Case Study #1 – Mrs. P
Patient Overview:
- Age: 77, Female, Caucasian, ASA 2
- Blood Pressure 100/65 normal, Pulse 80. Corresponds to normal.
- Special Needs: Vulnerable population (geriatric); psychological or mental health considerations
Medical History:
- Reported systemic conditions: Arthritis in the hands. Severe Electromagnetic Hypersensitivity (EHS) for the past 10+ years.
- Not currently on any medications.
- No known allergies.
Dental History:
- Last dental visit was 12 months ago for a checkup and cleaning
- Hasn’t had dental X-rays in 10+ years due to electric sensitivity
- Cannot use ultrasonic scalers, engine polishers, or expose radiographs.
- OHI: manual TB 2x/day, non-fluoridated toothpaste, floss picks daily.
Dental Findings:
- Case Value: Medium
- Periodontal Status: Localized Stage 3 Grade B, due to interdental CAL >5mm on molars
- Caries Risk: Moderate
3 Visits – Summary
Prior to the initial visit, it was difficult reaching Mrs. P to confirm her appointment. Due to her electrical sensitivity, she does not possess a mobile phone nor a computer. I had to make several attempts calling her landline which was occasionally disconnected before I was able to speak with her.
At the initial visit, I discovered that Mrs. P took frequent breaks due to her discomfort with the electricity surrounding us. I had to keep my computer screen off at all times, I couldn’t use the dental operatory light for prolonged periods of time, I had to lower the dental chair slowly, and the patient did not want the use of suction. The patient also took multiple long bathroom breaks and stop to chat with people in the hallways and clinics. After learning Mrs. P’s special needs considerations, I tailored her treatment plan to adjust to her needs. We would definitely only hand scale without suction, which meant that the patient had to frequently sit up in order to expectorate into the cuspidor. We had to shut off the dental light and take a break whenever the patient reported discomfort from too much exposure to light. We would have at least two more revisits since the appointments would take slower with the modifications and frequent breaks. I noticed that it was also challenging for the clinic professors. At the revisit appointments when the professors rotated, it was difficult for the clinic professors to understand my struggles with the patient since they didn’t meet the patient initially. I completed all assessments in the initial visit; scaled two quadrants at the first revisit, and the remaining two quadrants at the second revisit.
Mrs. P was a challenging case and definitely a significant learning experience. The thoughts that crossed my mind were: if the patient reported an electrical sensitivity, how were they able to take the subway to the appointment or even be at this school with the ceiling lights? Even though there was little to no scientific research on Electromagnetic Hypersensitivity, the patient’s care and comfort was still always the priority. I was patient and adjusted the way that I spoke to Mrs. P to motivate good homecare despite the challenges that she faced. As a healthcare provider, I know that I would encounter difficult patients on a daily basis and that I had to adjust accordingly.
Case Study #2 – Ms. A
Patient Overview:
- Age: 51, Female, African, ASA 2
- Blood Pressure 135/80, Pulse 80. Corresponds to Hypertension Stage 1.
- Special Needs: Psychological or mental health considerations
Medical History:
- No reported systemic conditions.
- Not currently on any medications.
- No known allergies
Social History:
- Smokes 5 cigarettes daily
- Drinks alcohol occasionally
- Smokes marijuana daily; smoked prior to dental hygiene appointment
Dental History:
- Last dental visit was two years ago for a checkup, Xrays, and a cleaning
- OHI: manual TB 1x/day, Crest toothpaste, doesn’t floss.
Dental Findings:
- Case Value: Heavy
- Periodontal Status: Generalized Stage 3 Grade B
- Caries Risk: Moderate
4 Visits – Summary
At the initial visit, Ms. A gave me a disclaimer that she is extremely sensitive to dental pain, that she hated dental visits and has dental phobia and white coat syndrome. In the past, she received local anesthesia at every dental visit, so she asked for injections during the assessments. I thought that she was exaggerating but the patient could not even tolerate the use of an explorer or probe. Even after applying topical benzocaine and Oraqix during probing and calculus detection, the patient groaned and screamed of pain. The gingiva was inflamed- bright red, shiny, enlarged, blood; and there was generalized heavy supra and subgingival calculus. The professor and I both explained to the patient that she has gum disease which is causing the discomfort. At the initial visit, we were able to complete only assessments due to taking frequent breaks to adjust to the patient’s pain levels.
At the first revisit, we exposed an FMS which showed generalized 40% horizontal bone loss, with a localized furcation involvement, and generalized heavy calculus buildup. To begin scaling, I administered local anesthesia (a third of a carpule for each: ASA, MSA, PSA, mental, buccal infiltrations). The patient still reported pain so the dentist administered more single tooth infiltrations in the maxilla and a IAN block to the mandible. The dentist explained that it was an excessive amount of anesthesia but we considered that 1- the patient smoked cigarettes which is a vasoconstrictor, 2- the patient smoked marijuana before her which may have affected the efficacy of the anesthesia, and 3- people of African descent have been observed to have higher bone density. These were considerations to keep in mind for all of Mrs. A’s appointments. At this appointment, we completed scaling two quadrants.
At the second revisit, we were only able to scale one quadrant on the maxilla because the dentist on the floor for that day did not administer blocks. I was advised that a mental and buccal infiltration should suffice if I injected more anesthesia. I started by adminstering half a carpule each via ASA, MSA, PSA, mental, buccal infiltrations and scaled one tooth in each quadrant to gauge how the patient reacted to the pain, specifically in Q3. The patient screamed from discomfort so I decided to only complete scaling Q2 for the day. At the third revisit, the dentist administered a IAN block to Q3 and I completed treatment.
At each appointment, Ms. A expressed how much she dreaded dental visits. I motivated the patient about the importance of routine dental cleaning by showing pictures of the calculus bridges in her lower anteriors as well as her posteriors. The patient showed concerned for her oral health but the her discomfort was a factor in her compliance. Whenever I used the explorer to check for residuals, the patient screamed. I attracted attention from other students and patients in neighboring cubicles. I was concerned that I was instilling dental phobia amongst other patients. Ms. A’s case definitely challenged me with patient management. I have kept in touch with her by sending her electric toothbrush and water flosser recommendations. I plan to continue following up with her for her 3 month recare appointments.