Case Presentation Flashcards
(24 cards)
Can you explain what type 2 diabetes is
There are two hormones which work to control blood glucose level; insulin and glucagon. When blood glucose levels are high, insulin is released from the pancreatic beta cells to increase the glucose uptake from the blood into adipose and muscle cells. This results in a lower blood glucose concentration
In diabetes, there is insulin resistance and the receptors for insulin don’t function properly. This results in high blood glucose levels for long periods of time
what is the usual dose and usage of metformin
500mg 3 times per day taken with breakfast, lunch and evening meal
Can you describe the drug metformin
metformin is a biguanide with antihyperglycaemic effects. It lowers both the basal and post-prandial plasma glucose. It doesnt stimulate insulin secretion and therefore doesn’t cause hypoglycaemia - it instead increases insulin sensitivity
what effects can metformin have on the oral cavity
metformin can alter taste sensation leaving a metallic taste in the mouth
metformin can cause vitamin b deficiency - which may cause mouth ulcers
can you describe the drug linagliptin
linagliptin is a competitive, reversible dipeptidy-peptidase-4 inhibitor used to manage hyperglycemia. It slows the breakdown of glucagon-like peptide 1 and glucose dependant insulinotropic polypeptide. These both stimulate release of insulin from beta cells in the pancreas whilst inhibiting the release of glucagon from pancreatic beta cells. This results in a reduction of glycogen breakdown in liver and an increase in insulin release
can you describe the typical dosage of linagliptin and its usage
5mg tablet taken once per day
can you describe the drug empagliflozin
Empagliflozin is a sodium-glucose co transporter 2 inhibitor. It works on the kidneys to increase the amount of glucose that the body removes in urine. It stops sodium-glucose transport proteins which have been filtered out of the blood by the kidneys being reabsorbed back into the blood
what is the typical dosage and usage of empagliflozin
10mg once daily, increased to 25mg if necessary
What is HbA1c and what is its relevance
Glycosylated haemoglobin level - it is a test which tells you a patients average blood glucose levels over the past three months and is therefore an indication as to whether they have diabetes or not. Red blood cells live for three months so the test shows the average level of glucose within the blood over the past three months.
what glycosylated haemoglobin level would suggest a patient has diabetes
over 48mmol/mol or 6.5% and above
What are the implications of uncontrolled diabetes on oral health
- Poor wound healing
o hyperglycaemia collates with stiffer blood vessels which cause slower circulation and microvascular dysfunction which results in reduced tissue oxygenation.
o It also results in reduced leukocyte migration into wound.
o The hyperglycaemic environment can also compromise leukocyte function
o Peripheral neuropathy can lead to a reduced ability to feel and perceive pain – can result in infection not being immediately noticed and properly treated - Candidiasis
o Diabetes is an independent predictor of oral candidiasis
o Candida albicans is the commensal yeast in the oral microbiome – higher blood glucose levels give better conditions for the yeast to grow
o The basement membrane of the parotid gland is more permeable - Taste disturbances (dysgeusia, ageusia and hypogeusia)
o Due to hyposalivation, neuropathy of nerves sensing taste, microangiopathy in taste buds (microangiopathy – disease of microvessels/ small blood vessels in microcirculation) - Burning mouth syndrome
o Systemic cause of secondary burning mouth syndrome. - Cancer
o Oral cancer greater risk in type 2 diabetics but pathophysiology not known - Periodontal disease
What is the patient’s pack years, how did you calculate this and what is the relevance
Pack years is the number of packs smoked per day multiplied by the number of years of smoking. It is the cumulative exposure indicator of smoking burden which is used to estimate a patient’s risk of developing smoking-related diseases - primarily used to estimate the lung cancer risk in smokers
Describe how you carry out smoking cessation
The 5A’s or the 3As
The 3 A’s are
Ask - ask about smoking once per year and quitting history
Advise - risks of smoking, advise to quit
Act - offer individualised help and refer to smoking cessation if appropriate
what implications does smoking have to this patients oral health
oral cancer - smokers are 2 to 4 times more at risk than non-smokers of potentially malignant lesions
- smoking increases dental treatment risk and problems
- negative effect on overall systemic health
- major risk factor for periodontal disease
why did you take a periapical and a bitewing radiograph when addressing the inital complaint
you’re extracting tooth 18 - what risk factors does this come with
- wisdom tooth root morphology can be unusual: the roots appear quite bulbous and so XLa may be difficult
- last standing lone molar so fracture of tuberosity
- gross caries, crown fracture during forceps extraction
- possibility of an OAC although less risk
how would you conduct the XLA of 18
- Local anaesthetic - lidocaine buccal and palatal infiltration
- Use warwick james elevator and rotate clockwise and anticlockwise
- Use bayonet forceps to remove tooth
- Must be careful that you do not elevate the tooth out and it goes down back of throat - once mobile use bayonets for safety
- Support the tuberosity with finger and thumb both whilst elevating and extracting
if XLA of 18 became surgical, what would you do
- raise a mucoperiosteal flap and remove bone to retrieve roots
- flap design - two sided flap with a mesial relieving incision
You’re extracting 28, what risk factors are specific to this tooth
you’re extracting retained roots 17 what type of flap
youre extracting 15 - what risk factors to consent the patient for
Why was the patient diagnosed as stage 3 grade C
- Stage shows severity of disease by looking at the interproximal bone loss at the worst site. It was diagnosed radiographically using the worst site which was distal to 21
- Can see bone loss in the middle third of the root (around 50% bone loss)
- Grade captures the progression of the disease. Patient was assigned grade C which is severe. % bone loss/age was more than 1
- Generalised as it is affecting more than 30% of teeth
Describe the healing following subgingival PMPR
- initially resolution of inflammation, with reduction of gingival swelling and bleeding
- gain in attachment due to long junctional epithelium formation and improved tissue tone
- maturation of gingival and periodontal collagen fibres occurs within 3 months.
Tooth is 21 mobile, why are you splinting it
when teeth are mobile there is a decreased attachment loss gain post hygiene phased therapy and an increase in clinical attachment loss over time. Splinting 21 may help with instrumentation during root surface debridement and also aid the tooth in gaining attachment after subgingival instrumentation
