A complex treatment plan for a phobic dental patient

Today’s experiences encompassed the evaluation and editing of a complex treatment plan. The patient is a 57 year old female patient who is extremely phobic in the dental setting. Her past medical history includes smoking 1 pack per day, sinus problems, migraines, and dental phobia. Her chief complaint was that she wanted her top teeth fixed for her son’s wedding this upcoming summer.

The patient’s dental phobia is a major contributor in the execution of her dental care. Her dental phobia is so severe that she sent her husband to the first few visits to take care of the treatment planning instead of personally being there, and, due to past dental related trauma, when she is in the dental office she cries. She would like the treatment done all in one day and under IV sedation so that she can get it done as quickly and as painlessly as possible.

The patient would only like to focus on the upper arch at this time. She has #4-11, 13, and 14. She is missing #1-3, 12, 15, and 16. The patient has periodontal disease which could be classified as moderate to severe chronic generalized periodontitis, evidenced by photographs and radiographs. (Figure 1)

Figure 1. The moderate to severe chronic generalized periodontal disease is evident in this radiograph. Notice the low bone height on both the maxilla and the mandible.

Therefore, initial scaling and root planing of the upper arch is indicated. Although the patient also has the disease on the lower, the patient would only like to focus on the upper arch and the dentist would like to avoid any sensitivity on the lower arch. Because the patient is afraid of any possible pain from her dental work, endodontic therapy was suggested in all of the upper teeth to avoid the pain. On most of the teeth the endodontic therapy is not indicated for carious or disease related reasons, but primarily to avoid any post-operative pain.

After the periodontal and endodontic therapy is done, the planned restorations will be prepared and inserted. There will be crowns on #4, 5, 13, and 14 and there will be resin veneers on #6-11. The crowns will only be temporary since the patient would only like to come in for 1 visit. The temporaries will be placed under a condition that the patient will come back for final crown insertion within 6 months of this treatment. The veneers will be resin because the patient does not want to come back for another visit, which would be necessary if porcelain veneers were fabricated. The patient was informed that resin veneers are not as strong or long lasting as porcelain veneers.

In addition to the aesthetic work which will be done on the maxilla, there is also a concern of a red lesion on the hard palate. Since the patient smokes 1 pack per day, this puts her at a higher risk for oral cancer. The oral surgeon will examine and possibly biopsy the lesion during the visit. (Figure 2)

Figure 2.  The red lesion on the palate is of concern, especially since the patient is a smoker. An oral surgeon will examine and possibly biopsy the lesion.

All of this therapy will be done in one visit in order to comprehensively deal with the patient’s phobia of dentistry and pain. In addition, since the husband is the primary person involved in the treatment planning process, both the husband and the patient will sign the treatment plan, confirming that they both understand and agree to the treatment outlined.

Lateral, front, and occlusal views of the maxilla before treatment.

N.S., New York University College of Dentistry

Categorised in: Dental Student Experiences

This post was written by Dr. Jeffrey Dorfman