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Course # 54961 • Oral Complications of Diabetes

CASE STUDY 1

Patient A is a woman, 69 years of age with a 25-year history of type 2 diabetes. She presents to the education department for information regarding diabetes self-management. She has not received any education previously and has had a difficult time controlling her glucose levels over the past 18 months. According to her primary care provider, Patient A's glycated hemoglobin (HbA1c) level has not been less than 8.5% for the past 12 months. She is currently performing self-monitoring of blood glucose three times per week.

Patient A's past medical history is positive for diabetes, hypertension, and a 52-year history of tobacco use. She is 5 feet 4 inches in height and currently weighs 225 pounds; her calculated BMI is 38.6 kg/m2, qualifying her as obese. Within the last two months, the patient visited an ophthalmologist, who has diagnosed her with cataracts and moderate non-proliferative retinopathy.

At her education appointment, Patient A complains of numbness in her feet and tingling in her mouth and jawline. When asked about her last dental visit, the patient states she does not go to the dentist because they always find something wrong and she hates the sound of the drill. When questioned about her daily oral hygiene routine, Patient A states she usually brushes her teeth in the morning but has begun to experience pain and notices blood in her saliva afterwards. She denies flossing because it is painful and she feels it is "messy." She does state that her daughter has encouraged her to brush her teeth more often because she has noticed increasingly bad breath over the past six months.

The certified diabetes educator asks to examine the patient's gums and oral cavity, but she states she would prefer not to because her teeth "aren't as nice as they once were." The diabetes educator explains the importance of good oral hygiene and the effect that diabetes can have on oral health. With some persuasion, Patient A permits the nurse to examine her mouth. The assessment reveals signs of gingivitis, a dry, cracked tongue, and two visible abscesses, one on the upper left gum and another on the lower left gum near the first molar. The presence of halitosis is noted.

The diabetes educator provides Patient A with information regarding the relationship between periodontal disease and other diabetes complications. Further instructions are given on the need for treatment to prevent or limit progressive damage. Patient A agrees to schedule an appointment with her dentist and promises to maintain her appointment.

Two weeks later, Patient A sees her dentist. Dr. T performs a complete oral examination, including x-rays. The patient is diagnosed with xerostomia, extensive dental caries with root involvement, and infected abscesses. The x-rays reveal dental caries with active infection of the central and lateral left upper and lower incisors progressing to the root. A probing depth of 4–5 mm is noted upon assessment of the gingiva, indicating probable periodontal disease. Abscesses are noted at the base of the upper central and lateral incisors. Patient A is scheduled for extraction of the affected teeth and antibiotic therapy to control the infectious process. She is encouraged to brush her teeth at least twice a day, floss daily, use an over-the-counter saliva replacement to improve oral moisture, stop smoking immediately, and follow-up in two weeks. Referral to a periodontist is also made.

Two weeks later, Patient A returns to see her dentist. Although her abscesses are clearing, they are not completely healed and antibiotic therapy is continued for an additional week. The patient reports attempts to stop smoking but is experiencing difficulties. Her halitosis is also improving. An appointment with the periodontist has been scheduled for the following week.

Patient A also follows up with the diabetes educator. Her blood glucose levels appear to be coming back to a normal level, although the evidence has not been seen in her HbA1c as of yet. Intensive education regarding the need to maintain her standards of care is provided, including self-blood glucose monitoring, weight management, dilated retinal eye examination, comprehensive foot examination, medical nutrition therapy, physical activity, immunizations, and dental care and follow-up. The nurse reiterates the relationship between diabetes and poor dental health, and Patient A states that she was never informed about the relationship by any of her healthcare providers or family members. Finally, the patient is enrolled in a smoking cessation class to support her efforts to quit smoking.

After three weeks, Patient A is informed by Dr. T that her general oral health is clear and she is free from oral abscesses, and a plan of care to address her periodontal disease has been established. Her oral mucosa moisture is increased, and her halitosis is resolved. She schedules another dental hygiene appointment for six months in the future. Although she has not yet quit smoking, she states that she has significantly decreased the number of cigarettes she smokes every week.

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