Case study # 2 – Trismus

CASE STUDY # 2 – TRISMUS (Limited mouth opening)

Patient info: “M.C. – a 76-year-old white female”. ASA: 2

MEDICAL HISTORY:  1) Lantus 4 units for diabetes

• Humalog for diabetes
• Synthroid 150ug for hypothyroidism.
• The patient had a very limited opening which made it difficult, if not impossible, to provide dental care.
• No pre-medication nor any allergies. No alcohol or tobacco consumption of any kind.

 

 

INITIAL VISIT ( RECARE PATIENT) – 11/07/23:

• While reviewing the history of the patient, I found that it will be a challenging case as it was mentioned in the previous visits that the patient has a very limited opening.
• She presented with a BP of 123/93 which reduced to 113/93 after 20 minutes.
• She had Type I diabetes and last Hba1c = 6 (a week ago).
• PAN taken at CityTech clinic in 04/2022.

Extra-oral Findings: The patient had a slightly enlarged thyroid.

Intra-oral Findings: Bilateral mandibular tori and a maxillary torus. Very limited mouth opening.

Summary of hard tissue: Dentin exposed of #5 at lingual cusp due to a fracture. The mandibular anteriors were impinging on the lingual gingiva of maxillary incisors.

Oral hygiene routine: She used an electric toothbrush followed by waterpik twice daily. Total care Listerine as rinse.

Periodontal Findings: Bright pink flaccid and edematous gingiva. Posterior margins were rolled and inflamed.

On perio chart, anteriors had a probing depth of 2-3 mm and posteriors had 4-5 mm of probing depth with few 6mm in molars.

She was thus classified as a stage III B based on the probing depths and generalized recession in the posterior teeth. Case value was heavy due to generalized subgingival calculus and caries risk was heavy due to multiple restorations present.

1^st visit summary (11/07/23) : The patient mentioned that it is very difficult to maintain oral hygiene due to the narrow opening. I recommend her to use a pedo brush for the posterior part of the dentition or those parts that she finds impossible to reach with her electric toothbrush. The Modified Bass method of toothbrushing was demonstrated on the patient`s mouth. She was advised to keep using Waterpik and Listerine.

Quadrant # 4 was scaled, and local anesthesia was used. This was a very challenging case because it was difficult to scale the areas properly. I was unable to angle the cavitron or hand instruments appropriately. A bite block was used but it was placed horizontally as the patient could not open enough to place the bite block appropriately. The patient was cooperative but asked for several breaks, as she could not keep her mouth open for longer periods. She was also given a referral to see her dentist and discuss a narrow mouth opening as it was hindering her routine oral hygiene.

 

2^nd visit summary (11/17/23): The patient discussed her oral hygiene and had tried using a children`s toothbrush for difficult-to-reach areas. She was positive about following her oral hygiene routine strictly. I revised toothbrushing with her and entertained her questions, followed by demonstrating interdental aids. She refused to learn string floss, so was advised to use floss picks for anteriors and keep using water pik for the rest of the mouth. Water pik available at clinic was used to demonstrate to patient. Patient had followed up on her referral and scheduled an appointment at NYU for January.

However, on this visit, she refused to take anesthesia and preferred to continue with oraqix. I used warm water bags on her TMJ before starting scaling, as advised by Dr. Haong. As expected, the patient felt comfortable and was able to open her mouth for a longer duration now. Quadrant # 1 was scaled with Oraqix alone, but the patient was clearly in pain in the posteriors. She was advised again to take local anesthesia so that the scaling could be done efficiently on this visit or we could reschedule for the remaining dentition. Fortunately, she agreed to take anesthesia for quadrant 2 & 3. By the end of the treatment, patient was very happy and satisfied with the scaling & oral hygiene demonstration

 

Recare visit summary (03/30/2023): In Den 2300 patient requested to schedule her recare visit with me. She has no changes in medical history from the previous visit. She presented with 138/88 BP on this visit. Her recent Hba1c was 6.3 (2 weeks ago). She followed up on the referral given and was under the care of a dentist at NYU. She started physical therapy on 03/06/2023 and reported a significant improvement post-therapy.

The patient further informed that she is brushing regularly but is not very regular with water pik now. Thus, toothbrushing was revised with her and the significance of an interdental aid was discussed with her. Probing depths were same as in previous visit however, plaque score had increased. Patient was made aware of these changes and recommended to follow a routine interdental aid.

She refused to take anesthesia and had discomfort in the posterior part of UL & LL quadrants. She was explained that deep pockets and lack of hygiene can lead to further bone loss. The whole dentition was scaled in this visit as the patient was much more tolerant compared to previous visits.

Overall, this case was a challenging and learning experience. I learned that patients could present with different health conditions which can hinder routine oral hygiene. As a professional, I had a chance to not only teach her to take care of oral hygiene efficiently but also encourage her by providing her with feasible alternatives. As she mentioned that it is impossible to reach mandibular anterior and posterior teeth lingually, I recommended she use a children`s toothbrush in those areas as a smaller head can be easier to adjust. Moreover, as the patient mentioned that she is not regular with water pik also, she was encouraged to not give up as it was very beneficial for her.