Matthew Su
Patient: #759625
September 11, 2018
Management of Patient with Complex Medical Conditions
My patient is a 63 year old African American patient male who presents to UHC clinic with a chief complaint of “I want a new set of dentures.” The patient is diagnosed in 2003 to be HIV positive with the following lab values: CD4 – 391, viral load – undetected, TWC – 2.9, ANC – 56.5, platelet count – 161; and current medication includes: combivir and viramune. Additionally, the patient is also diagnosed with hypertension and currently controlled with lisinopril and triamterene. Patient also suffers from seasonal allergies and is treated with loratadine. He is also diagnosed with schizophrenia and is being treated with gabapentin, clonazepam, quetiapine, benztropine mesylate. Patient states he is a current smoker (3 pack years). The patient also suffers from chronic arthritis and receives intra-joint injections once every six months and is taking norco for pain as prescribed by his primary care physician. His medical history will have a significant impact on his comprehensive dental treatment.
Upon clinical exam and radiographic findings reveal multiple missing teeth: #3, 4, 5, 8, 9, 10, 12, 13, 14, 17, 18, 19, 30, 31, 32; existing restorations on #1O, 2MODB, 16O, 28O, 21O, 29D, 2D; no active decay at this current time. Patient is currently wearing definitive RPD/RPD fabricated in 2018. Patient is diagnosed with history of periodontitis and localized slight gingivitis on teeth #1, 2, and 16 with a questionable diagnosis due to him being a current smoker. Patient’s current treatment plan includes regular 3-month periodontal maintenance and denture adjustments.
One condition that significantly affects my patient’s treatment is his diagnosis of schizophrenia. Schizophrenia is described as a psychological and mental disorder in which the individual suffers from thought disturbances, bizarre behavior and cognitive impairment. The exact cause of the condition is unknown but is thought to be influenced by genetics, altered brain chemistry and structure, and environmental factors. Individual who suffers with the conditions is often characterized by abnormal social behavior and difficulty in understanding reality. Symptoms can range from confused thinking, lack of motivation and the condition is sometimes associated with additional mental health issues like that of anxiety. Individuals with schizophrenia may likely have difficult time planning and performing oral care routines. This results in higher caries risk and activity and it has been reported that patients who suffer from a psychological disorder has a significantly higher number of missing teeth. Additionally, the medications prescribed to treat schizophrenia has also been associated with causing xerostomia and extra-pyramidal symptoms that could further hinder oral hygiene routines. In another recent study, it was discovered that there is an increased risk for candidiasis infections in men with cognitive disorders. Therefore, regular reminder and proper patient education is vital in ensuring longevity of his prosthetic appliances and in maintaining his overall oral health. My patient should also be provided with instrumental aids such as large handle toothbrushes to compensate for any physical hinderance associated with extra-pyramidal symptoms to facilitate easier homecare. At every appointment, patient should continue to be educated on proper care of his appliances as well as signs and symptoms of candidiasis infections in order to facilitate prompt diagnosis and treatments. Routine appointments should be made at every office visit.
On top of potential extra-pyramidal symptoms that may arise from the prescribed medications, my patient also suffers from osteoarthritis. Arthritis is the gradual deterioration of joint cartilage and the associated bone. Symptoms of osteoarthritis may range from stiffness, pain, to loss of function. Osteoarthritis is most commonly found in the knees, hands, hips, feet and spine. Due to the prevalence of osteoarthritis in the hands, patients who suffer from osteoarthritis may also suffer substantially from poor oral health due to lack of manual dexterity. In order to alleviate problems that my patient may face with osteoarthritis, it is critical to provide him with tools that will make his homecare easier such as large handled toothbrush or automatic toothbrush. Additionally, my patient will be scheduled for regular periodontal maintenance visits to assist him with the cleaning process.
Another condition that may influence my patient’s oral health is his diagnosis as HIV positive. HIV is a lentivirus that can lead to the condition of acquired immune deficiency syndrome. The virus causes slow degradation of the immune system and may eventually lead to death due to opportunistic infections. The prevalence of oral lesions in HIV infected individuals have been found to be between 40-70%. Oral candidiasis falls into the category of an opportunistic infection. Patients with removable prosthesis are also at an increased risk for candidiasis infection. With a combination of HIV positive and being a denture wearer, my patient is at an even greater risk. Removable prosthesis can act as a reservoir for candida species. Patient infected with candidiasis is instructed to swish and swallow a prescribed nystatin mouth rinse and remove their dentures at night to be soaked in solutions overnight. The patients will return for an re-evaluation appointment and further treatment, if required. Due to potential drug interactions between nystatin and antiretroviral medications, it would be wise to coordinate with patient’s primary care physician for candidiasis treatment prior to prescribing nystatin.
In addition to medication-induced hyposalivation, patients with HIV also have a higher rate of xerostomia due to viral infection at salivary glands. Without management, xerostmia could encourage rampant decay, ulcerations of oral mucosa, and fungal infections. It is important to regularly monitor the status of salivary flow at appointments and recommend my patient daily use of Biotene mouth rinse to increase salivary flow.
Because HIV-positive patients also have an increased risk of periodontitis, and my patient is a current smoker who is wearing an RPD, he has additional risk factors that may contribute to periodontitis. His routine periodontal maintenance and meticulous homecare are crucial to his overall oral health. My patient may also benefit from daily use of chlorhexidine mouth rinses. Also, my patient should be reminded the negative impact of smoking on oral and overall health. The patient should be offered tobacco cessation counselling when he is ready to quit.
All in all, my patient has a number of health conditions that require routine monitoring. The patient would benefit most from repeated OHI, tobacco cessation and close control of his current condition. Treatment should include strong home regime with aids that be help improve his routine. My patient’s risks factors include HIV, denture use, osteoarthritis, schizophrenia and medication-induced hyposalivation. As a result, he is at an increased risk for caries, candidiasis infections and periodontal diseases.