CASE REPORT
Australian Dental Journal 2000;45:(4):270-276
An interdisciplinary approach to the management of
complex medical and dental conditions
JPH Rogers,* PR Stewart,† JV Stapleton,‡ DL Hribar,§ P Adams,

AE Gale¶
Abstract
Dental and medical practice often requires an inter-
disciplinary approach integrating the knowledge,
skills and experience of all the disciplines of
dentistry, medicine and its associated fields into
comprehensive treatment to maximize results.
Rapid and comprehensive scientific and techno-
logical advances have made it difficult for dental
and medical practitioners to keep up to date in their
fields; thus, to decrease practitioner frustration and
increase patient benefits, an interdisciplinary
approach has become essential. This report
illustrates how therapy was coordinated for a young
medically compromised patient with dental phobia
and significant dental problems. The latest
advances in dental techniques and materials,
medical technology and pharmacology are high-
lighted. The communication and cooperation of
team members with each other and with the patient
and guardians is illustrated. The astute observation
by a medical practitioner in an unrelated discipline
led to the improvement in the quality of life for a
patient.
Key words: Medically compromized, dental phobia,
sedation, interdisciplinary therapy, case.
(Received for publication June 1999. Revised November
1999. Accepted November 1999.)
Introduction
This case history illustrates the need for medical
professionals to take into consideration patients’
dental problems. Medical professionals of all
disciplines should seek appropriate expert assistance
from the dental profession to assist in patient care.
The case history illustrates the value of conscious
sedation which, with the availability of safer short-
acting intravenous drugs, can be used to great effect
* General dental practitioner, private practice, Adelaide.
† Orthodontist, private practice, Adelaide.
‡ Specialist anaesthetist, private practice, Adelaide.
§ Specialist oral and maxillofacial surgeon, private practice, Adelaide.


Specialist cardiologist, private practice, Adelaide.
¶ Specialist allergist and respirologist, private practice, Adelaide.
270
in combination with orthodox local anaesthesia to
provide safe dental care in an outpatient environment.1
The professional satisfaction achieved in identifying
and managing these cases, with an interdisciplinary
approach, is illustrated by this case history.
Case report
Referred by his GP, a 15 year old boy presented to
an allergist for treatment of recurrent urticaria from
which he had suffered for the preceding four weeks.
His appointment with the allergist was one week
after an assessment angiogram for congenital heart
disease. The patient had undergone heart surgery as
a neonate at the age of 10 days and later had
repeated surgery involving implantation of a porcine
valve and insertion of a pacemaker. In the course of
his examination, the allergist discovered the boy had
been sucking sweets incessantly since the age of 10
years and had a severe oral phobia and associated
gag reflex, which may have been associated with a
multitude of cardiac problems and resultant
complex surgical procedures. The allergist examined
the oral cavity and noted severe deterioration of the
dentition. Despite protestations from the patient, his
parents agreed to consult a dentist immediately and
the patient was referred to one of the authors for
examination and assessment.
Medical history
The patient had the following medical conditions:
1. Severe cardiovascular problems.
2. Psychiatric problems and taking relevant
medication.
3. Chronic alcohol intake.
4. Varying degrees of social drug intake.
Specifically
Shortly after birth, the patient was diagnosed with
dextrocardia with atrio-ventricular (AV) discordance
and ventriculo-arterial (VA) discordance, with L-
Australian Dental Journal 2000;45:4.
 1 2

malposition of the aorta. The ventricular/septal
defect (VSD) had been repaired and the patient had
undergone surgery which involved the placement of a
porcine heterograft valve from the venous ventricle to
the pulmonary arteries. The patient had many
follow-up operations and his heart condition has
been stabilized. To prevent endocarditis, the patient
requires preoperative antibiotics for any dental
procedures.
The development of psychological problems
required the assistance of a psychotherapist to
modify the patient’s overt and at times aggressive
behaviour. The patient’s particular problem with
dental treatment involved a severe gag reflex and

3 4

5 6

Fig 1 – Preoperative view of full face.

Fig 2 – Preoperative view of maxillary teeth illustrating malalignment and repaired with resin-modified glass ionomer
cement delamination of incisor labial enamel.
Fig 3 – Preoperative labial view of incisor teeth with general demineralization of labial enamel.
Fig 4 – Postoperative view 14 months later, after preparation for full porcelain bonded crowns, indicating the substantial
demineralization that occurred into the dentine. This dentinal tissue was sclerotic.
Fig 5 – Pre-treatment cephalometric radiograph showing severe Class II Division 1 dentoskeletal malocclusion.
Fig 6 – Preoperative lateral view of facial profile.
Australian Dental Journal 2000;45:4. 271
panic attacks which were manifested with uncontrolled
rigors and aggressive verbal and physical behaviour
toward the healthcare workers. In an unsuccessful
attempt to modify this behaviour, the patient under-
went hypnotherapy. It is the contention of one of the
authors that it is highly probable, due to the many
and varied general anaesthetics this adolescent has
had to endure, he returned to partial consciousness
during or toward the end of a procedure, still
intubated, under the effects of the muscle relaxants
required for the surgery. This explains the patient’s
avoidance of any oral intervention by healthworkers,
his subsequent panic attacks and his predilection for
continuous oral stimulants, such as confectionery, as
some form of protection or security for his airway.
Dental diagnosis
The patient had moderate caries incidence, an
insignificant amount of previous restorative work
and active gingivitis. The most significant dental
finding was gross delamination of the labial enamel
of the anterior dentition due to demineralization
from very poor or non-existent oral hygiene and a
high-level sucrose diet.
The patient had a moderate to severe skeletal Class
II Division 1 malocclusion with a dental Class 2
anterior malocclusion due to the flaring of the upper
incisors (Fig 1). Impacted third molars were also
noted. Skeletally, the patient had a hypoplastic
mandible in the sagittal plane, which was affecting the
occlusion and his facial appearance (Fig 2, 3, 4). The
patient was very defensive and had low self-esteem.
Specifically
Moderate caries were noted on several posterior
molars (36, 46, 16 and 17). However, severe carious
Class V lesions were also noted on the upper
anteriors (13, 12, 11, 21, 22, 23, 31 and 41).
Delamination of the labial enamel due to severe
caries was noted on all anterior teeth. This may also
have been influenced by mouth breathing and the
consequential desiccation of the labial surfaces
(Fig 3, 4). Impacted third molars were noted
radiographically in each quadrant.
The patient had a skeletal Class II Division 1
malocclusion and a dental Class II malocclusion in
the anterior teeth. Severe proclination of the maxillary
incisors, which had resulted in a 10mm overjet and
100 per cent deep overbite, was also noted (Fig 5, 6).
Treatment planning
It was estimated that restoration of the dentition
would require treatment over a three-year period. It
was agreed that the general dental practitioner
should become the team coordinator.2
272
Pain control and anti-anxiety therapy
Apart from the obvious medical and psychological
problems exhibited by the patient, which were being
monitored and managed by the respective specialists,
the next priority was to determine the best means for
pain control and anti-anxiety therapy.3,4 The parents,
cardiologist, anaesthesists, cardiothoracic surgeon
and psychotherapist agreed that neuroleptic
anaesthesia with local anaesthesia would be the
appropriate choice for pain control and anti-anxiety
therapy wherever possible.5,6 However, it was agreed
that where a general anaesthetic was required the
risk of morbidity would still be minimal.
Dental caries
Treatment for the carious lesions would initially
involve the simple removal of active caries and
routine restoration of the posterior teeth with
amalgam and some simple resins. The anterior teeth
would require simple restoration with resin modified
glass ionomer and the subsequent regular use of
topical fluoride applied daily, along with a modified
diet and a strict oral hygiene regime. This routine
treatment would all be achieved in two long sessions
under intravenous sedation.
Periodontal disease
The patient’s poor oral hygiene and a severe gag
reflex had resulted in gross gingivitis The salivary
flow was copious and, surprisingly, the damage to
the attachment ligaments and investing bone
support was minimal. No pocketing of greater than
3-4mm was noted. The use of a competent hygienist
was invaluable in building rapport with the patient
and gradually gaining his trust to help him overcome
his panic attacks. The patient was asked to return to
the hygienist every four months during the
protracted course of treatment, so the tissues could
be maintained in optimal health, and the patient-
practitioner rapport preserved and reinforced.
Orthodontic and orthognathic surgery
The patient was advised to undergo orthognathic
surgery to correct the skeletal malocclusion, along
with subsequent corrective orthodontic manage-
ment. Consultations with an orthodontist, an oral
and maxillofacial surgeon and other specialists were
organized early in the program, so all disciplines
were aware of the proposed treatment and predicted
outcome. It was decided, due to ease of access under
intravenous sedation and the carious state of the
second molars, to extract the second molars in
preference to the completely impacted third molars.
The orthodontist agreed with the procedure and the
patient and parents requested the general dentist to
perform these extractions during the routine treat-
Australian Dental Journal 2000;45:4.
ment phase. This was agreed to as it would expedite
the subsequent orthodontics before orthognathic
surgery and remove the need for another anaesthetic
procedure.
Complex restorative treatment
After completion of the orthodontic treatment, all
anterior teeth would be reconstructed with full
coverage porcelain bonded crowns, using a resin-
bonded porcelain,7 correcting any minor anomalies
in the alignment and optimizing aesthetics.
Alternative restorative therapy, using resin-bonded
facings, was not considered appropriate due to the
paucity of healthy enamel. The demineralized nature
of the enamel of all the anterior teeth necessitated
the use of full coverage porcelain crowns.
Long-term maintenance
Orthodontic retainers would need to be worn
indefinitely which would also act as nightguards to
prevent damage from nocturnal bruxism. Biannual
examination and radiographs every two years, to
reexamine the interproximal surfaces, were essential
and accepted by the patient.
Biannual hygiene maintenance was considered
essential and includes hygiene therapy, the home use
of an electric toothbrush and dental floss along with
regular fluoride mouthwash. This was explained in
detail to both the parents and the patient and was
well accepted by the patient who has since followed
a strict maintenance regime.
Financial considerations
Each stage of the proposed treatment was
discussed with the parents, including alternative
treatment, estimates of costs and the timing of each
stage. The optimum treatment plan had substantial
costs associated with it but the parents were
committed to the best possible treatment for their
son, despite being offered less expensive alternatives.
Treatment and results
Initial treatment was carried out by the hygienist,
using a non-threatening approach and concentrating
on modifying the patient's diet, prophylaxis,
chlorhexidine and fluoride applications. Detailed
oral hygiene instruction was carried out, including
toothbrushing and dental floss. The technique
employed was designed to minimize the stimulation
of the gag reflex and to gain the patient’s confidence.
Routine restorative treatment was carried out by
the general dental practitioner, using local anaesthesia,
with the assistance of a specialist anaesthetist, using
neuroleptic anaesthesia. Anaesthesia was performed
with careful titration of fentanyl and midazolam and
with some occasional use of propofol to control
Australian Dental Journal 2000;45:4.
panic attacks and rigors.8,9 The procedure was
carried out in the dental practitioner’s rooms,
reducing the patient’s anxiety. Each session, the
patient was gradually weaned off the sedation drugs
and became more manageable, provided the
operators continually reassured him. A fully qualified
recovery sister was present at each session as well as
all necessary retrieval equipment and drugs.
Hygiene sessions were carried out with no
anaesthesia and without any overt behavioral
problems. Neuroleptic anaesthesia was used for all
orthodontic treatment, including impressions and
fixed brackets and wires.
Anaesthetic management
The anaesthetic management of this patient was
difficult.
Assessment by the cardiologist and cardiac
surgeon indicated the patient’s condition would be
better served by the use of neurolept anaesthesia.
However, general anaesthesia was not contra-
indicated.10 They recommended that standard pre-
emptive antibiotic treatment be instituted to prevent
a bacterial endocarditis.
The psychotherapist and the parents believed if
the work was to be carried out in a dental office it
would induce less psychological trauma and there-
fore less resistance from the patient than admission
to hospital and a general anaesthetic in an operating
theatre.
The provision of neurolept anaesthesia combined
with intraoral local anaesthesia in the dental
practitioner’s office was anticipated to be technically
more difficult than a general anaesthesia in an
operating theatre. The operating conditions would
be more taxing for the dentist, making progress
slower. However, it was deemed to be the
appropriate course of action for the patient. The
office was of suitable design and all the required
ancillary monitoring and resuscitation equipment
were located on site.11
Neurolept anaesthesia requires careful intra-
venous titration of fentanyl tartrate, a synthetic
narcotic drug, and midazolam, a drug in the benzo-
diazepine group, with the addition of boluses of
propofol, an anaesthetic induction agent, if
required.12 The patient breathes spontaneously and
remains in a state of obtunded sensation and
awareness. Neurolept anaesthesia causes profound
antereograde amnesia so that events which provoke
anxiety intraoperatively are not remembered by the
patient postoperatively.13 The patient received many
sessions of treatment using this technique. He was
monitored throughout each session by observation,
manual blood pressure measurement, electrocardio-
graph and electronic measurement of peripheral
pulse rate, pulse profile and percentage oxygen
273
 7

9 10

Fig 7 – Pre-treatment facial profile showing lip incompetence and demineralized and anterior teeth.
Fig 8 – Lateral cephalometric radiograph two weeks postoperative showing results from mandibular management.
Fig 9 – Lateral facial view two weeks postoperative.
Fig 10 – Lateral cephalometric radiograph six weeks postoperative.

saturation of haemoglobin. Most of the sessions
were very testing for the anaesthetist as the patient
required large quantities of drugs intravenously in
order to provide acceptable operating conditions.
The patient insisted on chewing or displacing the
bite block and raising his hands to repel or remove
the instruments and had frequent episodes of
uncontrollable coarse tremors which began in his
legs and ascended to involve his whole body. He was
able to voluntarily cease respiration for significant
periods causing episodes of relative oxygen
saturation.14,15
Because of the extensive dental work required, the
sessions averaged 90-120 minutes’ duration. The
patient became more restless and uncooperative as
the time passed and often exhibited a tachyphylaxis
to midazolam. Boluses of propofol were introduced
274
at that stage to maintain the neurolept state. The
dental treatment plan required that many dental
impressions be taken and this procedure commonly
occurred toward the end the session. Even under the
influence of neurolept anaesthesia the patient could
barely tolerate the intraoral manipulation required
to produce good dental impressions.
Over successive sessions, the patient gradually
became more tolerant of intraoral devices as he
gained confidence in himself and his attendants. At
the beginning of each session, the patient was
congratulated on his performance during the
previous session and encouraged by positive
reinforcement of his achievements. The patient’s
confidence levels slowly increased, he began to
control his oral phobia and although he required
similar quantities of drugs, he offered less physical
Australian Dental Journal 2000;45:4.
 surgery was carried out under general anaesthesia
without event.

11
Fig 11 – Lateral facial view six weeks postoperative.
resistance. His greatest achievement was to undergo
two brief but minor dental procedures performed
without the help of neurolept anaesthesia.
Surgery
The aim of the surgery was to align the lower
third of the face to attain aesthetic balance and to
achieve a functioning Class I occlusion. The ortho-
gnathic surgery of a bilateral sagittal split advance-
ment, which was stabilized with internal fixation,
was performed under hypotensive anaesthesia. Class
II box elastics were used for additional stabilization
for six weeks after surgery (Fig 7-10). Orthognathic
Prosthodontic management
Final reconstruction of the upper and lower
anterior teeth using porcelain bonded crowns was
performed in two 120-minute sessions under
neuroleptic anaesthesia backed up with local
anaesthesia. Results of this protracted but
coordinated treatment program can be seen in Fig
11-15. The patient and his parents were extremely
grateful for the coordinated and empathetic
management by the people from each professional
discipline.The patient’s psychological profile altered
remarkably during this protracted program, due
partly to his maturing through pubescence and the
finalization and stabilization of his medical
problems. The parents and authors also believe
remarkable changes to the patient’s attitude,
increased confidence and self-esteem were due in no
small way to the improvement of the patient’s facial
and dental appearance as seen in Fig 10, 14, 15.The
patient’s commitment to improved oral hygiene was
remarkable and was only hampered by a moderated
gag reflex.
Both patient and parents acknowledge these
changes in attitude and aesthetics and are pleased
with the results.
Discussion
This complex case involved a general medical
practitioner, cardiologist, cardiothoracic surgeon,
psychologists, anaesthetists, orthodontist, oral and

12 13

14 15

Fig 12 – New occlusion and incisor labial enamel repaired with resins 10 months postoperative.
Fig 13 – Postoperative view indicating new ‘smile line’ and incisor display.
Fig 14 – Final result of upper and lower incisors after restoration with bonded porcelain crowns.
Fig 15 – New incisor display with restored anterior dentition and the resultant aesthetics, including lip competence,
20 months postoperative.
Australian Dental Journal 2000;45:4. 275
maxillofacial surgeons and a general dentist.
However, in the first instance, it relied on astute
observation by a medical specialist whose discipline
was unrelated to the dental needs of the patient.This
case illustrates the need for interdisciplinary
cooperation and the need for the coordination of all
these disciplines toward successful long-term
management and improved quality of life for the
patient. In this case, it required an initial and
comprehensive diagnosis and treatment plan by the
general dentist to identify the overall needs of the
patient. The treatment plan was then refined in
consultation with each member of the team and, of
course, the parents and the patient. The treatment
plan required clear and mutual understanding
between all parties and the rapport between the
dental practitioner and the patient and his parents
was crucial to the success of the treatment.
Conclusion
This is an extreme case of interdisciplinary
management. It illustrates the mandatory require-
ment for care, attention to detail and the patient’s
needs. An excellent long-term result can be achieved
by a considered selection of medical and dental
professionals by the team leader who acts as the
coordinator of the treatment requirements and
procedures.2 Maintaining an understanding and
flexible approach to the patient’s needs, but not to
the exclusion of good clinical practice, was
fundamental to the success of this case. None of this
treatment would have been possible without the
consent of the patient and his parents and we thank
them for their cooperation.
This case is indicative of the profound positive
influence professionals can have on improving the
quality of a patient’s life, both physically and
psychologically.2,16 The results achieved by
cooperation between the medical and dental
professions are highlighted in this case as is the
obligation of medical practitioners to be alert to
patients’ underlying dental problems.
276
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Address for correspondence/reprints:
Dr Jonathan Rogers
155 Archer Street
North Adelaide, South Australia 5006
Australian Dental Journal 2000;45:4.