A Practical Approach to Special Care in Dentistry

Sensorineural deafness is commonly associated with genetic disorders, trauma, prematurity, infections, tumours, drug ototoxicity, otosclerosis and presbycusis, among others

The symptoms of auditory deficit depend on the cause and level of hearing loss

The presence of comorbidities is in general more common when the auditory deficiency occurs during the prenatal or perinatal stage

Children younger than 4 months do not turn face to noises; at 12 months, they are unable to articulate a single word and only respond when they can see the speaker or when certain sounds are produced

Older children talk in a high voice, continuously interrogate the speaker, and their pronunciation is unclear

Sudden loss of hearing can be a symptom of another disease, such as stroke

Initial examination with tuning fork and otoscope Figure 3.2.5 Cochlear implants in a child with congenital deafness.

Audiometry (auditory capacity curve that combines intensity and frequency) ( Figure 3.2.4)

Impedance (audiometry of electrical response or otoacoustic emissions)

Tympanometry and measurement of the stapedial reflex

Conductive auditory deficits can generally be treated with drugs or surgery (e.g. drainage, tympanoplasty and stapedectomy)

Sensorineural deafness can be improved with hearing aids and cochlear implants (surgically implanted electrical devices) ( Figure 3.2.5)

The prognosis for deafness depends on its aetiology

Conductive hearing loss usually has a better prognosis than sensorineural, which in some cases is irreversible

Deafness in the elderly usually leads to psychological problems and significantly increases the risk of dementia

The prevalence of hearing impairment in children and adults is substantially higher in low‐ to medium‐income countries than in high‐income countries; the regions with the highest prevalence of hearing impairment are southern Asia, sub‐Saharan Africa, Central/Eastern Europe and Central Asia

A significant percentage of cases of non‐syndromic deafness have a genetic origin; a number of mutations (especially in the GJB2 gene) are common in Middle Eastern countries, where carriers belonging to numerous ethnic groups have been identified

1 Alsmark, S.S., García, J., Martínez, M.R., and López, N.E. (2007). How to improve communication with deaf children in the dental clinic. Med. Oral Patol. Oral Cir. Bucal 12: E576–E581.

2 Ávila‐Curiel, B.X., Solórzano‐Mata, C.J., Avendaño‐Martínez, J.A. et al. (2019). Playful educational intervention for improvement of oral health in children with hearing impairment. Int. J. Clin. Pediatr. Dent. 12: 491–493.

3 Bimstein, E., Jerrell, R.G., Weaver, J.P., and Dailey, L. (2014). Oral characteristics of children with visual or auditory impairments. Pediatr. Dent. 36: 336–341.

4 Champion, J. and Holt, R. (2000). Dental care for children and young people who have a hearing impairment. Br. Dent. J. 189: 155–159.

5 Roberts, S., West, L.A., Liewehr, F.R. et al. (2002). Impact of dental devices on cochlear implants. J. Endod. 28: 40–43.

6 Shetty, V., Kumar, J., and Hegde, A. (2014). Breaking the sound barrier: oral health education for children with hearing impairment. Spec. Care Dentist. 34: 131–137.

7 Suhani, R.D., Suhani, M.F., and Badea, M.E. (2016). Dental anxiety and fear among a young population with hearing impairment. Clujul Med. 89: 143–149.

8 Wilson, B.S., Tucci, D.L., Merson, M.H., and O'Donoghue, G.M. (2017). Global hearing health care: new findings and perspectives. Lancet 390: 2503–2515.

A 43‐year‐old male presents to the dental clinic complaining of generalised pain in his mouth of several years' duration. He reports that the pain makes eating very difficult and feels that this is linked to his weight loss in the past year. You note that the patient is unable to communicate clearly and appears intoxicated.

Tuberculosis diagnosed at the age of 18 years of age – completed 8 months of drug therapy with pharmacological cure criteria achieved

Pulmonary mycetoma diagnosed 1 year earlier (pending surgery, which the patient has deferred on several occasions)

Tuberculous reinfection 4 months earlier (has been undergoing drug therapy since then)

Post‐trauma cataract in the right eye

Asthma

Depression/low mood

Constitutional syndrome (including malaise, fatigue, anorexia, weight loss) with protein‐calorie malnutrition

Isoniazid and rifampicin

Tiotropium bromide

Budesonide/formoterol

Folic acid

Lorazepam

Irregular attender as generally feels too tired to go out of the house

Last visit many years ago

Reports good co‐operation in the past

Does not brushing his teeth regularly

Married but separated and now lives with his mother

Unemployed/unable to work due to poor general health

Minimal financial resources

Tobacco consumption: 20 cigarettes/day since his adolescence

History of excess alcohol consumption (stopped consuming alcohol 5 years ago)

Intermittent use of recreational drugs; his wife, whom he sees occasionally, has drug addiction problems

Neglected dentition, with numerous caries and severe periodontal disease

Fixed prosthesis in the aesthetic zone #13–23

Caries in #16, #24 and #27

Missing teeth: #11, #12, #14, #15, #21, #22, #36, #37 and #46

Muscles of mastication tender on palpation

Orthopantomogram undertaken as the patient is unable to tolerate intraoral radiographs ( Figure 4.1.1)

Generalised alveolar bone loss demonstrated

Caries in #16, #23, #24, #25, #26 and #27

1 Is it likely that the patient's tuberculosis was active a year ago and led to the development of the pulmonary mycetoma?It is more likely that the patient had latent tuberculosis rather than active tuberculosis disease when the mycetoma was diagnosedA pulmonary mycetoma is a chronic, progressively infectious disease which can occur within a pulmonary cavity that is usually generated during the previous episode of active tuberculosis Figure 4.1.1 Orthopantomogram showing multiple caries and alveolar bone loss.It consists primarily of fungi, especially of the genus Aspergillus

2 What risk factors does this patient have for the development of tuberculosis?The use of recreational drugs is known to increase the risk of contracting tuberculosis, whether or not the individual has HIVThis has been linked to the sharing of drug equipment, such as marijuana water pipes

3 What factors could be contributing to the patient's oral symptoms?Poor oral health/recurrent dental infectionsTemporomandibular dysfunctionDepression/atypical facial painChronic pain associated with constitutional syndrome

4 The patient requests that all his remaining teeth are removed and dental implants are placed so that he can eat properly and gain weight. What factors should you consider when assessing the risk of managing this patient?SocialUnrealistic expectations – the weight loss may be due to other factors, including the constitutional syndrome; orofacial pain may not be related to dental healthImpaired capacity due to apparent intoxication – this may be linked to use of recreational drugs; unable to give informed consent, needs to be assessed at each visitLimited commitment to attend the dental clinic/hospital and follow‐upLimited financial meansMedicalFrail, malnourished patient with probable impaired wound healingRecurrent tuberculosisImpaired respiratory function: tuberculosis, mycetoma, asthmaPotential side‐effects of antituberculosis medication (infection/bleeding risk)Visual impairment due to the cataract and potential blurred vision with tiotropiumDentalNeglected mouth/poor commitment to maintaining oral healthActive smokingHyposalivation caused by tiotropium