called for further funding of research on oral health delivery and prevention models for people with special needs (Anzil,
et al. 2017; Alumran, et al., 2018; Gupta, et al., 2019; NCD , 2017).
CASE SCENARIO #1
Dr. Johnson is a relatively new dentist, having graduated from dental school only two years ago. He recently purchased a practice from a retiring dentist and is focused on enlarging the practice and acquiring new patients. Being new to the area, he has not yet established a reputation and depends heavily on external advertising. With student and practice loans to pay, he feels pressured to stay as busy and productive as possible. Dr. Johnson’s receptionist receives a phone call one afternoon from a woman named Sandra, who is seeking dental care for her elderly father, Jim. She states that he is in pain and has swelling on the upper right side of his mouth. Sandra has seen in an advertisement in the telephone book that Dr. Johnson performs oral surgery and extractions and thinks he may be able to help. Over the phone, the receptionist gathers that Jim is 90 years old, has severe dementia, and is unable to communicate. She schedules him for a 30-minute limited examination to evaluate the complaint that same afternoon. During the appointment, Dr. Johnson identifies an acute abscess in tooth #3 secondary to extensive caries and coronal tooth loss. Jim’s swelling and pain clearly originate from that tooth. In addition, Dr. Johnson notices heavy plaque coating all of Jim’s teeth, especially along the gumline, with generalized large Class V carious lesions on all of the upper teeth and a few on lower molars and premolars. Teeth #3, #4, and #14 appear to be nonrestorable. In addition to all of the third molars, teeth #19 and #31 are already missing. Bitewing radiographs reveal additional areas of interproximal caries, but generally normal alveolar bone levels. Although he is uncommunicative, Jim is cooperative during the examination. Before he returns to the operatory to consult with Sandra, who was present during the examination, Dr. Johnson takes a moment to evaluate Jim’s radiographs and condition. He is uncertain of how to proceed. Home care clearly appears to be lacking, if present at all, and the long-term prognosis is poor
if caries continues to progress. If he proceeds with long- term care, he is unsure whether the patient would benefit most from an upper denture to reduce the likelihood of further pain and abscesses or whether the caries should be restored where possible. From what he gathered during his initial discussion with Sandra, it also appears that finances are tight and he is concerned about whether Jim or his family will be able to afford anything beyond emergency care. Points to consider 1. What role should Dr. Johnson’s perception of Jim’s financial situation play in his recommendations for treatment? His primary consideration as a healthcare professional is to the needs of the patient. Ethically, he is responsible to care for disabled as well as healthy patients without discrimination. He should not make assumptions initially that prevent him from recommending proper care. However, he is also not obligated to provide care at no cost. He should discuss with Sandra, who makes decisions on behalf of the patient, multiple treatment options that he feels are best to fit Jim’s needs. When the treatment plan is agreed upon, a financial agreement can be signed that protects Dr. Johnson financially while he provides the most ideal care. 2. What are some factors that might influence Dr. Johnson’s decisions in planning and providing dental treatment? He should consider whether Jim has the cognitive ability to understand what is being done to him and to cope with the process and results of treatment. For example, how will Dr. Johnson communicate the need to remove one or multiple teeth, and how will Jim cooperate? He should also consider Jim’s physical health, which will play a role in determining appointment length, ability to recline in a dental chair, and safety of invasive versus noninvasive dental treatment.
CASE SCENARIO #2
After considering Jim’s case in the previous scenario, Dr. Johnson returns to the operatory. He realizes that the immediate concern is pain and swelling, and he is not comfortable with simply placing Jim on an antibiotic. He also does not feel that he has had adequate time to formulate a treatment plan for Jim’s long-term care. Looking at the day’s schedule, he feels he can work in the removal of the tooth without running behind. He suggests to Sandra that they schedule a follow-up consultation after Jim has had adequate time to heal. Sandra is extremely thankful for Dr. Johnson’s efforts to help and agrees to this plan. Shortly thereafter, tooth #3 is removed without complication and with excellent cooperation from Jim. Two weeks later, Dr. Johnson joins Sandra alone for a brief consultation. He has considered various solutions for managing Jim’s needs and presents the following options: ● Option 1 : Remove teeth #4 and #14. After a period of healing, restore all carious lesions (15 total). Dr. Johnson emphasizes that the long-term prognosis is guarded and depends on his ability to completely remove decay. Some cavities may be deep enough that pulp exposures may occur, necessitating the removal of more teeth. There is also a high risk that decay will recur and further restorations and/ or extractions may be needed. Because of Jim’s inability to tolerate longer appointments and the difficulty of decay removal, this plan would require a minimum of five one-hour visits. ● Option 2 : Refer Jim to an oral surgeon for the removal of all remaining upper teeth due to the near-hopeless outlook from carious damage. Prior to the extractions, an immediate
complete upper denture would be fabricated to deliver at the time of extractions, and follow-up care would be provided in Dr. Johnson’s office as Jim heals. The lower areas of decay would be restored before completion of the extractions. ● Option 3 : As long as Jim is not complaining of pain, do nothing. Provide dental care as needed on an emergency basis. Sandra has not realized how dire her father’s oral health has become and is not comfortable with the idea of leaving it that way. She does not know how much longer Jim will live, but does not want to make any assumptions. Although concerned about the possibility of future emergencies, she also worries that Jim would have too much trouble getting used to a denture with his dementia and that the process may be too confusing and frightening. She chooses to go forward with the first option to restore caries as best as possible. A detailed treatment plan is created, and Dr. Johnson’s office manager makes financial arrangements with Sandra. Points to consider 1. Besides Dr. Johnson’s best clinical efforts to restore Jim’s decayed teeth, what else can be done to reduce the risk of future decay? Dr. Johnson needs to bring Sandra into the management of Jim’s oral health. Regular and careful oral hygiene must be provided by a caregiver. Prescription fluoride toothpastes should be used.
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