social history?

From the social

a. Social History: Lives in supported accommodation with 5 other residents. He attends a day
program on working days and stays at home on weekends. Despite this, he relies on carer for
support with ADLs including oral hygiene. His sister has medical Power of Attorney. He is
not able to consent for himself. He is a non-smoker.

b. Supported accommodation is a type of housing that provides higher level care and support for
people with particular needs.

c. Impact on oral hygiene: difficulty flossing, using a tooth brush, not responsible for own oral
hygiene – OHI should be delivered to carer?

d. Not able to consent for himself/Sister has medical PoA: Need to contact sister for PoA

i. No decision making capacity

ii. Cannot understand the information relevant to the decision (including their medical
condition, treatment options, and risks and benefits of treatment options

iii. retain that information to the extent necessary to make the decision

iv. use or weigh that information as part of the process of making the decision

v. communicate their decision in some way, including by speech gesture or other means

vi. PoA makes decision on behalf of principle

vii. An enduring power of attorney is a legal document by which you appoint a trusted
person such as a family member or friend (referred to as 'the attorney') to make
financial, legal and property decisions on your behalf if you lose the mental capacity
to do so yourself

viii. advance care directive

 e. Non-smoker  no implications for perio, OSCC, impla nts, surgical procedures etc,

2. What are the dental implications of progressive depression?

3. How would you go about obtaining consent for this patient? What if you were unable to contact the
sister?

4. What questions would you ask him to gain a comprehensive history? What key elements in his history
are important to explore and why?

Questions to

5. What are all the different medications he is on and what are their clinical relevance for dentistry
(include a table of drugs, dose, indications, possible side effects and possible drug interactions)?

a. Akathisia, an often distressing sense of inner restlessness.

b. Dystonia, an abnormal muscle contraction
c. Pseudo-parkinsonism, symptoms that are similar to what people with Parkinson's disease
experience, including tremulousness and drooling
5. Would you need to speak to any other health care professionals and if so who? How would you go
about this?

a. GP, give them a call

6. What can you see on the current radiographs/clinical photo provided?

What is the relevance of a single point walking stick and the issues with the hip?

d. Cannot sit in dental chair for long period of time

e. Higher fall risk compared to

i. Fall risk assessment

f. Prophy

4. What are all the possible treatment plans that could you suggest for this patient? Please discuss the +/-
of each treatment plan you propose together with what materials you would use to restore the teeth.
Her sister wishes to know how much his treatment will cost.

The patient’s main presenting complaint

5. Is a denture an option for this patient? If so what design and materials would you use?

a. ??
 PLEASE NOTE YOU HAVE 1 HOUR TOTAL FOR YOUR FINAL ORAL PRESENTATION
SO BE JUDICIOUS WITH WHAT YOU PUT IN IT. IT IS NOT MEANT TO BE A
LECTURE, BUT A BRIEF PRESENTATION OF A CASE, JUSTIFYING WHY YOU HAVE
GIVEN THE ANSWERS YOU HAVE, AND DISCUSSION, QUESTIONS, CLARIFICATION
FROM THE REST OF THE YEAR SO THAT ALL UNDERSTAND THE CLINICAL
RELEVANCE, AND WHAT YOU WILL DO IF YOU SAW THIS PATIENT IN PRIVATE
PRACTICE. THE FINAL WRITTEN REPORT IS INSTEAD MORE COMPREHENSIVE
AND AS SUCH SHOULD BE THE DOCUMENT YOUR COLLEAGUES READ BEFORE
COMING TO CLASS. THE ORAL PRESENTATION IS ABOUT DISCUSING THE CASE
NOT RE-HASHING THE WRITTEN REPORT.

Saliva test:

Diet analysis

The patient is on a full liquid diet. Therefore it is important to examine the free sugar content.; caries risk

Help with diet counselling on the dentist

 CO2 and TTP testing of all remaining teeth is warranted in order to identify sources of
odontogenic pain and narrow down differential diagnosis.

 The patient’s periodontal condition should be determined as part of a comprehensive oral exam
with mobility, attachment loss and bleeding on probing documented for all remaining teeth.
Excessive mobile teeth such as the 35 and 43 represent an aspiration risk and should be extracted.

 Saliva testing is indicated as the patient is susceptible to hyposalivation induced by

polypharmacy. A saliva test will assist in determining the quality and quantity of the patient’s
saliva and possible ramifications on the caries risk.

 Similarly, a sugary liquid diet is a potential driver of caries progression and dietary analysis is
instrumental in elucidating whether dietary counselling must be incorporated as part of the
treatment plan.

Periapical radiographs

Of all teeth

Cold test