Case Presentation

Question 1

Can you explain what type 2 diabetes is

Answer 1

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

Question 2

what is the usual dose and usage of metformin

Answer 2

500mg 3 times per day taken with breakfast, lunch and evening meal

Question 3

Can you describe the drug metformin

Answer 3

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

Question 4

what effects can metformin have on the oral cavity

Answer 4

metformin can alter taste sensation leaving a metallic taste in the mouth

metformin can cause vitamin b deficiency - which may cause mouth ulcers

Question 5

can you describe the drug linagliptin

Answer 5

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

Question 6

can you describe the typical dosage of linagliptin and its usage

Answer 6

5mg tablet taken once per day

Question 7

can you describe the drug empagliflozin

Answer 7

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

Question 8

what is the typical dosage and usage of empagliflozin

Answer 8

10mg once daily, increased to 25mg if necessary

Question 9

What is HbA1c and what is its relevance

Answer 9

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.

Question 10

what glycosylated haemoglobin level would suggest a patient has diabetes

Answer 10

over 48mmol/mol or 6.5% and above

Question 11

What are the implications of uncontrolled diabetes on oral health

Answer 11

• 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

Question 12

What is the patient’s pack years, how did you calculate this and what is the relevance

Answer 12

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

Question 13

Describe how you carry out smoking cessation

Answer 13

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

Question 14

what implications does smoking have to this patients oral health

Answer 14

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

Question 15

why did you take a periapical and a bitewing radiograph when addressing the inital complaint

Question 16

you’re extracting tooth 18 - what risk factors does this come with

Answer 16

• 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

Question 17

how would you conduct the XLA of 18

Answer 17

1. Local anaesthetic - lidocaine buccal and palatal infiltration
2. Use warwick james elevator and rotate clockwise and anticlockwise
3. Use bayonet forceps to remove tooth
4. Must be careful that you do not elevate the tooth out and it goes down back of throat - once mobile use bayonets for safety
5. Support the tuberosity with finger and thumb both whilst elevating and extracting

Question 18

if XLA of 18 became surgical, what would you do

Answer 18

• raise a mucoperiosteal flap and remove bone to retrieve roots
• flap design - two sided flap with a mesial relieving incision

Question 19

You’re extracting 28, what risk factors are specific to this tooth

Question 20

you’re extracting retained roots 17 what type of flap

Question 21

youre extracting 15 - what risk factors to consent the patient for

Question 22

Why was the patient diagnosed as stage 3 grade C

Answer 22

• 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

Question 23

Describe the healing following subgingival PMPR

Answer 23

• 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.

Question 24

Tooth is 21 mobile, why are you splinting it

Answer 24

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