MEDICALLY COMPROMISED PATIENT MARGARET SNOWDEN
1. A The appearance of tissue under a removable denture can vary from highly keratinized to no keratinization, depending on several variables including the fit of the denture and the efficacy of oral hygiene self-care. A denture that does not fit correctly is likely to cause an irritated red, inflamed, or ulcerated lesion and not the bluish, tattoo-like appearance noted here.
B A dilated blood vessel, often observed in older adult patients, manifests as a deep red or bluish varicosity in the sublingual region or on the tongue. This condition should not be confused with the flat, bluish staining of the mucosa noted here.
C If the removable partial denture had a rough edge or otherwise was causing irritation, hyperkeratosis may result. Hyperkeratosis, a thickening of the tissues in response to the irritation, appears as patchy, white keratinized tissue.
D Normal melanin pigmentation changes the appearance of the gingiva to brownish or black. Pigmentation can vary among populations and may depend on race and genetics. Increased pigmentation in the labial mucosa has been linked with smoking. Changes in the pigmentation of the gingiva should not be confused with the bluish-gray hue noted here.
E An amalgam tattoo results when a particle of amalgam used to restore teeth
accidently becomes embedded under the soft tissues. The presence of amalgam under the translucent tissue manifests as a bluish-gray hue. Amalgam tattoos are often found in patients who have had extensive or large amalgam restora- tions. Although this patient has a significant number of crowns, it is very likely that these teeth exhibited numerous and large amalgam restorations prior to the need for crowns.
2. A,B,E An examination of the radiographs reveals that the maxillary left lateral, maxillary left second premolar, and mandibular right lateral incisor exhibit the radiopaque appearance of endodontic filling material. The radiopacity of this material extends throughout the pulp chamber and root canals. This appearance should not be confused with the appearance of a retention pin.
C A retention pin can be observed upon close examination of the radiograph of
the maxillary left first molar. In addition to the radiopaque endodontic filling material, a short, significantly wider metal object can be observed. The size and shape of retention pins help distinguish this dental restorative material from other types of restorations.
D The mandibular right lateral incisor exhibits less radiopaque-appearing composite restorations on the mesial and distal surfaces of the crown of the tooth.
3. 1. C The presence of the fixed bridge with pontics replacing the maxillary right second premolar and first molar makes the use of floss threaders the ideal choice from this list for oral self-care in this region.
2. E The appearance of recession and root exposure of the maxillary left first and second premolars in combination with the patient’s chief complaint regard- ing root sensitivity in this region make burnishing with a wooden toothpick a good choice from this list for oral self-care. Gently burnishing or rubbing the exposed region of the teeth roots can help stimulate the formation of second- ary dentin to diminish sensitivity.
Chapter 2 Tutorial: Getting Started with a Sample Case 23 3. A The inflamed and enlarged appearance of the gingiva in the region of the
mandibular left central and lateral incisors and canine, in combination with the periodontal probe readings recorded on the chart, and the radiographic appearance of reduced bone levels that indicate periodontal involvement make scaling and root detoxification the best choice from this list.
4. B The radiolucencies observed on the radiographs on the distal of the mandibu- lar right central incisor and on the mesial of the mandibular right lateral incisor indicate a deviation in the normal radiopaque appearance of intact enamel. These radiographic findings indicate a need for a referral for evaluation of caries. 5. D The mandibular right and left posterior teeth have been replaced with a
removable partial denture. It is important that the denture be removed and cleaned after each meal. Additionally, the underlying tissue should be cleaned and massaged to maintain good oral health.
4. 1. B The establishment of bacterial plaque biofilm is necessary for the proliferation of other pathogens.
2. E Two to 4 days after the establishment of bacterial plaque biofilm, leuko- cytes (neutrophils and macrophages) increase to defend against inflammation. There are no observable clinical changes in the tissue at this point.
3. D Beginning after 4 to 7 days, there are clinical signs of erythema, edema, and bleeding upon stimulation indicating gingivitis.
4. A Gingivitis that persists or is chronic is characterized by the increase in num- ber and predominance of β-cells and plasma cells.
5. C Gingivitis becomes periodontitis as the connective tissue fibers detach from the cementum and migrate apically contributing to resorption of the supporting bone.
5. A Brushing with a toothpaste with 1.1% neutral sodium fluoride provides
beneficial caries prevention. A neutral sodium fluoride will not harm the dental restorative materials present, making the statement correct. Xerostomia, a reduced salivary flow, increases the patient’s risk for caries, making the reason correct. The statement and the reason are related because appropriate management of xerostomia includes the use of fluoride therapies.
B,C,D,E These are incorrect answers, as explained previously.
6. A Both statements are true. Some chemotherapeutic agents used in the treatment
of cancer suppress the immune system, increasing the patient’s risk of developing oral infections such as Candida albicans or candidiasis. Especially at risk are patients who wear a removable partial denture. Chemotherapy and radiation therapy can cause changes in the oral cavity such as swelling and ulceration that may lead to denture irritation and an increased risk for fungal (and bacterial and viral) infections. Candidiasis can be treated with azole antifungals dispensed as a lozenge that is held in the mouth until dissolved. B,C,D,E Both statements are true, as explained previously.
7. A,D Problems with the temporomandibular joint (TMJ) such as pain or a limited ability to open the arches (trismus) may result from radiation therapy directed on the muscles in this region, as would be the case in radiation treatment of oral cancer. The radiation therapy this patient will undergo will not be likely to affect the TMJ or result in trismus.
B Chemotherapy and radiation therapy for breast cancer will not always result
in oral manifestations, especially if oral self-care is meticulous. Mucositis, inflammation, and ulceration of the mucosa are not direct side effects of these therapies, but due to the toxicity of chemotherapy and radiation therapies, the patient is at risk for these conditions.
C,E Xerostomia is a possible side effect of some chemotherapeutic agents used to
treat cancer, and xerostomia in turn will increase the risk for the development of caries. Additionally, if fungal, bacterial, or viral infections develop, these can make the oral cavity sore and compromise effective plaque control, in turn increasing caries risk.
F,G Some chemotherapeutic agents used to treat cancer suppress the immune sys-
tem, increasing the patient’s risk of developing candidiasis, a fungal infection of the oral cavity. A suppressed immune system also increases the risk of develop- ing viral and bacterial infections.
H Cellular changes that increase an inflammatory response and myelosuppres-
sion contribute to increased bleeding. Bacterial plaque exacerbates the bleeding response.
I Bruxism or clenching and grinding the teeth may be linked to how the patient responds to stress of the cancer and its treatments. However, this is not a direct side effect.
LEARNING TIPS
Use the answers and rationales to further your understanding of the topics addressed in the study questions. It may be tempting to only glance at this section of the book to score your answers as correct or incorrect, but this section provides more opportuni- ties for further learning. While it is important to have selected the correct answers to the study questions, it is equally important to understand why the other choices, called distracters, were incorrect. The rationales provide an opportunity to not only learn the key points for the topics addressed by the study question, but to ensure your understanding of the incorrect answers as well.
DID YOU NOTICE?
You can use the Answer Discussion and Rationales section (Chapter 18) to advance your learning. Consider this activity. “Teach” the topics addressed by the study ques- tions to a student partner, or, if practicing on your own, write out explanations of the topics that would assist a beginning student with learning the material.
For example, consider the first study question:
1. What is the most likely cause of the dark spot on the facial mucosa near the mandibular left canine?
A. Denture-induced oral lesion B. Dilated blood vessel C. Hyperkeratosis D. Normal pigmentation
E. Amalgam tattoo
The correct answer is E. Amalgam tattoo. But suppose your student partner asks you why B. Dilated blood vessel, which can appear bluish in color, is not the correct answer. Based on what you learned in the rationale section, use your own words to explain the difference between these two conditions. Continue teaching or explain- ing the differences between the correct answers and the rationales for each of the study questions. This exercise can strengthen your knowledge base.
Chapter 2 Tutorial: Getting Started with a Sample Case 25
To prepare to teach or explain a concept to someone, you must first learn the con- cept yourself.