Whatโs in a radiograph? The effort it took to get this Panoramic was quite massive and a definite concerted effort of the team Med Hx of Pt - I canโt recall the exact details. - basically stroke abt 18 months ago - almost complete paralysis, on PEG feeding and bed bound when Pt was being seen at our centre frm the start: 1 yr ago - locked in syndrome: can understand whatโs happening around him Dental Hx - limited examination could be done when he first came in 1 year ago by my colleague - because he was seen on a trolley bed - he was completely clenching most of the time - sent off for a 6 month to 1 year review due to the limitations of what could be done for him: no signs of infection at the time, just cleaning/swabbing for whatever accessible surfaces at the time + OHI for the caregiver Hx of complaint : - when I saw him one month ago, the family c/o Pt having and incident of facial swelling of the lower left submandivular area: according to the family - given antibiotics by his son who is a medical doctor by the time I saw the pt, the swelling had gone down I still saw him in the trolley bed and I could do another limited examination Findings: - heavily restored dentition, I couldnโt really see posterior beyond the #34i, #35i (didnโt even know they were implants at the time ). - Noted that #33 was mobile but we werenโt convinced if that was the cause of the swelling because there wasnโt any abscess/sinus tracts/swellings intra-orally. Unsure if it was the #34,#35 as well because they were firm but couldnโt really assess their integrity or condition. - With help of my department head, we could sort of pride his mouth opening, not enough to put a mouth prop in but enough to realise there was #37 there - I wasnโt convinced that that was a source of infection because it felt firm and I couldnโt feel any swellings or see any signs of infection (although it was really hard to see!) Further investigations : We tried to attempt intra oral radiographs. The radiographer has a hard time trying all sorts of films etc but most of the time we couldnโt even place the film in or the Pt would clench back up in protest and groan angrily So my consultant says to put on a one month review and see if swelling returns. As I spoke to his wife and caregiver, it turns out that patient has been making some improvements in his rehab. Has been doing speech therapy once a week to improve muscle control and attempt some verbalisation it sounds Been placing him on a wheelchair for 1-2hrs per day and they use a hoist on him for transfers at home. So my plan: N/v bring Pt in a wheelchair, see if that wheelchair can allow Pt to be seated to take an OPG which maybe more diagnostic than our previous feeble attempts at intra-oral radiographs Second visit w me: One month later (which was 2 weeks ago), we saw Pt again. He was in his reclinable wheelchair, and seemed to be in a more relaxed mood, didnโt seem to clench as much. Unfortunately the mechanics and design of the wheelchair didnโt allow him to be positioned him properly. The radiographer want him to sit in a specific chair that would be better. So 3 of us decided to use our available hoist to transfer Pt frm his wheelchair to the regular chair. Even this transfer was quite challenging because our x-ray room was really small. We had to do the hoist transfer outside the room and push him on the chair into the X-ray room. And someone has to support his neck while we pushed him on the regular chair. His caregiver wore a lead apron while supporting and positioning his neck when taking the X-ray itself. And I think the resulting radiograph was worth the effort. We have a clearer picture of his current dentition. I doubt that the source of infection was from the 35i 34i or 37. 33 was the one with mob2+ and u can discern some PARL. Wife agreed for exo the #33. Pt understood what was happening as I explained to him slowly and he rolled his eyes, the Wife says that means he agrees to it. Anyway 33 just popped out of the socket after I gave LA infiltration and when patient clenched down. I didnโt even have to use my forceps. It was a scary near miss as it rested on the ptโs tongue as I retrieved it quickly w my tweezers. So pressure gauze was applied with digital pressure until bleeding was stopped and pt was fit to go. Okay so that eventful appt took a whole 90 min but it felt satisfying. It may sound something really simple on the surface and even the radiograph looks unremarkable but the whole process was just the opposite. I was initially at a loss of what to do and how manage the Pt when I first saw him, but I feel a little bit more confident now. Of course it was a collective effort of so many ppl. We are fortunate to have a hoist and a radiographer who knows what heโs doing. We are fortunate that the ptโs family invested so much in his care: having a hoist that makes him familiar with the procedure, gg for rehab and speech therapy to help w his control, posture, etc. So all in all... yeah this long ramble was because I felt this was quite an interesting case.
