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Ethics & Law · patient case with 6 questions

Elderly man with Alzheimer disease and a symptomatic upper left molar

Patient: Male, 78 years old

Chief complaint: “His tooth has been hurting him and his face is swollen.” Reported by the wife, who accompanies him.

Background: Alzheimer disease, moderate stage. Medication: donepezil. His wife attends every appointment and manages his daily care.

Current findings: Periapical radiograph shows tooth #15 lying on its side (slanted/impacted) with an associated radiolucency. Swelling and pain localised to #15. Patient is pleasantly confused and defers all questions to his wife.

Question 1

What should be kept in mind above all while treating this patient?

  1. He should be given standard oral hygiene instructions
  2. Treatment must proceed on the basis of valid consent, with capacity and proxy authority established
  3. He should be prescribed an alcohol-free mouthwash
  4. His wife should brush his teeth twice daily after meals
Show answer and explanation

Correct answer: B. Treatment must proceed on the basis of valid consent, with capacity and proxy authority established

  • A. Hygiene instruction directed at a moderately demented patient has limited value — it is the CAREGIVER who must be instructed.
  • B. CORRECT. Cognitive impairment puts CAPACITY and CONSENT at the centre of the encounter. Before any treatment you must establish whether the patient can consent for himself and, if not, who holds legal authority to consent for him. Everything else is secondary to that.
  • C. Alcohol-free rinse is a sensible product choice (alcohol stings and risks aspiration), but again a minor point.
  • D. Caregiver-assisted brushing is genuinely useful in dementia, but it is a home-care detail, not the governing principle for delivering treatment.

Note: Consent and capacity is the recurring INBDE theme for any dementia, intellectual disability or paediatric case. Ask first: can this person consent, and if not, who can?

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Question 2

Which neurochemical is most associated with this patient's condition?

  1. Prostaglandin
  2. Nucleotide
  3. Acetylcholine
  4. Choline
Show answer and explanation

Correct answer: C. Acetylcholine

  • A. Prostaglandins are inflammatory mediators — the target of NSAIDs, unrelated to dementia.
  • B. Nucleotides are nucleic acid building blocks, with no role in this disease.
  • C. CORRECT. Alzheimer disease features degeneration of cholinergic neurons (notably the nucleus basalis of Meynert), producing an ACETYLCHOLINE deficit. This is precisely why his donepezil was prescribed.
  • D. Choline is the dietary precursor for acetylcholine synthesis, but the implicated neurotransmitter itself is acetylcholine.

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Question 3

The wife asks what donepezil actually does for him. What is the most accurate answer?

  1. It inhibits acetylcholinesterase, raising brain acetylcholine and improving cognitive function
  2. It is a sedative that controls his agitation
  3. It cures Alzheimer disease by clearing amyloid plaques
  4. It blocks NMDA receptors to prevent excitotoxicity
Show answer and explanation

Correct answer: A. It inhibits acetylcholinesterase, raising brain acetylcholine and improving cognitive function

  • A. CORRECT. Donepezil, rivastigmine and galantamine are ACETYLCHOLINESTERASE INHIBITORS. They block the enzyme that degrades acetylcholine, raising synaptic levels and producing modest symptomatic improvement in cognition. They do not halt the underlying disease.
  • B. Donepezil is not a sedative. If anything it can cause insomnia and vivid dreams.
  • C. No drug in routine use clears plaques and reverses the disease; these agents are symptomatic only.
  • D. That describes MEMANTINE, used in moderate-to-severe disease — a different drug class.

Note: Dental relevance: cholinesterase inhibitors increase salivation and can cause BRADYCARDIA. Avoid anticholinergic drugs in these patients — they worsen confusion.

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Question 4

When should this patient's appointment be scheduled?

  1. Late afternoon
  2. Evening
  3. Early afternoon
  4. Morning
Show answer and explanation

Correct answer: D. Morning

  • A. Late afternoon is squarely in the sundowning window.
  • B. Evening is the worst possible choice for a demented patient.
  • C. Cooperation is already declining by early afternoon.
  • D. CORRECT. Patients with dementia function best EARLY in the day. Confusion and agitation characteristically worsen as the day progresses — the phenomenon called SUNDOWNING. Short morning appointments give the best cooperation.

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Question 5

Regarding the role of his wife, which statement is NOT true?

  1. She may give informed consent for his dental treatment if she holds legal authority
  2. She can be given instructions for his daily home care
  3. Simply by being his spouse, she may legally make all decisions on his behalf
  4. She should be involved in planning and maintaining his oral health
Show answer and explanation

Correct answer: C. Simply by being his spouse, she may legally make all decisions on his behalf

  • A. True, PROVIDED she holds that authority. This is exactly what must be verified and documented.
  • B. True, and the caregiver is the appropriate recipient of hygiene instruction here.
  • C. CORRECT — this is the FALSE statement. Marriage alone does NOT confer blanket legal decision-making authority. That requires a formally established mechanism: guardianship, conservatorship, healthcare proxy or durable power of attorney. Many states do grant a spouse default surrogate status for healthcare decisions, but it is not automatic or unlimited, and it certainly does not extend to 'all legal decisions.'
  • D. True. Caregiver involvement is essential to any realistic care plan in dementia.

Note: Note the distinction the exam is testing: being a spouse and being a legally authorised surrogate are two different things. Verify and document which applies.

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Question 6

What is the most appropriate treatment for tooth #15?

  1. Pulpectomy
  2. Pulpotomy
  3. Extraction
  4. No treatment — keep it under observation
Show answer and explanation

Correct answer: C. Extraction

  • A. Pulpectomy of a horizontally impacted molar is not realistically achievable, and would commit a demented patient to multiple long visits.
  • B. Pulpotomy is a procedure for vital primary teeth or as an interim measure in immature permanent teeth — not applicable.
  • C. CORRECT. The tooth is impacted, lying on its side, symptomatic and associated with a radiolucency. It is not restorable or functionally useful. In a patient with moderate dementia and limited tolerance for lengthy or repeated appointments, definitive removal of the source of infection is the appropriate, humane and lowest-burden option.
  • D. Observation leaves an active infection in place, which is unacceptable given the pain and swelling.

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