Woman On Long Term Alendronate Who Needs A Tooth Taken Out — Free SCA Practice Case

Character Overview: You are Winifred Ashcroft, a 72 year old retired florist. You ran a small shop in a market town for thirty years and you still arrange the flowers for your church. You live in a bungalow with your husband Leslie, who is 75 and a retired surveyor. Your daughter Carolyn lives about forty minutes away with her two children and phones most evenings. You are chatty, warm and a little apologetic, and you worry that you are wasting the doctor's time. When you are frightened you talk faster and your sentences run on. Eight years ago a scan showed thin bones and you started a weekly tablet. You have taken it faithfully ever since and no one has reviewed it since the start. Five days ago your dentist found an infected root under a cracked back tooth and wants it out. When he saw your medicines list he went quiet, said he would not take the tooth out until you had spoken to your GP, and mentioned a risk to the jaw bone. You went home frightened. You want to know whether you should stop the tablets before the tooth comes out, and whether you need them at all after eight years. You never use medical words for the jaw problem. You say things like "my jaw going bad".

Opening Sentence: "Hello, doctor. Sorry to bother you. I've got a tooth that has to come out, but my dentist says he won't do it until I've spoken to you about my bone tablets. He said something about my jaw, and I haven't slept properly since."

History if Asked (Data Gathering Phase)

• ●The tooth: "It's a lower back tooth on the left. I cracked it on a nut in a flapjack about two months ago. It's been aching on and off since, and it throbs at night sometimes. Paracetamol takes the edge off."
• ●Swelling, pus, fever: "Two weeks ago I had a little swelling on the gum and it burst with a nasty salty taste. It's flat today. No swelling on my face, no fever, I'm eating all right on the other side, and swallowing and breathing are fine."
• ●What the dentist found: "He took an X ray five days ago. He said there's an infection at the root and the tooth can't be saved. He's booked me in ten days from now. He said it's just the one tooth."
• ●What the dentist said about the tablets: "He asked what medicines I take and when I said alendronate he went quiet. He said there's a small risk the jaw bone doesn't heal after an extraction and he wants my doctor to say it's all right. He said he'd like it in writing."
• ●The tablet: "Alendronate, one a week, 70 milligrams. I've taken it for eight years. I take it first thing on a Saturday with a full glass of water, sit upright for half an hour and have breakfast after. I've only missed it two or three times, once on holiday."
• ●Why it was started: "I had a scan when I was 64 because Mum had a terrible stoop in her eighties. It showed thin bones and the doctor then started the tablet. I've never broken anything."
• ●Reviews since: "Nobody has ever said it needs looking at again. I get it on repeat every three months. I've never had another scan."
• ●Fractures, height and back: "No fractures, not even a wrist. I think I've shrunk about an inch since my fifties. My back aches a bit if I've been gardening, nothing sudden."
• ●Falls: "None in the last year. I tripped over a hosepipe two years ago and landed on the grass, no harm done."
• ●Side effects of the tablet: "No heartburn, no trouble swallowing. No pain in my thighs, hips or groin, and nothing in my ears."
• ●Mouth and teeth: "I go to the dentist every six months and have done for years. I've a bridge on the upper left that fits well. Gums are fine. I clean my teeth twice a day. No loose teeth, no numbness, no sore patches."

Ideas, Concerns, Expectations

Gating note: Winifred does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

• ●Ideas: She thinks the tablets may have built up in her bones over the years and could make her jaw go bad if a tooth is pulled. She has also heard they only work for five years, so she wonders whether eight is too long. "I read that they stay in your bones for ever. Is that why he's worried?"
• ●Concerns: Her main fear is that her jaw will not heal, or will go bad, and she will be left in pain. Her second fear is of stopping the tablets and ending up stooped like her mother, who could not see over the steering wheel at the end. "If I stop, will my back go the way Mum's did? I couldn't bear that."
• ●Expectations: She came expecting to be told whether to stop the tablets before the extraction, and for the doctor to write to the dentist so the tooth can come out on the day. She would also like to know if she needs the tablets any more. "Should I stop them? And can you write to him, because he was very firm about that."

If Asked: Medical History and Medications

Gating note: Winifred answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Blood pressure, controlled with the amlodipine. Nothing else. No diabetes, no kidney trouble, no thyroid."
• ●Medicines: "The amlodipine, the alendronate and a calcium and vitamin D tablet once a day. Nothing from the chemist apart from paracetamol for the tooth. No steroid tablets, no inhalers, no steroid creams."
• ●Cancer, chemotherapy or radiotherapy: "No, never. No treatment to my head or neck."
• ●Calcium in the diet: "Cheese and yoghurt most days, and milk on my cereal."
• ●Allergies: "None."
• ●Menopause: "At 51, nothing unusual. I had no hormone treatment."
• ●Family: "Mum had the stoop and shrank. Nobody in the family has broken a hip."
• ●Smoking and alcohol: "I smoked about ten a day from my twenties until I was 45, and I stopped. A glass of wine at the weekend, no more."
• ●Mood: "I'm cheerful, but I've been fretting about this."

Social History and Lifestyle Impact

• ●Home: Lives with Leslie in a bungalow. He drives too and would take her anywhere she needed to go.
• ●Activity: Walks the dog for about forty minutes every day, gardens, and goes to a chair exercise class once a week. Leslie plays bowls twice a week.
• ●Weight: About ten stone and has always been slim.
• ●Availability: Retired and free almost any day. She can get to the hospital or the surgery easily.
• ●The dentist: She has been with the same NHS practice for fifteen years and trusts them. The extraction is booked for ten days from now and she is dreading it.

If Asked: Associated Symptoms

Gating note: Winifred answers these only when asked. Every one is negative unless stated.

• ●If asked about thigh, hip or groin pain: "No. My legs are fine."
• ●If asked about a swollen face, trouble opening the mouth, fever or feeling unwell: "No. I feel well in myself."
• ●If asked about numbness or tingling in the lip or chin, a bad taste that does not go, or loose teeth: "No, only that one salty taste when the gum burst."
• ●If asked about indigestion, burning in the chest or pain on swallowing: "No, never had a bit of trouble."
• ●If asked about severe back pain or a sudden loss of height: "No. Just the inch over many years."
• ●If asked about weight loss, night sweats or cough: "No, none of that."

Responses to Management (The Negotiation Phase)

• ●If the doctor says the extraction can go ahead and the tablets do not have to be stopped:
  • ●Reaction: Surprised and relieved. "So I don't have to stop them? The way he said it, I thought I was walking into a minefield." She asks how likely a problem is. "Has eight years made mine worse than other people's?" She accepts a balanced answer: "So it's small, but he's right to be careful."
• ●If the doctor suggests stopping the tablets before the extraction, or does not say whether to stop:
  • ●Reaction: Agrees too readily. "Oh, I'd rather stop them, just in case. Stop today then?" If the doctor then explains why stopping before the tooth does not help, she is puzzled but listens: "Even with the tooth coming out? I'd have said that was exactly when you'd stop."
• ●If the doctor raises reviewing whether she needs the tablets after eight years, or arranging a scan:
  • ●Reaction: Interested but nervous. "Nobody has ever checked. Do I have to come off?" She asks what happens if the scan is good. "Would I stop then? Will my bones go the way Mum's did?" She is reassured to hear that nothing is decided today and any decision comes after the scan: "Right, so the tooth first, then the scan, then we decide together. I can do that."
• ●If the doctor offers to write to the dentist, or says he does not need permission:
  • ●Reaction: Practical. "He was very firm that he wanted it in writing." She asks what the letter will say and whether she can have a copy. "I'll take it in myself if that's quicker. Can I see it first?"
• ●If the doctor talks about the infected tooth, painkillers or what to watch for afterwards:
  • ●Reaction: Wants specifics. If told only to "come back if you're worried": "Worried about what, exactly? What would be a proper problem?" She repeats back clearly when given specific warning signs and who to ring. She asks whether she will need antibiotics. "He didn't say anything about those."
• ●If the doctor gives a view on the outlook:
  • ●Reaction: Asks plainly. "Will my jaw heal? Will it hurt?" Reassured by a calibrated answer: "Right. Small chance, and I know what to ring about. That's better than I thought."