Interesting Case: Patient with severe periodontal disease undergoing radiation and chemotherapy

 

A patient I have not seen in over 20 years returned to my office recently with some dental issues. He has a very loose upper front central incisor that is fractured horizontally more than half way down the root.  He has also lost one of his lower incisors due to severe periodontal disease. He admitted to total negligence of his teeth for over 10 years and so has rampant decay.

I noticed a suspicious patch under his tongue and performed cancer screening.  (I like to do cancer screening on everybody, but especially those with a history of cancer as does this patient)

This patient is totally fearful of  dentistry, (as are many)  and he needs to be sedated for his treatments.

Preliminary steps include fabricating a dental treatment partial denture for the upper central incisor and the 3 lower incisors. Once completed, he can have his extractions and biopsy performed and have his treatment partial dentures delivered.

The next step will be for him to return to his periodontist whom he has not seen in years. After that he will need a complete evaluation of the remaining teeth to see which ones can be treated with routine fillings or something more extreme, like root canal therapy and crowns. This patient may need sedation dentistry to help him through improving his dental condition. If that goes well, he can be evaluated for having dental implants, or perhaps he will be satisfied with a removable partial denture.

At this point, this patient is lucky to be in a condition to be able to save many of his teeth. If his past radiation therapy had been a little higher, the recommendation would be to have all of his teeth extracted and complete dentures fabricated. The reason for this is a condition of osteoradionecrosis which can happen while having radiation to the head and neck. In this condition, if a patient needs to have extractions after radiation, the bone frequently doesn’t heal and the bone surround the socket will necrose, a most painful condition. To avoid this, all of the teeth are removed prior to radiation. In this group, implants are also contraindicated.

So the idea is to handle the emergency aspect of the dental condition first, and then make the patient stable at that level. Then move along and improve the next condition as the patient can handle that step. His overall health must be updated regularly as well. Any major change in the patient’s medical condition must be evaluated for existing and future dental treatment.