We present the case of a twenty- year-old male with profound intellectual disability who is referred to the dental clinic by day program staff secondary to the observation of new dysfunctional behaviors. The patient presents a diagnostic challenge in the outpatient setting, but many clues are available to set the stage for both medical and dental diagnostic assessment. Objective information from the exam is presented along with a treatment plan for subsequent care and evaluation.
Mr. M. is a twenty-year-old male patient with idiopathic intellectual disability, who presents to the Underwood and Lee outpatient dental clinic, accompanied by his father, for comprehensive dental evaluation and treatment. His father is referred to the clinic by the staff at his son's day program workshop. The day program staff has observed hand mouthing behaviors, and they have voiced concern that the patient may be in pain.
In the waiting room, the patient exhibits behaviors consistent with neurodevelopmental dysfunction. He is non-communicative, and his gaze aversion and tactile defensiveness are suggestive of autism. He is resistant and somewhat combative when directed to the dental chair, and effective behavior management in both the waiting room and operatory requires the combined efforts of his father and two staff members. The health history is positive for Attention Deficit Hyperactivity Disorder; there is no history of seizure or neuromotor impairment. The father indicates that, at age ten, the patient was admitted to an inpatient psychiatric unit for evaluation of his uncontrollable behavior. The following day, the parents were told that managing the patient's behavior was beyond the ability of the psychiatric unit staff, and the parents were asked to take the child home. The father indicates that the psychiatric unit staff described the child's behavior as overwhelming. Although he was designated as having profound intellectual disability as a child, and although he clearly is not capable of giving informed consent, the patient has never been adjudicated incompetent. The patient was last seen by a dentist twelve years ago; examination and treatment at that time were carried out in the operating room under general anesthesia.
A review of the health history reveals that the patient has no known allergies. His current medications include dextroamphetamine, 20 mg Q day, and amitriptyline, 10 mg Q day. He eats a regular diet with minimal assistance from his parents. He is continent of both bowel and bladder. His health history is, otherwise, unremarkable.
Effective oral examination of this patient requires utilization of papoose restraint and Molt mouth prop. Multiple options for behavior management, including utilization of general anesthesia in the operating room, are discussed with the father, and informed consent to utilize mechanical behavior management techniques for purposes of this examination is obtained and documented prior to taking the patient into the operatory. In the operatory, a dental examination is performed, and a baseline panel of digital radiographs is obtained.
Narrative Summary of Dental Findings:
Gross inspection of the oral cavity reveals poor oral hygiene. A thick plaque accumulate is present throughout, and food debris is noted in multiple quadrants. Calculus accretions are heavy, and gingival tissues are inflamed and friable. Sulcular hemorrhage is elicited with periodontal probing throughout the right upper quadrant (RUQ), and localized areas of frank hemorrhage are evident. Multiple 5 and 6 millimeter periodontal pockets are measured in the RUQ, with a 9 millimeter pocket isolated at the distofacial of the right maxillary third molar (#1). Periodontal probing of the remaining quadrants is deferred until next appointment secondary to resistant behavior.
Further intraoral inspection reveals an extremely narrowed, high-arched palate, with numerous malposed maxillary teeth. …