Download DEN2317 Parisa Nahvi Cheryl Ann Peters Tiffany Velez Octavia

DEN2317
Parisa Nahvi
Cheryl Ann Peters
Tiffany Velez
Octavia Williams
ABOUT THE PATIENT
The patient is a 30 year old female named Jessica Fleet. Mrs. Fleet has been diagnosed with Bipolar
disorder for three years now. She is married and self-employed. Jessica has a seven-year-old son and is currently
six months pregnant with her second child. Jessica is afraid that her unborn baby will inherit her mental disorder,
or be harmed by her medications. She does not even want to get out of bed most days, but she wants to do
everything in her power to protect her baby. Due to her mental disorder, Jessica’s psychiatrist suggested the
minimum dose of Lithium. She is currently taking 400 mg Lithium every eight hours. This dosage is used to
maximize the concentration amount to the mother’s brain, while maintaining the lowest fetal concentration to
reduce birth risks. She is also taking 27 mg of Iron per day as well as 400 to 600 mcg's of Folic acid and 1000 mg
of calcium for her pregnancy. Jessica is currently experiencing bleeding upon brushing as well as halitosis and a
receding gum line. She also is experiencing redness and swelling in her gingiva. Although Mrs. Fleet hasn't been
to the dentist within the last five years she feels it is absolutely necessary to go now. She fears in the old wives
tale with every pregnancy one loses a tooth because for her first son she did experience losing a tooth. She knows
her dental health is not in the best of shape. She wants to ensure that her disorder and dental health does not affect
her unborn baby.
SYSTEMIC CONDITIONS
Bipolar Disorder
Bipolar disorder, formerly known as manic depression, is a condition in which a person can go from being very
happy to being very sad and irritable within a matter of minutes. It is believed that chemical imbalances in the
brain of certain neurotransmitters, such as serotonin and dopamine, can lead to this psychiatric disorder. It is also
believed that genetics play a major role in the diagnosis of this disorder. People with bipolar disorder experience
extreme mood swings. They go through what is called mania, an extreme high or great feeling, and depression, a
very low, sad state. People usually develop bipolar disorder during adolescence and early adulthood.
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A person who is bipolar might experience symptoms such as…
Feeling sad and empty most of the time
Weight gain or loss
Loss of interest in fun or pleasurable activities
Loss of energy
Difficulty sleeping
Thinking of death and suicide
Feelings of worthlessness and/or inappropriate guilt
There are several forms of treatment for people suffering with bipolar disease. All forms of treatment aim to
reduce the occurrence of manic and depressive episodes, lessen the severity of the disorder, prevent thoughts of
death and suicide, and provide support for people suffering from the disease, as well as their families. Bipolar
people take a series of medications, as well as go to psychotherapy sessions to help them cope with thoughts of
suicide, their feelings, and their behaviors. Psychotherapy is a way for people with bipolar disorder to manage
their daily stresses, such as family issues, work, school, and becoming a parent. Some medications used for the
treatment of bipolar disorder are…
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SEROQUEL XR- FDA approved Pregnancy Risk Factor D
Lithium-GOLD STANDARD MOOD STABILIZER: Treats both manic an depressive episodes PRF D
Anticonvulsants- Depakote, Tegretol PRF D
Antipsychotics- Zyprexa, Abilify PRF C
Antidepressants- Enslam (Trycyclic), Elavil (Monoamine-oxidase Inhibitor) PRF C
Symbax- FDA approved specifically to treat bipolar disorder PRF C
Benzodiapines- Valium, Xanax PRF D
The adverse effects of these drugs include weight gain, dizziness, blurred vision, increased appetite, problems
with balance and memory, gastrointestinal upset, skin rashes, involuntary facial movements, frequent urination,
and increased thirst and hunger.
Adverse effects concerning dental treatment: Xerostomia/changes in saliva, orthostatic hypotension, Tardive
dyskinesia, fruity breath, taste perversion, periodontal abscess, toothache, edema of the tongue, metallic taste.
Pregnancy
Women who are pregnant take a number of prenatal vitamins to help support the bone growth of their growing
fetus. The vitamins they take are…
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Folic acid- Folate (B vitamin) important in the role of red blood cell production and the development of
the neural tube into the brain and spinal cord of the fetus. 400-600 mcg of folic acid every day
Iron- important in the production of red blood cells (carry oxygen around the body) 27 milligrams (mg) of
iron per day
Calcium- builds strong bones and teeth, allows for the growth of healthy nerves, muscles, a healthy heart
and it aids in the development of a normal heart beat and blood clotting abilities 1,000 milligrams (mg) a
day before, during, and after pregnancy
During pregnancy there is an imbalance of a woman’s hormones which in turn causes her to have morning
sickness, better known as nausea and vomiting during pregnancy. Morning sickness usually occurs within the first
trimester.
Pregnancy and Bipolar Disorder
Medications used for treatment of bipolar disorder can be associated with birth defects such as…
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Neural tube defects
Heart defects
Developmental delays
For some women, doctors suggest that they stop taking their bipolar medications, and other doctors suggest that
they switch to older generation antipsychotics which have less of a chance of the unborn baby having a birth
defect. Most drugs for treatment of bipolar disorder are categorized as Pregnancy Risk Factor C or D.
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C: Animal reproduction studies have shown an adverse effect on the fetus. There are no adequate and well
controlled studies in humans and the benefits from the use of the drug in pregnant women may be
acceptable, despite its potential risks. Animal reproduction studies have not been conducted.
D: Based on human data, the drug can cause fetal harm when administered to pregnant women, but the
potential benefits from the use of the drug may be acceptable, despite potential risks.
As the research shows, lithium, being a gold standard drug for the treatment of bipolar disorder, can be used
during pregnancy to prevent the relapse of a manic or depressive episode. The journal states that “the “best”
recommended dosage regimens to reduce risk are the 300/300/300/300 and 400/400/400”. This means that in
order to prevent a manic/depressive episode and reduce fetal defects as much as possible pregnant women must
use 300 or 400mg of lithium, having had about 1200mg/day, spaced out (evenly) over a 24 hour period. When
taking lithium, patients must be sure to have their serum lithium levels monitored to make sure that there is no
lithium toxicity.
Bipolar disorder and periodontal disease
The medications associated with bipolar disorder have dental adverse effects that have to be taken into
consideration when treating a patient…
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Xerostomia/changes in saliva
Orthostatic hypotension
Tardive dyskinesia,
Fruity breath
Taste perversion,
Periodontal abscess
Toothache
Edema of the tongue
Metallic taste
Salivary gland swelling
The dental team also has to recognize that patients with bipolar disorder will not be very compliant. They will
have….
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Poor oral hygiene
Toothbrush abrasion
Xerostomia
Pain
Bruxism
Caries
Missing teeth
Generalized stomatitis (with long term use of lithium)
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And sometimes they will not even show up for their appointments
Pregnancy and periodontal disease
Periodontal disease is the destruction of the attachment apparatus of the teeth by an overgrowth of harmful
bacterial species. The primary cause of periodontal disease is dental plaque, which is why daily homecare is very
important. There is…
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Bone loss
Pocket formation
Bleeding
Red, swollen gums
Recession
Bad breath/halitosis
Tooth mobility
When a person’s gingiva becomes inflamed, their body responds to the site(s) of inflammation.
Prostaglandins (fatty acids found in cell membranes) allow vasodilation to take place and is shown to have some
correlation with the pain and bone loss of periodontal diseases. Vasodilation or the widening of the blood vessels
causes the gingiva to become swollen and red. Studies have shown that the prostaglandins associated with
periodontal disease in pregnant women can led to miscarriage, low birth weight babies, and preterm births.
Compared to other people, pregnant women have extreme gingival changes due to their imbalance of
hormones. If a patient is pregnant, it does not necessarily mean that she will have pregnancy gingivitis. If the
patient is pregnant and already has preexisting plaque induced gingivitis they are at a greater risk of getting
pregnancy gingivitis. In pregnancy gingivitis the patient has red, swollen/enlarged gingiva, an absence of clinical
attachment loss, bone loss, and changes to the periodontal ligament. Pregnancy gingivitis is reversible, but it can
progress to periodontitis if it is not taken care of.
PHASE 1: MEDICAL HISTORY
The patient’s medical history shows that she is a 30yr old female, non- smoker, and she generally has
good health. She has bipolar disorder, and is currently taking 400 mg of lithium 3x a day, for the last six months.
She is also taking 400-600mcg of folic acid, 27 mg of iron and 1000mg of calcium daily, for the last 6 months.
She was hospitalized several times in 2009 for attempted suicide before she was diagnosed with bipolar disorder.
She experiences dry mouth (due to medication), morning sickness, and frequent urination (due to excess amount
of drinking water to reduce lithium toxicity to fetus, also due to pregnancy). Dental information tells us that the
patient experiences halitosis, bleeding upon brushing her teeth, and she has sensitivity to sweets. Mrs. Fleet
mentioned that she has not had any morning sickness, which is understandable since she is in her second trimester
of pregnancy. The last time the patient was seen by a dentist was in 2007, for a routine check-up and cleaning.
Four bitewings were taken during that time. The patient feels that her teeth could be in better shape.
ASSESSMENTS
After completing all of the assessments (head and neck examination and oral cancer screening, dental and
periodontal charts) there were several findings. Mrs. Fleet has caries present on teeth # 23, 14, 15, 18, 19, 31.
Tooth number 30 was extracted during her first pregnancy. She also has abrasion, abfractions, and attrition
localized to maxillary and mandibular molars. Her periodontal chart showed signs of early furcation involvement
and her pocket depths range from 1-8mm. She was diagnosed with Type III chronic periodontitis. As with
calculus detection, she was classified as a heavy with light staining.
TREATMENT PLAN
Mrs. Fleet was scheduled 2 appointments, to minimize the amount of travel time as a pregnant woman. I
will use a pillow to help keep her and the baby more comfortable. Also, I suggested that she uncross her legs
while sitting in the dental chair in the semi supine position. When I called the patient to confirm the appointment I
suggested that she bring headphones so that she could listen to some music during treatment.
Treatment planning
Visit 1- Disclose patient, introduce brushing technique as homecare, Scale UR and LR quadrants
Visit 2- Re-evaluate UR and LR quadrants, introduce flossing techniques, Scale UL and LL quadrants, do
selective polishing, apply neutral sodium fluoride.
First appointment: 60 min
After receiving the patients consent, I began oral hygiene instruction. I demonstrated the relationship
between the stained areas and bleeding as well as the relationship between the plaque accumulation and chronic
periodontal disease. I explained to her that pregnancy causes an increase in appetite and often a craving for
unusual foods. If these cravings are for cariogenic foods, she could increase her risk of caries at this time.
Therefore, it is important to reduce the frequency of having sugary snacks between meals. She has xerostomia and
I advised her to consume a lot of water and chew sugarless gum and candy to help alleviate the symptoms. I
informed her that flossing and brushing can improve her oral health and this could stop periodontitis from getting
worse. Therefore, preventing the progression of the disease can help prevent tooth loss. Also, scaling and root
planning shall be implemented to decrease the inflammation caused by her periodontal infection. Mrs. Fleet told
me that in the manic phase of her disease, she is likely to brush hard and abrasively and in the depressive phase,
she tends to clench her teeth together and neglects both brushing and flossing. I recommended that she use a night
guard to prevent occlusal trauma when she clenches. I advised her to use an Oral B Triumph power brush
because it is easier to use and it will motivate her to improve her oral hygiene. Moreover, if she brushes too hard,
the machine will automatically let her know that she is applying too much pressure. I also demonstrated the Bass
technique of brushing and showed her that with proper use of this technique, she will also be able to return to a
better state of health. I encouraged her to brush every morning and every night. As a professional I explained to
her that bad breath (halitosis) occurs when oral bacteria break down food between teeth and on the tongue. These
bacteria tend to give off a foul odor. I explained to her that halitosis could be treated by brushing her teeth and
tongue frequently and flossing to remove hidden food particles. I also stated that she drink water to keep her
mouth moist and have regular checkups to evaluate her xerostomia. She also has a coated tongue and I taught her
how to use a tongue scraper to remove the bacteria.
Once the patient was properly educated, I began to scale using the ultrasonic. The patient showed signs of
discomfort and wanted to insure that we were minimally invasive. Although lidocaine could have been
administered, we decided to go with Oraqix. I continued to complete the UR and LR quadrants. All areas of
supragingival and subgingival calculus were removed. Although the patient had frequent urination, she only took
one break to go the restroom.
Second Visit: 45 MIN
10 days after first visit- Rescheduled
15 days after first visit- Rescheduled
20 days after first visitI reviewed her medical and dental history. Then I evaluated the tissue response from the previous
treatment and recorded my findings. There was minimal new calculus forming, no inflammation, and minimal
bleeding. Her tissues were well adapted to her teeth and her gingiva returned to a pinkish color with melanin
pigmentation present. Jessica explained that due to her depression she did not want to leave the house, but she did
make sure to brush every morning and night using the Bass technique, reminding herself of her unborn baby’s
health. I recommended that she use an interproximal brush because she has blunted interproximal papilla and I
showed her how to use it. I also recommended that she invest in an oral irrigator such as the Waterpik 360, since
flossing will not be very effective being that she has Type III periodontitis. I encouraged Mrs. Fleet to maintain
her oral health as much as she could. I spoke to her about the risk of having a low birth weight baby, since she has
periodontal disease. I told that when our bodies respond to inflammation certain fatty acids, called prostaglandins,
are produced. I told that these prostaglandins can decrease the birth weight of her baby and that it is very
important for her to maintain her oral cavity in order to have a healthy, normal weight baby.
Once she became a pro at using the interproximal brush, I began scaling. I re-scaled the upper right and
lower right quadrants by hand. I applied Oraqix to relieve any discomfort and I continued to complete the upper
left and lower left quadrants, using an ultrasonic cavitron and hand scalers. Once all four quadrants were
completed, I began to do selective polishing and I removed any light staining that was present. As the final step in
treatment for Mrs. Fleet, I applied a neutral sodium fluoride.
I used my four minutes of waiting time during the fluoride application very productively, informing my
patient that she was classified as having a high risk for caries. I told her to use ADA-approved fluoride toothpaste
at least twice daily. I recommended that she use a natural oral rinse like Natural Dentist or Tom’s of Maine. They
both have the ADA seal of acceptance and have been clinically proven to kill germs naturally, reduce gingivitis
and bleeding gums, and relieve irritated and swollen gums as well as sore throat. On the other hand, I informed
her that these rinses have shorter shelf lives than any conventional mouth rinse and they are sensitive to extreme
temperature and sunlight. I told her that she could also use Biotene products to help manage her xerostomia.
Biotene products provide fast relief of xerostomia. I told her she may like to try a rinse with Cetylpyridinium
chloride (CPC) in it like Crest Pro-health, which is an alcohol free mouth rinse that decreases gingival
inflammation and periodontal disease in pregnant women without having strong taste.
I completed the treatment by giving her referral to a dentist to restore her active caries. I also gave her a
referral to see a periodontist for periodontal evaluation. Last but not least, I recommended that Mrs. Fleet returns
for a recall appointment of 3 months. This appointment will be after the birth of her child. I believe that Mrs. Fleet
will follow through with her daily homecare, being that she is concerned about her health as well as the health of
her unborn child. There may be some calculus present when she returns and her bone loss is not reversible, but I
expect for there to be an extreme difference in her oral health. If she maintains her oral health and follows up with
her dental appointments as she says, she will have a good prognosis, a healthy baby, and a better life.