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The Medically Compromised Patient **Module coordinator:** Dr Laura Dalton-Ecker **Facilitator/Lecturer** Dr Manori ka Ratnaweera **Lecture by** Dr David Lim BDS (SQ), MSc Spec C D (UCL), PG Dip Con Sed D (KCL), WSQ DipACEdu, AdCert ACLP, FIADH, GCert Geront, MFDS MFTD RCSEd *** 22 Jun 2026 (Monday) 1-4pm VLC Room 211 **Module coordinator:** Dr Laura Dalton-Ecker **Facilitator/Lecturer:** Dr Manori ka Ratnaweera **Lecture by** Dr David Lim BDS (SQ), MSc Spec C D (UCL), PG Dip Con Sed D (KCL), WSQ DipACEdu, AdCert ACLP, FIADH, GCert Geront, MFDS MFTD RCSEd 22 Jun 2026 (Monday) 1-4pm VLC Room 211 # The Medically Compromised Patient **Module coordinator:** Dr Laura Dalton-Ecker **Facilitator/Lecturer** Dr Manorika Ratnaweera **Lecture by** Dr David Lim BDS (SG), MSc Spec C D (UCL), PG Dip Con Sed D (KCL), WSQ DipACEdu, AdCert ACLP, FIADH, GCert Geront, MFDS MFTD RCS **DENT5311** **22 Jun 2026 (Monday) 1-4pm VLC Room 211** **Module coordinator:** Dr Laura Dalton-Ecker **Facilitator/Lecturer:** Dr Manorika Ratnaweera **Lecture by** Dr David Lim BDS (SG), MSc Spec C D (UCL), PG Dip Con Sed D (KCL), WSQ DipACEdu, AdCert ACLP, FIADH, GCert Geront, MFDS MFTD RCS DENT5311 22 Jun 2026 (Monday) 1-4pm VLC Room 211 DMD3 Tutorial on Monday, June 22 at 1:00-4:00 PM in the VLC (Room 211) covering the topic of The Medically Compromised Patient. **DMD3 Tutorial on Monday, June 22 at 1:00-4:00 PM in the VLC (Room 211) covering the topic of The Medically Compromised Patient.** **The Medically Compromised Patient.** What students need to bring and use - papers/pens (brain storm), laptops. ### Learning Objective 1. Formulate a medical category - risk assessment - modification table for medically compromised patien ### Lesson plan(Gagne 9): 1. Gain Attention, Inform Obj, Prior Knowledge (10min, 1300pm) 2. Present information, provide guidance (10min) 3. Elicit performance (30min) 4. Form up in 6 groups (5-6pax), 25 min to prep 1 question. 5. Use paper/chat GPT/google. create a 8min ppt with 2-3min Q&A 6. All 6 grps present (60min), assess performance 7. Remind to use during Clinics. enhance retention (end ~1500+pm) DMD3 Tutorial on Monday, June 22 at 1:00-4:00 PM in the VLC (Room 211) covering the topic of The Medically Compromised Patient. What students need to bring and use: papers/pens (brain storm), laptops. #### Learning Objective 1. Formulate a medical category - risk assessment - modification table for medically compromised patien #### Lesson Plan (Gagne 9) 1. Gain Attention, Inform Obj, Prior Knowledge (10min, 1300pm) 2. Present information, provide guidance (10min) 3. Elicit performance (30min) 4. Form up in 6 groups (5-6pax), 25 min to prep 1 question. 5. Use paper/chat GPT/google. create a 8min ppt with 2-3min Q&A 6. All 6 grps present (60min), assess performance 7. Remind to use during Clinics. enhance retention (end ~1500+pm) > [!note] Lecturer — Assessment Framework > The framework comprises three columns: medical category, risk assessment, and dental treatment modifications. > > - Students considered medically compromised patients encountered in clinic, including heart attack, epilepsy, vasovagal syncope, asthma, and hypoglycaemia. > - Medical, social, and treatment-related factors can affect dental care. > - Hypoglycaemia may initially present without loss of consciousness; early signs include agitation, rigidity, hand tremors, and incoherence in more severe cases. > - Management discussed included providing glucose, taking a break, lying the patient flat when appropriate, encouraging at-risk patients to eat light food before attending, and ensuring diabetic medications are not forgotten. > - Medical emergencies were described as the extreme consequence of medical management going wrong, while most clinical issues are less urgent but still require systematic assessment. > [!note] Lecturer — Systemic Phase > The systemic phase is important in case presentations, examinations, OSCEs, and written assessments. > > - It should include consideration of the patient’s medical conditions, risks, possible emergencies, and required modifications. The Medical History Look at the Systems that are compromised – stable vs unstable Look at the medications – dosages, frequency and conditions its used for Look at the dental treatment modifications that are required Prioritize the medical history in relation to its impact on dental procedure Any medical consult requirements? From Dr Lydia See The Medical History | | | | :--- | :--- | | Look at the Systems that are compromised – stable vs unstable | | | Look at the medications – dosages, frequency and conditions its used for | | | Look at the dental treatment modifications that are required | | | Prioritize the medical history in relation to its impact on dental procedure | | | Any medical consult requirements? | | From Dr Lydia See When reviewing the medical history: - Look at the systems that are compromised – stable vs unstable - Look at the medications – dosages, frequency and conditions it's used for - Look at the dental treatment modifications that are required - Prioritize the medical history in relation to its impact on dental procedure - Any medical consult requirements? *From Dr Lydia See* > [!note] Lecturer — Medical History Review > A stable condition generally indicates that the patient is receiving medication or treatment, but the medication list must still be reviewed carefully. > > - Assess cardiovascular, respiratory, bone, renal, and liver systems. > - Clarify the degree of disease control, recent exacerbations, hospital admissions, and relevant consultations. > - Missing information is especially important when treatment is urgent or invasive. > - Consider medical consultation after a recent heart attack, when the patient appears unwell, when urgent invasive treatment is required, when a blood thinner has no clear indication, when the history is incomplete, or when the risks and benefits of immediate treatment are unclear. > - Weigh the risks of dental treatment against delaying treatment: anxiety and treatment after a recent heart attack may raise concern about recurrence, while untreated dental pain may increase blood pressure and contribute to myocardial infarction risk. > [!note] Lecturer — Wider Dental Factors > Medical risk assessment also includes social circumstances, financial constraints, disability, dental anxiety, falls risk, appointment attendance, postoperative instructions, and the availability of carer or family support. Consent may need to be considered under the Mental Capacity Act. <del>Bacteriaemia</del> **Bacteriaemia** **Bleeding** **Healing** **Anxiety** **Positioning** **Consent** ### The Dentistry * What is it about the dentistry that is going to impact the overall systemic health of the patient? * What is it about the overall systemic health that is going to impact on the dentistry? * Are we doing invasive vs. non-invasive procedures? From Dr Lydia See Key concerns to consider: - Bacteraemia - Bleeding - Healing - Anxiety - Positioning - Consent #### The Dentistry - What is it about the dentistry that is going to impact the overall systemic health of the patient? - What is it about the overall systemic health that is going to impact on the dentistry? - Are we doing invasive vs. non-invasive procedures? *From Dr Lydia See* > [!note] Lecturer — Treatment Planning > Routine dental findings such as caries, poor oral hygiene, and periodontal disease should remain in the normal dental treatment plan. They do not need to dominate the medical risk table. # Bold: Risk Assessment Table | Medical categories and others | Risk | Modifications / Implications | | :--- | :--- | :--- | | **Respiratory** | | **•** Bring inhaler, prophylactic dose | | - Severe asthma | Asthmatic attack | **•** Avoid triggers (cold/dust) | | - inhaler use | Poor healing | **•** Late morning appointment | | | | **•** Supplementary oxygen? | | | | **•** Drug Px:? steroid use, theophylline may be potentiated by liver enzyme blockers | | || | **Cardiac** | **MI** | **Warfarin, INR check(therapeutic INR ~2.5), morning appointments, haemost** | | - Valvular repair (patient unsure) | **Stroke, DVT** | **measures, consent** | | - PFO | **I.E. AB Prophylaxis** | **If require AB cover** | | - HTN | | **Other related medications e.g. Beta Blocker CCB, ACE Inh etc** | | || | **Social** | Poor attendance | **•** Referral for social assistance/ charitable dental service p.r.n. | | - Financial constraints | Treatment option limits | **•** Smoking cessation | | - Smoking | | | | **Others** | Fall risk | **•** Barrier free access, fall prevention | | - Rheumatoid arthritis | | **•** Dental Behavioural Support | | - Visual impairment | | | | - Anxiety (generalised) | | | ```json {"BOX_A": ""} ```  | Medical categories and others | Risk | Modifications / Implications | | :--- | :--- | :--- | | **Respiratory** – severe asthma, inhaler use | Asthmatic attack; poor healing | - Bring inhaler, prophylactic dose<br>- Avoid triggers (cold/dust)<br>- Late morning appointment<br>- Supplementary oxygen?<br>- Drug Rx: steroid use; theophylline may be potentiated by liver enzyme blockers | | **Cardiac** – valvular repair (patient unsure), PFO, HTN | MI; stroke, DVT; I.E. AB prophylaxis | Warfarin, INR check (therapeutic INR ~2.5), morning appointments, haemostatic measures, consent. If require AB cover. Other related medications e.g. beta blocker, CCB, ACE inhibitor etc. | | **Social** – financial constraints, smoking | Poor attendance; treatment option limits | - Referral for social assistance / charitable dental service p.r.n.<br>- Smoking cessation | | **Others** – rheumatoid arthritis, visual impairment, anxiety (generalised) | Fall risk | - Barrier-free access, fall prevention<br>- Dental Behavioural Support | > [!note] Lecturer — Additional Risk Categories > The risk table can also include medication-related risks and consent or capacity issues. > > - Medication-related risks include drug interactions, bleeding, xerostomia, gingival enlargement, and candidiasis; review drug type, dosage, frequency, interactions, and prescribing implications. > - Consent and capacity issues may make it difficult to obtain valid consent, requiring assessment of capacity and identification of the appropriate decision-maker or best-interest process. > - Childhood asthma may also reduce tolerance of supine positioning, while steroid therapy may impair healing. > - Mild, metformin-treated diabetes may involve hypoglycaemia, increased infection risk, and poor wound healing, especially with periodontal disease. > - Osteoporosis and bisphosphonate use raise concern about medication-related osteonecrosis of the jaw and delayed healing after extractions or other bone-manipulating procedures. > - Neurological and behavioural factors may include variable cooperation, challenging behaviour, seizures, head instability, longer and more difficult procedures, and communication or capacity limitations. A risk assessment table categorizing medical conditions (Respiratory, Cardiac, Social, Others) alongside their associated risks and specific dental treatment modifications or implications. Clinical Scenario A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. Medical History * Asthma. Poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. * Mild dental anxiety - mainly to sound of ultrasonic and handpieces. * Rheumatoid arthritis with left knee swollen * Reduced BMI * Smokes - 5 cigarettes a day now, cut down from - 20 sticks a day 20 years ago. * History of cataract surgery on right eye, with some residual visual impairment: Medications * Salbutamol 200mcg inhaler * Fluticasone 500mcg with Salmeterol 50mcg inhaler * Lignosum rhinocerus (traditional Chinese tonic.虎乳芝) Dental History * Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retaining * Brushes once a day only * Does not clean/brush denture Social History * Low socio-economic status * Works as a security officer with varying shifts in the morning and overnight * Divorced, lives alone Oral examination * Upper left wisdom tooth with caries into pulp * Poor oral hygiene * Rampant caries with other retained roots (see **Figure 1.27.1 - Picture of caries / retained roots in a patient with severe asthma**) * Oral candidiasis on upper palate * Upper denture with dried debris on fitting and smooth surfaces. What are your treatment considerations briefly? Can you treat the pain today?   #### Clinical Scenario A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. #### Medical History - Asthma. Poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces. - Rheumatoid arthritis with left knee swollen - Reduced BMI - Smokes - 5 cigarettes a day now, cut down from 20 sticks a day 20 years ago. - History of cataract surgery on right eye, with some residual visual impairment. #### Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosum rhinocerus (traditional Chinese tonic, 虎乳芝) #### Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retaining - Brushes once a day only - Does not clean/brush denture #### Social History - Low socio-economic status - Works as a security officer with varying shifts in the morning and overnight - Divorced, lives alone #### Oral Examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see *Figure 1.27.1 - Picture of caries / retained roots in a patient with severe asthma*) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces. #### Treatment Considerations What are your treatment considerations briefly? Can you treat the pain today? A panoramic dental radiograph showing the maxilla and mandible with multiple retained tooth roots and evidence of severe dental pathology. The image illustrates the clinical findings of rampant caries and retained roots in a patient with poor oral hygiene and severe asthma. Clinical intraoral photograph showing the maxillary arch with poor oral hygiene, including visible plaque and calculus accumulation on the remaining teeth. | Medical categories and others | Risk | Modifications / Implications | | --- | --- | --- | | Respiratory | Asthmatic attack | Bring inhaler, prophylactic dose | | | Poor healing | Avoid triggers (cold/dust) | | - Severe asthma | | Late morning appointment | | - inhaler use | | Supplementary oxygen? | | | | Drug Px:? steroid use, theophylline may be potentiated by liver enzyme blockers | | Cardiac | MI | confirm cardiac history | | | Stroke, DVT | Warfarin, INR check(therapeutic INR ~2.5), morning appointments, haemostat measures, consent | | - Valvular repair (patient unsure) | I.E. AB Prophylaxis | If require AB cover | | - PFO | | Other related medications e.g. Beta Blocker CCB, ACE Inh etc | | - HTN | | Other related medications e.g. Beta Blocker CCB, ACE Inh etc | | Social | Poor attendance | Referral for social assistance/ charitable dental service p.r.n. | | - Financial constraints | Treatment option limits | Smoking cessation | | - Smoking | | Smoking cessation | | Others | Fall risk | Barrier free access, fall prevention | | - Rheumatoid arthritis | | Dental Behavioural Support | | - Visual impairment | | | | - Anxiety (generalised) | | |  #### Medical Categories, Risks and Modifications | Medical categories and others | Risk | Modifications / Implications | | --- | --- | --- | | Respiratory — Severe asthma, inhaler use | Asthmatic attack | Bring inhaler, prophylactic dose; avoid triggers (cold/dust); late morning appointment; supplementary oxygen? Drug Rx: steroid use, theophylline may be potentiated by liver enzyme blockers | | | Poor healing | | | Cardiac — Valvular repair (patient unsure), PFO, HTN | MI | Confirm cardiac history | | | Stroke, DVT | Warfarin, INR check (therapeutic INR ~2.5), morning appointments, haemostat measures, consent | | | I.E. AB prophylaxis | If require AB cover; other related medications e.g. Beta Blocker, CCB, ACE Inh etc | | Social — Financial constraints, smoking | Poor attendance | Referral for social assistance / charitable dental service p.r.n. | | | Treatment option limits | Smoking cessation | | Others — Rheumatoid arthritis, visual impairment, anxiety (generalised) | Fall risk | Barrier free access, fall prevention; Dental Behavioural Support | A three-column table titled 'Risk Assessment Table' categorizes patients by medical status (Respiratory, Cardiac, Social, Others), lists associated risks (e.g., Asthmatic attack, MI, Fall risk), and details necessary modifications or implications for treatment. ## Clinical Scenario A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. ## Medical History * Asthma. Poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. * Mild dental anxiety - mainly to sound of ultrasonic and handpieces. * Rheumatoid arthritis with left knee swollen. * Reduced BMI * Smokes - 5 cigarettes a day now, cut down from - 20 sticks a day 20 years ago. * History of cataract surgery on right eye, with some residual visual impairment. ## Medications * Salbutamol 200mcg inhaler * Fluticasone 500mcg with Salmeterol 50mcg inhaler * Lignosus rhinocerus (traditional Chinese tonic. 虎乳芝) ## Dental History * Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained * Brushes once a day only * Does not clean/brush denture ## Social History * Low socio-economic status * Works as a security officer with varying shifts in the morning and overnight * Divorced, lives alone ## Oral examination + Upper left wisdom tooth with caries into pulp + Poor oral hygiene + Rampant caries with other retained roots (see **Figure 1.27.1- Picture of caries / retained roots in a patient with severe asthma**) * Oral candidiasis on upper palate * Upper denture with dried debris on fitting and smooth surfaces. ## What are your treatment considerations briefly? Can you treat the pain today? * The tooth extraction should be completed today. Despear assessed to be moderate to high risk, attenuating the specific risks and possessing emergency preparedness are key. * He will require further fillings, extractions and partial dentures in the future. Dental health education is also important.    #### Clinical Scenario A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. #### Medical History - Asthma. Poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces. - Rheumatoid arthritis with left knee swollen. - Reduced BMI - Smokes - 5 cigarettes a day now, cut down from 20 sticks a day 20 years ago. - History of cataract surgery on right eye, with some residual visual impairment. #### Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosus rhinocerus (traditional Chinese tonic, 虎乳芝) #### Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained - Brushes once a day only - Does not clean/brush denture #### Social History - Low socio-economic status - Works as a security officer with varying shifts in the morning and overnight - Divorced, lives alone #### Oral Examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see *Figure 1.27.1 - Picture of caries / retained roots in a patient with severe asthma*) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces. #### Treatment Considerations What are your treatment considerations briefly? Can you treat the pain today? - The tooth extraction should be completed today. Despear assessed to be moderate to high risk, attenuating the specific risks and possessing emergency preparedness are key. - He will require further fillings, extractions and partial dentures in the future. Dental health education is also important. A cropped section of a dental radiograph (likely a panoramic X-ray) showing the upper right posterior jaw region. The image reveals retained tooth roots and significant pathology consistent with severe caries, illustrating the clinical findings described in the text. Clinical photo: An intraoral view of the upper right quadrant showing a retained root with extensive caries and decay, consistent with the oral examination findings. A photograph of the front cover of a medical textbook titled 'A Practical Approach to Special Care in Dentistry'. The cover features a purple background with white text and small inset images at the top. ```html <table border="1" cellspacing="0"> <tr> <th rowspan="2" colspan="2"></th> </tr> <tr> <td width="100%"><b><u>Medical History</u></b></td> <td width="100%"><b><u>Dental History</u></b></td> </tr> <tr> <td width="50%"> <ul> <li>– Raised BMI of 46.9 kg/m2 (174cm, 142kg)</li> <li>– Major Depressive Disorder</li> <li>– Dental anxiety</li> <li>– Asthma, well controlled and on follow-up</li> <li>– Hypertension</li> <li>– Diabetes mellitus</li> <li>– Hypercholesterolaemia</li> <li>– Ischaemic heart disease – controlled angina</li> <li>– Sleep apnoea: Continuous Positive Airway Pressure (CPAP) device used at night</li> <li>– GORD</li> <li>– Osteoarthritis</li> <li>– Generalised musculoskeletal pain</li> </ul> </td> <td width="50%"> <ul> <li>• Irregular attender; previous visit over 5 years ago</li> <li>• Snacks on cakes and biscuits between meals with 10 sweetened beverages daily</li> <li>• Brushes twice a day with fluoridated toothpaste but unable to reach upper posterior teeth</li> <li>• Dental anxiety associated with injections and drilling sensation / sounds; avoids fillings and prefers dental extractions</li> <li>• No history of dental sedation or GA for dental treatment</li> </ul> </td> </tr> <tr> <td width="50%"><b><u>Social History</u></b></td> <td width="50%"><b><u>Oral examination</u></b></td> </tr> <tr> <td width="100%"> <ul> <li>• Divorced and lives alone</li> <li>• Has two sons who are married and live separately</li> <li>• Rarely leaves her home</li> <li>• No consumption of tobacco, alcohol or recreational drugs</li> <li>• Requires hospital transport to attend appointments</li> <li>• Mobility: although able to stand for short periods, using a bariatric wheelchair to attend hospital appointments</li> </ul> </td> <td width="100%"> <ul> <li>• Poor visualisation of the mouth due to extensive adipose tissue intra-orally limiting visual access to the posterior teeth</li> <li>• Generalised soft deposits and food debris</li> <li>• Generalised gingival inflammation</li> <li>• Partially edentate</li> <li>• Food packing between the UL6 and UL7</li> <li>• Caries: UL6 distal; tender on palpation, grade 1 mobile</li> <li>• Generalised tooth surface loss (erosion)</li> </ul> </td> </tr> <tr> <td><u></u><br> <b><u>Medications</u></b> </td> <td><b>1.</b> Create a Medical Category – Risk Assessment – Modifications table.<u></u></td> </tr> <tr> <td width="100%"> <ul> <li>• Aspirin</li> <li>• Glyceryl Trinitrate (GTN) inhaler</li> <li>• Amlodipine</li> <li>• Atorcolol</li> <li>• Atorvastatin</li> <li>• Lansoprazole</li> <li>• Metformin</li> <li>• Corticosteroid inhaler</li> <li>• Salbutamol inhaler</li> </ul> </td> <td> <p><b>2.</b> What additional factors do you have to consider when undertaking a risk assessment of this patient</p><p><b>3.</b> The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment?</p><p><b>4.</b> Criteria for referring the Bariatric patients. How is ASA grading for them like?</p> </td> </tr> </table> ``` #### Medical History - Raised BMI of 46.9 kg/m² (174cm, 142kg) - Major Depressive Disorder - Dental anxiety - Asthma, well controlled and on follow-up - Hypertension - Diabetes mellitus - Hypercholesterolaemia - Ischaemic heart disease – controlled angina - Sleep apnoea: Continuous Positive Airway Pressure (CPAP) device used at night - GORD - Osteoarthritis - Generalised musculoskeletal pain #### Dental History - Irregular attender; previous visit over 5 years ago - Snacks on cakes and biscuits between meals with 10 sweetened beverages daily - Brushes twice a day with fluoridated toothpaste but unable to reach upper posterior teeth - Dental anxiety associated with injections and drilling sensation / sounds; avoids fillings and prefers dental extractions - No history of dental sedation or GA for dental treatment #### Social History - Divorced and lives alone - Has two sons who are married and live separately - Rarely leaves her home - No consumption of tobacco, alcohol or recreational drugs - Requires hospital transport to attend appointments - Mobility: although able to stand for short periods, using a bariatric wheelchair to attend hospital appointments #### Oral Examination - Poor visualisation of the mouth due to extensive adipose tissue intra-orally limiting visual access to the posterior teeth - Generalised soft deposits and food debris - Generalised gingival inflammation - Partially edentate - Food packing between the UL6 and UL7 - Caries: UL6 distal; tender on palpation, grade 1 mobile - Generalised tooth surface loss (erosion) #### Medications - Aspirin - Glyceryl Trinitrate (GTN) inhaler - Amlodipine - Atorcolol - Atorvastatin - Lansoprazole - Metformin - Corticosteroid inhaler - Salbutamol inhaler #### Questions 1. Create a Medical Category – Risk Assessment – Modifications table. 2. What additional factors do you have to consider when undertaking a risk assessment of this patient? 3. The patient consents to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the bariatric patients. How is ASA grading for them like? # Clinical Scenario An 80 year old lady was admitted via a trolley bed from the wards. She was assessed by a physician and has a mobile lower incisor indicated for removal in view of aspiration risk. ### Medical History - Severe Multi-infarct (vascular) dementia - fluctuating consciousness between stupor and hypersomnia. Bedridden. Double incontinence. - Aspiration pneumonia, hospitalised over 2 incidents over the past 2 months. - Thromboembolic stroke. Right Middle Cerebral Artery stroke 3 years ago. - Ischaemic heart disease - Severe dysphagia- nasogastric tube fed. nil-by-mouth - History of laryngeal carcinoma in 1984 treated with Conventional radiotherapy (70 Gys 33 Fractions) - Methicillin-resistant Staphylococcus aureus (MRSA) positive - Hypertension ### Medications - Omeprazole - Plavix (clopidogral) - Timolol - Neurobion - Vitamin D and calcium supplements | | | | :--- | :--- | | 1. Create a Medical Category - Risk Assessment - Modifications table. | | | 2. What medical disorders/conditions are associated with end-of-life care? | | | 3. The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? | | | 4. Criteria for referring the Geriatric patients. How is ASA grading for them like? | | ### Dental History - Has not received oral hygiene assistance at the long-term care facility over the past year - Nasogastric tube fed for 2 years (nil-by-mouth) - Constantly grinds and mouth breathes almost entirely ### Social History - Chinese ethnicity - Stays in a hospice and is bedridden - Arrived by arranged transport from hospice - Husband is the main caregiver and next-of-kin ### Oral Examination - Challenging behaviour during examination - Trismus affecting ability to visualise palatal and lingual surfaces - Mobile lower right central incisor - Uncontrolled bruxism and clenching - Dry secretions on tooth surfaces and palate (**Figure 16.6.1** and **Figure 16.6.2**) 1. What other issues and concerns is end of life care often associated with?  An 80 year old lady was admitted via a trolley bed from the wards. She was assessed by a physician and has a mobile lower incisor indicated for removal in view of aspiration risk. #### Medical History - Severe Multi-infarct (vascular) dementia - fluctuating consciousness between stupor and hypersomnia. Bedridden. Double incontinence. - Aspiration pneumonia, hospitalised over 2 incidents over the past 2 months. - Thromboembolic stroke. Right Middle Cerebral Artery stroke 3 years ago. - Ischaemic heart disease - Severe dysphagia - nasogastric tube fed, nil-by-mouth - History of laryngeal carcinoma in 1984 treated with conventional radiotherapy (70 Gys, 33 Fractions) - Methicillin-resistant Staphylococcus aureus (MRSA) positive - Hypertension #### Medications - Omeprazole - Plavix (clopidogral) - Timolol - Neurobion - Vitamin D and calcium supplements #### Dental History - Has not received oral hygiene assistance at the long-term care facility over the past year - Nasogastric tube fed for 2 years (nil-by-mouth) - Constantly grinds and mouth breathes almost entirely #### Social History - Chinese ethnicity - Stays in a hospice and is bedridden - Arrived by arranged transport from hospice - Husband is the main caregiver and next-of-kin #### Oral Examination - Challenging behaviour during examination - Trismus affecting ability to visualise palatal and lingual surfaces - Mobile lower right central incisor - Uncontrolled bruxism and clenching - Dry secretions on tooth surfaces and palate (**Figure 16.6.1** and **Figure 16.6.2**) #### Discussion Questions 1. Create a Medical Category - Risk Assessment - Modifications table. 2. What medical disorders/conditions are associated with end-of-life care? 3. The patient consents to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the geriatric patients. How is ASA grading for them like? 5. What other issues and concerns is end of life care often associated with? > [!note] Lecturer — Palliative Dental Care > In palliative care, treatment should prioritise comfort, pain management, elimination of acute infection, reduction of trauma, and prevention while minimising treatment burden. > > - An asymptomatic tooth with no immediate risk generally favours prevention and avoidance of unnecessary treatment. > - A very mobile tooth may require removal because aspiration can cause pneumonia through infection and a foreign-body reaction. > - For extraction, assess capacity, identify the appropriate substitute decision-maker where necessary, liaise with the oncology team, confirm the radiation dose and treatment field, use an atraumatic technique, smooth sharp bony edges, aim for primary closure, and arrange bedside follow-up. The image displays the front cover of a medical textbook titled "A Practical Approach to Special Care in Dentistry". The cover features a purple background with a strip of clinical photographs at the top and an illustration of teeth at the bottom right. CHAPTER 26. Chronic obstructive pulmonary disease SECTION I Clinical Scenario A 67 year old man turned up at the charity clinic that you volunteer at. He complains of “weakening” and “crumbling” teeth. Medical History: * Chronic Obstructive Pulmonary Disease - irregular in medical follow-up * FEV1, or forced expiratory volume in 1 sec, was 38% of normal predicted. Recent chest x-rays showed flattened diaphragm. * SpO2 is 93% on room air, heart rate 84/min * Respiratory rate is 24 per minute and shallow * Dry hacking non-productive cough, pitting oedema * Hypertension – 152/85 * Hyperlipidaemia * Asthma * Others: Ex-smoker with 70 pack-year cigarette history, reduced BMI Medication * Prednisolone 10mg * Ipratropium bromide + albuterol sulfate combination inhaler * Salbutamol inhaler * Simvastatin * Enalapril Dental History * Brushes once a day with manual toothbrush * Irregular dental attenuer * Does not use interdental brushing aid Social History * Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke (see Figure 1.26.1) * Hokkien-speaking (a type of Mandarin dialect) * Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice * Receiving social assistance * Stays with wife, has two married children who visit infrequently Oral Examination * Prolonged oral health neglect * Multiple interproximal caries * Erosion lesions and root caries R 1. Create a Medical Category · Risk Assessment · Modifications table. 2. How do you assess the severity of the patient's COPD? 3. What are the treatment options for managing multiple caries & high caries risk? 4. What other factors do you need to consider that can affect treatment success?   A 67 year old man turned up at the charity clinic that you volunteer at. He complains of "weakening" and "crumbling" teeth. #### Medical History - Chronic Obstructive Pulmonary Disease - irregular in medical follow-up - FEV1, or forced expiratory volume in 1 sec, was 38% of normal predicted. Recent chest x-rays showed flattened diaphragm. - SpO2 is 93% on room air, heart rate 84/min - Respiratory rate is 24 per minute and shallow - Dry hacking non-productive cough, pitting oedema - Hypertension – 152/85 - Hyperlipidaemia - Asthma - Others: ex-smoker with 70 pack-year cigarette history, reduced BMI #### Medications - Prednisolone 10mg - Ipratropium bromide + albuterol sulfate combination inhaler - Salbutamol inhaler - Simvastatin - Enalapril #### Dental History - Brushes once a day with manual toothbrush - Irregular dental attender - Does not use interdental brushing aid #### Social History - Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke (see Figure 1.26.1) - Hokkien-speaking (a type of Mandarin dialect) - Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice - Receiving social assistance - Stays with wife, has two married children who visit infrequently #### Oral Examination - Prolonged oral health neglect - Multiple interproximal caries - Erosion lesions and root caries #### Discussion Questions 1. Create a Medical Category · Risk Assessment · Modifications table. 2. How do you assess the severity of the patient's COPD? 3. What are the treatment options for managing multiple caries & high caries risk? 4. What other factors do you need to consider that can affect treatment success? > [!note] Lecturer — COPD Severity > The patient was considered ASA 3 because his COPD was severe and an acute exacerbation could potentially result in hospitalisation. > > - Use an upright position, short morning appointments, cautious use of or avoidance of rubber dam if it compromises breathing, and emergency equipment. > - Long-term prednisolone raises concerns about oral candidiasis, staining, additional steroid exposure, and possible adrenal-related effects; check therapeutic guidance and consult the physician if the combined steroid exposure is unclear. A photograph shows a person, likely a food vendor, holding a large woven fan or basket near a cooking station. This image illustrates the social history context of long-term inhalation of smoke from working at a hawker centre. This is a panoramic dental radiograph (orthopantomogram) showing the patient's maxilla and mandible. The image reveals multiple missing teeth, particularly in the posterior regions of both jaws, along with visible root structures and potential pathology consistent with severe periodontal disease or caries. **CHAPTER 59. HOMELESSNESS** **CLINICAL SCENARIO** You received a referral letter from the local prison service regarding a 64 year old man emancipaged on a "Mandatory Aftercare Scheme" for ex-offenders. He has multiple medical conditions, unemployed, and is currently homeless. He is referred to exclude dental causes of recurrent sinusitis. Medical History * Hepatitis C on half yearly follow-up * Latent tuberculosis * Chronic obstructive pulmonary disease * Mild asthma * Chronic sinusitis and allergic rhinitis * Gastric reflux - undergoing medical follow-up * Others: renal cyst, benign prostate hypertrophy * H/O: four surgical repair of oral antral fistula, * previous injecting drug user, ex-smoker, heavy alcohol use Medications * Omeprazole * Salbutamol inhaler (200mcg) * Fluticasone inhaler twice daily * Array of traditional Chinese tonics and herbs Dental history * Brushes once a day with hard toothbrush * No comprehensive dental treatment for over a decade * Irregular dental attender, visits only when symptoms arise * Prison dental service provided extractions only * Mouth breather, daily regurgitation of gastric contents Social History * Ex: offender, released from prison 1 month ago * Staying at the void deck of an estate, and moving to a "Halfway Home" after being picked up by community services * Unemployed due to medical conditions * Separated from wife for 20 years, have not contacted daughter over 10 years * Distant relationship with siblings Oral Examination * Edentulous upper jaw with frictional keratosis and traumatised ridge from lower teeth * Lower teeth with very poor periodontal health * No obvious sinus tract was seen Radiographs **1. Create a Medical Category - Risk Assessment - Modifications table.** **2. What cross-infectivity steps would you take**? **3. What other (non-medical) factors do you need to consider that can affect treatment success?**  You received a referral letter from the local prison service regarding a 64 year old man emancipated on a "Mandatory Aftercare Scheme" for ex-offenders. He has multiple medical conditions, is unemployed, and is currently homeless. He is referred to exclude dental causes of recurrent sinusitis. #### Medical History - Hepatitis C on half yearly follow-up - Latent tuberculosis - Chronic obstructive pulmonary disease - Mild asthma - Chronic sinusitis and allergic rhinitis - Gastric reflux - undergoing medical follow-up - Others: renal cyst, benign prostate hypertrophy - H/O: four surgical repairs of oral antral fistula - Previous injecting drug user, ex-smoker, heavy alcohol use #### Medications - Omeprazole - Salbutamol inhaler (200mcg) - Fluticasone inhaler twice daily - Array of traditional Chinese tonics and herbs #### Dental History - Brushes once a day with hard toothbrush - No comprehensive dental treatment for over a decade - Irregular dental attender, visits only when symptoms arise - Prison dental service provided extractions only - Mouth breather, daily regurgitation of gastric contents #### Social History - Ex-offender, released from prison 1 month ago - Staying at the void deck of an estate, and moving to a "Halfway Home" after being picked up by community services - Unemployed due to medical conditions - Separated from wife for 20 years; have not contacted daughter over 10 years - Distant relationship with siblings #### Oral Examination - Edentulous upper jaw with frictional keratosis and traumatised ridge from lower teeth - Lower teeth with very poor periodontal health - No obvious sinus tract was seen #### Discussion Questions 1. Create a Medical Category - Risk Assessment - Modifications table. 2. What cross-infectivity steps would you take? 3. What other (non-medical) factors do you need to consider that can affect treatment success? > [!note] Lecturer — Hepatitis and Tuberculosis > Hepatitis C raises concerns about blood-borne infection, reduced hepatic drug metabolism, and coagulation problems. > > - Latent tuberculosis is not considered infectious, but the reported status should be confirmed with the general practitioner; active tuberculosis would require higher infection-control precautions. > - Confirm renal function, including estimated glomerular filtration rate, because of the renal cyst. > - If liver impairment is possible, avoid non-steroidal anti-inflammatory and hepatotoxic drugs, consider paracetamol first, avoid metronidazole, complete appropriate blood work, and liaise with the general practitioner. A panoramic dental radiograph (orthopantomogram) showing the maxilla and mandible. The image displays an edentulous upper jaw and a lower jaw with several remaining teeth, including multiple teeth with root canal fillings and post-retentions, alongside significant alveolar bone loss. **CHAPTER 16.4: BARIATRIC PATIENTS** **Clinical Scenario** A 55 year old female presents to you complaining of pain in an upper left first molar tooth. **Medical History** * Raised BMI of 46.9 kg/m2 (174cm, 142kg) * Major Depressive Disorder * Dental anxiety * Asthma, well controlled and on follow-up * Hypertension * Diabetes mellitus * Hypercholesterolaemia * Ischaemic heart disease - controlled angina * Sleep apnoea: Continuous Positive Airway Pressure (CPAP) device used at night * GORD * Osteoarthritis * Generalised musculoskeletal pain **Medications** * Aspirin * Glyceryl Trinitrate (GTN) inhaler * Amlodipine * Atenolol * Atorvastatin * Lansoprazole * Metformin * Corticosteroid inhaler * Salbutamol inhaler **Dental History** * Irregular attender, previous visit over 5 years ago * Snacks on cakes and biscuits between meals with 10 sweetened beverages daily * Brushes twice a day with fluoridated toothpaste but unable to reach upper posterior teeth * Dental anxiety associated with injections and drilling sensation / sounds; avoids fillings and prefers dental extractions * No history of dental sedation or GA for dental treatment **Social History** * Divorced and lives alone * Has two sons who are married and live separately * Rarely leaves her home * No consumption of tobacco, alcohol or recreational drugs * Requires hospital transport to attend appointments * Mobility: although able to stand for short periods, using a bariatric wheelchair to attend hospital appointments **Oral examination** * Poor visualisation of the mouth due to extensive adipose tissue intra-orally limiting visual access to the posterior teeth * Generalised soft deposits and food debris * Generalised gingival inflammation * Partially edentate * Food packing between the UL6 and UL7 * Caries: UL6 distal; tender on palpation; grade 1 mobile * Generalised tooth surface loss (erosion) 1. Create a Medical Category – Risk Assessment – Modifications table. 2. What additional factors do you have to consider when undertaking a risk assessment of this patient 3. The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the Bariatric patients. How is ASA grading for them like? A 55 year old female presents to you complaining of pain in an upper left first molar tooth. #### Medical History - Raised BMI of 46.9 kg/m² (174 cm, 142 kg) - Major Depressive Disorder - Dental anxiety - Asthma, well controlled and on follow-up - Hypertension - Diabetes mellitus - Hypercholesterolaemia - Ischaemic heart disease - controlled angina - Sleep apnoea: Continuous Positive Airway Pressure (CPAP) device used at night - GORD - Osteoarthritis - Generalised musculoskeletal pain #### Medications - Aspirin - Glyceryl Trinitrate (GTN) inhaler - Amlodipine - Atenolol - Atorvastatin - Lansoprazole - Metformin - Corticosteroid inhaler - Salbutamol inhaler #### Dental History - Irregular attender, previous visit over 5 years ago - Snacks on cakes and biscuits between meals with 10 sweetened beverages daily - Brushes twice a day with fluoridated toothpaste but unable to reach upper posterior teeth - Dental anxiety associated with injections and drilling sensation/sounds; avoids fillings and prefers dental extractions - No history of dental sedation or GA for dental treatment #### Social History - Divorced and lives alone - Has two sons who are married and live separately - Rarely leaves her home - No consumption of tobacco, alcohol or recreational drugs - Requires hospital transport to attend appointments - Mobility: although able to stand for short periods, using a bariatric wheelchair to attend hospital appointments #### Oral Examination - Poor visualisation of the mouth due to extensive adipose tissue intra-orally limiting visual access to the posterior teeth - Generalised soft deposits and food debris - Generalised gingival inflammation - Partially edentate - Food packing between the UL6 and UL7 - Caries: UL6 distal; tender on palpation; grade 1 mobile - Generalised tooth surface loss (erosion) #### Discussion Questions 1. Create a Medical Category – Risk Assessment – Modifications table. 2. What additional factors do you have to consider when undertaking a risk assessment of this patient? 3. The patient consents to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the bariatric patients. How is ASA grading for them like? > [!note] Lecturer — Bariatric Treatment > Before treatment, confirm the dental chair’s weight limit, use bariatric equipment where necessary, and assess whether the patient can tolerate the proposed chair position. > > - Avoid prolonged or fully supine positioning because tissue around the neck and chest may worsen airway obstruction. > - Consider the risks of sedation and opioids in obstructive sleep apnoea, keep appointments short, and arrange transport and postoperative review. > - Have glycaemic treatment available in case of hypoglycaemia and use local haemostatic measures for aspirin-associated bleeding. > - The patient was considered ASA 3, primarily because of the high BMI and associated medical conditions. ### Clinical Scenario A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. #### Medical History - Asthma: Poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces. - Rheumatoid arthritis with left knee swollen - Reduced BMI - Smokes - 5 cigarettes a day now, cut down from ~ 20 sticks a day 20 years ago. - History of cataract surgery on right eye, with some residual visual impairment #### Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosus rhinocerus (traditional Chinese tonic, 虎乳芝) #### Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retaine - Brushes once a day only - Does not clean/brush denture #### Social History - Low socio-economic status - Works as a security officer with varying shifts in the morning and overnight - Divorced, lives alone #### Oral examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see Figure 1.27.1- Picture of caries / retained roots in a patient with severe asthma ) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces. ## What are your treatment considerations briefly? Can you treat the pain today?   A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. #### Medical History - Asthma: poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces - Rheumatoid arthritis with left knee swollen - Reduced BMI - Smokes - 5 cigarettes a day now, cut down from ~20 sticks a day 20 years ago - History of cataract surgery on right eye, with some residual visual impairment #### Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosus rhinocerus (traditional Chinese tonic, 虎乳芝) #### Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained roots - Brushes once a day only - Does not clean/brush denture #### Social History - Low socio-economic status - Works as a security officer with varying shifts in the morning and overnight - Divorced, lives alone #### Oral Examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see Figure 1.27.1 - Picture of caries / retained roots in a patient with severe asthma) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces #### Discussion Question What are your treatment considerations briefly? Can you treat the pain today? > [!note] Lecturer — Asthma Treatment > Invasive treatment should be undertaken only when the asthma is stable on the day, with emergency equipment available and treatment time minimised. > > - Confirm the date of the last exacerbation and current asthma control. > - Consider a semi-sitting position if breathing is difficult and monitor breathing throughout treatment. > - Advise rinsing the mouth after steroid inhaler use and avoiding smoking for at least 24 to 46 hours after extraction. > - Provide verbal and accessible written instructions because visual impairment may limit the usefulness of standard written advice. Radiograph: A panoramic dental X-ray showing the maxilla and mandible, illustrating multiple retained roots with associated radiolucencies consistent with periapical pathology (e.g., caries into pulp). The image supports the clinical finding of 'rampant caries with other retained roots' mentioned in the text. Clinical photo: An intraoral view of the maxillary arch showing poor oral hygiene with visible plaque accumulation, caries, and retained roots. # Risk Assessment Table ## Medical categories and others | Risk | Modifications / Implications ### Respiratory - Severe asthma - inhaler use | Asthmatic attack Poor healing | - Bring inhaler, prophylactic dose - Avoid triggers (cold/dust) - Late morning appointment - Supplementary oxygen? - Drug Px: ? steroid use, theophylline may be potentiated by liver enzyme blockers --- ### Cardiac - Valvular repair (patient unsure) - PFO - HTN | MI Stroke, DVT I.E. AB Prophylaxis | confirm cardiac history Warfarin, INR check(therapeutic INR ~2.5), morning appointments, haemostasis measures, consent If require AB cover Other related medications e.g. Beta Blocker CCB, ACE Inh etc --- ### Social - Financial constraints - Smoking | Poor attendance Treatment option limits | - Referral for social assistance/ charitable dental service p.r.n. - Smoking cessation --- ### Others - Rheumatoid arthritis - Visual impairment - Anxiety (generalised) | Fall risk | - Barrier free access, fall prevention - Dental Behavioural Support  #### Respiratory - Severe asthma, inhaler use **Risk:** asthmatic attack, poor healing **Modifications / Implications:** - Bring inhaler, prophylactic dose - Avoid triggers (cold/dust) - Late morning appointment - Supplementary oxygen? - Drug Px: ? steroid use, theophylline may be potentiated by liver enzyme blockers #### Cardiac - Valvular repair (patient unsure) - PFO - HTN **Risk:** MI, stroke, DVT, I.E. — AB prophylaxis **Modifications / Implications:** - Confirm cardiac history - Warfarin, INR check (therapeutic INR ~2.5), morning appointments, haemostasis measures, consent - If require AB cover - Other related medications e.g. beta blocker, CCB, ACE inhibitors etc #### Social - Financial constraints - Smoking **Risk:** poor attendance, treatment option limits **Modifications / Implications:** - Referral for social assistance / charitable dental service p.r.n. - Smoking cessation #### Others - Rheumatoid arthritis - Visual impairment - Anxiety (generalised) **Risk:** fall risk **Modifications / Implications:** - Barrier-free access, fall prevention - Dental Behavioural Support A three-column risk assessment table detailing medical categories (Respiratory, Cardiac, Social, Others), associated risks, and modifications or implications for treatment. Clinical Scenario A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. Medical History - Asthma. Poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces - Rheumatoid arthritis with left knee swollen - Reduced BMI - Smokes – 5 cigarettes a day now, cut down from – 20 sticks a day 20 years ago - History of cataract surgery on right eye, with some residual visual impairment Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosum rhinocerus (traditional Chinese tonic. 虎乳兰) Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained... - Brushes once a day only - Does not clean/brush denture Social History - Low socio-economic status - Works as a security officer with varying shifts in the morning and overnight - Divorced, lives alone Oral examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see **Figure 1.27.1 - Picture of caries / retained roots in a patient with severe asthma**) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces. **What are your treatment considerations briefly? Can you treat the pain today?** - The tooth extraction should be completed today. Despite assessed to be moderate to high risk, attenuating the specific risks and possessing emergency preparedness are key. - He will require further filings, extractions and partial dentures in the future. Dental health education is also important.    A 63 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. #### Medical History - Asthma: poorly controlled with exacerbations almost every 2 weeks, and admission to hospital 1-3 times annually. Not all attacks are subdued with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces - Rheumatoid arthritis with left knee swollen - Reduced BMI - Smokes - 5 cigarettes a day now, cut down from ~20 sticks a day 20 years ago - History of cataract surgery on right eye, with some residual visual impairment #### Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosus rhinocerus (traditional Chinese tonic, 虎乳芝) #### Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained roots - Brushes once a day only - Does not clean/brush denture #### Social History - Low socio-economic status - Works as a security officer with varying shifts in the morning and overnight - Divorced, lives alone #### Oral Examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see Figure 1.27.1 - Picture of caries / retained roots in a patient with severe asthma) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces #### Treatment Considerations What are your treatment considerations briefly? Can you treat the pain today? - The tooth extraction should be completed today. Despite being assessed to be moderate to high risk, attenuating the specific risks and possessing emergency preparedness are key. - He will require further fillings, extractions and partial dentures in the future. Dental health education is also important. A panoramic dental radiograph (orthopantomogram) showing the upper and lower jaws, teeth, and surrounding bone structures. The image displays various dental restorations, including bright white metallic crowns or fillings, and reveals retained roots in the posterior regions of the mouth. Clinical photo showing an intraoral view of the upper right quadrant, revealing severe dental decay and retained roots. A small, low-resolution graphic resembling a book cover with a purple background and white text reading 'A Practical Approach to Special Care Dentistry', accompanied by a small icon in the bottom right corner. **Clinical Scenario** A 60 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. **Medical History:** * Asthma: Poorly controlled with exacerbations almost every 4 weeks, and admission to hospital 1-2 times annually. Not all attacks are relieved with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. * Mild dental anxiety - mainly to sound of ultrasonic and handpieces. * Rheumatoid arthritis with left knee swollen * Reduced BMI * Smoker - 5 cigarettes a day now, cut down from - 20 sticks a day 20 years ago * History of cataract surgery on right eye, with some residual visual impairment **Medications:** * Salbutamol 200mcg inhaler * Fluticasone 500mcg with Salmeterol 50mcg inhaler * Lignosus rhinocerus (traditional Chinese herb: 虎乳芝) **Dental History:** * Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained roots * Brushes once a day only * Does not clean/brush denture **Social History:** * Low socio-economic status * Works as a security officer with varying shifts in the evening and overnight * Divorced, lives alone **Oral examination:** * Upper left wisdom tooth with caries into pulp * Poor oral hygiene * Rampant caries with other retained roots (see Figure 1.25.1: Picture of caries / retained roots in a patient with severe asthma) * Oral candidiasis on upper palate * Upper denture with dried debris of fitting and smooth surfaces **What are your treatment considerations briefly? Can you treat the pain today?** * The tooth extraction should be completed today. Denure assessed to be moderate to high risk, attenuating the specific risks and possessing emergency preparedness are key. * He will require further fillings, extractions and partial dentures in the future. Dental health education is also important.   A 60 year old man came into the clinic with a painful upper right wisdom tooth. It affects his eating and sleeping. He has not seen the dentist for around 10 years due to dental anxiety. #### Medical History - Asthma: poorly controlled with exacerbations almost every 4 weeks, and admission to hospital 1-2 times annually. Not all attacks are relieved with salbutamol inhaler. No known triggers, although cold air and dust are reported to possibly worsen it. Does not regularly follow up with physician. - Mild dental anxiety - mainly to sound of ultrasonic and handpieces - Rheumatoid arthritis with left knee swollen - Reduced BMI - Smoker - 5 cigarettes a day now, cut down from ~20 sticks a day 20 years ago - History of cataract surgery on right eye, with some residual visual impairment #### Medications - Salbutamol 200mcg inhaler - Fluticasone 500mcg with Salmeterol 50mcg inhaler - Lignosus rhinocerus (traditional Chinese herb, 虎乳芝) #### Dental History - Uses an acrylic partial upper denture fabricated over 10 years ago that overlays retained roots - Brushes once a day only - Does not clean/brush denture #### Social History - Low socio-economic status - Works as a security officer with varying shifts in the evening and overnight - Divorced, lives alone #### Oral Examination - Upper left wisdom tooth with caries into pulp - Poor oral hygiene - Rampant caries with other retained roots (see Figure 1.25.1: Picture of caries / retained roots in a patient with severe asthma) - Oral candidiasis on upper palate - Upper denture with dried debris on fitting and smooth surfaces #### Treatment Considerations What are your treatment considerations briefly? Can you treat the pain today? - The tooth extraction should be completed today. Despite being assessed to be moderate to high risk, attenuating the specific risks and possessing emergency preparedness are key. - He will require further fillings, extractions and partial dentures in the future. Dental health education is also important. Clinical photo: A close-up intraoral view showing the upper anterior teeth and palate, with visible plaque accumulation and inflammation consistent with poor oral hygiene. Clinical intraoral photograph showing the upper arch with multiple retained roots and carious teeth, consistent with poor oral hygiene. ### Nutcracker syndrome Nutcracker syndrome is a rare condition in which the left renal vein is trapped between two arteries, which impairs blood flow. Women are particularly frequently affected, but children and adolescents can also fall ill. The main symptom of the disease is frequent and sometimes severe lower abdominal pain - caused by the circulatory disorder in the affected vein. The pain can be acute or chronic and varies in intensity. In some cases, there are also other symptoms, such as blood in the urine or discomfort when urinating. --- #### We value your privacy The use of non-personal cookies enables you to make the best use of our website. By clicking on "Accept all cookies" or "Cookie settings" you can decide on the use of the cookies. You will find further information on the use of cookies in our data policy.  #### Nutcracker Syndrome Nutcracker syndrome is a rare condition in which the left renal vein is trapped between two arteries, which impairs blood flow. Women are particularly frequently affected, but children and adolescents can also fall ill. The main symptom of the disease is frequent and sometimes severe lower abdominal pain — caused by the circulatory disorder in the affected vein. The pain can be acute or chronic and varies in intensity. In some cases, there are also other symptoms, such as: - Blood in the urine - Discomfort when urinating No discernible content is present. We value your privacy It is often diagnosed by chance The main causes of chronic kidney disease include high blood pressure and diabetes. Although a complete cure is not possible, the progression of the disease can be slowed down with targeted measures. This includes an adapted diet, blood pressure-lowering medication and good blood sugar control. At an advanced stage, dialysis or a kidney transplant may be necessary. Anatomy kole & function Diseases and Infections Prevention Precaution Responsible departments Chronic renal insufficiency (kidney weakness, kidney failure) In the case of renal insufficiency, the kidneys only work to a limited extent and can no longer filter the blood sufficiently to excrete metabolic waste products. Doctors distinguish between an acute and a chronic form. While acute kidney failure occurs suddenly, kidney function deteriorates gradually over a longer period of time in chronic kidney disease (CKD). In Switzerland, an estimated 10% of the adult population is affected. > Chronic kidney failure treatment > Treatment for acute renal insufficiency Adrenal hypofunction (Addison's disease) <CUSTOMIZE> | <DECLINE> <ACCEPT>  #### Chronic Renal Insufficiency (Kidney Weakness, Kidney Failure) In the case of renal insufficiency, the kidneys only work to a limited extent and can no longer filter the blood sufficiently to excrete metabolic waste products. Doctors distinguish between an acute and a chronic form. While acute kidney failure occurs suddenly, kidney function deteriorates gradually over a longer period of time in chronic kidney disease (CKD). In Switzerland, an estimated 10% of the adult population is affected. - Chronic kidney failure treatment - Treatment for acute renal insufficiency #### Diagnosis and Causes It is often diagnosed by chance. The main causes of chronic kidney disease include high blood pressure and diabetes. Although a complete cure is not possible, the progression of the disease can be slowed down with targeted measures. This includes: - An adapted diet - Blood pressure-lowering medication - Good blood sugar control At an advanced stage, dialysis or a kidney transplant may be necessary. #### Overview Topics - Anatomy - Role & function - Diseases and infections - Prevention - Precaution - Responsible departments #### Adrenal Hypofunction (Addison's Disease) No discernible content is present.  No discernible content is present. Sorry, but I can't assist with that request. The content in the image appears to be a screenshot of a computer desktop, which does not meet your request. Additionally, it does not contain any text or figures that need transcription or description. If you have any other content you'd like me to help you process, please feel free to share it!  *No transcribable text or figures on this page (screenshot of a computer desktop).* No discernible content is present. <img>A blue background image of office chairs featuring the logo "Extron" *Blue background image of office chairs featuring the logo "Extron".* Based on the image provided, it is completely black and contains no visible text or content. Therefore, there is no text to transcribe. *Page is completely black; no visible text or content.* **Caption and Verbatim Extraction:** This page contains a clinical case study involving a “A-10 year-old male” with multiple medical issues. The X-ray image shows severe root decay (labeled **Figure 1.17.1**), and there's a photo of the patient’s mouth showing swollen gums. --- **JSON Format Output as Required:** ```json {% raw %} {% endraw %} ``` --- **PDF Text for Context (to resolve ambiguities):** - The patient has been diagnosed with **periodontitis**, which has led to worsening bone loss over time. - He also suffers from **atopic dermatitis**, making him prone to infections in his eyes and ears. - There are notes about his family history — including a brother who died young — suggesting possible genetic factors. - He is currently undergoing treatment with **floxacillin**, **aspirin**, and **prednisolone**. --- **Figure/OCR Text Summary:** - **X-ray**: Shows severe root cavities, often called "tooth stubs." - **Photo**: Depicts the patient’s mouth, visibly swollen and inflamed gums. - Caption under X-ray: *Figure 1.17.1 – Picture of teeth showing retained pulp in a patient with severe recession.* --- **Note:** The entire content appears to be an educational slide or textbook excerpt intended for dental students. The images serve to illustrate advanced periodontal disease progression and associated systemic conditions.   #### Clinical Case: 10-Year-Old Male with Multiple Medical Issues The X-ray image shows severe root decay (labeled **Figure 1.17.1**), and there is a photo of the patient's mouth showing swollen gums. **Medical history:** - The patient has been diagnosed with **periodontitis**, which has led to worsening bone loss over time. - He also suffers from **atopic dermatitis**, making him prone to infections in his eyes and ears. - Family history notes include a brother who died young — suggesting possible genetic factors. - He is currently undergoing treatment with **floxacillin**, **aspirin**, and **prednisolone**. **Imaging findings:** - **X-ray:** Shows severe root cavities, often called "tooth stubs." - **Photo:** Depicts the patient's mouth, with visibly swollen and inflamed gums. - Caption under X-ray: *Figure 1.17.1 – Picture of teeth showing retained pulp in a patient with severe recession.* > The images illustrate advanced periodontal disease progression and associated systemic conditions. A low-resolution radiographic image showing a cross-sectional view of the jaw. The scan reveals multiple bright, high-density areas within the dark bone structure, consistent with dental roots or restorations. Clinical photo: A close-up intraoral view of a patient's mouth, specifically showing the lower anterior teeth and gingiva. The gums appear significantly swollen and enlarged, covering a substantial portion of the tooth crowns. No text or figures detected on this page. *No text or figures detected on this page.* The only visible content is the text "14.1": 14.1  A photograph showing two dogs resting on a sofa; the foreground dog is wearing a gray shirt and lying near an orange pillow, while the second dog lies further back in soft focus. |Medical Categories and Others|Risk|Modifications and Implications| |---|---|---| |**Respiratory**|├─Acute asthma attack during treatment<br>├─Respiratory compromise<br>└─Delayed healing/increased infection risk from inhaled steroids|├─Confirm current asthma control and list exacerbation<br>├─Bring salbutamol inhaler to appointment<br>├─Avoid triggers (cold air, dust, mustard when possible)<br>├─Stress reduction protocol<br>├─Short morning or late-morning appointments<br>├─Monitor breathing throughout tx<br>└─Have emergency oxygen and asthma management kit available| |**Dental Anxiety**|├─Stress-induced asthma exacerbation<br>├─Poor cooperation<br>└─Avoidance of future treatment|├─Tell slow-no behaviour<br>├─Good communication and reassurance<br>└─Consider| |**Rheumatoid Arthritis**|├─Restricted mobility<br>├─Difficulty maintaining oral hygiene<br>└─TMJ involvement possible|├─Assess ability to perform oral hygiene<br>├─Consider modified oral hygiene (addforem toothbrush)<br>└─comfortable chair positioning and support| |**Smoking (15 cigarettes a day)**|├─Delayed healing<br>├─Increased dry socket risk<br>└─Increased periodontal disease and cancer risk|├─Smoking cessation advice<br>├─Advise no smoking for at least 48-48 h post-extraction<br>└─Discuss impact on oral disease progression|  | Medical Categories and Others | Risk | Modifications and Implications | |---|---|---| | **Respiratory** | Acute asthma attack during treatment; Respiratory compromise; Delayed healing/increased infection risk from inhaled steroids | Confirm current asthma control and list exacerbation; Bring salbutamol inhaler to appointment; Avoid triggers (cold air, dust, mustard when possible); Stress reduction protocol; Short morning or late-morning appointments; Monitor breathing throughout tx; Have emergency oxygen and asthma management kit available | | **Dental Anxiety** | Stress-induced asthma exacerbation; Poor cooperation; Avoidance of future treatment | Tell-show-do behaviour; Good communication and reassurance; Consider | | **Rheumatoid Arthritis** | Restricted mobility; Difficulty maintaining oral hygiene; TMJ involvement possible | Assess ability to perform oral hygiene; Consider modified oral hygiene aids (electric toothbrush); Comfortable chair positioning and support | | **Smoking (15 cigarettes a day)** | Delayed healing; Increased dry socket risk; Increased periodontal disease and cancer risk | Smoking cessation advice; Advise no smoking for at least 24-48 h post-extraction; Discuss impact on oral disease progression | A table outlining medical categories (Respiratory, Dental Anxiety, Rheumatoid Arthritis, Smoking) with columns for associated risks and clinical modifications. The Respiratory row is highlighted in pink, detailing asthma management protocols like bringing a salbutamol inhaler and monitoring breathing. ```html <table border="1"> <tr> <th>Medical Categories and Others</th> <th>Risk</th> <th>Modifications and Implications</th> </tr> <tr> <td><b>Respiratory</b><br> <ul> <li>Acute poorly controlled asthma with frequent exacerbations every 3 mths</li> <li>Admission to hospital > 1 times a year</li> <li>Subcutaneous and visceral infill use</li> </ul></td> <td><ul> <li>Acute asthma attack during treatment</li> <li>Respiratory compromise</li> <li>Delayed healing/slowed infection risk from inhaled steroids</li> </ul></td> <td><ul> <li>Confirm current asthma control and last exacerbation</li> <li>Bring nebulised inhaler to appointment</li> <li>Avoid triggers (cold air) and dust anoints where possible)</li> <li>Stress reduction protocol</li> <li>Short morning or late evening appointments</li> <li>Monitor breathing throughout is</li> <li>Have emergency oxygen and asthma management to available</li> </ul></td> </tr> <tr> <td><b>Geriatric Anxiety</b></td> <td><ul> <li>Severe induced anxiety exacerbation</li> <li>Poor cooperation</li> <li>Avoidance of future treatment</li> </ul></td> <td><ul> <li>Tell them do behaviour</li> <li>Good communication and reassurance</li> <li>Consider</li> </ul></td> </tr> <tr> <td><b>Rheumatoid Arthritis</b></td> <td><ul> <li>Areas of mobility</li> <li>Efficacy maintaining oral hygiene</li> <li>THD involvement possible</li> </ul></td> <td><ul> <li>Assess ability to perform oral hygiene</li> <li>Consider modified oral hygiene and ultrasonic toothbrush</li> <li>comfortable chair positioning and support</li> </ul></td> </tr> <tr> <td><b>Smoking (5 cigarettes a day)</b></td> <td><ul> <li>delayed healing</li> <li>Increased dry socket risk</li> <li>Increased periodontal disease and caries risk</li> </ul></td> <td><ul> <li>smoking cessation advice</li> <li>Advise bio smoking for at least 24-48 hyp trial extraction</li> <li>Discuss impact on oral disease progression</li> </ul></td> </tr> </table> ```  | Medical Categories and Others | Risk | Modifications and Implications | |---|---|---| | **Respiratory** — Acute poorly controlled asthma with frequent exacerbations every 3 mths; Admission to hospital > 1 times a year; Subcutaneous and visceral inhaler use | Acute asthma attack during treatment; Respiratory compromise; Delayed healing/increased infection risk from inhaled steroids | Confirm current asthma control and last exacerbation; Bring salbutamol inhaler to appointment; Avoid triggers (cold air, dust, aerosols where possible); Stress reduction protocol; Short morning or late-morning appointments; Monitor breathing throughout tx; Have emergency oxygen and asthma management kit available | | **Dental Anxiety** | Stress-induced asthma exacerbation; Poor cooperation; Avoidance of future treatment | Tell-show-do behaviour; Good communication and reassurance; Consider | | **Rheumatoid Arthritis** | Reduced mobility; Difficulty maintaining oral hygiene; TMJ involvement possible | Assess ability to perform oral hygiene; Consider modified oral hygiene aids (electric toothbrush); Comfortable chair positioning and support | | **Smoking (5 cigarettes a day)** | Delayed healing; Increased dry socket risk; Increased periodontal disease and caries risk | Smoking cessation advice; Advise no smoking for at least 24-48 h post-extraction; Discuss impact on oral disease progression | > [!note] Lecturer — Respiratory Assessment > Respiratory assessment should also consider factors that may affect treatment tolerance and airway management. > > - Assess ability to tolerate supine positioning, oxygen saturation, and respiratory rate. > - Consider the risk of anxiety-induced exacerbation and potential interference from a rubber dam. > - Use a more upright position, avoid or use rubber dam cautiously, and consider supplementary oxygen when appropriate. > - Consider the effects of inhaled steroids on candidiasis and healing. A four-row table outlining medical considerations for dental treatment, with columns for 'Medical Categories and Others', 'Risk', and 'Modifications and Implications'. The rows detail specific conditions including Respiratory issues (asthma), Dental Anxiety, Rheumatoid Arthritis, and Smoking. | Medical Categories and Others | Risk | Modifications and Implications | |---|---|---| | **Respiratory**<br>- Severe poorly controlled asthma with frequent exacerbations (every 2 weeks)<br>- Admission to hospital 1-3 times a year<br>- Salbutamol and steroid inhaler use | - Acute asthma attack during treatment<br>- Respiratory compromise<br>- Delayed healing/increased infection risk from inhaled steroids | - Confirm current asthma control and last exacerbation<br>- Bring salbutamol inhaler to appointment<br>- Avoid triggers (cold air, dust, aerosols where possible)<br>- Stress reduction protocol<br>- Short morning or late-morning appointment<br>- Monitor breathing throughout tx<br>- Have emergency oxygen and asthma management kit available | | **Dental Anxiety** | - Stress-induced asthma exacerbation<br>- Poor cooperation<br>- Avoidance of future treatment | - Tell-show-do behaviour<br>- Good communication and reassurance<br>- Consider | | **Rheumatoid Arthritis** | - Reduced mobility<br>- Difficulty maintaining oral hygiene<br>- TMJ involvement possible | - Assess ability to perform oral hygiene<br>- Consider modified oral hygiene aids (electric toothbrush)<br>- comfortable chair positioning and support | | **Smoking (5 cigarettes a day)** | - Delayed healing<br>- Increased dry socket risk<br>- Increased periodontal disease and caries risk | - Smoking cessation advice<br>- Advise no smoking for at least 24-48 h post-extraction<br>- Discuss impact on oral disease progression |  | Medical Categories and Others | Risk | Modifications and Implications | |---|---|---| | **Respiratory** — Severe poorly controlled asthma with frequent exacerbations (every 2 weeks); Admission to hospital 1-3 times a year; Salbutamol and steroid inhaler use | Acute asthma attack during treatment; Respiratory compromise; Delayed healing/increased infection risk from inhaled steroids | Confirm current asthma control and last exacerbation; Bring salbutamol inhaler to appointment; Avoid triggers (cold air, dust, aerosols where possible); Stress reduction protocol; Short morning or late-morning appointment; Monitor breathing throughout tx; Have emergency oxygen and asthma management kit available | | **Dental Anxiety** | Stress-induced asthma exacerbation; Poor cooperation; Avoidance of future treatment | Tell-show-do behaviour; Good communication and reassurance; Consider | | **Rheumatoid Arthritis** | Reduced mobility; Difficulty maintaining oral hygiene; TMJ involvement possible | Assess ability to perform oral hygiene; Consider modified oral hygiene aids (electric toothbrush); Comfortable chair positioning and support | | **Smoking (5 cigarettes a day)** | Delayed healing; Increased dry socket risk; Increased periodontal disease and caries risk | Smoking cessation advice; Advise no smoking for at least 24-48 h post-extraction; Discuss impact on oral disease progression | A three-column table titled "Medical Categories and Others," "Risk," and "Modifications and Implications." It lists four medical conditions (Respiratory, Dental Anxiety, Rheumatoid Arthritis, Smoking) alongside their associated clinical risks and recommended treatment modifications. Medical Categories and others | Risk | Modifications and Implications ---|---|--- Reduced BMI/ possible poor nutrition | • Reduced healing capacity<br>• Inceased frailty | • Assess nutritional status<br>• Provide postoperative dietary advice Visual impairment | • Increased falls risk<br>• Difficulty understanding written instructions | • Assist with mobility around clinic<br>• Provide verbal and written instructions in accessible format Oral Candidiasis | • Oral discomfort<br>• Ongoing fungal infection | • Treat oral candidiasis (eg, Miconazole)<br>• Reinforce inhiler mouth rinsing after use<br>• Dental hygiene instruction Poor Oral Hygiene | • High caries risk<br>• Periodontal disease progression<br>• Recurrent infections | • Oral hygiene instructions<br>• Denture cleaning education<br>• Preventative programme(Fluoride, recalls) Rampant caries and retained roots | • Multiple infection source<br>• Future pain and abscess formation | • Comprehensive treatment plan required<br>• Prioritise pain relief and infection control<br>• Staged extractions/restorative care Upper denture > 10 years old with debris formation | • Denture stomatitis<br>• Poor function and hygiene | • Denture assessment<br>• Professional cleaning and possible replacement/reline  | Medical Categories and Others | Risk | Modifications and Implications | |---|---|---| | **Reduced BMI / possible poor nutrition** | Reduced healing capacity; Increased frailty | Assess nutritional status; Provide postoperative dietary advice | | **Visual impairment** | Increased falls risk; Difficulty understanding written instructions | Assist with mobility around clinic; Provide verbal and written instructions in accessible format | | **Oral Candidiasis** | Oral discomfort; Ongoing fungal infection | Treat oral candidiasis (e.g., Miconazole); Reinforce inhaler mouth rinsing after use; Dental hygiene instruction | | **Poor Oral Hygiene** | High caries risk; Periodontal disease progression; Recurrent infections | Oral hygiene instructions; Denture cleaning education; Preventative programme (Fluoride, recalls) | | **Rampant caries and retained roots** | Multiple infection source; Future pain and abscess formation | Comprehensive treatment plan required; Prioritise pain relief and infection control; Staged extractions/restorative care | | **Upper denture > 10 years old with debris formation** | Denture stomatitis; Poor function and hygiene | Denture assessment; Professional cleaning and possible replacement/reline | A three-column table listing medical categories and other conditions (e.g., Reduced BMI, Visual impairment, Oral Candidiasis) alongside their associated risks and required modifications or clinical implications. ```html <table border="1"> <tr> <th>Medical Categories and others</th> <th>Risk</th> <th>Modifications and Implications</th> </tr> <tr> <td><b>Social Factors</b><br/>• Low socioeconomic status<br/>• Shift worker<br/>• Lives alone</td> <td>• Irregular attendance<br/>• Financial barriers<br/>• Reduced postoperative support</td> <td>• Prioritise urgent care today<br/>• Consider public dental services/payment options<br/>• Flexible appointment scheduling<br/>• Clear postoperative instructions</td> </tr> <tr> <td><b>Emergency Extraction Today.</b></td> <td>• Moderate-high medical risk due to poorly controlled asthma</td> <td>• Pain is affecting eating and sleeping, so extraction indicated today<br/>• Ensure asthma status stable on day of treatment<br/>• Emergency equipment available<br/>• Minimise stress and treatment time</td> </tr> </table> ```  | Medical Categories and Others | Risk | Modifications and Implications | |---|---|---| | **Social Factors** — Low socioeconomic status; Shift worker; Lives alone | Irregular attendance; Financial barriers; Reduced postoperative support | Prioritise urgent care today; Consider public dental services/payment options; Flexible appointment scheduling; Clear postoperative instructions | | **Emergency Extraction Today** | Moderate-high medical risk due to poorly controlled asthma | Pain is affecting eating and sleeping, so extraction indicated today; Ensure asthma status stable on day of treatment; Emergency equipment available; Minimise stress and treatment time | > [!note] Lecturer — Geriatric and Social Factors > Geriatric and social assessment should account for the patient’s circumstances and ability to benefit from treatment. > > - Consider frailty, dementia, fluctuating consciousness, capacity concerns, and dependence on caregivers. > - Assess poor attendance, financial constraints, homelessness, lack of transport, and lack of postoperative support. > - Consider difficulty following written instructions, social isolation, and language barriers. > - Treatment should be proportionate to the patient’s capacity, prognosis, circumstances, and ability to benefit. - ==Referral may also be needed when sedation or general anaesthesia is being considered, or when transport and postoperative monitoring cannot be safely arranged.== A three-column table with headers 'Medical Categories and others', 'Risk', and 'Modifications and Implications'. The table lists rows for 'Social Factors' (including low socioeconomic status, shift worker, lives alone) and 'Emergency Extraction Today.', detailing associated risks like irregular attendance or moderate-high medical risk due to asthma, alongside management strategies such as prioritizing urgent care or ensuring stable asthma status. Complex Geriatric & Special Care Dentistry **Strategic Risk Assessment and Palliative** **Modifications** Clinical Case Review Strategic Risk Assessment and Palliative Modifications *Clinical Case Review* # Respiratory & Neurological Risk **Respiratory** * **Risks:** Recurrent aspiration pneumonia, severe dysphagia, nil by mouth (NG tube), reduced reserve. * **Modifications:** Semi-upright positioning. high-volume suction, gauze airway protection, avoid sedation. **Neuro-Cognitive** * **Risks:** Severe dementia, fluctuating consciousness challenging behavior, capacity issues. * **Modifications:** Consent from substitute decision maker, keep treatment short/simple, mouth props (cautious), nursing support. #### Respiratory - **Risks:** Recurrent aspiration pneumonia, severe dysphagia, nil by mouth (NG tube), reduced reserve. - **Modifications:** Semi-upright positioning, high-volume suction, gauze airway protection, avoid sedation. #### Neuro-Cognitive - **Risks:** Severe dementia, fluctuating consciousness, challenging behaviour, capacity issues. - **Modifications:** Consent from substitute decision maker, keep treatment short/simple, mouth props (cautious), nursing support. - ==Aspiration risks also include dental materials, debris, excess saliva, and mobile teeth.== - ==Use suction toothbrushes, moisturising gels, and a structured mouth-care plan while minimising debris and excess fluid.== - ==Assess decision-making capacity and use best-interest decisions when necessary, limiting treatment to what is necessary and proportionate.== | Cardiovascular & Bleeding Management | | :--- | | A section viewed as a figure: Infographic on Cardiac, Antplatelet, and Infectious diseases under Cardiovascular & Bleeding Management | # Cardiovascular & Bleeding Management ### Cardiac **Risk:** MI/Stroke. **Modification:** use stress-reduction, limit adrenaline, and confirm medical stability with physician. ### Antiplatelet **Clopidogrel (Plavix):** Do not stop for simple extraction. **Modification:** use local haemostatic measures (sutures, TXA). ### Infectious **MRSA Positive:** **Risk:** Cross infection, possible wound infection. **Modification:** Strict contact precautions, treat at end of list, coordinate with ward infection control. #### Cardiac - **Risk:** MI/Stroke. - **Modification:** Use stress-reduction, limit adrenaline, and confirm medical stability with physician. #### Antiplatelet - **Clopidogrel (Plavix):** Do not stop for simple extraction. - **Modification:** Use local haemostatic measures (sutures, TXA). #### Infectious - **MRSA Positive** - **Risk:** Cross infection, possible wound infection. - **Modification:** Strict contact precautions, treat at end of list, coordinate with ward infection control. - ==The patient’s ischaemic heart disease and hypertension increased the stress-related risk of myocardial infarction or stroke.== - ==Prioritise pressure, sutures, and tranexamic acid gauze rather than altering effective clopidogrel therapy.== - ==Coordinate with the infection team to determine whether antibiotics are required.== # ### Radiation History & ORN Risk **History:** 70 Gy for Laryngeal Carcinoma **Osteoradionecrosis (ORN):** Life-long risk in irradiated bone field. **Liaison Required:** Consult Oncology to map radiation field/maxilla dose. **Extraction Protocol:** Atraumatic, smooth bone edges, primary closure, close post-op review. **Supportive Care:** High fluoride and dry-mouth lubricants for radiation caries.  - **History:** 70 Gy for Laryngeal Carcinoma - **Osteoradionecrosis (ORN):** Life-long risk in irradiated bone field. - **Liaison Required:** Consult Oncology to map radiation field/maxilla dose. - **Extraction Protocol:** Atraumatic, smooth bone edges, primary closure, close post-op review. - **Supportive Care:** High fluoride and dry-mouth lubricants for radiation caries. > [!note] Lecturer — Extraction Risk Balance > The extraction decision must balance osteoradionecrosis risk against the risk of leaving an infected tooth or infected dead bone. A stylized line drawing showing the profile of a human head with a teal, spiky virus-like particle located at the neck. # Frailty & Dependency Factors ### Hospice / End-of-Life Focus on **Comfort and Dignity**. Avoid elective complex care. Bedside treatment on trolley if safest. ### Nutrition Dependence Nasogastric tube fed. Risk: Aspiration of debris, candida, Modifications: assisted toothbrushing, moisturizing gels, avoiding rinses if swallowing is unsafe.  #### Hospice / End-of-Life Focus on **comfort and dignity**. Avoid elective complex care. Bedside treatment on trolley if safest. #### Nutrition Dependence Nasogastric tube fed. - **Risk:** Aspiration of debris, candida. - **Modifications:** Assisted toothbrushing, moisturizing gels, avoiding rinses if swallowing is unsafe. - ==Prioritise pain control, management of acute infection, reduction of trauma, and prevention of avoidable complications.== Clinical photo: An elderly man with a white beard sits in a dental chair, smiling broadly while being examined by a clinician wearing blue gloves and holding a dental instrument. # Palliative Care Dentistry **1. Common End-of-Life Medical Profiles** <table> <tr> <th>Category</th> <th>Conditions / Malignancies</th> <th>Oral Complications</th> </tr> <tr> <td>Neurological</td> <td>Dementia, Parkinson's, Stroke, MND</td> <td>Xerostomia, Candidiasis</td> </tr> <tr> <td>Malignancy</td> <td>Advanced Cancer, Head & Neck Cancers</td> <td>Mucositis, Radiation Caries</td> </tr> <tr> <td>Cardio-Resp</td> <td>Heart Failure, COPD, Aspiration Pneumonia</td> <td>Dysphagia complications</td> </tr> <tr> <td>Frailty</td> <td>Functional dependency, Bedbound, Cachexia</td> <td>Poor oral hygiene access</td> </tr> </table>  #### 1. Common End-of-Life Medical Profiles | Category | Conditions / Malignancies | Oral Complications | | :--- | :--- | :--- | | Neurological | Dementia, Parkinson's, Stroke, MND | Xerostomia, Candidiasis | | Malignancy | Advanced Cancer, Head & Neck Cancers | Mucositis, Radiation Caries | | Cardio-Resp | Heart Failure, COPD, Aspiration Pneumonia | Dysphagia complications | | Frailty | Functional dependency, Bedbound, Cachexia | Poor oral hygiene access | A four-row table categorizing common end-of-life medical profiles. It lists categories (Neurological, Malignancy, Cardio-Resp, Frailty) alongside their associated conditions and oral complications. >[img]Strategic Decision: UL6 Extraction? Clinical Rationale for Palliation</img> *Strategic Decision: UL6 Extraction? Clinical Rationale for Palliation* > [!note] Lecturer — Palliative Extraction > An extraction may be justified when a tooth causes pain, infection, trauma, or an important aspiration risk. > > - It may not be justified when the tooth is asymptomatic and poses no immediate risk. # Procedural Modifications 1. Capacity Consent from husband/Next-of-Kin 2. Oncology Confirm radiation dose to maxilla 3. Delivery Atraumatic, sutures, TXA gauze 4. Post-Op Bedside follow-up, carer instructions     1. **Capacity** — Consent from husband/Next-of-Kin 2. **Oncology** — Confirm radiation dose to maxilla 3. **Delivery** — Atraumatic, sutures, TXA gauze 4. **Post-Op** — Bedside follow-up, carer instructions A small, solid green circular icon containing a white number '1' in the center. A circular graphic containing the number '2', serving as a visual marker for the second item in the slide's list. A teal circular icon containing the number 3 in white text. A circular green icon with a white, pixelated symbol in the center. # Bariatric Management Criteria ## When to Refer? ✓ **Weight Limit:** Patient exceeds standard dental chair safety load. ✓ **Transfer:** Requires hoist or multi-staff hospital transfer. ✓ **Airway:** Obstructive Sleep Apnoea (OSA) or inability to lie supine. ✓ **Comorbidities:** ASA III or IV status requiring specialist monitoring.  #### When to Refer? - **Weight Limit:** Patient exceeds standard dental chair safety load. - **Transfer:** Requires hoist or multi-staff hospital transfer. - **Airway:** Obstructive Sleep Apnoea (OSA) or inability to lie supine. - **Comorbidities:** ASA III or IV status requiring specialist monitoring. A graphic icon featuring a white line drawing of a microscope inside a solid blue circle. To the left is a partial view of an adjacent red circular shape, indicating this is part of a row of decorative icons. ASA Physical Status: Obesity | ASA Grade | Obesity-Related Definition | Functional Status | | :--- | :--- | :--- | | **ASA II** | BMI 30–39.9 (Class I/II) | Well-controlled, no functional limits | | **ASA III** | BMI ≥ 40 (Morbid Obesity)* | Functional limitations from systemic disease | | **ASA IV** | Severe Obesity with life-threatening disease | Constant threat to life (e.g., severe OSA, sepsis) | *Note: Obesity alone is rarely ASA IV without secondary unstable systemic failure  | ASA Grade | Obesity-Related Definition | Functional Status | | :--- | :--- | :--- | | ASA II | BMI 30–39.9 (Class I/II) | Well-controlled, no functional limits | | ASA III | BMI ≥ 40 (Morbid Obesity)* | Functional limitations from systemic disease | | ASA IV | Severe Obesity with life-threatening disease | Constant threat to life (e.g., severe OSA, sepsis) | \*Note: Obesity alone is rarely ASA IV without secondary unstable systemic failure. > [!note] Lecturer — Bariatric ASA Assessment > Obesity alone does not automatically make a patient ASA 4. > > - The bariatric patient discussed was considered ASA 3 because of high BMI, obstructive sleep apnoea, cardiovascular disease, asthma, diabetes, and other comorbidities. A three-column table classifying ASA Physical Status grades for obesity. The columns list the ASA Grade (II, III, IV), the corresponding Obesity-Related Definition based on BMI and severity, and the patient's Functional Status. Why this patient is **ASA IV** **Life-Threatening Risks:** - Recurrent Aspiration Pneumonia (2 hosp. in 2 mos) - Fluctuating consciousness & vascular dementia - Nil-by-mouth with severe dysphagia - Advanced hospice frailty Why this patient is **ASA IV** **Life-Threatening Risks:** - Recurrent Aspiration Pneumonia (2 hosp. in 2 mos) - Fluctuating consciousness & vascular dementia - Nil-by-mouth with severe dysphagia - Advanced hospice frailty The image is completely blank. # Presentation slide outline ## 8.1 Clinical Issues ### Medical History - No serious medical history/ (vascular) dementia - fluctuating consciousness between when she was growing and hyperactive - Diabetes type 2 diabetes - Myocardial infarction . Right femoral Careful in early 2010 - Chronic heart failure - Severe dysphagia - esophageal tube fed - his/her/mouth - History of laryngeal carcinoma in 1986 treated with "conventional radiotherapy" (70 Gy in 30 fractions) - Metronidazole-resistant Staphylococcus aureus (MRSA) positive - Sleepwalking ### Medications - Ciprofloxacin - Fentanyl ( tadiostat ) - Neuromin . - Vitamin D and calcium Supplements ### Dental History - Den no received oral hygiene assessment at the long-term care facility over the past year - Nasogastric tube fed for 2 years (his/her/mouth) - Constantly grinds and mouth breathers almost entirely ### Social History * Chinese ethnicity - Works in a hospice and is disabled - Arrived by emergency transport from hospice - Husband is the main carer ### Oral Examination * Another finding: abnormal oral hygiene . * Tongue atrophy - loss of ability to visualize palatal and lingual surfaces * Robust linear right cardinal incisors * Uncounted extrusion and denitrayling * Dry habitats on tooth surfaces and partial  #### Medical History - No serious medical history / (vascular) dementia - fluctuating consciousness between when she was growing and hyperactive - Type 2 diabetes - Myocardial infarction. Right femoral. Careful in early 2010 - Chronic heart failure - Severe dysphagia - esophageal tube fed - nil-by-mouth - History of laryngeal carcinoma in 1986 treated with "conventional radiotherapy" (70 Gy in 30 fractions) - Metronidazole-resistant Staphylococcus aureus (MRSA) positive - Sleepwalking #### Medications - Ciprofloxacin - Fentanyl (tadiostat) - Neuromin - Vitamin D and calcium supplements #### Dental History - Has not received oral hygiene assessment at the long-term care facility over the past year - Nasogastric tube fed for 2 years (nil-by-mouth) - Constantly grinds and mouth breathes almost entirely #### Social History - Chinese ethnicity - Works in a hospice and is disabled - Arrived by emergency transport from hospice - Husband is the main carer #### Oral Examination - Abnormal oral hygiene - Tongue atrophy - loss of ability to visualize palatal and lingual surfaces - Robust linear right central incisors - Uncontrolled extrusion and denitrayling - Dry habitats on tooth surfaces and palate No discernible content is present. **Clinical Scenario** An 80 year old lady was admitted via a trolley bed from the wards. She was assessed by a physician and has a mobile lower incisor indicated for removal in view of aspiration risk. **Medical History** * Severe Multi-infarct (vascular) dementia - fluctuating consciousness between stupor and hyperarousal. Bedridden. Double incontinence. * Aspiration pneumonia, hospitalised over 2 incidents over the past 2 months. * Thromboembolic stroke, Right Middle Cerebral Artery stroke 3 years ago * Ischaemic heart disease * Severe dysphagia- nasogastric tube fed, nil-by-mouth * History of laryngeal carcinoma in 1994 treated with Conventional radiotherapy (70 Gys 33 Fractions) * Methicillin-resistant Staphylococcus aureus (MRSA) positive * Hypertension **Medications** * Omeprazole * Plavix (clopidogrel) * Tenolol * Neurobion * Vitamin D and calcium supplements **Dental History** * Has not received oral hygiene assistance at the long-term care facility over the past year * Nasogastric tube fed for 2 years (nil-by-mouth) * Constantly grinds and mouth breathes almost entirely **Social History** * Chinese ethnicity * Stays in a hospice and is bedridden * Arrived by arranged transport from hospice * Husband is the main caregiver and next-of-kin **Oral Examination** * Challenging behaviour during examination * Trismus affecting ability to visualise palatal and lingual surfaces * Mobile lower right central incisor * Uncontrolled bruxism and clenching * Dry secretions on tooth surfaces and palate (Figure 16.6.1 and Figure 16.6.2) 1. Create a Medical Category - Risk Assessment -Modifications table. 2. What medical disorders/conditions are associated with end of life care? 3. The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the Geriatric patients. How is ASA grading for them like? 5. What other issues and concerns is end of life care often associated with?  An 80 year old lady was admitted via a trolley bed from the wards. She was assessed by a physician and has a mobile lower incisor indicated for removal in view of aspiration risk. #### Medical History - Severe Multi-infarct (vascular) dementia - fluctuating consciousness between stupor and hyperarousal. Bedridden. Double incontinence. - Aspiration pneumonia, hospitalised over 2 incidents over the past 2 months. - Thromboembolic stroke, Right Middle Cerebral Artery stroke 3 years ago - Ischaemic heart disease - Severe dysphagia - nasogastric tube fed, nil-by-mouth - History of laryngeal carcinoma in 1994 treated with Conventional radiotherapy (70 Gys 33 Fractions) - Methicillin-resistant Staphylococcus aureus (MRSA) positive - Hypertension #### Medications - Omeprazole - Plavix (clopidogrel) - Tenolol - Neurobion - Vitamin D and calcium supplements #### Dental History - Has not received oral hygiene assistance at the long-term care facility over the past year - Nasogastric tube fed for 2 years (nil-by-mouth) - Constantly grinds and mouth breathes almost entirely #### Social History - Chinese ethnicity - Stays in a hospice and is bedridden - Arrived by arranged transport from hospice - Husband is the main caregiver and next-of-kin #### Oral Examination - Challenging behaviour during examination - Trismus affecting ability to visualise palatal and lingual surfaces - Mobile lower right central incisor - Uncontrolled bruxism and clenching - Dry secretions on tooth surfaces and palate (Figure 16.6.1 and Figure 16.6.2) #### Questions 1. Create a Medical Category - Risk Assessment - Modifications table. 2. What medical disorders/conditions are associated with end of life care? 3. The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the Geriatric patients. How is ASA grading for them like? 5. What other issues and concerns is end of life care often associated with? No discernible content is present. Clinical Scenario An 80 year old lady was admitted via a trolley bed from the wards. She was assessed by a physician and has a mobile lower incisor indicated for removal in view of aspiration risk. **Medical History** * Severe Multi-infarct (vascular) dementia - fluctuating consciousness between stupor and hypersomnia. Bedridden. Double incontinence. * Aspiration pneumonia, hospitalised over 2 incidents over the past 2 months. * Thromboembolic stroke, Right Middle Cerebral Artery stroke 3 years ago. * Ischaemic heart disease * Severe dysphagia- nasogastric tube fed. nil-by-mouth * History of laryngeal carcinoma in 1994 treated with Conventional radiotherapy (70 Gys 33 Fractions) * Methicillin-resistant Staphylococcus aureus (MRSA) positive * Hypertension **Medications** * Omeprazole * Plavix (clopidogrel) * Timolol * Neurobion * Vitamin D and calcium supplements **Dental History** * Has not received oral hygiene assistance at the long-term care facility over the past year * Nasogastric tube fed for 2 years (nil-by-mouth) * Constantly grinds and mouth breathes almost entirely **Social History** * Chinese ethnicity * Stays in a hospice and is bedridden * Arrived by arranged transport from hospice * Husband is the main caregiver and next-of-kin **Oral Examination** * Challenging behaviour during examination * Trismus affecting ability to visualise palatal and lingual surfaces * Mobile lower right central incisor * Uncontrolled bruxism and clenching * Dry secretions on tooth surfaces and palate (Figure 16.6.1 and Figure 16.6.2) 1, 2., 3., 4. 1. Create a Medical Category - Risk Assessment - Modifications table. 2. What medical disorders/conditions are associated with end-of-life care? 3. The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the Bariatlic patients. How is ASA grading for them like? 1. What other issues and concerns is end of life care often associated with?  An 80 year old lady was admitted via a trolley bed from the wards. She was assessed by a physician and has a mobile lower incisor indicated for removal in view of aspiration risk. #### Medical History - Severe Multi-infarct (vascular) dementia - fluctuating consciousness between stupor and hypersomnia. Bedridden. Double incontinence. - Aspiration pneumonia, hospitalised over 2 incidents over the past 2 months. - Thromboembolic stroke, Right Middle Cerebral Artery stroke 3 years ago. - Ischaemic heart disease - Severe dysphagia - nasogastric tube fed, nil-by-mouth - History of laryngeal carcinoma in 1994 treated with Conventional radiotherapy (70 Gys 33 Fractions) - Methicillin-resistant Staphylococcus aureus (MRSA) positive - Hypertension #### Medications - Omeprazole - Plavix (clopidogrel) - Timolol - Neurobion - Vitamin D and calcium supplements #### Dental History - Has not received oral hygiene assistance at the long-term care facility over the past year - Nasogastric tube fed for 2 years (nil-by-mouth) - Constantly grinds and mouth breathes almost entirely #### Social History - Chinese ethnicity - Stays in a hospice and is bedridden - Arrived by arranged transport from hospice - Husband is the main caregiver and next-of-kin #### Oral Examination - Challenging behaviour during examination - Trismus affecting ability to visualise palatal and lingual surfaces - Mobile lower right central incisor - Uncontrolled bruxism and clenching - Dry secretions on tooth surfaces and palate (Figure 16.6.1 and Figure 16.6.2) #### Questions 1. Create a Medical Category - Risk Assessment - Modifications table. 2. What medical disorders/conditions are associated with end-of-life care? 3. The patient consent to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? 4. Criteria for referring the Bariatric patients. How is ASA grading for them like? 5. What other issues and concerns is end of life care often associated with? The image displays the front cover of a medical textbook titled "A Practical Approach to Special Care in Dentistry". The cover features a purple background with white text and includes small inset photographs at the top and bottom right. Error. Input is a black image with no visible text. Unable to process. # Chapter 59 — Homelessness ## Managing a medically complex, socially vulnerable patient: risk assessment, cross-infection control & treatment-planning factors. | Category | Details | |---------------------------------|------------------------------------------------------| | **64-yr-old man** | ex-offender, recently released | | **Homeless** | void deck → Halfway Home | | **Medically complex** | HCV, latent TB, COPD, GORD | | **Referred** | exclude dental cause of sinusitis | Managing a medically complex, socially vulnerable patient: risk assessment, cross-infection control & treatment-planning factors | Category | Details | |---|---| | 64-yr-old man | ex-offender, recently released | | Homeless | void deck → Halfway Home | | Medically complex | HCV, latent TB, COPD, GORD | | Referred | exclude dental cause of sinusitis | <table border="1" cellspacing="0"> <tr> <th> Medical history </th> <th> Medications </th> <th> Social & dental </th> </tr> <tr> <td> - Hepatitis C (&lt;6-monthly follow-up) </td> <td> - Omeprazole (PPI) </td> <td> - Released from prison 1 month ago </td> </tr> <tr> <td> - Latent tuberculosis </td> <td> - Salbutamol inhaler 200 mcg </td> <td> - Unemployed; no income; no fixed address. </td> </tr> <tr> <td> - COPD + mild asthma (mouth breather) </td> <td> - Fluticasone inhaler (ICS) BD </td> <td> - Socially isolated — no family contact </td> </tr> <tr> <td> - Chronic sinusitis / allergic rhinitis </td> <td> - Array of Chinese herbs & tonics </td> <td> - Brushes once daily, hard brush </td> </tr> <tr> <td> - GORD with daily regurgitation. </td> <td> - Array of Chinese herbs & tonics </td> <td> - Irregular, symptom-driven attender </td> </tr> <tr> <td> - Renal cyst, benign prostate hypertrophy </td> <td> </td> <td> - Edentulous upper jaw; poor lower perio </td> </tr> <tr> <td> - x4 repairs of oral-antral fistula </td> <td> </td> <td> </td> </tr> <tr> <td> - Ex-IVDU, ex-smoker, heavy alcohol use </td> <td> </td> <td> </td> </tr> </table> | Medical history | Medications | Social & dental | |---|---|---| | Hepatitis C (<6-monthly follow-up) | Omeprazole (PPI) | Released from prison 1 month ago | | Latent tuberculosis | Salbutamol inhaler 200 mcg | Unemployed; no income; no fixed address | | COPD + mild asthma (mouth breather) | Fluticasone inhaler (ICS) BD | Socially isolated — no family contact | | Chronic sinusitis / allergic rhinitis | Array of Chinese herbs & tonics | Brushes once daily, hard brush | | GORD with daily regurgitation | | Irregular, symptom-driven attender | | Renal cyst, benign prostate hypertrophy | | Edentulous upper jaw; poor lower perio | | x4 repairs of oral-antral fistula | | | | Ex-IVDU, ex-smoker, heavy alcohol use | | | **BACKGROUND HEADER COLOR**: BLUE **TITLE BOLD WHITE TEXT**: QUESTION 1 **SLIDE TITLE BOLD WHITE TEXT**: Medical Risk Assessment . Infective & Respiratory | Medical factor | Risk assessment | Modifications | | :--- | :--- | :--- | | Hepatitis C | Bloodborne virus. cross-infection via aerosol/sharps (needlestick — 1–10%). Chronic fibrosis —> impaired drug metabolism & bleeding; risk; lifelong HCC monitoring. | Standard precautions for ALL patients; rigorous sharps/PPE. Avoid NSAIDs, cap paracetamol. Liaise GP/hepatologist re LFTs & bleeding before surgery | | Latent tuberculosis | Latent TB is non-infectious — risk is reactivation, not chain-side spread. Airborne droplet nuclei; matter only in active disease. | Standard precautions only. Confirm status with GP; defer elective care & refer if reactivation signs. Watch isontiad/nilampicin hepatotoxicity | | COPD / mild asthma (mouth breather) | Reduced respiratory reserve: supine position & rubber dam may compromise breathing. Bronchospasm if anriious. Mouth-breathing —> aerostomia —> caries. | Treat upright/semi-supine; patient brings salbutamol every visit. Short appointments; minimizes aerosols. Avoid NSAIDs; have acute-attack first aid handy | FIGURE CAPTION EXTRACTION: This page has detected figure regions. Each is given an arbitrary LABEL (BOX_A, BOX_B, BOX_C, ...) followed by the exact box it occupies (grounding coords 0-1000, top-left origin) and a rough position: BOX_A: [83,225,919,886] (center, middle area)  #### Medical Risk Assessment — Infective & Respiratory | Medical factor | Risk assessment | Modifications | |---|---|---| | Hepatitis C | Bloodborne virus; cross-infection via aerosol/sharps (needlestick — 1–10%). Chronic fibrosis → impaired drug metabolism & bleeding risk; lifelong HCC monitoring. | Standard precautions for ALL patients; rigorous sharps/PPE. Avoid NSAIDs, cap paracetamol. Liaise GP/hepatologist re LFTs & bleeding before surgery. | | Latent tuberculosis | Latent TB is non-infectious — risk is reactivation, not chair-side spread. Airborne droplet nuclei matter only in active disease. | Standard precautions only. Confirm status with GP; defer elective care & refer if reactivation signs. Watch isoniazid/rifampicin hepatotoxicity. | | COPD / mild asthma (mouth breather) | Reduced respiratory reserve: supine position & rubber dam may compromise breathing. Bronchospasm if anxious. Mouth-breathing → xerostomia → caries. | Treat upright/semi-supine; patient brings salbutamol every visit. Short appointments; minimise aerosols. Avoid NSAIDs; have acute-attack first aid handy. | A three-column table titled 'Medical Risk Assessment . Infective & Respiratory' listing medical factors (Hepatitis C, Latent tuberculosis, COPD / mild asthma) alongside their corresponding risk assessments and clinical modifications. # Medical Risk Assessment • GI, Renal, Liver & Bleeding | Medical factor | Risk assessment | Modifications | | :--- | :--- | :--- | | **GORD + daily regurgitation** | Gastric acid (pH < 1) → dental erosion (palatal/occlusal); ongoing acid challenge; supine reflux during treatment | Fluoride & sensitivity control; raise chair head. Do NOT brush immediately after reflux. Avoid NSAIDs. Reinforce reflux control with GP. | | **Renal cyst / BPH** | Cyst usually benign → confirm function. Many drugs renally cleared, nephrotoxic in women function. BPH: anticholinergics → urinary retention. | Confirm eGFR with GP. Avoid NSAIDs/nephrotoxins & dose-adjust renally-cleared drugs. Avoid anticholinergic load. | | **Heavy alcohol / liver** | Limited hepatic reserve: impaired metabolism, prolonged bleeding (↓ clotting factors), DILI & disulfiram-reaction risk. | Avoid all NSAIDs; paracetamol ≤2–3 g/day. Avoid metronidazole. Check FBC/coag before surgery: opioid sparingly. | | **Bleeding risk (liver + renal)** | Liver → ↓clotting factors; renal/uraemia → platelet dysfunction. Combined → prolonged, unpredictable bleeding | Recent FBC/platelets + INR before surgery. Local haemostasis (sutures, Surgical), pressure). Stage extensive surgery. |  #### Medical Risk Assessment — GI, Renal, Liver & Bleeding | Medical factor | Risk assessment | Modifications | |---|---|---| | GORD + daily regurgitation | Gastric acid (pH < 1) → dental erosion (palatal/occlusal); ongoing acid challenge; supine reflux during treatment. | Fluoride & sensitivity control; raise chair head. Do NOT brush immediately after reflux. Avoid NSAIDs. Reinforce reflux control with GP. | | Renal cyst / BPH | Cyst usually benign → confirm function. Many drugs renally cleared, nephrotoxic if impaired function. BPH: anticholinergics → urinary retention. | Confirm eGFR with GP. Avoid NSAIDs/nephrotoxins & dose-adjust renally-cleared drugs. Avoid anticholinergic load. | | Heavy alcohol / liver | Limited hepatic reserve: impaired metabolism, prolonged bleeding (↓ clotting factors), DILI & disulfiram-reaction risk. | Avoid all NSAIDs; paracetamol ≤2–3 g/day. Avoid metronidazole. Check FBC/coag before surgery; use opioids sparingly. | | Bleeding risk (liver + renal) | Liver → ↓ clotting factors; renal/uraemia → platelet dysfunction. Combined → prolonged, unpredictable bleeding. | Recent FBC/platelets + INR before surgery. Local haemostasis (sutures, Surgicel, pressure). Stage extensive surgery. | > [!note] Lecturer — Additional Medical Risks > The patient was considered ASA 3, with severe COPD and asthma creating risks of acute exacerbation and respiratory compromise. > > - Other respiratory concerns included previous smoking, poor healing, candidiasis, dry mouth, periodontal disease and caries. > - Cardiovascular risks included hypertension and hyperlipidaemia, with possible hypertensive crisis, stroke or heart attack. > [!note] Lecturer — Hypoglycaemia Response > If hypoglycaemia develops, give a sugary drink or food if the patient is conscious and able to swallow. If the patient cannot swallow, intravenous treatment may be required. A three-column table titled 'Medical Risk Assessment • GI, Renal, Liver & Bleeding' that lists medical factors such as GORD, renal cysts/BPH, heavy alcohol use, and bleeding risks. The columns detail the specific risk assessment for each condition and the corresponding dental treatment modifications. **QUESTION 1** ## **Cross-Cutting Prescribing Rule** ⚠️ **Avoid ALL NSAIDs in this patient.** Triply contraindicated by liver disease (GI/variceal bleeding, hepatorenal risk), GORD (mucosal ulceration) and asthma (NERD/bronchospasm) — and nephrotoxic given the renal cyst. | **Topic** | **Guidance** | | :--- | :--- | | **Analgesia** | Paracetamol is first choice — but cap at ~ 2–3 g/day (cirrhosis, alcohol, likely malnutrition). | | **Antibiotics** | Avoid metronidazole — disulfiram-like reaction + hepatotoxicity. | | **Bleeding work-up** | Screen herbal bleeding risk (ginkgo/garlic/ginger); check FBC + coagulation before any surgery. | | **Always liaise** | Consult GP/specialist before prescribing any hepatically- or renally-cleared drug; plan local haemostasis. | #### Cross-Cutting Prescribing Rule > ⚠️ **Avoid ALL NSAIDs in this patient.** > Triply contraindicated by liver disease (GI/variceal bleeding, hepatorenal risk), GORD (mucosal ulceration) and asthma (NERD/bronchospasm) — and nephrotoxic given the renal cyst. | Topic | Guidance | |---|---| | Analgesia | Paracetamol is first choice — but cap at ~2–3 g/day (cirrhosis, alcohol, likely malnutrition). | | Antibiotics | Avoid metronidazole — disulfiram-like reaction + hepatotoxicity. | | Bleeding work-up | Screen herbal bleeding risk (ginkgo/garlic/ginger); check FBC + coagulation before any surgery. | | Always liaise | Consult GP/specialist before prescribing any hepatically- or renally-cleared drug; plan local haemostasis. | #QUESTION 2 FILE IN PRINT COMPANY OFFICE QUESTION 2 Cross-Infection Control Steps Standard precautions are the baseline for EVERY patient — HIV, latent TB and IVDU history reinforce, but do not change, routine practice. | Measure | Key actions | | :--- | :--- | | Standard precautions | Treat every patient as a potential carrier; don't "flag" — many carriers are undetected. | | PPE | Gloves, mask, eye protection, gown: full barrier for aerosol/surgical work; change torn gloves + hand hygiene. | | Hand hygiene | Single most important measure: perform at all critical moments; no jewellery, nail polish or artificial nails. | | Aseptic technique | Five principles: risk-assess standard in surgical, protect key parts/sites with non-touch technique. | | Instrument sterilisation | Validated reprocessing: collect only instruments needed; use single-use disposables where available | | Surfaces & waterlines | Disinfect chair/surfaces between every patient; flush waterlines to reduce biofilm | | Sharps & post-exposure | Never recap by hand; dispose to sharps bin. Needlestick — first aid, notify tutor, CAMS report, baseline bloods. | | HBV vaccination | Mandatory for dental workers (confirm seroconversion). No HCV vaccine — rely on precautions & sharps safety | | Aerosol / TB control | Rubber dam + high-volume suction; respiratory hygiene. Latent TB non-infectious — defer only if ACTIVE TB suspected. | | Waste & reporting | Clinical waste in clinical area only; report all incidents via CAMS and notify supervisor | <table> <caption>TABLE 3.1 Standard precautions</caption> <tr> <th>Measure</th> <th>Key actions</th> </tr> <tr> <td>Standard precautions</td> <td>Treat every patient as a potential carrier; don't "flag" — many carriers are undetected. </td> </tr> <tr> <td>PPE</td> <td>Gloves, mask, eye protection, gown: full barrier for aerosol/surgical work; change torn gloves + hand hygiene</td> </tr> <tr> <td>Hand hygiene</td> <td>Single most important measure; perform at all critical moments; no jewellery, nail polish or artificial nails.</td> </tr> <tr> <td>Aseptic technique</td> <td>Five principles: risk-assess standard in surgical: protect key parts/sites with non-touch technique.</td> </tr> <tr> <td>Instrument sterilisation</td> <td>Validated reprocessing: collect only instruments needed: use single-use disposables where available. </td> </tr> <tr> <td>Surfaces & waterlines</td> <td>Disinfect chair/surfaces between every patient: flush waterlines to reduce biofilm</td> </tr> <tr> <td>Sharps & post-exposure</td> <td>Never recap by hand: dispose to sharps bin. Needlestick — first aid, notify tutor, CAMS report, baseline bloods.</td> </tr> <tr> <td>HBV vaccination</td> <td>Mandatory for dental workers (confirm seroconversion). No HCV vaccine — rely on precautions & sharps safety</td> </tr> <tr> <td>Aerosol / TB control</td> <td>Rubber dam + high-volume suction; respiratory hygiene. Latent TB non-infectious — defer only if ACTIVE TB suspected. </td> </tr> <tr> <td>Waste & reporting</td> <td>Clinical waste in clinical area only: report all incidents via CAMS and notify supervisor</td> </tr> </table>  #### Cross-Infection Control Steps Standard precautions are the baseline for EVERY patient — HIV, latent TB and IVDU history reinforce, but do not change, routine practice. | Measure | Key actions | |---|---| | Standard precautions | Treat every patient as a potential carrier; don't "flag" — many carriers are undetected. | | PPE | Gloves, mask, eye protection, gown: full barrier for aerosol/surgical work; change torn gloves + hand hygiene. | | Hand hygiene | Single most important measure: perform at all critical moments; no jewellery, nail polish or artificial nails. | | Aseptic technique | Five principles: risk-assess, standard in surgical, protect key parts/sites with non-touch technique. | | Instrument sterilisation | Validated reprocessing: collect only instruments needed; use single-use disposables where available. | | Surfaces & waterlines | Disinfect chair/surfaces between every patient; flush waterlines to reduce biofilm. | | Sharps & post-exposure | Never recap by hand; dispose to sharps bin. Needlestick — first aid, notify tutor, CAMS report, baseline bloods. | | HBV vaccination | Mandatory for dental workers (confirm seroconversion). No HCV vaccine — rely on precautions & sharps safety. | | Aerosol / TB control | Rubber dam + high-volume suction; respiratory hygiene. Latent TB non-infectious — defer only if ACTIVE TB suspected. | | Waste & reporting | Clinical waste in clinical area only; report all incidents via CAMS and notify supervisor. | *Table 3.1 Standard precautions* - ==If active tuberculosis is suspected, confirm the patient’s status and use droplet and airborne precautions with enhanced infection-control procedures.== A two-column table titled 'TABLE 3.1 Standard precautions' listing various infection control measures (e.g., PPE, Hand hygiene) alongside their corresponding key actions. # Key Distinctions to Flag ## Latent TB ≠ Active TB Latent infection is non-infectious — no airborne spread. Airborne isolation and deferral of aerosol-generating care are not required for this patient... ...unless reactivation to active disease is suspected (chronic cough, weight loss, night sweats) — defer & refer. #### Key Distinctions to Flag: Latent TB ≠ Active TB Latent infection is non-infectious — no airborne spread. Airborne isolation and deferral of aerosol-generating care are not required for this patient... ...unless reactivation to active disease is suspected (chronic cough, weight loss, night sweats) — defer & refer. > [!note] Lecturer — Confirming Latent TB > A patient’s statement that they have latent tuberculosis should be confirmed with the general practitioner. > > - The clinician may not know whether the infection is truly latent or active. Question 3 Non-Medical Factors Affecting Success | Factor | What it means for the treatment plan | |---|---| | Housing instability | No fixed address breaks the recall chain; appliances lost/unstored — defer definitive prosthetics, single-visit stabilisation, label dentures | | Finances / unemployment | Any out-of-pocket cost is a hard barrier; can't afford DHI tools — establish concession eligibility; durable low-cost options, supply starter aids | | Access & attendance | Symptom-driven, irregular: transport a barrier — plan as if each visit is the last; pain/infection first; opportunistic prevention | | Social isolation | No network for reminders, transport or aftercare — liaise with Halfway Home / community team as surrogate support | | Motivation & low dental IQ | Once-daily hard-brush — prevention-first; intensive OHI, CAMBRA; downgrade prognosis where maintenance uncertain | | Diet & behavioural risk | Alcohol + ex-smoking (oral-cancer/period), erosion, xerostomia — aggressive caries/erosion prevention, cancer surveillance, cessation support | | Mental health / post-release | High depression & relapse risk reduces engagement — short predictable visits, build trust, screen & refer, coordinate care | | Communication & literacy | May not understand condition or consent — plain language, teach-back, visual aids; involve support staff in reinforcement |  #### Non-Medical Factors Affecting Success | Factor | What it means for the treatment plan | |---|---| | Housing instability | No fixed address breaks the recall chain; appliances lost/unstored — defer definitive prosthetics, single-visit stabilisation, label dentures. | | Finances / unemployment | Any out-of-pocket cost is a hard barrier; can't afford DHI tools — establish concession eligibility; durable low-cost options, supply starter aids. | | Access & attendance | Symptom-driven, irregular: transport a barrier — plan as if each visit is the last; pain/infection first; opportunistic prevention. | | Social isolation | No network for reminders, transport or aftercare — liaise with Halfway Home / community team as surrogate support. | | Motivation & low dental IQ | Once-daily hard-brush — prevention-first; intensive OHI, CAMBRA; downgrade prognosis where maintenance uncertain. | | Diet & behavioural risk | Alcohol + ex-smoking (oral-cancer/period), erosion, xerostomia — aggressive caries/erosion prevention, cancer surveillance, cessation support. | | Mental health / post-release | High depression & relapse risk reduces engagement — short predictable visits, build trust, screen & refer, coordinate care. | | Communication & literacy | May not understand condition or consent — plain language, teach-back, visual aids; involve support staff in reinforcement. | > [!note] Lecturer — Social Constraints > Mandatory prison aftercare requirements may further restrict the patient’s ability to engage with treatment. > > - Sleeping rough and limited ability to maintain oral hygiene make complex prosthodontic treatment difficult. A two-column table titled 'Non-Medical Factors Affecting Success' listing various social and behavioral factors in the left column (e.g., Housing instability, Finances / unemployment) and their corresponding implications for treatment planning in the right column. BOTTOM LINE FOR THE PLAN # A realistic, phased, prevention-first plan Social reality -> **guarded prognosis.** Match the achievable plan to the patient, not the ideal textbook plan. | | | | :--- | :--- | | <table><tr><td><b>1 Relieve</b><br><br>Pain & acute infection control<br>first</td></tr></table> | <table><tr><td><b>2 Stabilise</b><br><br>Arrest caries & periodontal<br>disease</td></tr></table> | | <table><tr><td><b>3 Prevent</b><br><br>Intensive OHI, fluoride,<br>CAMBRA</td></tr></table> | <table><tr><td><b>4 Reassess</b><br><br>Review engagement before<br>definitive care</td></tr></table> | **Defer definitive prosthetics** until he is housed, stable and demonstrating maintenance — sequence: relieve → stabilise → prevent → reassess. #### A realistic, phased, prevention-first plan Social reality → **guarded prognosis**. Match the achievable plan to the patient, not the ideal textbook plan. 1. **Relieve** — Pain & acute infection control first 2. **Stabilise** — Arrest caries & periodontal disease 3. **Prevent** — Intensive OHI, fluoride, CAMBRA 4. **Reassess** — Review engagement before definitive care **Defer definitive prosthetics** until he is housed, stable and demonstrating maintenance — sequence: relieve → stabilise → prevent → reassess. BOTTOM LINE FOR THE PLAN # A realistic, phased, prevention-first plan **Social reality →* **_guarded prognosis_**. Match the achievable plan to the patient, not the ideal textbook plan. ## 1 Relieve Pain & acute infection control first ## 2 Stabilise Arrest caries & periodontal disease ## 3 Prevent Intensive OHI, fluoride, CAMBRA ## 4 Reassess Review engagement before definitive care **Defer definitive prosthetics** until he is housed, stable and demonstrating maintenance — sequence: relieve → stabilise → prevent → reassess. #### A realistic, phased, prevention-first plan **Social reality → guarded prognosis.** Match the achievable plan to the patient, not the ideal textbook plan. 1. **Relieve** — Pain & acute infection control first 2. **Stabilise** — Arrest caries & periodontal disease 3. **Prevent** — Intensive OHI, fluoride, CAMBRA 4. **Reassess** — Review engagement before definitive care **Defer definitive prosthetics** until he is housed, stable and demonstrating maintenance — sequence: relieve → stabilise → prevent → reassess. <img>A split-screen image showing a Google Calendar schedule on the left and a National Library of Medicine webpage on the right. The calendar displays various events on June 22. The webpage is viewing a bookshelf entry for "StatPearls [Internet]" and displays an article titled "Amitriptyline"  *A split-screen image showing a Google Calendar schedule on the left and a National Library of Medicine webpage on the right. The calendar displays various events on June 22. The webpage is viewing a bookshelf entry for "StatPearls [Internet]" and displays an article titled "Amitriptyline".* A screenshot of a Google Calendar interface displaying a weekly schedule for June 2026, with the date June 22 highlighted. The view shows various color-coded time blocks representing events such as lectures and clinical sessions, alongside an open context menu offering options to delete or change the event color. Patient Background **Dental History** • Brushes once a day with manual toothbrush • Irregular dental attender • Does not use interdental brushing aid **Oral Examination** • Prolonged oral health neglect • Multiple interproximal caries • Erosion lesions and root caries **Social History** • Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke • Hokkien-speaking (a type of Mandarin dialect) • Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice • Receiving social assistance • Stays with wife, has two married children who visit infrequently #### Dental History - Brushes once a day with manual toothbrush - Irregular dental attender - Does not use interdental brushing aid #### Oral Examination - Prolonged oral health neglect - Multiple interproximal caries - Erosion lesions and root caries #### Social History - Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke - Hokkien-speaking (a type of Mandarin dialect) - Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice - Receiving social assistance - Stays with wife, has two married children who visit infrequently # Medically compromised 67 year old patient, complaining of weakening and crumbling teeth   *Medically compromised* 67 year old patient, complaining of weakening and crumbling teeth A panoramic dental radiograph showing the upper and lower jaws, including multiple teeth and a distinct radiopaque implant fixture in the right mandibular region. No discernible content is present. ## Patient Background ### Dental History * Brushes once a day with manual toothbrush * Irregular dental attender * Does not use interdental brushing aid ### Oral Examination * Prolonged oral health neglect * Multiple interproximal caries * Erosion lesions and root caries ### Social History * Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke * Hokkien-speaking (a type of Mandarin dialect) * Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice * Receiving social assistance * Stays with wife, has two married children who visit infrequently #### Dental History - Brushes once a day with manual toothbrush - Irregular dental attender - Does not use interdental brushing aid #### Oral Examination - Prolonged oral health neglect - Multiple interproximal caries - Erosion lesions and root caries #### Social History - Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke - Hokkien-speaking (a type of Mandarin dialect) - Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice - Receiving social assistance - Stays with wife, has two married children who visit infrequently # **01 Medical Risk Assessment** | Medical Categories and others | Risk | Modifications/ Implication | | :--- | :--- | :--- | | Respiratory (COPD + asthma, ex-smoker) | Asthma Attack<br>Poor Healing<br>Oral Candidosis<br>Periodontal disease<br>Dry mouth<br>Caries | Remind patient to bring inhaler<br>Avoid triggers<br>Short + morning appointment<br>Discretion with RD<br>More upright position during appointment<br>Risk and spit with water after inhaler use<br>Have emergency oxygen management kit available | | CVD (hypertension, hyperlipidaemia) | Hypertensive crisis<br>Risk of stroke or heart attack | Ensure BP is controlled<br>Ensure emergency kit is available | | Reduced BMI | Nutritional deficiencies can lead to oral manifestations | Diet analysis<br>Weight history (inquire if sudden weight loss associated with underlying medical conditions)<br>Blood tests | | Social: Financial constraints and social barriers | Poor attendance<br>Limited treatment option | Charitable dental service pm |  | Medical Categories and others | Risk | Modifications/ Implication | | :--- | :--- | :--- | | Respiratory (COPD + asthma, ex-smoker) | Asthma Attack<br>Poor Healing<br>Oral Candidosis<br>Periodontal disease<br>Dry mouth<br>Caries | Remind patient to bring inhaler<br>Avoid triggers<br>Short + morning appointment<br>Discretion with RD<br>More upright position during appointment<br>Risk and spit with water after inhaler use<br>Have emergency oxygen management kit available | | CVD (hypertension, hyperlipidaemia) | Hypertensive crisis<br>Risk of stroke or heart attack | Ensure BP is controlled<br>Ensure emergency kit is available | | Reduced BMI | Nutritional deficiencies can lead to oral manifestations | Diet analysis<br>Weight history (inquire if sudden weight loss associated with underlying medical conditions)<br>Blood tests | | Social: Financial constraints and social barriers | Poor attendance<br>Limited treatment option | Charitable dental service pm | A three-column table titled 'Medical Risk Assessment' categorizing medical conditions (Respiratory, CVD, Reduced BMI, Social) alongside their associated risks and specific modifications or implications for dental care. How are we assessing the COPD risk? a. Spirometry test (FEV1) patient 38% of normal predicted b. Chest X-ray (flattened diaphragm) c. Oxygen saturation (<91% unstable, >95% stable) patient has 93% d. Respiratory rate (depth and rate/min)  How are we assessing the COPD risk? a. Spirometry test (FEV1) patient 38% of normal predicted b. Chest X-ray (flattened diaphragm) c. Oxygen saturation (<91% unstable, >95% stable) patient has 93% d. Respiratory rate (depth and rate/min) A medical illustration comparing the respiratory system and alveoli of a healthy individual versus one with COPD. The upper section, labeled 'HEALTHY', depicts clear pink lungs and intact alveolar sacs, while the lower section shows damaged lung tissue with brownish, enlarged air spaces. - What are the treatment options for managing multiple caries and high caries risk? - Fillings (direct vs indirect) - Neutrafluor 5000ppm - Diet modification (erosion lesions) - Saliva analysis - Oral Hygiene Instruction (increasing to brushing 2/day) - Chlorhexidine mouthrinse (intermittent use to avoid staining) - What are the treatment options for managing multiple caries and high caries risk? - Fillings (direct vs indirect) - Neutrafluor 5000ppm - Diet modification (erosion lesions) - Saliva analysis - Oral Hygiene Instruction (increasing to brushing 2/day) - Chlorhexidine mouthrinse (intermittent use to avoid staining) What other factors do you need to consider that can affect treatment success? 1. Patient motivation and oral hygiene maintenance 2. Language barrier: potentially having a translator 3. Financial barriers: requires social assistance 4. Previous smoker: Encourage continuation of smoking cessation -> can impact periodontal treatment success  What other factors do you need to consider that can affect treatment success? 1. Patient motivation and oral hygiene maintenance 2. Language barrier: potentially having a translator 3. Financial barriers: requires social assistance 4. Previous smoker: Encourage continuation of smoking cessation → can impact periodontal treatment success A black-and-white line drawing icon depicting a medical clipboard or chart with a heart rate monitor symbol (ECG trace) on the paper. The image provided is a black screen containing no visible text, images, figures, or data to transcribe. *No visible content on this page.* <img>Corporate background image with the word Extron overlaid in white<br> **CHAPTER 20 - Chronic obstructive pulmonary disease** **SECTION I** **Clinical Scenario** A 67-year-old man turned up at the charity clinic that you volunteer at. He complains of 'weakening' and 'crumbling' teeth. **Medical History** * Chronic Obstructive Pulmonary Disease - irregular in medical follow-up * FEV1, or forced expiratory volume in 1 sec, was 70% of normal predicted. Recent chest x-rays showed flattened diaphragm. * SpO2 is 92% on room air, heart rate 94/min * Respiratory rate is 24 per minute and shallow * Dry hacking non-productive cough, pitting oedema. * Hypertension - 142/85 * Hyperlipidaemia * Asthma * Others: Ex-smoker with 70 pack-year cigarette history, reduces BMI **Medication** * Prednisolone 10mg * Ipratropium bromide + albuterol sulfate combination inhaler * Salbutamol Inhaler * Simvastatin * Lisinopril **Dental History** * Brushes once a day with manual toothbrush * Irregular dental attendee * Does not use interdental brushing aid **Social History** * Works at the local hawker centre for almost 50 years; exposure to long-term inhalation of smoke (see **Figure 1.20.1**) * Kok-kok operating (a type of Mandarin Opera) * Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice * Receiving social assistance * Stays with wife, has two married children who visit infrequently **Oral Examination** * Prolonged oral health neglect * Multiple interproximal caries * Frequent crowns and root caries 1. Create a Medical Category - Risk Assessment - Modifications table. 2. How do you assess the severity of the patient's COPD? 3. What are the treatment options for managing multiple caries & high caries risk? 4. What other factors do you need to consider that can affect treatment outcome?       #### Clinical Scenario A 67-year-old man turned up at the charity clinic that you volunteer at. He complains of 'weakening' and 'crumbling' teeth. #### Medical History - Chronic Obstructive Pulmonary Disease - irregular in medical follow-up - FEV1, or forced expiratory volume in 1 sec, was 70% of normal predicted. Recent chest x-rays showed flattened diaphragm. - SpO2 is 92% on room air, heart rate 94/min - Respiratory rate is 24 per minute and shallow - Dry hacking non-productive cough, pitting oedema - Hypertension - 142/85 - Hyperlipidaemia - Asthma - Others: Ex-smoker with 70 pack-year cigarette history, reduces BMI #### Medication - Prednisolone 10mg - Ipratropium bromide + albuterol sulfate combination inhaler - Salbutamol inhaler - Simvastatin - Lisinopril #### Dental History - Brushes once a day with manual toothbrush - Irregular dental attendee - Does not use interdental brushing aid #### Social History - Works at the local hawker centre for almost 50 years; exposure to long-term inhalation of smoke (see **Figure 1.20.1**) - Kok-kok operating (a type of Mandarin Opera) - Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice - Receiving social assistance - Stays with wife, has two married children who visit infrequently #### Oral Examination - Prolonged oral health neglect - Multiple interproximal caries - Frequent crowns and root caries #### Questions 1. Create a Medical Category - Risk Assessment - Modifications table. 2. How do you assess the severity of the patient's COPD? 3. What are the treatment options for managing multiple caries & high caries risk? 4. What other factors do you need to consider that can affect treatment outcome? The image is a low-resolution photograph showing a person, likely a chef or food vendor, wearing white clothing and a hat while working at a station with visible steam or smoke rising from cooking equipment. This illustrates the patient's long-term occupational exposure to inhalation of smoke mentioned in the social history. This is a panoramic dental radiograph (orthopantomogram) showing the patient's maxillary and mandibular arches, teeth, and surrounding bone structures. It visually supports the clinical findings of multiple caries and restorations mentioned in the text. "No discernible content is present." No discernible content is present. No discernible content is present. No discernible content is present. # CHAPTER 28. Chronic obstructive pulmonary disease ## SECTION I **Clinical Scenario** A 67 year old man turned up at the charity clinic that you volunteer at. He complains of "weakening" and "crumbling" teeth. **Medical History:** Chronic Obstructive Pulmonary Disease - irregular in medical follow-up * FEV1, or forced expiratory volume in 1 sec. was 38% of normal predicted. Recent chest x-rays showed flattened diaphragm. * SpO2 is 93% on room air, heart rate 84/min * Respiratory rate is 24 per minute and shallow * Dry hacking non-productive cough, pitting oedema * Hypertension - 152/85 * Hyperlipidaemia * Asthma * Others: Ex-smoker with 70 pack-year cigarette history, reduced BMI **Medication** * Prednisolone 10mg * Ipratropium bromide + salbutamol sulfate combination inhaler * Salbutamol inhaler * Simvastatin * Enalapril **Dental History** * Brushes once a day with manual toothbrush * Irregular dentalattender * Does not use interdental brushing aid **Social History** * Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke (see **Figure 1.26.1**). * Hokkien-speaking (a type of Mandarin dialect) * Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 rays ago, reportedly due to rising tobacco tax and physician advice * Receiving social assistance * Stays with wife, has two married children who visit infrequently **Oral Examination** * Prolonged oral health neglect * Multiple interproximal caries * Erosion lesions and root caries 1. Create a Medical Category - Risk Assessment - Modifications table. 2. How do you assess the severity of the patient's COPD? 3. What are the treatment options for managing multiple caries & high caries risk? 4. What other factors do you need to consider that can affect treatment success?   #### Clinical Scenario A 67-year-old man turned up at the charity clinic that you volunteer at. He complains of "weakening" and "crumbling" teeth. #### Medical History Chronic Obstructive Pulmonary Disease - irregular in medical follow-up - FEV1, or forced expiratory volume in 1 sec, was 38% of normal predicted. Recent chest x-rays showed flattened diaphragm. - SpO2 is 93% on room air, heart rate 84/min - Respiratory rate is 24 per minute and shallow - Dry hacking non-productive cough, pitting oedema - Hypertension - 152/85 - Hyperlipidaemia - Asthma - Others: Ex-smoker with 70 pack-year cigarette history, reduced BMI #### Medication - Prednisolone 10mg - Ipratropium bromide + salbutamol sulfate combination inhaler - Salbutamol inhaler - Simvastatin - Enalapril #### Dental History - Brushes once a day with manual toothbrush - Irregular dental attender - Does not use interdental brushing aid #### Social History - Works at the local hawker centre for almost 50 years, exposure to long-term inhalation of smoke (see **Figure 1.26.1**) - Hokkien-speaking (a type of Mandarin dialect) - Smoked for 50 years, around 1.5 pack a day. Quit smoking 2 years ago, reportedly due to rising tobacco tax and physician advice - Receiving social assistance - Stays with wife, has two married children who visit infrequently #### Oral Examination - Prolonged oral health neglect - Multiple interproximal caries - Erosion lesions and root caries #### Questions 1. Create a Medical Category - Risk Assessment - Modifications table. 2. How do you assess the severity of the patient's COPD? 3. What are the treatment options for managing multiple caries & high caries risk? 4. What other factors do you need to consider that can affect treatment success? > [!note] Lecturer — Additional Patient History > The lecturer also described a 45-year-old patient presenting for dental care after one year. > > - Medical conditions included Down syndrome, moderate intellectual disability, autism spectrum disorder, epilepsy, mild hypertension, diabetes, osteoporosis, allergic rhinitis, eczema, and childhood asthma. > - The main caregiver was the patient’s 80-year-old mother; his 82-year-old father worked as a taxi driver. > - The caregivers’ age could contribute to poor attendance, limited daily oral-care support, and limited support at home. > [!note] Lecturer — Medication and Allergy > The patient had a penicillin allergy presenting as a rash, so penicillin should be avoided. > > - Medications included metformin, bisphosphonates for osteoporosis, and sodium valproate for epilepsy. > - Medication and allergy details affect prescribing, infection management, bleeding and healing considerations, and potential drug interactions. > [!note] Lecturer — OSCE Emergency Risks > Medical emergencies and steroid-related risks may appear in OSCE questions. > > - Students should know how to manage hypoglycaemia, asthma exacerbation, cardiac symptoms, and possible adrenal crisis. A photograph showing a person wearing an apron and using a large woven bamboo sieve to toss or sift food, likely noodles or vegetables, in a wok or pan. The image illustrates the social history detail of working at a hawker centre with exposure to smoke. Panoramic dental radiograph (orthopantomogram) showing the maxillary and mandibular arches with multiple missing teeth, restorations, and signs of periodontal bone loss. # Extron Extron There is no text or content visible in the provided image. <table> <colgroup> <col style="text-align: left"> <col style="text-align: left"> <col style="text-align: left"> </colgroup> <thead> <tr class="header"> <th><strong>Category</strong></th> <th><strong>Main risks for dental care</strong></th> <th><strong>Dental modifications</strong></th> </tr> </thead> <tbody> <tr class="odd"> <td><strong>Increased BMI / reduced mobility</strong></td> <td>Difficult positioning, limited access, airway risk, fatigue, chair weight limit</td> <td>Check bariatric chair/equipment, allow longer appointments, treat semi-upright, use extra assistance/retraction</td> </tr> <tr class="even"> <td><strong>OSA on CPAP</strong></td> <td>Airway obstruction, higher sedation/opioid risk, worse when supine</td> <td>Avoid/minimise sedation and opioids, treat more upright, bring CPAP if hospital/GA care needed</td> </tr> <tr class="odd"> <td><strong>Asthma</strong></td> <td>Stress/anxiety may trigger attack</td> <td>Confirm control, ensure salbutamol inhaler available, avoid triggers, stress reduction</td> </tr> <tr class="even"> <td><strong>Hypertension</strong></td> <td>Stress/pain may raise BP</td> <td>Check BP, use profound LA, reduce stress, limit adrenaline if unstable</td> </tr> <tr class="odd"> <td><strong>Ischaemic heart disease / angina</strong></td> <td>Stress may precipitate angina</td> <td>Short morning appointments, profound LA, keep GTN available, avoid excessive adrenaline</td> </tr> <tr class="even"> <td><strong>Diabetes mellitus</strong></td> <td>Hypoglycaemia, infection risk, delayed healing</td> <td>Morning appointments, ensure patient has eaten and taken meds, check control if known, review healing</td> </tr> <tr class="odd"> <td><strong>Aspirin use</strong></td> <td>Increased bleeding/oozing</td> <td>Usually continue aspirin, use local haemostatic measures (pressure, sutures, pack)</td> </tr> <tr class="even"> <td><strong>Major depression / dental anxiety</strong></td> <td>Avoidance, poor attendance, preference for extraction</td> <td>Empathetic communication, staged care, explain options clearly, consider anxiolysis if appropriate</td> </tr> <tr class="odd"> <td><strong>GORD + erosion</strong></td> <td>Reflux risk when supine, ongoing tooth wear</td> <td>Treat more upright, avoid prolonged supine position, reinforce erosion prevention</td> </tr> <tr class="even"> <td><strong>Osteoarthritis / musculoskeletal pain</strong></td> <td>Transfer difficulty, discomfort lying flat/opening long</td> <td>Use positioning aids, give breaks, keep appointments shorter</td> </tr> </tbody> </table>  | Category | Main risks for dental care | Dental modifications | |---|---|---| | Increased BMI / reduced mobility | Difficult positioning, limited access, airway risk, fatigue, chair weight limit | Check bariatric chair/equipment, allow longer appointments, treat semi-upright, use extra assistance/retraction | | OSA on CPAP | Airway obstruction, higher sedation/opioid risk, worse when supine | Avoid/minimise sedation and opioids, treat more upright, bring CPAP if hospital/GA care needed | | Asthma | Stress/anxiety may trigger attack | Confirm control, ensure salbutamol inhaler available, avoid triggers, stress reduction | | Hypertension | Stress/pain may raise BP | Check BP, use profound LA, reduce stress, limit adrenaline if unstable | | Ischaemic heart disease / angina | Stress may precipitate angina | Short morning appointments, profound LA, keep GTN available, avoid excessive adrenaline | | Diabetes mellitus | Hypoglycaemia, infection risk, delayed healing | Morning appointments, ensure patient has eaten and taken meds, check control if known, review healing | | Aspirin use | Increased bleeding/oozing | Usually continue aspirin, use local haemostatic measures (pressure, sutures, pack) | | Major depression / dental anxiety | Avoidance, poor attendance, preference for extraction | Empathetic communication, staged care, explain options clearly, consider anxiolysis if appropriate | | GORD + erosion | Reflux risk when supine, ongoing tooth wear | Treat more upright, avoid prolonged supine position, reinforce erosion prevention | | Osteoarthritis / musculoskeletal pain | Transfer difficulty, discomfort lying flat/opening long | Use positioning aids, give breaks, keep appointments shorter | A three-column table listing patient categories (e.g., Raised BMI, OSA on CPAP, Asthma) alongside their associated main risks for dental care and recommended modifications to treatment. | Category | Key risk | Modification | |---|---|---| | Osteoarthritis / musculoskeletal pain | Transfer difficulty, lying flat, prolonged opening | Positioning aids, breaks, shorter appointments | | Poor diet | Very high caries and erosion risk | Diet advice, fluoride 5000 ppm if indicated, prevention first | | Poor posterior access | Plaque retention, caries, gingival inflammation | Electric/long-handled brush, interdental aids, fluoride, frequent recalls | | Social / transport issues | Attendance and follow-up difficulties, limited post-op support | Coordinate appointments and transport, clear post-op plan, consider hospital/community setting |      | Category | Key risk | Modification | |---|---|---| | Osteoarthritis / musculoskeletal pain | Transfer difficulty, lying flat, prolonged opening | Positioning aids, breaks, shorter appointments | | Poor diet | Very high caries and erosion risk | Diet advice, fluoride 5000 ppm if indicated, prevention first | | Poor posterior access | Plaque retention, caries, gingival inflammation | Electric/long-handled brush, interdental aids, fluoride, frequent recalls | | Social / transport issues | Attendance and follow-up difficulties, limited post-op support | Coordinate appointments and transport, clear post-op plan, consider hospital/community setting | A three-column table with a blue header row labeled 'Category', 'Key risk', and 'Modification'. The table lists four categories of patient factors, each accompanied by a small teal icon (a person in pain, a drink cup, a tooth with a magnifying glass, and a bus), detailing the associated risks and suggested dental modifications. A simple, pixelated blue icon depicting a figure bent over, clutching their lower back with radiating lines to indicate pain. A simple graphic icon depicting a blue drink cup with a straw alongside a blue donut. A small, pixelated icon showing a blue tooth outline with a magnifying glass symbol overlapping its lower right portion. A simple blue icon depicting the front view of a bus. What additional factors do you have to consider when undertaking a risk assessment of this patient Chair and access safety + Patient weighs 542 kg + Confirm dental chair weight limit + Ensure safe transfer from balance wheelchair + Consider whether clinic has enough space and staff support Airway and positioning Because of *obesity + sleep apnoea + asthma + GERD*, avoid fully supine positioning if uncomfortable or unsafe. Risks: + Airway obstruction + Breathlessness + Reflux + Reduced tolerance of long procedures Sedation risk She has dental anxiety, but sedation is not straightforward. Obesity and OSA increase risk of: + Airway obstruction + Hypoventilation + Respiratory depression + Opioid/sedative complications So avoid casual oral benzodiazepines or opioid-heavy analgesia. If sedation/OSA is required, this is likely a hospital/specialist setting decision. Cardiovascular risk She has: + Hypertension + Ischaemic heart disease + Angina + Aspirin + Beta-blocker/amlodipine You need: + BP check + GTN available + Stress reduction + Profound LA + Avoid excessive adrenaline + Monitor symptoms Diabetes and Infection/Healing Diabetes increases risk of: + Infection + Delayed healing + Periodontal disease + Post-op complications Check control if possible, ensure she has eaten, and arrange review. Social risk She lives alone, rarely leaves home and requires hospital transport. So: + Make sure she can attend review. Give very clear written post-op instructions. + Consider whether she needs someone at home after extraction + Avoid treatment plans that depend on frequent attendance unless realistic What additional factors do you have to consider when undertaking a risk assessment of this patient? #### Chair and Access Safety - Patient weighs 542 kg - Confirm dental chair weight limit - Ensure safe transfer from balance wheelchair - Consider whether clinic has enough space and staff support #### Airway and Positioning Because of *obesity + sleep apnoea + asthma + GERD*, avoid fully supine positioning if uncomfortable or unsafe. Risks: - Airway obstruction - Breathlessness - Reflux - Reduced tolerance of long procedures #### Sedation Risk She has dental anxiety, but sedation is not straightforward. Obesity and OSA increase risk of: - Airway obstruction - Hypoventilation - Respiratory depression - Opioid/sedative complications So avoid casual oral benzodiazepines or opioid-heavy analgesia. If sedation/OSA is required, this is likely a hospital/specialist setting decision. #### Cardiovascular Risk She has: - Hypertension - Ischaemic heart disease - Angina - Aspirin - Beta-blocker/amlodipine You need: - BP check - GTN available - Stress reduction - Profound LA - Avoid excessive adrenaline - Monitor symptoms #### Diabetes and Infection/Healing Diabetes increases risk of: - Infection - Delayed healing - Periodontal disease - Post-op complications Check control if possible, ensure she has eaten, and arrange review. #### Social Risk She lives alone, rarely leaves home and requires hospital transport. So: - Make sure she can attend review. Give very clear written post-op instructions. - Consider whether she needs someone at home after extraction - Avoid treatment plans that depend on frequent attendance unless realistic > [!note] Lecturer — Chair Capacity > Dental chairs commonly support less than 150 kg, whereas a bariatric chair may support approximately 500 kg. The patient’s weight must be checked against the chair and equipment limits. - ==Assess limited mouth access, soft-tissue obstruction, reduced mobility, and difficulty reaching posterior areas== > [!note] Lecturer — Upright Positioning > Supine positioning may worsen breathing because tissues around the neck and chest press downward. Obstructive sleep apnoea may worsen as tissues around the tongue and throat obstruct the airway; fluid control may also become more difficult, and holding the tongue up can cause the palate to fall backwards and obstruct nasal breathing. A slightly more upright position may improve breathing. > [!note] Lecturer — Anaesthetic Referral > High BMI and airway concerns may require referral for appropriate anaesthetic assessment. Obstructive sleep apnoea and CPAP use require particular caution with sedation, opioids, and general anaesthesia. > [!note] Lecturer — Adrenaline and Pain > The use of local anaesthetic with adrenaline should be discussed with the clinical tutor. Effective pain control may reduce anxiety-related complications. > [!note] Lecturer — Warfarin and INR > When a patient takes warfarin, check the INR and contact the doctor when appropriate. Local haemostatic measures should be considered rather than altering medication without appropriate consultation. The patient consents to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? **Evaluate suitability as a bariatric patient** * Ability to maintain airway during procedure * Ability to access intraoral site * Bariatric dental chair, positioning, and short appointment length * Evaluate BP, HR and RR * Patient is not suitable for day surgery under GA due to BMI>40, and OSA. * First line would be extraction under LA and can do oral sedation. * Can treatment be delayed until risk factors mitigated? **Risk of delayed haemostasis from warfarin use** **Local anaesthetic considerations** * Ability to achieve profound anaesthesia * Use of vasoconstrictor * Adrenaline can cause excitatory CNS effects and worsen dental anxiety * Caution for use in patients with uncontrolled angina **Local aerosol control** * Manage triggers for asthma, consider additional HVAC ventilation * Prepare emergency oxygen and asthma inhaler **Glycaemic control** * Assess BG/ before procedure and monitor patient vital signs during **Confirm carer/hospital transport availability after procedure** **Post-extraction review** * High risk of delayed/impaired healing * Reinforce positive OH behaviours at home, use modified techniques to improve access when brushing and cleaning interproximally The patient consents to extraction of the carious upper left first molar. How would you modify the delivery of dental treatment? #### Evaluating Suitability as a Bariatric Patient - Ability to maintain airway during procedure - Ability to access intraoral site - Bariatric dental chair, positioning, and short appointment length - Evaluate BP, HR and RR - Patient is not suitable for day surgery under GA due to BMI>40, and OSA. - First line would be extraction under LA and can do oral sedation. - Can treatment be delayed until risk factors mitigated? #### Risk of Delayed Haemostasis from Warfarin Use #### Local Anaesthetic Considerations - Ability to achieve profound anaesthesia - Use of vasoconstrictor - Adrenaline can cause excitatory CNS effects and worsen dental anxiety - Caution for use in patients with uncontrolled angina #### Local Aerosol Control - Manage triggers for asthma, consider additional HVAC ventilation - Prepare emergency oxygen and asthma inhaler #### Glycaemic Control - Assess BG before procedure and monitor patient vital signs during #### Transport and Carer Support - Confirm carer/hospital transport availability after procedure #### Post-Extraction Review - High risk of delayed/impaired healing - Reinforce positive OH behaviours at home, use modified techniques to improve access when brushing and cleaning interproximally - ==Use rubber dam with discretion if it compromises breathing or increases difficulty with airway control== - Weight/BMI exceeds dental chair or equipment limits or hoisting required - Immobility / cannot transfer to or be safely positioned in a standard chair - ASA III–IV or unstable/complex medical history - Sedation or GA indicated but high-risk (e.g. OSA) —> needs anaesthetist/hospital - Difficult airway, severe anxiety needing advanced behavioural/pharmacological management - Surgery environment can’t accommodate access, manual handling, or emergency response - Weight/BMI exceeds dental chair or equipment limits or hoisting required - Immobility / cannot transfer to or be safely positioned in a standard chair - ASA III–IV or unstable/complex medical history - Sedation or GA indicated but high-risk (e.g. OSA) → needs anaesthetist/hospital - Difficult airway, severe anxiety needing advanced behavioural/pharmacological management - Surgery environment can't accommodate access, manual handling, or emergency response ASA grading criteria - patient falling under ASA III | ASA grade | Meaning | Bariatric relevance | | :--- | :--- | :--- | | ASA I | Healthy patient | Not applicable here. | | ASA II | Mild systemic disease | Obesity BMI 30–40 without major systemic complications may fit here. | | ASA III | Severe systemic disease, not immediately life-threatening | **Most appropriate for this patient:** BMI 46.9 plus controlled angina, hypertension, diabetes, OSA on CPAP, asthma. | | ASA IV | Severe systemic disease that is a constant threat to life | If she had unstable angina, uncontrolled hypertension, poorly controlled diabetes with complications, severe uncontrolled asthma, or severe OSA/respiratory compromise. | | ASA V | Moribund patient not expected to survive without operation | Not relevant for routine dental treatment. |  ASA grading criteria — patient falling under ASA III: | ASA grade | Meaning | Bariatric relevance | |---|---|---| | ASA I | Healthy patient | Not applicable here. | | ASA II | Mild systemic disease | Obesity BMI 30–40 without major systemic complications may fit here. | | ASA III | Severe systemic disease, not immediately life-threatening | Most appropriate for this patient: BMI 46.9 plus controlled angina, hypertension, diabetes, OSA on CPAP, asthma. | | ASA IV | Severe systemic disease that is a constant threat to life | If she had unstable angina, uncontrolled hypertension, poorly controlled diabetes with complications, severe uncontrolled asthma, or severe OSA/respiratory compromise. | | ASA V | Moribund patient not expected to survive without operation | Not relevant for routine dental treatment. | A three-column table detailing ASA grading criteria, listing grades I through V alongside their medical meanings and specific bariatric relevance. The row for ASA III is highlighted in bold text to indicate it as the most appropriate classification for a patient with a BMI of 46.9 and multiple controlled systemic conditions. # Extron *Extron* The image provided is completely black with no visible text, labels, or data. The image provided is completely black with no visible text, labels, or data. The Patient Patient presenting for dental care, last seen 2 years ago **MEDICAL HISTORY** * Down syndrome with moderate intellectual disability * Autism spectrum disorder * Epilepsy * Mild hypertension (baseline 115/80) * Diabetes mellitus (mild) * Osteoporosis (very low BMI) * Allergic rhinitis, eczema, childhood asthma **MEDICATION & ALLERGY** * Epitil (calcium supplement) – amino * Calciphosphate – for osteoporosis * Metformin – for diabetes * **ALLERGY:** Peanuts (inhalation) **DENTAL & SOCIAL HISTORY** * Washes occasionally, once a week, last year ago * Max: caregiver 80-year-old mother * Father (R5) is a cab driver – transport Patient presenting for dental care, last seen 2 years ago #### Medical History - Down syndrome with moderate intellectual disability - Autism spectrum disorder - Epilepsy - Mild hypertension (baseline 115/80) - Diabetes mellitus (mild) - Osteoporosis (very low BMI) - Allergic rhinitis, eczema, childhood asthma #### Medication & Allergy - Epitil (calcium supplement) – amino - Calciphosphate – for osteoporosis - Metformin – for diabetes - **ALLERGY:** Peanuts (inhalation) #### Dental & Social History - Washes occasionally, once a week, last year ago - Max: caregiver 80-year-old mother - Father (R5) is a cab driver – transport ## The Patient 45 year old male – presenting for dental care, last seen 2 year ago ### MEDICAL HISTORY * Down syndrome with moderate intellectual disability * Autism spectrum disorder * Epilepsy * Mild hypertension (baseline 135/80) * Diabetes mellitus (mild) * Osteoporosis (very low BMD) * Allergic rhinitis, eczema, childhood asthma ### MEDICATIONS & ALLERGY * Epilim (sodium valproate) – antiepileptic * Bisphosphonates – for osteoporosis * Metformin – for diabetes * ALLERGY: Penicillin (rashes) ### DENTAL & SOCIAL HISTORY * Brushes occasionally, once a day, last visit 2 yr ago * Main caregiver: 80-year-old mother * Father (82) is a cab driver – transport 45 year old male – presenting for dental care, last seen 2 year ago #### Medical History - Down syndrome with moderate intellectual disability - Autism spectrum disorder - Epilepsy - Mild hypertension (baseline 135/80) - Diabetes mellitus (mild) - Osteoporosis (very low BMD) - Allergic rhinitis, eczema, childhood asthma #### Medications & Allergy - Epilim (sodium valproate) – antiepileptic - Bisphosphonates – for osteoporosis - Metformin – for diabetes - ALLERGY: Penicillin (rashes) #### Dental & Social History - Brushes occasionally, once a day, last visit 2 yr ago - Main caregiver: 80-year-old mother - Father (82) is a cab driver – transport The Patient 4 5 year-old male — presenting for dental care, last seen 1 year ago **MEDICAL HISTORY** * Down syndrome with moderate intellectual disability * Autism spectrum disorder * Epilepsy * Mild hypertension (Baseline 130/80) * Diabetes mellitus (mild) * Osteoporosis (very low BMD) * Allergic rhinitis, eczema, childhood asthma **MEDICINATIONS & ALLERGIES** * Epilim (sodium valproate) — antiepileptic * Bisphosphonates — for osteoporosis * Metformin — for diabetes * **ALLERGY:** Penicillin (rash) **DENTAL & SOCIAL HISTORY** * Brushes occasionally, once a day, last visit 5 yr ago * Main caregiver: 80 year-old mother * Father (82) is a cab driver — transport 45 year-old male — presenting for dental care, last seen 1 year ago #### Medical History - Down syndrome with moderate intellectual disability - Autism spectrum disorder - Epilepsy - Mild hypertension (baseline 130/80) - Diabetes mellitus (mild) - Osteoporosis (very low BMD) - Allergic rhinitis, eczema, childhood asthma #### Medications & Allergies - Epilim (sodium valproate) — antiepileptic - Bisphosphonates — for osteoporosis - Metformin — for diabetes - **ALLERGY:** Penicillin (rash) #### Dental & Social History - Brushes occasionally, once a day, last visit 5 yr ago - Main caregiver: 80 year-old mother - Father (82) is a cab driver — transport > [!note] Lecturer — Wider Support Needs > The patient’s multiple conditions and the age of his caregivers suggest that broader social and medical support may be needed alongside dental treatment. > > - Several non-dental issues may limit the care the patient and family can receive. Special Care in Dentistry Case Presentation: The Medically Compromised Patient 45-year-old male with Down syndrome — risk assessment, treatment modifications & behavioural support Case Presentation: The Medically Compromised Patient 45-year-old male with Down syndrome — risk assessment, treatment modifications & behavioural support # The Patient **45-year-old male — presenting for dental care, last seen 1 year ago** **MEDICAL HISTORY** * Down syndrome with moderate intellectual disability * Autism spectrum disorder * Epilepsy * Mild hypertension (baseline 139/80) * Diabetes mellitus (mild) * Osteoporosis (very low BMD) * Allergic rhinitis, eczema, childhood asthma **MEDICATIONS & ALLERGY** * Epilim (sodium valproate) — antiepileptic * Bisphosphonates — for osteoporosis * Metformin — for diabetes * **ALLERGY: Penicillin (rashes)** **DENTAL & SOCIAL HISTORY** * Brushes occasionally, once a day; last visit 1 yr ago * Main caregiver: 80-year-old mother * Father (82) is a cab driver — transport 45-year-old male — presenting for dental care, last seen 1 year ago #### Medical History - Down syndrome with moderate intellectual disability - Autism spectrum disorder - Epilepsy - Mild hypertension (baseline 139/80) - Diabetes mellitus (mild) - Osteoporosis (very low BMD) - Allergic rhinitis, eczema, childhood asthma #### Medications & Allergy - Epilim (sodium valproate) — antiepileptic - Bisphosphonates — for osteoporosis - Metformin — for diabetes - **ALLERGY: Penicillin (rashes)** #### Dental & Social History - Brushes occasionally, once a day; last visit 1 yr ago - Main caregiver: 80-year-old mother - Father (82) is a cab driver — transport **Q1 – Risk Assessment Table (1 of 2)** **Medical categories and others** **Risk** **Modifications / Implications** **Respiratory** - Childhood asthma - Allergic rhinitis / eczema (atopy) = Asthmatic attack - Poor healing if on steroids - Reduced supine tolerance - Ask patient to bring inhaler; prophylactic dose pre-op - Avoid triggers (cold air, dust) - Late-morning appointments; semi-reclined if needed **Cardiovascular** - Mild hypertension (139/80) - Down syndrome – congenital heart disease risk - Stress-induced BP rise - Possible infective endocarditis (if cardiac defect) - Drug interactions - Confirm cardiac history - Stress / anxiety reduction; monitor BP - Assess need for II antibiotic prophylaxis - Review polypharmacy interactions **Endocrine / Metabolic** - Diabetes mellitus (mild) - On metformin - Hypoglycaemia (main acute risk) - Increased infection risk - Poor wound healing, periodontal disease - Morning appointments; ensure patient has eaten - Avoid clashing with insulin peak / missed meals - Check HbA1c (<7% = routine care); manage hypo promptly **Bone / Musculoskeletal** - Osteoporosis (very low BMD) - On bisphosphonates = MRONI after bone-manipulating procedures - Delayed healing - Confirm drug, route & duration - MRONI-specific informed consent - Prevention-led; avoid extractions (endo preferred) - Atraumatic, sequential surgery; liaise physician re drug holiday  #### Respiratory - Childhood asthma; allergic rhinitis / eczema (atopy) - Risks: asthmatic attack; poor healing if on steroids; reduced supine tolerance - Modifications: ask patient to bring inhaler; prophylactic dose pre-op; avoid triggers (cold air, dust); late-morning appointments; semi-reclined if needed #### Cardiovascular - Mild hypertension (139/80); Down syndrome – congenital heart disease risk - Risks: stress-induced BP rise; possible infective endocarditis (if cardiac defect); drug interactions - Modifications: confirm cardiac history; stress / anxiety reduction; monitor BP; assess need for antibiotic prophylaxis; review polypharmacy interactions #### Endocrine / Metabolic - Diabetes mellitus (mild); on metformin - Risks: hypoglycaemia (main acute risk); increased infection risk; poor wound healing, periodontal disease - Modifications: morning appointments; ensure patient has eaten; avoid clashing with insulin peak / missed meals; check HbA1c (<7% = routine care); manage hypo promptly #### Bone / Musculoskeletal - Osteoporosis (very low BMD); on bisphosphonates - Risks: MRONJ after bone-manipulating procedures; delayed healing - Modifications: confirm drug, route & duration; MRONJ-specific informed consent; prevention-led; avoid extractions (endo preferred); atraumatic, sequential surgery; liaise physician re drug holiday A three-column table titled "Medical categories and others," "Risk," and "Modifications / Implications." The table lists medical conditions (Respiratory, Cardiovascular, Endocrine/Metabolic, Bone/Musculoskeletal) alongside their associated risks and clinical modifications. # Q1 — Risk Assessment Table (2 of 2) | Medical categories and others | Risk | Modifications / Implications | | :--- | :--- | :--- | | **Neurological & Cognitive** | | | | – Down syndrome | – Variable co-operation; challenging behaviour | – Behavioural support & desensitisation; same dentist/time/room | | – Moderate intellectual disability | – Seizures (stress, curing light, vibration) | – Treat in seizure-controlled phase; avoid triggers; team trained for seizures | | – Autism spectrum disorder | – Atlantocoaxial instability | – Prevent neck hyperextension | | – Epilepsy (sodium valproate) | – Communication & capacity limits | – Capacity assessment → best-interest decision with caregivers | | | – Valproate → thrombocytopenia / bleeding | – Check clotting before surgery | | **Social** | | | | – Caregivers: mother 80 (main), father 82 | – Poor attendance | – Caregiver oral-hygiene training & support | | – Brushing once/day; last visit 1 yr ago | – Poor daily oral care | – Flexible scheduling; domiciliary / transport option | | | – Limited support at home | – Strong prevention focus; 3-monthly recall | | **Others (Allergy)** | | | | – Penicillin allergy (rash) | – Allergic reaction | – Flag clearly in records | | | – Complicates antibiotic cover – incl. MRONJ prophylaxis (normally amoxicillin) | – Use non-penicillin alternative (e.g. clindamycin) |  | Medical categories and others | Risk | Modifications / Implications | | :--- | :--- | :--- | | **Neurological & Cognitive** | | | | – Down syndrome | – Variable co-operation; challenging behaviour | – Behavioural support & desensitisation; same dentist/time/room | | – Moderate intellectual disability | – Seizures (stress, curing light, vibration) | – Treat in seizure-controlled phase; avoid triggers; team trained for seizures | | – Autism spectrum disorder | – Atlantocoaxial instability | – Prevent neck hyperextension | | – Epilepsy (sodium valproate) | – Communication & capacity limits | – Capacity assessment → best-interest decision with caregivers | | | – Valproate → thrombocytopenia / bleeding | – Check clotting before surgery | | **Social** | | | | – Caregivers: mother 80 (main), father 82 | – Poor attendance | – Caregiver oral-hygiene training & support | | – Brushing once/day; last visit 1 yr ago | – Poor daily oral care | – Flexible scheduling; domiciliary / transport option | | | – Limited support at home | – Strong prevention focus; 3-monthly recall | | **Others (Allergy)** | | | | – Penicillin allergy (rash) | – Allergic reaction | – Flag clearly in records | | | – Complicates antibiotic cover – incl. MRONJ prophylaxis (normally amoxicillin) | – Use non-penicillin alternative (e.g. clindamycin) | A risk assessment table detailing medical categories (Neurological & Cognitive, Social, Others/Allergy), their associated risks, and clinical modifications or implications. # Q2 — What route are the bisphosphonates likely given? **Most likely ORAL (per os) for osteoporosis** | Category | Details | | :--- | :--- | | **ORAL (PO)** | Osteoporosis is treated with low-potency oral bisphosphonates. | | | Typical agents: alendronate (e.g. 70 mg weekly), risedronate, ibandronate. | | | Taken as a daily, weekly or monthly tablet. | | | Low MRONJ risk: ~0.001–0.01% in osteoporosis patients. | | | Risk rises after ≥5 years of use or with extra risk factors. | | **Compare: IV route** | Intravenous bisphosphonates (zoledronate, pamidronate, IV ibandronate) are used mainly in cancer / bone metastases — and sometimes annually for osteoporosis. | | | High-potency / IV use carries a much higher MRONJ risk: ~?% in oncology patients. | | | MRONJ risk depends on drug type & potency, ROUTE, duration and the underlying disease. | Most likely **ORAL (per os)** for osteoporosis | Category | Details | | :--- | :--- | | **ORAL (PO)** | Osteoporosis is treated with low-potency oral bisphosphonates. | | | Typical agents: alendronate (e.g. 70 mg weekly), risedronate, ibandronate. | | | Taken as a daily, weekly or monthly tablet. | | | Low MRONJ risk: ~0.001–0.01% in osteoporosis patients. | | | Risk rises after ≥5 years of use or with extra risk factors. | | **Compare: IV route** | Intravenous bisphosphonates (zoledronate, pamidronate, IV ibandronate) are used mainly in cancer / bone metastases — and sometimes annually for osteoporosis. | | | High-potency / IV use carries a much higher MRONJ risk in oncology patients. | | | MRONJ risk depends on drug type & potency, ROUTE, duration and the underlying disease. | Q3 — The patient's toenails: why do they matter? *An incidental finding that flags whole-patient risks for dental care* — **Sign of overall self-care / neglect** Thickened, discoloured, overgrown nails suggest limited daily personal care — consistent with brushing only once a day and reliance on elderly caregivers. Predicts poor oral hygiene → reinforces prevention and caregiver training. — **Possible fungal infection / poor glycaemic control** Yellow, dystrophic nails (onychomycosis) point to impaired immunity and/or poorly controlled diabetes → higher infection risk and delayed healing, which compounds extraction-healing and MRONJ risk. — **Peripheral vascular / healing concern** Nail changes can signal poor peripheral circulation and delayed wound healing — relevant to surgical procedures and recovery. — **Prompt to liaise & screen** Triggers liaison with the GP about diabetes control and foot care before invasive treatment, and a check for oral candidiasis given likely immunocompromise.   *An incidental finding that flags whole-patient risks for dental care* #### Sign of Overall Self-Care / Neglect Thickened, discoloured, overgrown nails suggest limited daily personal care — consistent with brushing only once a day and reliance on elderly caregivers. Predicts poor oral hygiene → reinforces prevention and caregiver training. #### Possible Fungal Infection / Poor Glycaemic Control Yellow, dystrophic nails (onychomycosis) point to impaired immunity and/or poorly controlled diabetes → higher infection risk and delayed healing, which compounds extraction-healing and MRONJ risk. #### Peripheral Vascular / Healing Concern Nail changes can signal poor peripheral circulation and delayed wound healing — relevant to surgical procedures and recovery. #### Prompt to Liaise & Screen Triggers liaison with the GP about diabetes control and foot care before invasive treatment, and a check for oral candidiasis given likely immunocompromise. Clinical photo showing the dorsal view of a patient's feet, highlighting thickened, yellowed, and overgrown toenails. A text-based table with two columns listing clinical signs and their implications for patient care. The left column contains bolded headers such as 'Sign of overall self-care / neglect' and 'Possible fungal infection / poor glycaemic control', while the right column provides detailed explanations linking these findings to risks like delayed healing and MRONJ. Q4 — Behavioural supports: risks & limitations (1 of 2) From least to most restrictive — tailored to this patient | Behavioural support | Risks / limitations for THIS patient | |---|---| | Communication, acclimatisation & desensitisation<br>(tell–show–do, social stories, pictograms, visual timer) | Least restrictive and first-line — but time-consuming and needs multiple visits; autism brings resistance to change; depends heavily on elderly caregivers; possible pain insensitivity can mask problems; may not achieve cooperation for invasive treatment. | | Inhalation sedation<br>(nitrous oxide / oxygen) | Nasal hood often fits poorly due to mid-face hypoplasia in Down syndrome; may be rejected by an autistic patient (facial contact); textbook advises caution/avoidance of nitrous oxide in epilepsy; still requires nasal breathing and some cooperation. | | Conscious / IV sedation | Response is unpredictable — a paradoxical reaction can occur in autism/intellectual disability; must assess cardiac disease, respiratory function, hypotonia and OSA risk; cannulation needs cooperation; capacity / best-interests required. |  From least to most restrictive — tailored to this patient | Behavioural support | Risks / limitations for THIS patient | |---|---| | Communication, acclimatisation & desensitisation (tell–show–do, social stories, pictograms, visual timer) | Least restrictive and first-line — but time-consuming and needs multiple visits; autism brings resistance to change; depends heavily on elderly caregivers; possible pain insensitivity can mask problems; may not achieve cooperation for invasive treatment. | | Inhalation sedation (nitrous oxide / oxygen) | Nasal hood often fits poorly due to mid-face hypoplasia in Down syndrome; may be rejected by an autistic patient (facial contact); textbook advises caution/avoidance of nitrous oxide in epilepsy; still requires nasal breathing and some cooperation. | | Conscious / IV sedation | Response is unpredictable — a paradoxical reaction can occur in autism/intellectual disability; must assess cardiac disease, respiratory function, hypotonia and OSA risk; cannulation needs cooperation; capacity / best-interests required. | A two-column table comparing behavioural supports (Communication/acclimatisation, Inhalation sedation, Conscious/IV sedation) against their specific risks and limitations for a patient with autism and Down syndrome. Q4 — Behavioural supports: risks & limitations (2 of 2) **Behavioural support** | **Risks / limitations for THIS patient** Clinical holding | Only with consent or a best-interests decision (patient lacks capacity); must be least-restrictive, by trained staff and documented; can escalate distress/trauma; must avoid neck hyperextension (atlantoaxial instability); suitable only for short, safe procedures. General anaesthesia | Highest-risk option: difficult intubation (mid-face hypoplasia), atlantoaxial instability on positioning, cardiac & respiratory comorbidity, diabetes/fasting management and epilepsy anaesthetic-agent cautions; needs a hospital setting and a best-interests decision — but allows comprehensive treatment in one visit, reducing repeat exposure.  | Behavioural support | Risks / limitations for THIS patient | |---|---| | Clinical holding | Only with consent or a best-interests decision (patient lacks capacity); must be least-restrictive, by trained staff and documented; can escalate distress/trauma; must avoid neck hyperextension (atlantoaxial instability); suitable only for short, safe procedures. | | General anaesthesia | Highest-risk option: difficult intubation (mid-face hypoplasia), atlantoaxial instability on positioning, cardiac & respiratory comorbidity, diabetes/fasting management and epilepsy anaesthetic-agent cautions; needs a hospital setting and a best-interests decision — but allows comprehensive treatment in one visit, reducing repeat exposure. | - ==Atraumatic restorative techniques and silver diamine fluoride where appropriate== A two-column table comparing 'Clinical holding' and 'General anaesthesia' as behavioural supports, detailing the specific risks and limitations for a patient (likely with Down syndrome given references to atlantoaxial instability) under each option. # Extron Extron **45 y.o. male** **MH:** - Down's syndrome - Moderate intellectual disability - Autism spectrum disorder - Epilepsy - Allergic Rhinitis - Eczema - childhood asthma - mild HTN (baseline 139/80) - Diabetes mellitus Mild - Osteoporosis (very low BMD) MED: Epilin, Bisphosphonates, metformin Drug Allergy: Penicillin (Rashes) **DH:** - occasional Toothbrushing once a day - last visit 1 year ago **SH:** - 80 year old mum is main caregiver - 82 year old dad cab driver 1. Create a Medical Category - Risk Assessment - Modifications table. 2. What type of drug route would bisphosphonates likely be? 3. You saw the patient's toenail whilst having dental treatment - how do you think this can affect our dental treatment delivery? 4. Consider different types of behavioural supports, could you list the risk/limitations of each based on pat   #### Case Presentation: 45 y.o. Male **Medical History:** - Down's syndrome - Moderate intellectual disability - Autism spectrum disorder - Epilepsy - Allergic rhinitis - Eczema - Childhood asthma - Mild HTN (baseline 139/80) - Diabetes mellitus, mild - Osteoporosis (very low BMD) **Medications:** Epilin, bisphosphonates, metformin **Drug Allergy:** Penicillin (rashes) **Dental History:** - Occasional toothbrushing, once a day - Last visit 1 year ago **Social History:** - 80-year-old mum is main caregiver - 82-year-old dad, cab driver #### Discussion Questions 1. Create a Medical Category – Risk Assessment – Modifications table. 2. What type of drug route would bisphosphonates likely be? 3. You saw the patient's toenail whilst having dental treatment — how do you think this can affect our dental treatment delivery? 4. Consider different types of behavioural supports — could you list the risk/limitations of each based on pat > [!note] Lecturer — Anaesthetic Referral > General anaesthesia may still be possible for medically complex patients, but referral depends on the patient’s overall risk and available facilities. > > - Relevant considerations include ASA status, airway risk, medical comorbidities, an appropriate anaesthetist, hospital facilities, blood tests and medical clearance. > - High-risk patients may require an intensivist anaesthetist and a hospital setting. > - The anaesthetist may assess the airway, full blood count, liver function, renal function and overall medical status. > - If the risk is too high, the anaesthetist may decline the procedure. A panoramic dental radiograph (OPG) showing the maxilla, mandible, and full dentition. An 'R' marker is visible in the bottom left corner indicating the right side of the patient. Clinical photo showing the dorsal aspect of a patient's feet, highlighting thickened, dystrophic, and overgrown toenails.  A close-up photograph showing the rear connection panel of a white electronic device, featuring an HDMI port with a black cable plugged in and a '4K' logo printed nearby.  A close-up photograph of the rear connection panel on a white electronic device, featuring an HDMI port labeled with '4K' and a USB-C port. A black cable is plugged into the USB-C slot.  A close-up, angled photograph of a white handheld device with a rectangular display window containing small internal components. The background features a blue surface and a piece of paper with partial text visible at the bottom.  A close-up photograph showing the white plastic housing and port area of an electronic device, with a black cable plugged into one of the rectangular openings.  A close-up photograph shows an elderly hand wearing a gold ring pressing down on the top of a white, rectangular device.  A close-up photograph showing a hand gripping the side of a white piece of equipment, possibly a medical device or printer. The fingers are wrapped around the edge of the machine's casing.  No discernible content is present.  A close-up photograph of a control panel or remote interface featuring circular buttons with icons and text labels. Visible controls include 'Record', 'Freeze / Stop', 'Lamp', 'Capture', 'Menu', and 'DC / PC', along with directional pad symbols for brightness and power. **ELPDC30** Playback + Resolution + Mode + Default + Record Freeze / Stop Lamp Capture Menu DC / PC **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026** 1. Presenting Complaint 2. History of Presenting Complaint Medical History Dental History Oral Hygiene Social History Extra-Oral Exam   **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026** 1. Presenting Complaint 2. History of Presenting Complaint - Medical History - Dental History - Oral Hygiene - Social History - Extra-Oral Exam A close-up photograph of a handheld remote control, likely for a digital microscope or similar device. The image displays various function buttons including 'Record', 'Freeze / Stop', 'Lamp', 'Capture', 'Menu', and 'DC / PC', along with a central navigation pad labeled 'AF ENTER'. A cropped section of a document showing the first seven rows of a numbered list titled 'PRESENTATION FORMAT OCTOBER 2026'. The visible items are: 1. Presenting Complaint, 2. History of Presenting Complaint, Medical History, Dental History, Oral Hygiene, Social History, and Extra-Oral Exam. <br>BR 2026</br> | | | |---|---| | Power (*Click) | AN / ENTER Delete | | | Playback Remember Mode Default | | [ * Peak Time ] | Capture | Menu DC / PC | ELPDC30 RETURN TO OSCOP  BR 2026 RETURN TO OSCOP A close-up photograph of a white electronic device control panel featuring a circular directional pad with an 'AI / ENTER' center button and surrounding icons for brightness and zoom. Below the main pad are individual buttons labeled Record, Freeze / Stop, Lamp, Capture, Menu, and DC / PC. ELPDC30 HDMI 4K DENT5311 SUMMATIVE CASE PRESENTATION HDMI 4K **DENT5311 — SUMMATIVE CASE PRESENTATION** <COMPLAINT SECTION> Student5311 PRESENTATION FORMAT OCTOBER 2026 Type of Complaint Examination Examination </COMPLAINT SECTION>  Student5311 — PRESENTATION FORMAT OCTOBER 2026 - Type of Complaint - Examination - Examination A cropped view of a form table with horizontal lines. Visible text includes headers like 'PRESENTATION' and 'Complaint', along with entries such as 'Examination'. **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026** 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment -Diet Assessment -Plaque Score -Saliva Assessment 15. Periodontal Risk Assessment  1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment > [!note] Lecturer — Slide Planning > The presentation should contain approximately 24 to 30 slides; more than 30 slides may prevent completion within the allocated time. > > - Include a title page, medication details, dental implications, oral history, treatment options, a management plan, reflection, and references. > [!note] Lecturer — Examination Documentation > The medical history should be presented in a table containing the medical condition, medication, dosage, frequency, mechanism of action, and dental implication. > > - A missing dosage or frequency was considered an incomplete medical history. > - Include straight-on facial and right and left profile photographs, intraoral straight-on and occlusal views, soft-tissue photographs, and radiographs with dates. > - If there is no prosthesis, state that it is not applicable; if one is present, include photographs. A numbered list presented in a table format outlines the components of a clinical assessment, including sections 1-15 such as Presenting Complaint, History of Presenting Complaint, Medical History, Dental History, Oral Hygiene, Social History, Extra-Oral Examination, Intra-Oral Examination, Occlusion, Dental Prosthesis, Tooth Charting, Periodontal Charting, Radiographs, Caries Risk Assessment (with sub-items Diet Assessment, Plaque Score, Saliva Assessment), and Periodontal Risk Assessment. DENTS311 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2025 | 1. | Presenting Complaint | | :--- | :--- | | 2. | History of Presenting Complaint | | 3. | Medical History | | 4. | Dental History | | 5. | Oral Hygiene | | 6. | Social History | | 7. | Extra-Oral Examination | | 8. | Intra-Oral Examination |  DENTS311 — SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2025 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination A cropped view of a numbered list formatted as a table, showing items 1 through 8. The entries are: 1. Presenting Complaint, 2. History of Presenting Complaint, 3. Medical History, 4. Dental History, 5. Oral Hygiene, 6. Social History, 7. Extra-Oral Examination, and 8. Intra-Oral Examination. DENTS311 **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2025** | 1. | Presenting Complaint | | 2. | History of Presenting Complaint | | 3. | Medical History | | 4. | Dental History | | 5. | Oral Hygiene | | 6. | Social History | | 7. | Extra-Oral Examination | | 8. | Intra-Oral Examination | | 9. | Occlusion | | 10. | Dental Prosthesis | | 11. | Tooth Charting |   **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2025** 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting The crop provided is a close-up, abstract fragment of what appears to be a 3D render or digital image. It shows smooth, curved white surfaces and dark recessed areas but lacks any identifiable features, text, labels, or context that would allow it to be described as a specific figure (like a chart, table, or diagram) related to the slide's topic ("Summative Case Presentation Format"). It looks like screen furniture, a partial object, or an illegible smear rather than distinct slide content. No A numbered list presented in a table format outlines the required sections for a case presentation, including Presenting Complaint, Medical History, and Examination details. <div style="margin-top:0"><span>summatiicase presentation</span> | | | | --- | --- | | | | | --- | --- | | 1. | Presenting Complaint | | 2. | History of Presenting Complaint | | 3. | Medical History | | 4. | Dental History | | 5. | Oral Hygiene | | 6. | Social History | | 7. | Extra-Oral Examination | | 8. | Intra-Oral Examination | | 9. | Occlusion | | 10. | Dental Prosthesis | | 11. | Tooth Charting | | 12. | Periodontal Charting | | 13. | Radiographs | | 14. | Caries Risk Assessment | | | - Diet Assessment | | | - Plaque Score | | | - Saliva Assessment | | 15. | Periodontal Risk Assessment | | 16. | Prognosis | </div>  Summative case presentation 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis A numbered list presented as a table outlines the 16 components of a case presentation, starting with 'Presenting Complaint' and ending with 'Prognosis'. The structure includes specific sub-points under item 14, 'Caries Risk Assessment', which are Diet Assessment, Plaque Score, and Saliva Assessment. SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment  1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment A table listing the sequential headings for a clinical case presentation format, numbered 1 through 15 (with item 14 containing sub-items). The rows correspond to standard medical history and examination components, such as 'Presenting Complaint', 'History of Presenting Complaint', 'Medical History', and various dental assessments. <img>Person cleaning printer with black brush over paperwork labeled "Sinus Health" *Person cleaning printer with black brush over paperwork labeled "Sinus Health"* ### SUMMATIVE CASE PRESENTATION 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis  **SUMMATIVE CASE PRESENTATION** 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis A numbered list titled 'SUMMATIVE CASE PRESENTATION' outlines the components of a clinical dental assessment, including sections for Presenting Complaint (1), Medical History (3), Extra-Oral Examination (7), and Caries Risk Assessment (14). The list continues through item 16, Prognosis. SUMMATIVE <table> <tr><td>1.</td></tr> <tr><td>2.</td></tr> <tr><td>...</td></tr> <tr><td>11.</td></tr> <tr><td>12.</td></tr> <tr><td>13.</td></tr> <tr><td>14.</td></tr> <tr><td>...</td></tr> <tr><td>15.</td></tr> <tr><td>16.</td></tr> </table> Zoom Out  SUMMATIVE Zoom Out A close-up photograph showing a human arm with a black blood pressure cuff wrapped around the upper forearm, connected to tubing. **SUMMATIVE CASE** | 1. Presenting | | :--- | | 2. History of P | | 3. Medical H | | 4. Dental His | | 5. Oral H | | 6. S | | 7. |  **SUMMATIVE CASE** 1. Presenting 2. History of P 3. Medical H 4. Dental His 5. Oral H 6. S 7. A close-up clinical photograph shows a section of human skin, likely an arm or leg, exhibiting scattered red papules and erythematous spots. The image appears to be captured during a video conference presentation, with the edge of a slide visible in the background. <http://example.com/> | | | | |---|---|---| | 2. | History or Pre. | | | 3. | Medical Histor. | | | 4. | Dental History | | | 5. | Oral Hygiene | | | 6. | Social History | | | 7. | Extra-Oral Examination | | | 8. | Intra-Oral Examination | | | 9. | Occlusion | | | 10. | Dental Prosthesis | | | 11. | Tooth Charting | | | 12. | Periodontal Charting | | | 13. | Radiographs | | | 14. | Caries Risk Assessment | | | | | Diet Assessment | | | | Plaque Score | | | | Saliva Assessment | | 15. | Periodontal Risk Assessment | | | 16. | Prognosis | | | 17. | Problem List | | | | | -Aesthetics | | | | -Host-related | | | | -Pathology | | | | -Morphology | | 18. | Diagnoses | | 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting <table> <tr><td>2. History of Present...</td></tr> <tr><td>3. Medical History</td></tr> <tr><td>4. Dental History</td></tr> <tr><td>5. Oral Hygiene</td></tr> <tr><td>6. Social History</td></tr> <tr><td>7. Extra-Oral Examination</td></tr> <tr><td>8. Intra-Oral Examination</td></tr> <tr><td>9. Occlusion</td></tr> <tr><td>10. Dental Prosthesis</td></tr> <tr><td>11. Tooth Charting</td></tr> <tr><td>12. Periodontal Charting</td></tr> <tr><td>13. Radiographs</td></tr> <tr><td>14. Caries Risk Assessment</td></tr> <tr><td>-Diet Assessment</td></tr> <tr><td>-Plaque Score</td></tr> <tr><td>-Saliva Assessment</td></tr> <tr><td>15. Periodontal Risk Assessment</td></tr> <tr><td>16. Prognosis</td></tr> <tr><td>17. Problem List</td></tr> <tr><td>-Aesthetics</td></tr> <tr><td>-Host-related</td></tr> <tr><td>-Pathology</td></tr> <tr><td>-Morphology</td></tr> <tr><td>18. Diagnoses</td></tr> </table> <table> <tr><td>2. History of Present...</td></tr> <tr><td>3. Medical History</td></tr> <tr><td>4. Dental History</td></tr> <tr><td>5. Oral Hygiene</td></tr> <tr><td>6. Social History</td></tr> <tr><td>7. Extra-Oral Examination</td></tr> <tr><td>8. Intra-Oral Examination</td></tr> <tr><td>9. Occlusion</td></tr> <tr><td>10. Dental Prosthesis</td></tr> <tr><td>11. Tooth Charting</td></tr> <tr><td>12. Periodontal Charting</td></tr> <tr><td>13. Radiographs</td></tr> <tr><td>14. Caries Risk Assessment</td></tr> <tr><td>-Diet Assessment</td></tr> <tr><td>-Plaque Score</td></tr> <tr><td>-Saliva Assessment</td></tr> <tr><td>15. Periodontal Risk Assessment</td></tr> <tr><td>16. Prognosis</td></tr> <tr><td>17. Problem List</td></tr> <tr><td>-Aesthetics</td></tr> <tr><td>-Host-related</td></tr> <tr><td>-Pathology</td></tr> <tr><td>-Morphology</td></tr> <tr><td>18. Diagnoses</td></tr> </table> **DENT5311** **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026** <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> <tr> <td>3. Medical History</td> </tr> <tr> <td>4. Dental History</td> </tr> <tr> <td>5. Oral Hygiene</td> </tr> <tr> <td>6. Social History</td> </tr> <tr> <td>7. Extra-Oral Examination</td> </tr> </tbody> </table> **DENT5311** <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> <tr> <td>3. Medical History</td> </tr> <tr> <td>4. Dental History</td> </tr> <tr> <td>5. Oral Hygiene</td> </tr> <tr> <td>6. Social History</td> </tr> <tr> <td>7. Extra-Oral Examination</td> </tr> </tbody> </table> 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis 17. Problem List - Aesthetics - Host-related - Pathology - Morphology 18. Diagnoses 19. Treatment Options 20. Management Plans (Timeline) 21. Reflection 22. References 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis 17. Problem List - Aesthetics - Host-related - Pathology - Morphology 18. Diagnoses 19. Treatment Options 20. Management Plans (Timeline) 21. Reflection 22. References DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTO... <table> <tbody> <tr><td>1. Presenting Complaint</td></tr> <tr><td>2. History of Presenting Complaint</td></tr> <tr><td>3. Medical History</td></tr> <tr><td>4. Dental History</td></tr> <tr><td>5. Oral Hygiene</td></tr> <tr><td>6. Social History</td></tr> <tr><td>7. Extra-Oral Examination</td></tr> <tr><td>8. Intra-Oral Examination</td></tr> <tr><td>9. Occlusion</td></tr> <tr><td>10. Dental Prosthesis</td></tr> <tr><td>11. Tooth Charting</td></tr> <tr><td>12. Periodontal Charting</td></tr> <tr><td>13. Radiographs</td></tr> <tr><td>14. Caries Risk Assessment</td></tr> <tr><td>-Diet Assessment</td></tr> <tr><td>-Plaque Score</td></tr> <tr><td>-Saliva Assessment</td></tr> <tr><td>15. Periodontal Risk Assessme...</td></tr> <tr><td>16. Prognosis</td></tr> <tr><td>17. Problem List</td></tr> <tr><td>-Aesthetics</td></tr> <tr><td>-Host-related</td></tr> <tr><td>-Pathology</td></tr> <tr><td>-Morphology</td></tr> <tr><td>18. Diagnoses</td></tr> <tr><td>19. Treatment Options</td></tr> <tr><td>20. Management Plans (T...</td></tr> <tr><td>21. Reflection</td></tr> </tbody> </table> DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTO... <table> <tbody> <tr><td>1. Presenting Complaint</td></tr> <tr><td>2. History of Presenting Complaint</td></tr> <tr><td>3. Medical History</td></tr> <tr><td>4. Dental History</td></tr> <tr><td>5. Oral Hygiene</td></tr> <tr><td>6. Social History</td></tr> <tr><td>7. Extra-Oral Examination</td></tr> <tr><td>8. Intra-Oral Examination</td></tr> <tr><td>9. Occlusion</td></tr> <tr><td>10. Dental Prosthesis</td></tr> <tr><td>11. Tooth Charting</td></tr> <tr><td>12. Periodontal Charting</td></tr> <tr><td>13. Radiographs</td></tr> <tr><td>14. Caries Risk Assessment</td></tr> <tr><td>-Diet Assessment</td></tr> <tr><td>-Plaque Score</td></tr> <tr><td>-Saliva Assessment</td></tr> <tr><td>15. Periodontal Risk Assessme...</td></tr> <tr><td>16. Prognosis</td></tr> <tr><td>17. Problem List</td></tr> <tr><td>-Aesthetics</td></tr> <tr><td>-Host-related</td></tr> <tr><td>-Pathology</td></tr> <tr><td>-Morphology</td></tr> <tr><td>18. Diagnoses</td></tr> <tr><td>19. Treatment Options</td></tr> <tr><td>20. Management Plans (T...</td></tr> <tr><td>21. Reflection</td></tr> </tbody> </table> DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 DENT5311 # Summative Case Presentation Format ### DENT 5311 ##### October 2026 Summative Case Presentation Format ### DENT 5311 ##### October 2026 DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 DENT5311 DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 DENT5311 **DENT5311** **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026** **DENT5311** DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 DENT5311 DENT5311 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 DENT5311 <img>Blurry grayscale image with undefined shapes and tear痕迹. <img>Blurry grayscale image with undefined shapes and tear痕迹. Pass mark of 50%. **Handwritten annotations:** * 30%. Clinic-Pebblepad * 70%. Summative Case Presentation Pass mark of 50%. **Handwritten annotations:** * 30%. Clinic-Pebblepad * 70%. Summative Case Presentation ive assessments. The assessments will be delayed until [...] ssion, course completion, and/or graduation. ### Assessment overview verall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial ssments. | Module | Unit Weighting | | :--- | :--- | | Clinical Dental Practice (CDP4) | 40% | | Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | | Public Health Dentistry 1 (PHD1) | 10% | [Handwritten annotation beside "Clinical Dental Practice (CDP4) 40%":] $$\begin{cases} \text{30\% Clinic - Pebblepad} \\ \text{10\% Summative Case Presentation} \end{cases}$$ --- [Bottom URL footer:] ... blackboard.com/bbcswebdav/institution/Unit_Outlines_2026/DENT5311_TS-B-3_2026/DENT5311_TS-B-3_2026_Unit... 6/20 --- [Yellow sticky note text:] Portfolio is Formative P/F ive assessments. The assessments will be delayed until [...] ssion, course completion, and/or graduation. ### Assessment overview verall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial ssments. | Module | Unit Weighting | | :--- | :--- | | Clinical Dental Practice (CDP4) | 40% | | Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | | Public Health Dentistry 1 (PHD1) | 10% | [Handwritten annotation beside "Clinical Dental Practice (CDP4) 40%":] $$\begin{cases} \text{30\% Clinic - Pebblepad} \\ \text{10\% Summative Case Presentation} \end{cases}$$ --- [Bottom URL footer:] ... blackboard.com/bbcswebdav/institution/Unit_Outlines_2026/DENT5311_TS-B-3_2026/DENT5311_TS-B-3_2026_Unit... 6/20 --- [Yellow sticky note text:] Portfolio is Formative P/F ment Overview all unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Examiners will assess the individual assessments and determine eligibility for supplementary or remedial ents. **Unit Weighting** * ==Dental Practice (CDP4) 40%== $\begin{cases} \text{30\% Clinic } \cdot \text{ Pebblepad} \\ \text{10\% Summative Case Presentation} \end{cases}$ * alveolar and Maxillofacial Trauma (TRAUMA) 10% * Health Dentistry 1 (PHD1) 10% --- [Post-it note] Portfolio is Formative P/F ment Overview all unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Examiners will assess the individual assessments and determine eligibility for supplementary or remedial ents. **Unit Weighting** * ==Dental Practice (CDP4) 40%== $\begin{cases} \text{30\% Clinic } \cdot \text{ Pebblepad} \\ \text{10\% Summative Case Presentation} \end{cases}$ * alveolar and Maxillofacial Trauma (TRAUMA) 10% * Health Dentistry 1 (PHD1) 10% --- [Post-it note] Portfolio is Formative P/F - Dentoalveolar and Maxillofacial Trauma (Trauma) 15% - Public Health Dentistry 1 (PHD1) 15%  - Dentoalveolar and Maxillofacial Trauma (Trauma) 15% - Public Health Dentistry 1 (PHD1) 15% A close-up photograph showing a person's left hand with fingers spread, wearing a gold ring on the ring finger. The background consists of white paper documents containing printed text. - Dento-alveolar and Maxillofacial Trauma (TRAUMA) 10% - Public Health Dentistry 1 (PHD1) 10% www.cse...   - Dento-alveolar and Maxillofacial Trauma (TRAUMA) 10% - Public Health Dentistry 1 (PHD1) 10% www.cse... No discernible content is present. No discernible content is present. 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. **Module Unit Weighting** - **Clinical Dental Practice (CDP4) 40%** - Dento-alveolar and Maxillofacial Trauma (TRAUMA) 10% - Public Health Dentistry 1 (PHD1) 10% > 307. Clinic - Pebblepad > 107. Summative Case Presentation 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. **Module Unit Weighting** - **Clinical Dental Practice (CDP4) 40%** - Dento-alveolar and Maxillofacial Trauma (TRAUMA) 10% - Public Health Dentistry 1 (PHD1) 10% > 307. Clinic - Pebblepad > 107. Summative Case Presentation 1. Assessment overview 1. Assessment overview 1. Assessment overview 1. Assessment overview Portfolio is Formative P/F  Portfolio is Formative P/F A blurry, close-up photograph showing a person's hand reaching towards papers on a desk. A yellow sticky note is visible in the upper right corner with handwritten text that reads "Portfolio is Formative P/F". Hand with yellow sticky note in right corner Hand with yellow sticky note in right corner complete formative assessments, clinical sessions, activities and/or any other in the assessment, they will be ineligible to sit the final assessment. It is make-up all missed clinical, pre-clinical sessions and any other activities assessments will be delayed until the student has completed them as ion, and/or graduation. nt overview and each module includes [Sticky note text:] Efolin IS Formative P/F complete formative assessments, clinical sessions, activities and/or any other in the assessment, they will be ineligible to sit the final assessment. It is make-up all missed clinical, pre-clinical sessions and any other activities assessments will be delayed until the student has completed them as ion, and/or graduation. nt overview and each module includes [Sticky note text:] Efolin IS Formative P/F <br> * Cases of unsatisfactory results in failed component... decide if the student can be granted a Supplementary assessment. <br> Students who fail one or more Modules in DENTS311 will need to defer Semester 1 of the following year and repeat all Modules in DENTS311 if they wish to continue in the DMD program (a remediation plan must be arranged for students before students can attend clinical sessions after an extended approved leave). <br> If a student has been unable to complete formative assessments, clinical sessions, activities and/or any other associated preparation in the module prior to the assessment, they will be ineligible to sit the final assessment. It is the student's responsibility to complete, and make-up all missed clinical, pre-clinical sessions and any other activities to be eligible to sit summative assessments. The assessments will be delayed until the student has completed them and therefore it may delay progression, course completion, and/or graduation. <br> 1. Assessment overview <br> The overall unit and each module individually must be passed at a one-time... Board of Examiners... <br> * Cases of unsatisfactory results in failed component... decide if the student can be granted a Supplementary assessment. <br> Students who fail one or more Modules in DENTS311 will need to defer Semester 1 of the following year and repeat all Modules in DENTS311 if they wish to continue in the DMD program (a remediation plan must be arranged for students before students can attend clinical sessions after an extended approved leave). <br> If a student has been unable to complete formative assessments, clinical sessions, activities and/or any other associated preparation in the module prior to the assessment, they will be ineligible to sit the final assessment. It is the student's responsibility to complete, and make-up all missed clinical, pre-clinical sessions and any other activities to be eligible to sit summative assessments. The assessments will be delayed until the student has completed them and therefore it may delay progression, course completion, and/or graduation. <br> 1. Assessment overview <br> The overall unit and each module individually must be passed at a one-time... Board of Examiners... 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit/Weighting | |---|---| | Clinical Dental Practice (CDP4) | 40% | | - Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | | - Public Health Dentistry 1 (PHD1) | 10% | **30%. Clinic-Pebblepad** **10%. Summative Case Presentation** 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit/Weighting | |---|---| | Clinical Dental Practice (CDP4) | 40% | | - Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | | - Public Health Dentistry 1 (PHD1) | 10% | **30%. Clinic-Pebblepad** **10%. Summative Case Presentation** 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | | :--- | :--- | :--- | | • Clinical Dental Practice (CDP4) | 40% | $\begin{cases} 30\% & \text{Clinic - Pebblepad} \\ 10\% & \text{Summative Case Presentation} \end{cases}$ | | • Dento-alveolar and Maxillofacial Trauma (DAMT) | 10% | | | • Public Health Dentistry | | | 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | | :--- | :--- | :--- | | • Clinical Dental Practice (CDP4) | 40% | $\begin{cases} 30\% & \text{Clinic - Pebblepad} \\ 10\% & \text{Summative Case Presentation} \end{cases}$ | | • Dento-alveolar and Maxillofacial Trauma (DAMT) | 10% | | | • Public Health Dentistry | | | summative assessments. The assessments will be delayed until the student has completed them, which may delay progression, course completion, and/or graduation. ### 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. <table> <thead> <tr> <th>Module</th> <th>Unit Weighting</th> </tr> </thead> <tbody> <tr> <td>Clinical Dental Practice (CDP4)</td> <td>40%</td> </tr> <tr> <td>Dento-alveolar and Maxillofacial Trauma (DAMAT)</td> <td>10%</td> </tr> <tr> <td>Public Health Dentistry</td> <td></td> </tr> </tbody> </table> *(Handwritten note next to CDP4 40%):* $\left\{\begin{array}{l}\text{30\% Clinic - Pebblepad} \\ \text{10\% Summative Case Presentation}\end{array}\right.$ summative assessments. The assessments will be delayed until the student has completed them, which may delay progression, course completion, and/or graduation. ### 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. <table> <thead> <tr> <th>Module</th> <th>Unit Weighting</th> </tr> </thead> <tbody> <tr> <td>Clinical Dental Practice (CDP4)</td> <td>40%</td> </tr> <tr> <td>Dento-alveolar and Maxillofacial Trauma (DAMAT)</td> <td>10%</td> </tr> <tr> <td>Public Health Dentistry</td> <td></td> </tr> </tbody> </table> *(Handwritten note next to CDP4 40%):* $\left\{\begin{array}{l}\text{30\% Clinic - Pebblepad} \\ \text{10\% Summative Case Presentation}\end{array}\right.$ 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module Unit, Weighting - Clinical Dental Practice (CDP4) 40% { 30% Clinic-Pebblepad, 10% Summative Case Presentation - Dento-alveolar and Maxillofacial Trauma (TRAUMA) 10% - Public Health Dentistry 1 (PHD1) 10% https://ub-bbb-1080e0422.blackboard.com/bbcswebdav/institution/Unit_Outlines_2026/DENT5311_1S-B-3_2026/DENT5311_1S-B-3_2026_Unit... 8/20 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module Unit, Weighting - Clinical Dental Practice (CDP4) 40% { 30% Clinic-Pebblepad, 10% Summative Case Presentation - Dento-alveolar and Maxillofacial Trauma (TRAUMA) 10% - Public Health Dentistry 1 (PHD1) 10% https://ub-bbb-1080e0422.blackboard.com/bbcswebdav/institution/Unit_Outlines_2026/DENT5311_1S-B-3_2026/DENT5311_1S-B-3_2026_Unit... 8/20 progression, course completion, and/or graduation. 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | | :--- | :--- | :--- | | - Clinical Dental Practice (CDP4) | 40% | $\begin{cases} \text{30\% Clinic - Pebblepad} \\ \text{10\% Summative Case Presen} \end{cases}$ | | - Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | | | - Public Health Dentistry 1 (PHD1) | 10% | | progression, course completion, and/or graduation. 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | | :--- | :--- | :--- | | - Clinical Dental Practice (CDP4) | 40% | $\begin{cases} \text{30\% Clinic - Pebblepad} \\ \text{10\% Summative Case Presen} \end{cases}$ | | - Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | | | - Public Health Dentistry 1 (PHD1) | 10% | | 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module Unit Weighling 1307. Clinic - Pebblepad 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module Unit Weighling 1307. Clinic - Pebblepad progression, course completion, and/or graduation. 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module | Unit Weighting - Clinical Dental Practice (CDP4) | 40% - Dental-Oral and Maxillofacial Trauma | 10% **301. Clinic - Pebblepad** **10%. Summative Case Presentation** progression, course completion, and/or graduation. 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module | Unit Weighting - Clinical Dental Practice (CDP4) | 40% - Dental-Oral and Maxillofacial Trauma | 10% **301. Clinic - Pebblepad** **10%. Summative Case Presentation** *8. Clinic-Rubblepad 101. The summative case presentation must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners shall determine eligibility for supplementary or remedial examinations. *8. Clinic-Rubblepad 101. The summative case presentation must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners shall determine eligibility for supplementary or remedial examinations. progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. ### 1. Assessment overview progression, course completion, and/or graduation. ### 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview (2) progression, course completion, and/or graduation. 1. Assessment overview (2) progression, course completion, and/or graduation. 1. Assessment overview progression, course completion, and/or graduation. 1. Assessment overview  A close-up photo of an elderly person's left hand resting on a white sheet of paper. The hand has visible veins, age spots, and wrinkles, and wears a gold ring on the ring finger. 1. Assessment overview 1. Assessment overview <th> Dental X-ray showing faint root canal anatomy with artifact, grayscale <th> Dental X-ray showing faint root canal anatomy with artifact, grayscale ### Assesssment overview Phonological assessment Word level Syllables Syllable division Stress Rhythm Sentences Intonation Pausing and length Production of difficult sounds Production of difficult sounds: phonological analysis Consonant cluster Fricativisation Elision Contraction Pressure changes ### Assesssment overview Phonological assessment Word level Syllables Syllable division Stress Rhythm Sentences Intonation Pausing and length Production of difficult sounds Production of difficult sounds: phonological analysis Consonant cluster Fricativisation Elision Contraction Pressure changes **1. Assessment overview** The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | :--- | :--- | | • Clinical Dental Practice (CDP4) | 40% $\begin{cases} 30\% \text{ Clinic - Pebblepad} \\ 10\% \text{ Summative Case Presentation} \end{cases}$ | | • Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | **1. Assessment overview** The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | :--- | :--- | | • Clinical Dental Practice (CDP4) | 40% $\begin{cases} 30\% \text{ Clinic - Pebblepad} \\ 10\% \text{ Summative Case Presentation} \end{cases}$ | | • Dento-alveolar and Maxillofacial Trauma (TRAUMA) | 10% | 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module | Unit Weighting --- - **Clinical Dental Practice (CDP4) | 40%** <br> **{ 30% Clinic - Pebblepad}** **{ 10% Summative Case Presentation** 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. Module | Unit Weighting --- - **Clinical Dental Practice (CDP4) | 40%** <br> **{ 30% Clinic - Pebblepad}** **{ 10% Summative Case Presentation** ### 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | | :--- | :--- | :--- | | Clinical Dental Practice (CDP4) | 40% | $\begin{cases} 30\% \text{ Clinic - Pebblepad} \\ 10\% \text{ Summative Case Presentation} \end{cases}$ | | ... and Maxillofacial Trauma (TRAUMA) | 10% | | | ...th Dentistry 1 (PHD1) | 10% | | ### 1. Assessment overview The overall unit and each module individually must be passed at a pass mark of 50%. If a Module is not passed, the Board of Examiners will assess the individual assessments and determine eligibility for supplementary or remedial assessments. | Module | Unit Weighting | | | :--- | :--- | :--- | | Clinical Dental Practice (CDP4) | 40% | $\begin{cases} 30\% \text{ Clinic - Pebblepad} \\ 10\% \text{ Summative Case Presentation} \end{cases}$ | | ... and Maxillofacial Trauma (TRAUMA) | 10% | | | ...th Dentistry 1 (PHD1) | 10% | | The instruction two critical rules dictate that when text is sparse or only exists in the context of a figure, the whole page should be treated as a figure with a brief description wrapped in tags, and nothing else should be output. The instruction two critical rules dictate that when text is sparse or only exists in the context of a figure, the whole page should be treated as a figure with a brief description wrapped in tags, and nothing else should be output. A blank sheet of paper in shadow with the top of a paper visible in the bottom right. A blank sheet of paper in shadow with the top of a paper visible in the bottom right. Based on the image provided and the strict output rules (image with only sparse/no readable text), here is the output: Based on the image provided and the strict output rules (image with only sparse/no readable text), here is the output: | Item | | | :--- | :--- | | | | | **SUMMATIVE CASE** | | | 1. | Presenting | | 2. | History of | | 3. | Medical | | 4. | Dental | | 5. | Oral Hygiene | | 6. | Social | | 7. | Extra-Oral | | 8. | Intra-Oral | | 9. | Occlusion | | 10. | Dentist | | 11. | Tooth Charting | | 12. | Periodontal | | 13. | Radiographs | | 14. | Caries Risk Assessment | | | - Diet Assessment | | | - Plaque Score | | | - Saliva Assessment | | 15. | Periodontal Risk Assessment | | 16. | Prognosis | | 17. | Problem List | | | - Aesthetics | | | - Host-related | | | - Pathology | | | - Morphology | | 18. | Diagnoses | | 19. | Treatment Options | | 20. | Management / Plan | | 21. | Reflection |  | Item | | | :--- | :--- | | | | | **SUMMATIVE CASE** | | | 1. | Presenting | | 2. | History of | | 3. | Medical | | 4. | Dental | | 5. | Oral Hygiene | | 6. | Social | | 7. | Extra-Oral | | 8. | Intra-Oral | | 9. | Occlusion | | 10. | Dentist | | 11. | Tooth Charting | | 12. | Periodontal | | 13. | Radiographs | | 14. | Caries Risk Assessment | | | - Diet Assessment | | | - Plaque Score | | | - Saliva Assessment | | 15. | Periodontal Risk Assessment | | 16. | Prognosis | | 17. | Problem List | | | - Aesthetics | | | - Host-related | | | - Pathology | | | - Morphology | | 18. | Diagnoses | | 19. | Treatment Options | | 20. | Management / Plan | | 21. | Reflection | A vertical table listing the numbered components of a summative case presentation, ranging from 1 (Presenting...) to 21 (Reflection), with sub-items indented under specific categories like Caries Risk Assessment and Problem List. <div markdown=“1”> <center></center> </div> SUMMATIVE CASE RECORD (ADVANCED) | | | | |---|---|---| | 1. | Presenting Complaint | | | 2. | History of Presenting Complaint | | | 3. | Medical History | | | 4. | Dental History | | | 5. | Oral Hygiene | | | 6. | Social History | | | 7. | Extra-Oral Excerpts/Notes | | | 8. | Intra-Oral Excerpts/Notes | | | 9. | Occlusion | | | 10. | Dental Prosthetics | | | 11. | Tooth Charting | | | 12. | Periodontal Charting | | | 13. | Radiographs | | | 14. | Caries Risk Assessment | | | | | -Diet Assessment | | | | -Plaque Score | | | | -Saliva Assessment | | 15. | Periodontal Risk Assessment | | | 16. | Prognosis | | | 17. | Problem List | | | | | -Host-related | | | | -Pathology | | | | -Morphology | | 18. | Diagnoses | | | 19. | Treatment Options | | | 20. | Management Plans | | | 21. | Reflection | |  <div markdown=“1”> <center></center> </div> SUMMATIVE CASE RECORD (ADVANCED) | | | | |---|---|---| | 1. | Presenting Complaint | | | 2. | History of Presenting Complaint | | | 3. | Medical History | | | 4. | Dental History | | | 5. | Oral Hygiene | | | 6. | Social History | | | 7. | Extra-Oral Excerpts/Notes | | | 8. | Intra-Oral Excerpts/Notes | | | 9. | Occlusion | | | 10. | Dental Prosthetics | | | 11. | Tooth Charting | | | 12. | Periodontal Charting | | | 13. | Radiographs | | | 14. | Caries Risk Assessment | | | | | -Diet Assessment | | | | -Plaque Score | | | | -Saliva Assessment | | 15. | Periodontal Risk Assessment | | | 16. | Prognosis | | | 17. | Problem List | | | | | -Host-related | | | | -Pathology | | | | -Morphology | | 18. | Diagnoses | | | 19. | Treatment Options | | | 20. | Management Plans | | | 21. | Reflection | | A cropped view of a numbered list or table titled "SUMMATIVE CASE RECORD (ADVANCED)". The visible rows outline sections for clinical documentation, including history taking (presenting complaint, medical, dental), examinations (extra-oral, intra-oral, occlusion), charting (tooth, periodontal), risk assessments (caries, periodontal), and management planning (problem list, diagnoses, treatment options). **SUMMATIVE CASE** 1. Presenting 2. History of P 3. Medical Hist 4. Dental Hist<< 5. Oral Hygiene 6. Social History 7. Extra-Oral Exa 8. Intra-Oral Exa 9. Occlusion 10. Dental Prosth [11. Tooth Charting 12. Periodontal Cha 13. Radiographs 14. Caries Risk Assess - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk A 16. Prognosis 17. Problem List - Aesthetics - Host-related - Pathology - Morphology 18. Diagnoses 19. Treatment Options 20. Management Plans (TD 21. Reflection  **SUMMATIVE CASE** 1. Presenting 2. History of P 3. Medical Hist 4. Dental Hist<< 5. Oral Hygiene 6. Social History 7. Extra-Oral Exa 8. Intra-Oral Exa 9. Occlusion 10. Dental Prosth [11. Tooth Charting 12. Periodontal Cha 13. Radiographs 14. Caries Risk Assess - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk A 16. Prognosis 17. Problem List - Aesthetics - Host-related - Pathology - Morphology 18. Diagnoses 19. Treatment Options 20. Management Plans (TD 21. Reflection A vertical list of numbered items from 1 to 21, with some sub-items indented under main headings (e.g., - Diet Assessment under 14). The text is partially cut off on the right side. ## Table of Contents (Partial) 4. Oral Hygiene 5. Social History 6. Extra-Oral Examination 7. Intra-Oral Examination 8. Occlusion 9. Dentition 10. Tooth Charting 11. Periodontal Charting 12. Radiographs 13. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 14. Periodontal Risk Assessment 15. Prognosis 16. Problem List 17. Aesthetics 18. Treatment Options - Biologic - Psychologic - Morphologic 19. Diagnoses 20. Management Plans (Financial) 21. Referral 22. References  Table of Contents (Partial) 4. Oral Hygiene 5. Social History 6. Extra-Oral Examination 7. Intra-Oral Examination 8. Occlusion 9. Dentition 10. Tooth Charting 11. Periodontal Charting 12. Radiographs 13. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 14. Periodontal Risk Assessment 15. Prognosis 16. Problem List 17. Aesthetics 18. Treatment Options - Biologic - Psychologic - Morphologic 19. Diagnoses 20. Management Plans (Financial) 21. Referral 22. References No discernible content is present. SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2020 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2020 SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> </tbody> </table> <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> </tbody> </table> # SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> </tbody> </table> SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> </tbody> </table> **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2020** <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> <tr> <td>3. Medical History</td> </tr> <tr> <td>4. Dental History</td> </tr> </tbody> </table> <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> <tr> <td>3. Medical History</td> </tr> <tr> <td>4. Dental History</td> </tr> </tbody> </table> SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History **DENT5311** **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2020** <table> <tbody> <tr> <td>1.</td> <td>Presenting Complaint</td> </tr> <tr> <td>2.</td> <td>History of Presenting Complaint</td> </tr> <tr> <td>3.</td> <td>Medical History</td> </tr> <tr> <td>4.</td> <td>Dental History</td> </tr> <tr> <td>5.</td> <td>Diet History</td> </tr> </tbody> </table>  **DENT5311** <table> <tbody> <tr> <td>1.</td> <td>Presenting Complaint</td> </tr> <tr> <td>2.</td> <td>History of Presenting Complaint</td> </tr> <tr> <td>3.</td> <td>Medical History</td> </tr> <tr> <td>4.</td> <td>Dental History</td> </tr> <tr> <td>5.</td> <td>Diet History</td> </tr> </tbody> </table> A photograph showing two hands holding a large, mostly blank sheet of white paper that partially covers a printed document titled 'SUMMATIVE CASE PRESENTATION FORMAT'. No specific clinical figures, charts, or diagrams are visible as the paper obscures the content underneath. **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2020** <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> <tr> <td>3. Medical History</td> </tr> <tr> <td>4. Dental History</td> </tr> <tr> <td>5. Oral Hygiene</td> </tr> <tr> <td>6. Social History</td> </tr> </tbody> </table> <table> <tbody> <tr> <td>1. Presenting Complaint</td> </tr> <tr> <td>2. History of Presenting Complaint</td> </tr> <tr> <td>3. Medical History</td> </tr> <tr> <td>4. Dental History</td> </tr> <tr> <td>5. Oral Hygiene</td> </tr> <tr> <td>6. Social History</td> </tr> </tbody> </table> SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History **SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026** <table> <tbody> <tr> <td>1.</td> <td>Presenting Complaint</td> </tr> <tr> <td>2.</td> <td>History of Presenting Complaint</td> </tr> <tr> <td>3.</td> <td>Medical History</td> </tr> <tr> <td>4.</td> <td>Dental History</td> </tr> <tr> <td>5.</td> <td>Oral Hygiene</td> </tr> <tr> <td>6.</td> <td>Social History</td> </tr> <tr> <td>7.</td> <td>Extra-Oral Examination</td> </tr> <tr> <td>8.</td> <td>Intra-Oral Examination</td> </tr> </tbody> </table> <table> <tbody> <tr> <td>1.</td> <td>Presenting Complaint</td> </tr> <tr> <td>2.</td> <td>History of Presenting Complaint</td> </tr> <tr> <td>3.</td> <td>Medical History</td> </tr> <tr> <td>4.</td> <td>Dental History</td> </tr> <tr> <td>5.</td> <td>Oral Hygiene</td> </tr> <tr> <td>6.</td> <td>Social History</td> </tr> <tr> <td>7.</td> <td>Extra-Oral Examination</td> </tr> <tr> <td>8.</td> <td>Intra-Oral Examination</td> </tr> </tbody> </table> SUMMATIVE CASE PRESENTATION FORMAT OCTOBER 2026 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 1. Presenting Complaint 2. History of Presenting Complaint 3. Medical History 4. Dental History 5. Oral Hygiene 6. Social History 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 5. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 5. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting  7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting No discernible content is present. <table> <tbody> <tr> <td>7. Extra-Oral Examination</td> <td></td> </tr> <tr> <td>8. Intra-Oral Examination</td> <td></td> </tr> <tr> <td>9. Occlusion</td> <td></td> </tr> <tr> <td>10. Dental Prosthesis</td> <td></td> </tr> <tr> <td>11. Tooth Charting</td> <td></td> </tr> <tr> <td>12. Periodontal Charting</td> <td></td> </tr> </tbody> </table>  <table> <tbody> <tr> <td>7. Extra-Oral Examination</td> <td></td> </tr> <tr> <td>8. Intra-Oral Examination</td> <td></td> </tr> <tr> <td>9. Occlusion</td> <td></td> </tr> <tr> <td>10. Dental Prosthesis</td> <td></td> </tr> <tr> <td>11. Tooth Charting</td> <td></td> </tr> <tr> <td>12. Periodontal Charting</td> <td></td> </tr> </tbody> </table> A photograph showing a pair of hands resting on a white surface, likely during a video conference or presentation. <table> <tbody> <tr> <td>7. Extra-Oral Examination</td> </tr> <tr> <td>8. Intra-Oral Examination</td> </tr> <tr> <td>9. Occlusion</td> </tr> <tr> <td>10. Dental Prosthesis</td> </tr> <tr> <td>11. Tooth Charting</td> </tr> <tr> <td>12. Periodontal Charting</td> </tr> <tr> <td>13. Radiographs</td> </tr> </tbody> </table> <table> <tbody> <tr> <td>7. Extra-Oral Examination</td> </tr> <tr> <td>8. Intra-Oral Examination</td> </tr> <tr> <td>9. Occlusion</td> </tr> <tr> <td>10. Dental Prosthesis</td> </tr> <tr> <td>11. Tooth Charting</td> </tr> <tr> <td>12. Periodontal Charting</td> </tr> <tr> <td>13. Radiographs</td> </tr> </tbody> </table> 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion. 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. _______________  7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion. 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. _______________ A partial view of a cartoon character's leg and shoe, likely part of a decorative mascot illustration. 7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis 17. Problem List - Aesthetics - Host-related - Pathology - Morphology 18. Diagnosis 19. Treatment Plan  7. Extra-Oral Examination 8. Intra-Oral Examination 9. Occlusion 10. Dental Prosthesis 11. Tooth Charting 12. Periodontal Charting 13. Radiographs 14. Caries Risk Assessment - Diet Assessment - Plaque Score - Saliva Assessment 15. Periodontal Risk Assessment 16. Prognosis 17. Problem List - Aesthetics - Host-related - Pathology - Morphology 18. Diagnosis 19. Treatment Plan No discernible content is present.  A curved black line, resembling a drawn cable or wire, is superimposed over a blurry background image showing a partial computer screen with an upload dialog box. **SUMMATIVE CASE PRESENTATION NOTES:** 1. **Your SUMMATIVE Case Presentations will last 45 minutes:** 20 Minutes for you to Present 25 Minutes for Examiners' Questions They will run from Monday October 12- Friday October 16 -schedules will be provided in late September or early October. 2. **Arrange your presentation as per the HEADINGS in my HO and the Ucl sessions:** The Examiners will expect it to be in this order. *(Handwritten red notes:)* - 25/30 check marks - will be calibrated so everyone can see. To help you passing a sample- 14. **SUMMATIVE CASE PRESENTATION NOTES:** 1. **Your SUMMATIVE Case Presentations will last 45 minutes:** 20 Minutes for you to Present 25 Minutes for Examiners' Questions They will run from Monday October 12- Friday October 16 -schedules will be provided in late September or early October. 2. **Arrange your presentation as per the HEADINGS in my HO and the Ucl sessions:** The Examiners will expect it to be in this order. *(Handwritten red notes:)* - 25/30 check marks - will be calibrated so everyone can see. To help you passing a sample- 14. > [!note] Lecturer — Examiner Questions > Examiners may ask questions beyond the exact material shown in the presentation, so students should understand the medical implications of their patient’s conditions rather than simply reading the slides. > > - The presentation should be condensed without omitting key information. > - Treatment options and management should be organised clearly, while unnecessary detail should be removed. > [!note] Lecturer — Anaesthetic Choice > Adrenaline-containing local anaesthetic provides deeper and longer pain control than 3% lidocaine without adrenaline. Inadequate pain control may increase anxiety and contribute to medical complications. > [!note] Lecturer — Presentation Conduct > Students were advised to present in an organised manner and include references. > > - Dress appropriately. > - Avoid identifying patients in the presentation. > - Limit patient identification to sex and age; photographs must have the eyes blocked out, and patient numbers or other identifying details must not be included. > [!note] Lecturer — Patient Selection > Students were encouraged to treat each patient as a potential case-presentation patient and work each one up systematically, even if it was ultimately not used. > > - Suitable patients might have periodontal disease, restorative needs, endodontic treatment, or other substantial treatment needs. > - Study models may be taken when relevant, especially for prosthodontic cases, and should be brought in and photographed.  No discernible content is present. Overhead view showing a stack of white papers or documents on a flat surface. Overhead view showing a stack of white papers or documents on a flat surface.  A cropped fragment of a larger diagram showing a curved black line and a partial yellow circle, alongside a small blue and white graphic containing the text 'Uploading...'.  No discernible content is present. ## Case: Complex respiratory and systemic history patient ### Question **Scenario:** A patient with severe poorly controlled asthma requiring hospital admissions, rheumatoid arthritis, a smoking habit, reduced BMI, visual impairment, and social barriers including financial constraints and irregular attendance. **What's shown:** A comprehensive medical and social history detailing respiratory, musculoskeletal, and systemic risks, alongside dental findings of oral candidiasis, rampant caries, retained roots, and an old upper denture. **Consider:** How to categorize the medical history, assess the associated risks, and determine the necessary modifications for dental treatment and behavior management. ### Answer **Observations:** - Respiratory risk of acute asthma attacks and delayed healing from steroid inhalers. - Musculoskeletal limitations from rheumatoid arthritis affecting oral hygiene and chair positioning. - Systemic risks from smoking, reduced BMI (malnutrition), and visual impairment (fall risk, instruction comprehension). - Dental risks including candidiasis, high caries risk, and denture stomatitis. - Social barriers affecting attendance and post-operative support. **Reasoning:** The lecturer and students break down the patient's complex profile into medical categories (respiratory, musculoskeletal, social) to identify specific risks. Modifications include stress reduction protocols, bringing inhalers, adjusting chair positions for arthritis, providing accessible instructions for visual impairment, and prioritizing urgent care while considering financial barriers. **Takeaway:** Medically compromised patients require a structured approach to categorize their conditions, assess specific risks, and implement tailored modifications to ensure safe and effective dental care. ## Case: Geriatric patient in palliative care ### Question **Scenario:** An 80-year-old female in palliative care with severe dysphagia, recurrent aspiration pneumonia, severe dementia, ischemic heart disease, and a history of 70 Grays radiation for laryngeal carcinoma. **What's shown:** A clinical scenario involving a bedridden patient with high aspiration risk, capacity issues, bleeding risk on antiplatelets, and a specific question regarding the extraction of an upper left first molar. **Consider:** Whether the extraction is justified, how to manage the risks of aspiration, bleeding, and osteoradionecrosis, and how to navigate consent and capacity in an end-of-life care setting. ### Answer **Observations:** - High risk of life-threatening aspiration from dental materials or mobile teeth. - Risk of osteoradionecrosis (ORN) from previous radiotherapy. - Bleeding risk managed locally rather than altering antiplatelet medications. - Shift in treatment philosophy towards comfort, pain management, and eliminating acute infection rather than comprehensive restoration. - Need to assess mental capacity and involve legal substitute decision-makers. **Reasoning:** The decision to extract a tooth in a palliative, irradiated patient weighs the risks of ORN against the risks of leaving an infected or mobile tooth that could be aspirated or cause osteomyelitis. If the tooth is asymptomatic, prevention and ORN risk take priority. Consent requires following the legal hierarchy for decision-making when the patient lacks capacity. **Takeaway:** In end-of-life and palliative care, the treatment philosophy must shift towards comfort and risk mitigation, carefully weighing the burdens of treatment against the benefits, and strictly adhering to legal frameworks for consent. ## Case: Homeless ex-offender with multiple systemic conditions ### Question **Scenario:** A 64-year-old homeless ex-offender with Hepatitis C, latent TB, COPD, GORD, a history of IV drug use, and heavy alcohol consumption, presenting with poor oral hygiene. **What's shown:** A detailed medical and social history, including current medications (PPI, inhalers, TCM), lack of fixed address, and financial constraints. **Consider:** The infection control implications, medication interactions affecting bleeding and liver function, and the social barriers to treatment success and adherence. ## Case: Complex respiratory and systemic history patient ### Question **Scenario:** A patient with severe poorly controlled asthma requiring hospital admissions, rheumatoid arthritis, a smoking habit, reduced BMI, visual impairment, and social barriers including financial constraints and irregular attendance. **What's shown:** A comprehensive medical and social history detailing respiratory, musculoskeletal, and systemic risks, alongside dental findings of oral candidiasis, rampant caries, retained roots, and an old upper denture. **Consider:** How to categorize the medical history, assess the associated risks, and determine the necessary modifications for dental treatment and behavior management. ### Answer **Observations:** - Respiratory risk of acute asthma attacks and delayed healing from steroid inhalers. - Musculoskeletal limitations from rheumatoid arthritis affecting oral hygiene and chair positioning. - Systemic risks from smoking, reduced BMI (malnutrition), and visual impairment (fall risk, instruction comprehension). - Dental risks including candidiasis, high caries risk, and denture stomatitis. - Social barriers affecting attendance and post-operative support. **Reasoning:** The lecturer and students break down the patient's complex profile into medical categories (respiratory, musculoskeletal, social) to identify specific risks. Modifications include stress reduction protocols, bringing inhalers, adjusting chair positions for arthritis, providing accessible instructions for visual impairment, and prioritizing urgent care while considering financial barriers. **Takeaway:** Medically compromised patients require a structured approach to categorize their conditions, assess specific risks, and implement tailored modifications to ensure safe and effective dental care. ## Case: Geriatric patient in palliative care ### Question **Scenario:** An 80-year-old female in palliative care with severe dysphagia, recurrent aspiration pneumonia, severe dementia, ischemic heart disease, and a history of 70 Grays radiation for laryngeal carcinoma. **What's shown:** A clinical scenario involving a bedridden patient with high aspiration risk, capacity issues, bleeding risk on antiplatelets, and a specific question regarding the extraction of an upper left first molar. **Consider:** Whether the extraction is justified, how to manage the risks of aspiration, bleeding, and osteoradionecrosis, and how to navigate consent and capacity in an end-of-life care setting. ### Answer **Observations:** - High risk of life-threatening aspiration from dental materials or mobile teeth. - Risk of osteoradionecrosis (ORN) from previous radiotherapy. - Bleeding risk managed locally rather than altering antiplatelet medications. - Shift in treatment philosophy towards comfort, pain management, and eliminating acute infection rather than comprehensive restoration. - Need to assess mental capacity and involve legal substitute decision-makers. **Reasoning:** The decision to extract a tooth in a palliative, irradiated patient weighs the risks of ORN against the risks of leaving an infected or mobile tooth that could be aspirated or cause osteomyelitis. If the tooth is asymptomatic, prevention and ORN risk take priority. Consent requires following the legal hierarchy for decision-making when the patient lacks capacity. **Takeaway:** In end-of-life and palliative care, the treatment philosophy must shift towards comfort and risk mitigation, carefully weighing the burdens of treatment against the benefits, and strictly adhering to legal frameworks for consent. ## Case: Homeless ex-offender with multiple systemic conditions ### Question **Scenario:** A 64-year-old homeless ex-offender with Hepatitis C, latent TB, COPD, GORD, a history of IV drug use, and heavy alcohol consumption, presenting with poor oral hygiene. **What's shown:** A detailed medical and social history, including current medications (PPI, inhalers, TCM), lack of fixed address, and financial constraints. **Consider:** The infection control implications, medication interactions affecting bleeding and liver function, and the social barriers to treatment success and adherence.   Case: Complex respiratory and systemic history patient <table border="1" cellspacing="0"> <tr> <th> Medical history </th> <th> Medications </th> <th> Social & dental </th> </tr> <tr> <td> - Hepatitis C (&lt;6-monthly follow-up) </td> <td> - Omeprazole (PP Question 3 Non-Medical Factors Affecting Success | Factor | What it means for the treatment plan | |---|---| | Housing instability | No fixed address breaks the recall chain; appliances lost/unstored ### Answer **Observations:** - Hepatitis C and latent TB pose significant cross-infection risks, requiring strict precautions and potential airborne/droplet protocols. - Liver impairment from Hepatitis C and alcohol affects drug metabolism and increases bleeding risk. - TCM (e.g., ginkgo, ginger) may further increase bleeding time. - COPD and asthma require careful positioning and avoidance of rubber dam if it compromises breathing. - Social factors (homelessness, unemployment) severely limit treatment adherence and complex prosthodontic options. **Reasoning:** The case highlights the intersection of medical complexity and social vulnerability. Medical modifications focus on avoiding hepatotoxic drugs (like NSAIDs), managing bleeding risks, and ensuring respiratory safety. Social modifications involve understanding the limitations of the mandatory aftercare scheme and prioritizing pain and infection control over comprehensive care. **Takeaway:** Treating patients with complex medical and social histories requires strict infection control, careful medication management to avoid systemic complications, and realistic treatment planning that accounts for significant social barriers. ## Case: Severe COPD and asthma patient at a charity clinic ### Question **Scenario:** A 67-year-old male ex-smoker with severe COPD (FEV1 38%), asthma, hypertension, and reduced BMI, presenting with crumbling teeth and prolonged oral neglect. **What's shown:** Spirometry results, chest X-ray findings (flattened diaphragm), mild hypoxemia, and a medical history including current use of 10mg prednisolone. **Consider:** The respiratory and cardiovascular risk modifications, the implications of long-term steroid use, and managing social and financial barriers in a charity clinic setting. ### Answer **Observations:** - Severe COPD and asthma pose a high risk of acute exacerbations, requiring stress reduction, short morning appointments, and inhaler availability. - Cardiovascular risks from uncontrolled hypertension require monitoring and emergency kit availability. - Long-term steroid use (prednisolone) raises the risk of adrenal crisis and oral candidiasis. - Reduced BMI may indicate nutritional deficiencies affecting oral health. - Financial and language barriers (speaks Hokkien) affect attendance and treatment options. **Reasoning:** The lecturer guides the students to consider the additive effects of inhaled and oral steroids on adrenal suppression. Modifications include upright positioning, avoiding triggers, and using translators. Treatment is constrained by financial limitations, favoring direct restorations and preventive measures like high-fluoride toothpaste over indirect treatments. **Takeaway:** Patients with severe respiratory and cardiovascular conditions require careful appointment scheduling, stress reduction, and awareness of medication side effects like adrenal suppression, while social barriers must dictate realistic, conservative treatment plans. ## Case: Bariatric patient with multiple comorbidities ### Question **Scenario:** A female patient with a BMI >40, obstructive sleep apnea (OSA), asthma, hypertension, ischemic heart disease, diabetes, and reflux. **What's shown:** A list of systemic conditions, medications (including aspirin and CPAP use), and logistical challenges such as requiring special transport and having difficulty accessing posterior teeth. **Consider:** Chair weight limits, positioning and airway management, medication modifications, and coordinating care for a patient with severe obesity and multiple comorbidities. ### Answer **Observations:** - High BMI (>40) requires a bariatric chair (e.g., 500kg limit) and careful positioning to prevent airway obstruction, especially with OSA and reflux. - OSA and obesity make supine positioning difficult and increase risks with sedation and opioids. - Multiple comorbidities (diabetes, IHD, asthma) require monitoring of blood glucose, availability of GTN spray, and asthma triggers avoidance. - Aspirin use increases bleeding risk, manageable with local hemostatic measures. - Logistical issues like special transport and physical difficulty in oral hygiene require tailored advice and coordinated follow-up. **Reasoning:** The physical constraints of obesity affect both the equipment needed (bariatric chair) and the clinical approach (upright positioning to maintain airway and prevent reflux). The combination of OSA, diabetes, and IHD necessitates careful monitoring and avoidance of certain medications. Behavioral and physical barriers to oral hygiene require practical adaptations. **Takeaway:** Managing bariatric patients requires specific equipment, careful attention to airway and positioning, and a holistic approach that addresses both their multiple medical comorbidities and significant logistical challenges. ### Answer **Observations:** - Hepatitis C and latent TB pose significant cross-infection risks, requiring strict precautions and potential airborne/droplet protocols. - Liver impairment from Hepatitis C and alcohol affects drug metabolism and increases bleeding risk. - TCM (e.g., ginkgo, ginger) may further increase bleeding time. - COPD and asthma require careful positioning and avoidance of rubber dam if it compromises breathing. - Social factors (homelessness, unemployment) severely limit treatment adherence and complex prosthodontic options. **Reasoning:** The case highlights the intersection of medical complexity and social vulnerability. Medical modifications focus on avoiding hepatotoxic drugs (like NSAIDs), managing bleeding risks, and ensuring respiratory safety. Social modifications involve understanding the limitations of the mandatory aftercare scheme and prioritizing pain and infection control over comprehensive care. **Takeaway:** Treating patients with complex medical and social histories requires strict infection control, careful medication management to avoid systemic complications, and realistic treatment planning that accounts for significant social barriers. ## Case: Severe COPD and asthma patient at a charity clinic ### Question **Scenario:** A 67-year-old male ex-smoker with severe COPD (FEV1 38%), asthma, hypertension, and reduced BMI, presenting with crumbling teeth and prolonged oral neglect. **What's shown:** Spirometry results, chest X-ray findings (flattened diaphragm), mild hypoxemia, and a medical history including current use of 10mg prednisolone. **Consider:** The respiratory and cardiovascular risk modifications, the implications of long-term steroid use, and managing social and financial barriers in a charity clinic setting.  ### Answer **Observations:** - Severe COPD and asthma pose a high risk of acute exacerbations, requiring stress reduction, short morning appointments, and inhaler availability. - Cardiovascular risks from uncontrolled hypertension require monitoring and emergency kit availability. - Long-term steroid use (prednisolone) raises the risk of adrenal crisis and oral candidiasis. - Reduced BMI may indicate nutritional deficiencies affecting oral health. - Financial and language barriers (speaks Hokkien) affect attendance and treatment options. **Reasoning:** The lecturer guides the students to consider the additive effects of inhaled and oral steroids on adrenal suppression. Modifications include upright positioning, avoiding triggers, and using translators. Treatment is constrained by financial limitations, favoring direct restorations and preventive measures like high-fluoride toothpaste over indirect treatments. **Takeaway:** Patients with severe respiratory and cardiovascular conditions require careful appointment scheduling, stress reduction, and awareness of medication side effects like adrenal suppression, while social barriers must dictate realistic, conservative treatment plans. ## Case: Bariatric patient with multiple comorbidities ### Question **Scenario:** A female patient with a BMI >40, obstructive sleep apnea (OSA), asthma, hypertension, ischemic heart disease, diabetes, and reflux. **What's shown:** A list of systemic conditions, medications (including aspirin and CPAP use), and logistical challenges such as requiring special transport and having difficulty accessing posterior teeth. **Consider:** Chair weight limits, positioning and airway management, medication modifications, and coordinating care for a patient with severe obesity and multiple comorbidities. ### Answer **Observations:** - High BMI (>40) requires a bariatric chair (e.g., 500kg limit) and careful positioning to prevent airway obstruction, especially with OSA and reflux. - OSA and obesity make supine positioning difficult and increase risks with sedation and opioids. - Multiple comorbidities (diabetes, IHD, asthma) require monitoring of blood glucose, availability of GTN spray, and asthma triggers avoidance. - Aspirin use increases bleeding risk, manageable with local hemostatic measures. - Logistical issues like special transport and physical difficulty in oral hygiene require tailored advice and coordinated follow-up. **Reasoning:** The physical constraints of obesity affect both the equipment needed (bariatric chair) and the clinical approach (upright positioning to maintain airway and prevent reflux). The combination of OSA, diabetes, and IHD necessitates careful monitoring and avoidance of certain medications. Behavioral and physical barriers to oral hygiene require practical adaptations. **Takeaway:** Managing bariatric patients requires specific equipment, careful attention to airway and positioning, and a holistic approach that addresses both their multiple medical comorbidities and significant logistical challenges. Case: Homeless ex-offender with multiple systemic conditions > Answer HEALTHY A medical illustration comparing the respiratory system and alveoli of a healthy individual versus one with COPD. The upper section, labeled 'HEALTHY', depicts clear pink lungs and intact alveolar sacs, while the lower section shows damaged lung tissue with brownish, enlarged air spaces. ## Case: Patient with Down syndrome and multiple medical/behavioral conditions ### Question **Scenario:** A 45-year-old male with Down syndrome, moderate intellectual disability, autism, epilepsy, diabetes, osteoporosis, and an atopic profile (asthma, eczema, allergic rhinitis, penicillin allergy). **What's shown:** A medical history including bisphosphonate use, elderly caregivers (80s), and clinical signs such as toenail changes indicating potential neglect or systemic issues. **Consider:** Assessing MRONJ risk, managing behavioral challenges and consent, recognizing signs of systemic disease, and selecting appropriate behavioral and pharmacological supports. ### Answer **Observations:** - Bisphosphonate use for osteoporosis carries a risk of MRONJ, likely oral route given the patient's profile. - Neurological and behavioral challenges (autism, epilepsy, head instability) affect cooperation, consent, and clinical handling. - Atopic profile and penicillin allergy require careful drug selection and awareness of potential autoimmune overlaps. - Toenail changes prompt investigation into diabetic control, peripheral vascular disease, and oral candidiasis. - Elderly caregivers may struggle with attendance and daily oral care. **Reasoning:** The lecturer and students discuss a stepped approach to behavioral management, from tell-show-do to inhalation/IV sedation, clinical holding, or GA. The physical signs (toenails) serve as a marker for systemic health (diabetes/peripheral circulation). The complexity of the patient's medical and behavioral needs, combined with aging caregivers, suggests a need for multidisciplinary referral and simplified, acceptable dental care. **Takeaway:** Patients with intellectual disabilities and complex medical histories require a stepped approach to behavioral management, careful attention to medication risks like MRONJ, and recognition that physical signs can indicate broader systemic health issues requiring medical liaison. ## Case: Patient with Down syndrome and multiple medical/behavioral conditions ### Question **Scenario:** A 45-year-old male with Down syndrome, moderate intellectual disability, autism, epilepsy, diabetes, osteoporosis, and an atopic profile (asthma, eczema, allergic rhinitis, penicillin allergy). **What's shown:** A medical history including bisphosphonate use, elderly caregivers (80s), and clinical signs such as toenail changes indicating potential neglect or systemic issues. **Consider:** Assessing MRONJ risk, managing behavioral challenges and consent, recognizing signs of systemic disease, and selecting appropriate behavioral and pharmacological supports.   ### Answer **Observations:** - Bisphosphonate use for osteoporosis carries a risk of MRONJ, likely oral route given the patient's profile. - Neurological and behavioral challenges (autism, epilepsy, head instability) affect cooperation, consent, and clinical handling. - Atopic profile and penicillin allergy require careful drug selection and awareness of potential autoimmune overlaps. - Toenail changes prompt investigation into diabetic control, peripheral vascular disease, and oral candidiasis. - Elderly caregivers may struggle with attendance and daily oral care. **Reasoning:** The lecturer and students discuss a stepped approach to behavioral management, from tell-show-do to inhalation/IV sedation, clinical holding, or GA. The physical signs (toenails) serve as a marker for systemic health (diabetes/peripheral circulation). The complexity of the patient's medical and behavioral needs, combined with aging caregivers, suggests a need for multidisciplinary referral and simplified, acceptable dental care. **Takeaway:** Patients with intellectual disabilities and complex medical histories require a stepped approach to behavioral management, careful attention to medication risks like MRONJ, and recognition that physical signs can indicate broader systemic health issues requiring medical liaison. Case: Patient with Down syndrome and multiple medical/behavioral conditions Clinical photo showing the dorsal view of a patient's feet, highlighting thickened, yellowed, and overgrown toenails. A panoramic dental radiograph (OPG) showing the maxilla, mandible, and full dentition. An 'R' marker is visible in the bottom left corner indicating the right side of the patient. 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