Oral Health 2 Assignment: Clinical Case Scenario Assignment
Case study
Introduction
Sandra is a 12-year-old patient attending the AIH adolescent clinic for the first time; the last visit to a Dental Therapist being two years ago in a general dental practice. Sandra is a known Down Syndrome (DS) person with a mild intellectual impairment. She had a heart operation at 2 with no further heart problems. Sandra is on Levothyroxine OD on an empty stomach.
She sits happily on the examination chair but complains that her neck hurts when she lays back for long. She also mentions that her tooth sometimes hurts, pointing to the lower left side of her cheek. Accompanying Sandra is her mother who says that she has noticed her daughter seem to a lot of food in the sides of her mouth; she also mentions that Sandra`s gums bleed when she brushes once a day (after breakfast) and occasionally has bad breath lasting throughout the day.
Oral Examination and Diagnosis
On visual examination of Sandra’s deciduous molars are present. All permanent first molars, central incisors, and lower lateral incisors have fully erupted. The upper permanent lateral incisors appear to be absent. The lower permanent canines have partially erupted and the upper deciduous canines show no sign of mobility. The permanent canines are not visible. Sandra is noted to have a Class 3 skeletal pattern and shows signs of excessive tooth wear on all deciduous teeth and slight wear is evident on the permanent incisors and first molars. Her tongue seems to be larger.
Sandra likes to consume a lot of sugary foods. Her parents reveal that she is addicted to any fizzy drink and will not drink water. Sandra also indicates that her upper teeth hurt when she drinks anything cold.
Sandra has 74 and 64 disto – Occlusal amalgam restorations. Her Mesial Marginal ridge has broken down on the 75 because of dental caries; however, the tooth is symptomless. She has a large temporary filling (IRM) 65 mesial which appears to be sound on examination. 74 clinically appears sound, however, there is a lesion present on the buccal surface of the 74. Sandra’s permanent incisors and first molar teeth show signs of mild- moderate hypoplasia. The mirror examination of palatal surfaces reveals the start of tooth surface loss on the palatal surfaces of the 11 and 21.
Sandra`s Oral Hygiene is very neglected with generalized mature plaque deposits detected along the upper and lower gingival margins as well as interproximal deposits including plaque biofilm and subgingival calculus around the all posterior teeth. Fine supragingival calculus was also apparent during your examination on the lingual aspects of the 33-43. Periodontal probing depths ranged between 2 and 4mm in most areas except on the mesial surfaces of 11, 21, 31 and 41, where it measured between 5 and 6 mm. Sandra also had a quite bad breath.
Risk assessment
Risk assessment provides data critical to quantifying the susceptibility of a person to an oral problem, and additionally, presents room for preventative measure. From the medical history and clinical findings obtained, Sandra is a high risk person – presenting with multiple confounding factors that predispose her to numerous oral and even systemic infection. She observes poor oral hygiene, does not regularly brush her teeth and consume copious quantities of sugary substances. Other factors to be taken into consideration include the levels of exposure to fluoride, the education level of her parents, and the socioeconomic status of the family.
Oral Health Care Plan
Gupta (2016) explains that the provision of a comprehensive oral health care plan for persons suffering from DS requires caregivers to adopt skills used on a daily basis. Researchers posit that people with mild to moderate forms of DS can be successfully treated with the principles of general practice. The oral health care program is designed then in such a manner as to encompass the management of common oral problems associated with DS such as periodontal diseases, tooth abnormalities, dental carries, and the increased susceptibility to infections. Early professional management of oral problems in DS potentially leads to the improvement of the quality of life.
The, an aggressive preventive dental program would include: encouraging the person to conduct three to four monthly dental recalls: consistent preventive care can help reduce the incident of periodontal diseases. Encouragement of good oral hygiene and dietary management: giving practical advice to minimize the consumption of cariogenic foods together with an explanation of the effects of these foods on teeth. Topical fluoride application is essential for both the prevention and reduction of dentitial hypersensitivities. Prophylactic treatment with chlorhexidine gluconate 0.12% rinse can be instated to reduce the bacterial burden.
Treatment plan: Points to be considered
Whereas the mental capability of persons with DS widely varies, most tend to have mild to moderate intellectual disabilities which in turn affect their ability to communicate, learn and adapt to her surroundings (Watt-Smith, 2009). From the patient history provided, Sandra appears to be happy on her dental visit. A key point that a dentist would note is that persons with DS tend to have a delay in language development; that they understand things but cannot verbalize (Batshaw, Roizen & Lotrecchiano, 2013).
A practitioner would be keen to actively listen to Sandra speak, more so as her speaking may be difficult. This would also include showing the patient whether they have understood the point being communicated or not. Secondly, the intellectual and functional abilities of Sandra can be determined by asking her parents (mother in this case) explorative questions, which is then followed up a by a concise explanation of the procedures to be conducted at the level that she can understand. Additional time can be allowed for the explanation of the prevalent oral health issues, or instructions and demonstration of the instruments to be used (Walsh & Darby, 2014). Thirdly, simple and concrete instructions should be provided in a repeated manner to compensate for problems in short term memory.
Oral Manifestations of DS and their Management
Microdontia and Congenitally Missing Teeth
Between 35-55% of people suffering from DS frequently have microdontia; 50% of these people are likely to have congenitally missing teeth (Fenton, Perlman & Turner, 2003). Third molars, lateral, and mandibular second bicuspids are the most commonly missing teeth. The absence of teeth, especially the frontal incisors, leads to problems in articulation. Sandra presents with irregularities in the normative processes of tooth formation. She has shorter than the average roots and smaller crowns. Her teeth also show features of enamel hypo-calcification and hypoplasia.
Large Tongue
Tongue enlargement is relative. Enlargement of the tongue can result from tongue tissue hyperplasia or that they may have an average sized tongue with a smaller maxilla which makes their tongue too large for their mouth (Caballero, Allen & Prentice, 2005).
Bite Problems
Microdontia in persons with DS causes spacing between teeth; which may be accompanied by the underdevelopment of the maxilla (Desai, 1997). Underdevelopment of the maxilla leads to the crowding of teeth, potentially causing permanent impaction of teeth because of limited space in the mouth for them to come in (Dyke et al., 2012). It also creates a situation whereby the top teeth fail to go over the bottom teeth as normal teeth are meant to; instead, the lower teeth may be projected out further than the top teeth in the back of the jaw, the front of the jaw, or both (Darby & Walsh, 2010). Commonly, frontal teeth in these people also do not touch.
Persons with DS may also have a V-shaped palate, an incomplete development of the midface complex and insufficiency of the soft palate. Their orbicularis oris, temporalis, and zygomaticus muscles may be hypotonic. Hypotonic muscles have may also complicate bite problems (Gupta, 2016).
Gum Diseases
People with DS are at increased risk of developing periodontal diseases. Even if these individuals do not have a lot of calculus (tartar) or plaque, they suffer from periodontal diseases more often than others. Susceptibility to oral infections is worsened by an impaired immune system. Reduced monocyte and neutrophil chemotaxis, defective phagocytosis and both defective and reduced T-cell proliferation and maturity play a role in the increased prevalence of periodontal diseases among persons with DS (Watt-Smith, 2009; Gupta, 2016).
Gingivitis develops earlier and more rapidly and extensively in people with DS (Caballero, Allen & Prentice, 2005). Persons with DS tend to have an altered microbiological composition of the subgingival plaque, including the presence of Haemophilus and Actinomyces strains. Bleeding gums are an indication of gum inflammation. Tooth brushing and flossing should not be stopped because of gum bleeding. Instead, proper tooth brushing and mouth flossing lowers the bacterial burden in inflamed gums, therefore minimizing the inflammation (Cawson & Odell, 2008).
Restorative Treatment
Restoration procedures can manage some oral manifestations of DS. Restoration treatment available to Sandra is dependent on her cooperation. High levels of corporation lead to high-quality dentistry. Lack of cooperation will require treatment under sedation or general anesthesia (Oredugba & Ayanbadejo, 2012).
Bite problems can be improved with orthodontics. An orthodontic examination will be conducted on Sandra to uncover problems such as alignment and occlusion on her teeth. Orthodontics, however, requires a lot of cooperation and may make the teeth even harder to keep clean; therefore, the technique may not be possible for all people (Neville et al., 2015). This will necessitate orthodontic classification of Sandra.
The presence of orthodontic appliances in the mouth may worsen the already impaired articulation (Caballero, Allen & Prentice, 2005). Typically, children without DS can adapt to the orthodontic devices quickly and develop proper speech. In children with DS, adapting to these devices may be an insurmountable hurdle. It may be wise therefore if these orthodontic devices are placed when the child is older and has further along developed speech.
Chin cup therapy is indicated for mandibular prognathism; presenting the person with positive effects on the mandible and maxilla. Chin cup therapy makes a retardation of the vertical ramus growth, retardation of the vertical and sagittal development of the mandible and retardation of vertical development in the posterior maxilla (Neville et al., 2015). Chin Cups are indicated for persons with skeletal class 3 malformation. Sandra, in this case, would benefit with a better ANB angle and profile aesthetic.
In functional orthopedics therapy, growth and developmental stages are important. Key points to be considered is that this therapy at changing growth is best achieved when the person is ta peak of pubertal growth; ages 12 for girls and ages 14 of boys. Sandra is 12 years, making her a good candidate for this restorative procedure.
Dental Carries
Dental caries is a transmissible bacterial disease caused by the destruction of teeth by bacterial organic acids – the by-products of carbohydrate fermentation. The produced acids diffuse into the enamel and dentine of normal teeth, in the process eroding and dissolving teeth minerals (Dyke et al., 2012). The process of dental carries is a continuum resulting from continued mineralization and demineralization of normal teeth. Tooth demineralization commences at the atomic level at the crystal surface inside the enamel or dentine and can progress unless halted; the end point is tooth cavitation (Oredugba & Ayanbadejo, 2012).
Demineralization and mineralization of teeth is affected by various factors, including adherence to oral hygiene, the presence of saliva in the mouth, diet, exposure to fluoride and the general health of the person (Dyke et al., 2012). Children, especially, are at a greater risk of developing tooth problems because they are likely to fail to adhere to instituted teeth care regimens and that primary teeth in children have a thinner enamel all of which lead to a rapid progression of dental carries.
Children and younger adults with DS have a lower incidence of dental carries (Weddell, Sanders & Jones, 2004). Various factors have been posited to play a role in this phenomenon; including the delayed eruption of primary and permanent teeth; the absence of permanent teeth; microdontia with wider spaces between them, which makes it easier to remove plaque (Watt-Smith, 2009). Other factors include the fact that persons with DS are put on strictly supervised diets to prevent obesity; which in turn contributes to minimizing the intake of cariogenic beverages and foods. However, the consumption of cariogenic foods and xerostomia increases the risk for dental caries. Muscle hypotonia also contributes to problems in chewing, and inefficiencies in natural cleansing actions which then allows food to remain on the surface of teeth after meals (Finkbeiner, 2016).
The presence of chalky and white spots on the front side of teeth near the gum lines are the initial indicative signs of dental carries (Gupta, 2016). Strategic management at this stage includes regular dental visits; observing proper oral hygiene; regular teeth brushing, and drinking water – all of which promote normative teeth healing. Dietetic changes, including limiting foods and drinks rich in sugars and processed carbohydrates will minimize the accumulation of sugars on tooth surfaces (Bird & Robinson, 2017). Observing poor oral hygiene is dangerous; failing to brush one’s teeth with fluoride and observing poor dietary behaviors leads to the formations of teeth cavitation on the tooth enamel (Watt-Smith, 2009).
Dental carries may complicate to tooth erosion and cavitation, which demand the services of a dentist who will remove the infected part and fill the cavity. Infection of tooth cavitations is dangerous. These bacterial organisms release acids that further dissolve and weaken teeth (Fenton, Perlman and Turner, 2003). Spread of the infections to the pulp cavity – where teeth arteries, veins, and nerves are located – leads to severe tooth pain. Hematogenous dissemination of bacteria to other parts of the body may cause systemic diseases, necessitating the services of a physician (Watt-Smith, 2009. Therefore, tooth infections must be immediately treated.
Persons on drugs that lead to xerostomia can be advised to drink water often (Caballero, Allen & Prentice, 2005). If medicines that are sugar-free are available, they can be recommended in addition to adequately rinsing the mouth with water after dosing. Preventive measures such as sealants and topical fluorides can be recommended (Ansell, 010). Fluoride containing toothpaste, gels or rinses can be advised depending on the abilities and needs of the person. Parents should be advised on minimizing the frequency and quantity of cariogenic foods and beverages offered either as rewards or incentives (Glassman & Subar, 2009)
Periodontal Disease
Periodontal disease is a pathological condition that causes gum and bone support inflammation. The common forms of periodontal disease are Gingivitis (an inflammation of the gum and necks of the teeth) and periodontitis (inflammation of the tissues supporting teeth – including bones). Gingivitis is the inflammation of gingival tissues at the necks of teeth. The disease is characterized by easy bleeding on brushing, gum swelling, and redness of the gum margins. Gingivitis can occur in both chronic and acute forms. Acute disease is associated with specific bacterial infections, microorganisms or oral trauma. Chronic inflammation of gum tissue is associated with bacterial biofilms around the teeth and gum lines. Gingivitis is an initial process of a chronic degenerative oral disease that may lead to the loss of both tooth and gum if not treated (Pihlstrom, Michalowicz & Johnson, 2005). Fortunately, gingivitis does not often develop into periodontal disease
Periodontitis is characterized by the formation of pockets of space between tooth and gums. Progression of illness may result in periodontal loosening of teeth and subsequent loss of teeth. Disease dynamics are that the affected individual can experience episodes of rapid periodontal disease activity in a short period, followed by periods of remission. Periodontitis complicates to periodontal disease.
Periodontal disease is a diagnostic challenge as it is a silent disease; lack of early arrest of the disease is detrimental (Gupta, 2016). Consequently, then, if the putative sequence of the disease is not arrested early, periodontal diseases tend to lead to the loss of permanent anterior teeth. Identified risk factors include malocclusion, failing to observe proper oral hygiene, conically shaped tooth roots, bruxism and an abnormal host immune system response to common infectious agents (Glassman & Subar, 2009; Pihlstrom, Michalowicz & Johnson, 2005).
According to Oredugba (2007), persons with DS, such as Sandra, may then gain from the daily use of bacteriostatic pharmaceutical agents such as Chlorhexidine. The recommended delivery mode of the drug is dependent on the abilities of a person. Rinsing of the mouth, for example, is ineffective in a person with swallowing problems or one who cannot expectorate. Application of Chlorhexidine using a toothbrush or a spray bottle has equally been found to be effective (Dyke et al., 2012). If the use of certain pharmacological agents leads to the development of gingival hyperplasia, the dentist has to single out the importance of frequent professional cleanings and daily oral hygiene (Weddell, Sanders & Jones, 2004).
Prevention of periodontal diseases additionally entails encouraging person independence in daily oral hygiene (Pat Ansell, 2010). The dentist can request the person to demonstrate how they brush their teeth, then conduct a follow-up with specifications on the recommended brushing methods or toothbrush adaptations. Persons with DS can brush their teeth and floss their mouth independently, but then may need help. Persons should also be involved in the hands-on demonstration of flossing and brushing (Pilcher, 1998).
It would be necessary then that the dentist talks to that caregivers on the importance of daily oral hygiene. Assumptions that all caregivers are acquainted with the basics should not be made; proper brushing and techniques in mouth flossing should be demonstrated (Batshaw, Roizen & Lotrecchiano, 2013). A floss holder or a power toothbrush can ease oral care. Dentists can use their experiences with the persons to perform a demonstration of proper standing and sitting positions for the caregiver. Emphasis should be put on the importance of always approaching oral hygiene by the caregivers – trying to use the same location, positioning, and timing (Oredugba, 2007).
Preventative Program and Recall Regime
Behavioural Management
Scheduling visits in the morning is key to ensuring that the dental team remains alert. The dental team can also be encouraged to be warm, attentive, portray a caring attitude and provide a friendly environment for the person on arrival. An environment free of distraction is paramount to a successful visit. Comforting those who resist oral care and rewarding any cooperative behavior may go a long way (Desai, 1997).
In the management of children, a little extra time can be dedicated by a dentist to persons who are stubborn or uncooperative to feel comfortable. The dentist will aim at gaining the person’s trust. Sandra’s parents can talk to the attendant dentist on the techniques that have proved in the management of Sandra’s behaviors. The parents will be encouraged to share ideas, including what might motivate the person. For example, incentives and gifts such as a new toothbrush at the end of a dental visit may rise.
Managing Bacterial Bio-Burdens
Bacterial bioburdens in dental plaques can be mechanically removed by either using a toothbrush, a minuscule smear or pea-sized amount of fluoride toothpaste to strengthen teeth (Gupta, 2016). Routine and proper brushing of teeth with fluoride kinds of toothpaste can reduce the prevalence of gum diseases and tooth decaying (Neville et al., 2015). Brushing after eating or drinking can remove and control the growth of bacterial plaque. Sandra’s parents can also encourage her to brush her tooth twice daily, floss her mouth and regularly visit a dentist.
In children who consume a lot of fizzy foods, the frequency and quantities of foods or drinks with a high content of sugar and carbohydrates can be decreased by their parents. Children should never go to sleep at night or take a nap during the day with sugary foods. Children aged 1-6 years should not consume more than 4-6 ounces of fruit juice per day, from a cup, (not a Sippy cup or a bottle) and as part of a meal or snack (Darby & Walsh, 2010).
Limiting the Amount and Frequency of Sugary Foods Consumed
The amount of sugar taken can be controlled by appropriately regarding the nutrition facts and ingredient labels on beverages and foods, and choosing foods low on sugar (Fenton, Perlman & Turner, 2003). Other tips include drinking plenty of water after meals and encouraging the child to consume a variety of food from each of the five major groupings of food (Bird & Robinson, 2017).
Limiting the number of snacks consumed per day will go a long way in promoting proper oral hygiene (Walsh & Darby, 2014). If the child chooses to consume a snack, a healthy snack, such as those containing fruits, vegetables or cheese should be chosen. Consuming these foods as part of a meal causes less harm to teeth than consuming plenty of snacks throughout the day (Pilcher, 1998). The produced saliva during meals helps wash away these foods from her mouth and lessens the negative effects of acids that potentially cause tooth cavities (Dyke et al., 2012). This is of importance as persons with DS have a reduced saliva flow.
Antibacterial Prophylaxis for a Compromised Immune System
A compromised immune system leads to frequent oral infections and an increased incidence of periodontal diseases (Dyke et al., 2012). Common infections include oral candidiasis, aphthous ulcers, and acute necrotizing ulcerative gingivitis. Mouth breathing is contributed by chronic respiratory infections, fissured tongues and lips, and xerostomia. Aggressive pharmacology is the recommend approach to necrotizing ulcerative gingivitis and other oral infections (Cawson & Odell, 2008).
Additionally, persons suffering from DS are more likely to require SBE prophylaxis before any dental process because of their increased incidence of congenital heart defects (Caballero, Allen, & Prentice, 2005). Dentists should contact the persons’ physicians before any major dental procedures to minimize the risk of bacterial endocarditis. The use of fluoride in the prevention of dental caries associated with xerostomia has to be stressed. The use of lip balms during treatment is necessary to ease the strain on the person’s lips (Oredugba, 2007).
Assessment tool
Using the Oral Assessment in Down Syndrome Questionnaire (OADS) tool, assessment of adherence to the oral care plan will be analyzed. Sandra’s parent will fill the tool. Then, a comprehensive oral examination will be conducted on a dental visit. The necessary tools required will include a dental light, a mirror, and an explorer. Sandra, at this point, will be encouraged be calm. An in-depth examination of the gingiva, periodontal tissues, hard palate, soft palate, buccal floor, oral soft tissues and tonsillar regions will be conducted. Deviations in texture, normal color and size, will be noted. Saliva quantity and quality will also be surveyed.
An extensive examination of teeth will also be conducted. This would give a clear indication of whether her teeth are in line with her age. The presence of oral plaques, chalky spots, retentive fissure and enamel defects will be noted. The integrity of any restorative processes conducted will be examined. Other areas of interest also will include any notable occlusion and alignment of her teeth (Weddell, Sanders & Jones, 2004). Orthodontic correction of misalignments such as anterior open bites increased overjet, overbites, edge to edge bite, cross bites and crowding will be thoroughly examined. Changes in the color of the tongue will be noted. Importantly, these procedures when Sandra is in various positions on the examination table.
Radiological exams will also be conducted regularly and ONLY when necessary. A radiological examination will be critical in measuring Sandra’s dental carries. Bitewing radiological tests are essential for the detection of interproximal carious lesions at an early stage as well as occult occlusal lesions. Radiological exams will be important in the detection of irregularities in oral restorations, tooth reabsorption, ankyloses, supernatary teeth and other peripheral (bone) pathologies.
Indeed, literature continues to illustrate that persons with DS is especially predisposed to orofacial problems. Systemic dysfunction in these people may additionally predispose them to oral diseases which may, in turn, aggravate their systemic problems. These problems, therefore, necessitate persons with DS visit a dental clinic regularly for reviews; preferably conducted by a specialist team who will identify, prevent, and stop any oral diseases and functional problems. An effective plan of managing oral problems in persons with DS may at first progress slowly, but then determination from both the affected person, the immediate caregivers (parents and other family members), and the dentist may go a long way in bringing about positive outcomes – with long-term invaluable rewards. By properly adopting the oral management strategies and care plan highlighted above will bring about a significant positive impact on Sandra’s life.
References
Batshaw, M. L., Roizen, N. J., & Lotrecchiano, G. R. (2013). Children with disabilities. Baltimore: Paul H. Brookes Pub.
Bird, D. L. & Robinson, D. S. (2017). Modern Dental assessing – E-Book. [Place of publication not identified]: Saunders.
Caballero, B., Allen, L. H., & Prentice, A. (2005). Encyclopaedia of human nutrition. Amsterdam; Boston; Elsevier/Academic Press.
Cawson, R. A. & Odell, E. W. (2008). Cawson’s essentials of oral pathology and oral medicine. Edinburgh; New York: Churchill Livingstone.
Darby, M. L., & Walsh, M. M. (2010). Procedures manual to accompany dental hygiene: Theory and practice. St. Luis, Mo.: Saunders/Elsevier.
Desai, S. S. (1997). Down syndrome: a review of the literature. Oral surgery, oral medicine, oral pathology, oral radiology, and Endodontology, 84(3), 279-285.
Dyke, D. C., Lang, D. J., Heide, F., Duyne, S., & Soucek, J. (2012). Clinical perspectives in the management of Down’s Syndrome. New York, NY; Springer US.
Fenton, S. J., Perlman, S., & Turner, H. (2003). Oral health care for people with special needs: guidelines for comprehensive care. River Edge, NJ: Exceptional Parent, Psyc-Ed Corp.
Finkbeiner, B. L. (2016). Mosby review questions and answers for dental assisting. St. Louis, Missouri: Elsevier/Mosby.
Glassman, P., & Subar, P. (2009). Planning dental treatment for people with special needs. Dental Clinics of North America, 53(2), 195-205.
Gupta, P. V. (2016). Pediatric dentistry for a special child. [Place of Publication not identified]: Jaypee Brothers Medical P.
Neville, B. W., Damm, D. D., Chi, A. C., & Allen, C. M. (2015). Oral and maxillofacial pathology. Elsevier Health Sciences.
Oredugba, F. (2007). Oral health condition and treatment needs of a group of Nigerian individuals with down syndrome. Down syndrome research and practices, 12 (1), 72-76.
Oredugba, F., & Ayanbadejo, P. (2012). Gingivitis in children and adolescents. INTECH Open Access Publisher.
Pat Ansell Ph.D., R. H. V. (2010). Oral disease in children with Down’s syndrome: causes and prevention. Community Practitioner, 82(2), 18.
Pihlstrom, B. L., Michalowicz, B. S., & Johnson, N. W. (2005). Periodontal diseases. The Lancet 366(9499), 1809-1820.
Pilcher, E. (1998). Dental care for the person with Down Syndrome. Down syndrome research and practice, 5(3), 111-116.
Walsh, M., & Darby, M. L. (2014). Dental hygiene: Theory and practice. St. Louis, Missouri: Elsevier Health Sciences.
Watt-Smith, P. (2009). Dental care and oral health. Profound intellectual and multiple disabilities. Nursing complex needs, 202-235.
Weddell, J. A., Sanders, B. J., & Jones, J. E. (2004). Dental problems of children with disabilities. Dentistry for the child and adolescent, 524-556.
