SPECIAL PATIENT

WRITTEN CASE REPORT

JOSE MENDEZ

Patient profile, medical history and current systemic signs and

symptoms

Fifty-seven year old caucasian male presents for dental hygiene

services. Patient presents to the dental hygiene clinic with history of
esophageal cancer and esophagectomy. Due to the surgery on the
esophagus he has trouble swallowing. The patient also checked yes to the
following: chest pains, rapid heart beat and heart defects. For the chest pain
he is taking Lisinopril 10 mg 3x daily. He also has hypertension and is taking
Metaprol 25mg1 xdaily. The patient is not taking any medications for his
arthritis, nor his anemia. He also has mild COPD, and acid reflux which he
does not show any medications for in his health history form. Centrum
500mg 1x daily multi vitamin is also taken by the patient which there are no
contraindications for treatment. It was not noted in the patient medical
history what time he takes his medication so information could not be
disclosed. Patient stated in health history form that he is/has smoked and
is/has abused alcohol. Lastly, he has allergies to latex, keflex, prednisone,
and IV tape.
Patients current medications
Lisinopril 10mg 3xday
Cardiovascular Disease
Pharmacological Category: Angiotensin Converting
Enzyme(ACE inhibtor), Antihypersensitivity.
Use: Acute myocardial infarction, heart failure,
hypertension
Effects on Dental treatment: Patients may experience
orthostatic hypotension as they stand up after treatment. Due to
ACE inhibitor, pt can have dry cough, hacking, coughing can
interfere with longer dental procedures if patient has this side
effects.
Effects on Bleeding: None
Adverse Effects: CNS 12-19%
Metoprol 25mg 1xday

 Cardiovascular Disease
Pharmacological Category: Beta Blocker
Use: Acute myocardial infarction , angina pectoris,
hypertension,.
Local Anesthetic/Vasoconstrictor Precaution: None
Effects on dental treatment: non selective beta
blockers enhance the precursor response to epinephrine,
resulting in hypertension and bradycardia. This has not been
reported for metoprolol.
Effects on bleeding: none
Adverse Effects: Hypotension 1-27%, bradycardia 216%
Centrum 500mg 1xday
Vitamin
Use: prev/tx of vitamin and mineral
deficiencies; labeled for OTC use as a dietary supplement.
Effects on Dental tx: no significant effects
or complications reported.
Effects on Bleeding: No information avail
to require special precautions.
Summary of current periodontal and oral conditions
Patient presents with generalized 2-3 mm probing depths with localized
4-5mm probing depths. Patient presents with + mobility and class I
furcations in the mandibular molar region. Patient presents with calculus
code of Light 2, according to West Los Angeles College calculus code. Oral
health was documented as fair. The patient's AAP classification was noted
by clinician as Generalized Slight Chronic Periodontitis.
How the patient was managed
The patient was managed very well throughout the appointment.
Although the treating clinician decided the treatment was a full mouth
prophy, it is best the patient would be a full mouth periodontal maintenance
appointment. Reviewing the notes from the previous clinicians some

overlooked the acid reflux and did not document seating the patient in semisupine positioning for future clinicians reference. It is very important to
document that as well as latex allergies.
Treatment alteration considerations/consultations
During the treatment plan that was carried out by the dental hygienist,
the clinician did a great job but there could have been some improvements
to make the procedure a little easier for the patient. Firstly, the patient is
taking 3 medications: Centrum Mens which is a multivitamin with no
contraindications for treatment, Metoprolol which the patient's primary
physician put the patient on to control the hypertension with no
contraindication for dental treatment. Lastly, the patient is taking Lisinopril
which is also to aid in reducing the patients hypertension however, the
effect on dental treatment is that it causes the patient to have dry cough,
and orthostatic hypotension. With that being said positioning the patient is
important, because as a clinician one would want to make sure the patient
rises slowly, to not cause any dizziness, also if the patient has frequent
coughing spells, a break may be needed during treatment.
The patients medical history reported the following: Acid Reflux,
Arthritis, mild COPD Esophageal cancer with an Esophagectomy, and
allergies to latex, keflex, prednsone, and IV tape. During the treatment for
the Extraoral and Intraoral examination, as well as patient treatment it is
pertinent to keep the patient in a semi supine position so that the patient
does not have an episode triggering acid reflux. For the patients mild COPD,

during treatment only hand scaling is appropriate because contraindications

for the ultrasonic scaler states, Do not use on patients with upper
respiratory infections, shielded cardiac pacemakers, and restorations in the
oral cavity 1(Darby, Walsh 2015). For the patients arthritis, it is important to
ask usually where he feels pain. Assuming if it is in the hand OHI would be
altered to better suit the needs of the needs of the patient. If the patient
states Has arthritis in left hand many a stress ball could help reduce the
feeling during treatment. If the patient is stating pain a referral to the
primary care physician should be given so the doctor can offer medical relief
for the patient. The patient's comfort and safety is always priority. The
esophageal cancer and esophagectomy is very important. Esophageal cancer
defined by MayoClinic.org indicates, a cancer that occurs in the esophagus
a long, hollow tube that runs from your throat to your stomach. Your
esophagus carries food you swallow to your stomach to be digested. It is
most common in men than in women2(mayoClinic.org).. A referral should be
made to the primary care physician to address the status of the patients
medical condition since he is still having a difficult time with the acid reflux.
Also, a referral to the dietician to access his dieting as well. For the patients
allergies to latex, nitrile gloves should be utilized during the appointment to
avoid type IV hypersensitivity reactions from occurring. Also, to notify future
clinicians that work with the patient of knowing, a pop up should be created
to alert the clinician.

Due to the patient's periodontal charting instead of treatment being a

full mouth prophylaxis, a full mouth periodontal maintenance appointment
would be the best treatment option. Reason being is due to the generalized
2-3mm probing depths with localized 4-5mm probing depths, class I furcation
involvement, and +mobility. The AAP classification should render Generalized
Moderate Chronic Periodontitis with Localized Severe Chronic Periodontitis.
The patients oral health was termed FAIR, however there can be room for
improvement. When introducing OHI to patient, reviewing what type of
toothbrush he uses and the motion he is utilizing is important for his oral
health. Introducing him to proxy brushes for the type II embrasure space
would reduce the amount of plaque as opposed to utilizing string floss in that
area. To keep the patient's, bridge clean, a floss threader could be used in
the area to remove food debris from the gum line. The Tell, Show Do
method should also be incorporated before treatment to make sure the
patient understands the importance of reducing the plaque biofilm. Since the
patient suffers from acid reflux, before the end of the appointment, or the
patient's benefit 5%sodium fluoride varnish should be applied to all teeth
and important emphasis placed on the maxillary anterior lingual since that
area is affected mostly. Post-operative instructions should be delivered to the
patient so that he does not brush and the teeth can absorb as much fluoride
as possible.
Evidence to support proper management

What is cancer? Cancer is a group of specialized cells that grow at a

mitotic rate uncontrollably and metastasize to many different areas of the
body causing complications throughout the body. Esophageal cancer is rare,
however the effects on oral cavity and nutrition are important for patients
who suffer from esophageal cancer. Patients who suffer from esophageal
cancer must maintain a healthy diet, and have improved oral hygiene to
reduce the chances of meticulous growth of plaque biofilm, oral candidiasis,
and increased caries risk.
The Cancer Treatment Center of America studied the risk factors for
esophageal cancer as a preventative measure to reduce the likelihood of
developing the disease. The risk factors are as follows: Tobacco users- The
use of cigarettes, pipes, and cigars all increase the likelihood of esophageal
cancer. Alcohol users- Excessive use of alcohol can increase the risk of
developing esophageal cancer. Chronic acid reflux is termed GERD, and
increases esophageal cancer risk depending on the frequency and severity
of the acid reflux. Barretts Esophagus- An condition caused by chronic acid
reflux that changes the cells lining the esophagus increases the risk of
adenocarcinoma. cancer. Esophageal Webs- Tissue flaps that develop on the
esophagus, making it difficult to swallow, can increase the risk of developing
esophageal cancer (Cancer Center Treatment Centers of America, 2015).

Reference Page:
Al-Shahri, M. Z., Eldali, A. M., & Al-Zahrani, O. (2012). Prevalence and severity
of suffering among patients with advanced cancer. Support Care Cancer Supportive
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Darby, M. (2015). Chp 27 Ultrasonic Instrumentation. In M. Walsh (Ed.),

Dental Hygiene Theory and Practice (4th ed., p. 498). St. Louis, MO: Elsevier.
Esophageal cancer. (2014, May 25). Retrieved May 23, 2016, from
http://www.mayoclinic.org/diseases-conditions/esophagealcancer/basics/causes/con-20034316
Esophageal cancer risk factors. (0001). Retrieved May 23, 2016, from
http://www.cancercenter.com/esophageal-cancer/risk-factor
Mariette, C., Botton, M. D., & Piessen, G. (2012). Surgery in Esophageal and
Gastric Cancer Patients: What is the Role for Nutrition Support in your Daily
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doi:10.1245/s10434-012-2225-6
Yoshioka, M., Hinode, D., Yamamoto, Y., Furukita, Y., & Tangoku, A. (2013).
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the perioperative period. J. Appl. Oral Sci. Journal of Applied Oral Science, 21(2),
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