The anxious patient: Empathy, planning and a team-approach
[ Ilyaas Rehman, BDS (Glas) ]
A 41-year-old anxious female patient attended the practice for an examination in February 2019; the first time in nine years. She complained of a broken tooth in the lower right side, which was presently asymptomatic but felt sharp to the tongue. In addition to this, the patient was aware of the poor condition of her remaining dentition, stating that she was unable to eat or socialise confidently. She alerted us to using Superglue to hold her remaining crowns in, and teeth together.
The patient was now keen to try to rehabilitate her dentition and therefore the motivating factors for her attendance were:
- Embarrassment: unable to socialise confidently, unable to smile without covering her mouth.
- Function: unable to eat hard or crunchy foods, insufficient posterior teeth to chew with.
- Poor quality of life.
Medical, Dental and Social History
The patient informed us of having multiple sclerosis and hypertension, which were being controlled by Interferon and Amlodipine respectively. She reported previous asthma, for which medication was no longer required. She also reported taking Fluoxetine, Lansoprazole, Thyroxine and Dihydrocodeine.
The patient could not remember the last time she attended the dentist, however, computer records confirmed this to be nine years ago. She reported having several bad experiences in the past which have amounted to severe general dental anxiety. She brushed twice daily with a manual toothbrush and was not presently using any interdental aids or mouthwashes.
She worked full-time as a veterinary nurse. She quit smoking 6-7 years ago after smoking roughly twenty cigarettes a day for twenty years (twenty pack years) and reported zero alcohol consumption.
No abnormalities were detected on extra-oral examination.
Intra-orally, the patient’s soft tissues showed no abnormalities. The patient was partially dentate with a heavily restored remaining dentition, including failing crowns. The occlusal relationship was class 1 and there was a lack of posterior occlusal support. Oral hygiene was poor, with evidence of generalised gingivitis and plaque. Despite this, the present BPE scores did not exceed 2s. A fractured 44 amalgam was observed, and a temporary filling was placed here prior to further radiographic and clinical assessment.
There was also evidence of excess material across the upper anterior teeth, which the patient informed us of being Superglue to hold in the crowns. Application of firm digit pressure to the upper anterior teeth caused mobility of 2-3mm of the entire sextant. Caries was recorded clinically in teeth 13, 11, 21, 44, 31 and 33. There was also presence of several retained roots.
Due to the clinical findings, periapical radiographs and clinical photographs were taken.
A list of diagnoses was subsequently established:
- Generalised gingivitis.
- Generalised Periodontitis Stage II Grade B – currently stable – risk(s): ex-smoker.
- Primary caries: 13, 31.
- Secondary caries: 11, 21, 44, 33.
- Defective restorations: UR2, UL2.
- UR1 previously RCT with asymptomatic PAP.
- UR4 retained root, previously RCT with asymptomatic PAP.
- LR3 vertical fracture, previously RCT with asymptomatic PAP.
- UL4 retained root with asymptomatic PAP.
Aims of treatment were to restore health, function and aesthetics. Four possible avenues were discussed:
- Deconstruing the upper anterior segment, reassess and potentially restore: Re-RCT 11 12 22 and restore with post-core crowns.
– Caries removal and restoration Extraction of retained roots and LR3.
– Provision of upper and lower immediate partial dentures.
- Extraction of all teeth of poor prognosis – 13, 12, 11, 21, 22 and retained roots. Provision of immediate upper and lower partial dentures – Caries removal and restoration.
- Extraction of all teeth of poor prognosis, implant approach to restoring gaps, caries removal and restoration.
- Referral to specialist service (NHS/Private).
Each option was discussed in detail. Following this, the patient initially opted to try option one, despite understanding the plethora of risks attached and the poor prognosis of the remaining teeth. However, further probing revealed this was due to severe anxiety of extractions.
Appropriate evidence-based anxiety management techniques were discussed, including desensitisation, acclimatisation and in-house IV sedation. The patient subsequently made an informed decision to proceed with option two. All items of treatment were to be carried out under the NHS, excluding the LR4 due to lack of mechanical retention for amalgam.
A staged treatment plan was proposed as follows:
- Immediate – Temporisation of fractured LR4.
– Hygiene Phase Therapy: OHI (tipps), diet advice, supragingival scale.
– Extractions under IVS: 13, 12, 11, 21, 22, 43 and retained roots 14, 24, 47, 34.
– Provision of immediate upper and lower partial acrylic dentures.
– Caries removal and restoration: LR4, LL1, LL3.
– Provision of new upper and lower partial dentures.
The patient showed exceptional motivation to overcome anxiety and strive towards a healthier oral environment. There were two key problems encountered with treatment. Firstly, extraction of 47, 43 and 34 required a surgical approach. This was carried out in-house on the same appointment with assistance and therefore was rectified accordingly. Secondly, the patient found that she was unable to tolerate the lower denture. However, rather than this being due to the lower denture fitting poorly and uncomfortably, the patient felt she would prefer to firstly get accustomed to the upper denture alone. In effect, the patient was functioning with a modified shortened dental arch.
Subsequent to completion of the initial treatment, the patient returned with irreversible pulpitis associated with 35 and root canal therapy was carried out.
The patient expressed thorough delight with the result of the treatment carried out and has, as a result, developed trust with the practice and treatment providers. She is now able to interact and socialise confidently, smile freely and eat healthily.
Though arguably no part of this treatment plan is especially complex, this case has been a thorough learning experience in the management of an anxious patient. With the assistance of senior colleagues, I was able to provide the patient with an outcome that we are both very pleased with. I believe that, as a result of implementing basic principles successfully from the onset, the patient has regained her trust in the profession.