responding to the emergency treatment, emergency medical services should be summoned. Fortunately, the actions of Dr. Milford and the staff have been successful, and Thomas’s blood glucose levels have returned to a normal range. He should be referred to his physician and advised as to the underlying cause of today’s episode of insulin shock so that it will not occur again. Dental treatment must be deferred until Thomas has been seen by his physician. Because patients who experience insulin shock will be “shaken,” even after blood glucose levels return to a normal range, it would be prudent to arrange for a responsible adult or a taxi service to provide transportation home. she has with her dentures and create an oral environment that is favorable for the development of oral candidiasis. Impressions for new dentures cannot be taken until the oral candidiasis is eradicated. Treatment options include a thorough cleaning of the dentures and the tissues to remove any residual denture adhesive. The dentures must be soaked overnight in a 1:10 hypochlorite (bleach) solution or a nystatin solution to eradicate the residual spores of the fungal organism. Nystatin ointment can be placed on each of the dentures in the same fashion as a denture adhesive to exert a fungicidal effect against the fungal organisms that reside on the tissue surface. Nystatin ointment can also be placed on the areas of the commissures of the lips to treat the angular cheilitis. When new dentures are made, the problems with the inadequate vertical dimension can be addressed. This will decrease the fungi-laden saliva that pools at the commissures of the lips and precipitates the development of angular cheilitis. Systemic antifungal medications should be used only for cases of oral candidiasis that are refractory to empiric treatment. Caution must be exercised in the use of these medications, as they have many adverse interactions with other prescribed medications. Question What is the source of John’s emergent condition, and what should Dr. Lee and his staff do to remedy this situation? Discussion Given John’s history of type 1 diabetes and the symptoms presented, John is in the midst of a hyperglycemic crisis. Unlike the rapid development of a hypoglycemic crisis, the development of the symptoms of hyperglycemia can progress over several days. However, the final stages can escalate rapidly and lead to ketoacidosis, coma, and death. A glucometer can be utilized to determine John’s blood glucose level. John’s condition is a medical emergency that requires immediate activation of emergency medical services and transport to the local hospital for evaluation and treatment. Dr. Lee and his staff should monitor John’s vital signs and administer oxygen until emergency medical services arrives. Dental emergency kits contain medications that can increase blood glucose levels in the event of a hypoglycemic crisis. However, they do not contain insulin, which is the only substance that can lower blood glucose levels. Only trained medical personnel can determine the type and amount of insulin a patient should receive in the midst of a hyperglycemic crisis. An excess amount of insulin administered in these circumstances can cause a hypoglycemic crisis. John must be referred to his physician for appropriate medical follow- up and must have his dental treatment deferred until his blood glucose levels are stabilized.
Thomas can be given a small amount of fruit juice or regular soda to provide a rapid increase in his blood glucose. There are also commercially available preparations with the consistency of frosting that could be applied to the buccal mucosa that can be absorbed rapidly to raise the blood glucose. If Thomas were to become unconscious, Dr. Milford or a staff member could inject a dose of 1 mg of glucagon. Vital signs should be monitored throughout. If a glucometer is available, the blood glucose levels should be checked immediately to establish a baseline blood glucose level and at regular intervals after the emergency treatment has begun to determine whether the blood glucose levels are increasing. If there is any doubt that Thomas is Case scenario 2 Wendy is a 50-year-old patient with type 2 diabetes who has worn complete maxillary and mandibular dentures for more than 20 years. She has had the same set for the past 10 years and states that the dentures have become so loose, she needs to place a lot of denture adhesive inside them “so they don’t fall out.” She also states that her mouth is dry, which makes the dentures uncomfortable to wear. She remarks that she is not very compliant with her oral hypoglycemic medications. In any case, she has finally decided to have new dentures made. When her dentist, Dr. Phillips, removes her current dentures to examine the tissues, he diagnoses a case of oral candidiasis on both the maxillary and the mandibular arches. Extraorally, he diagnoses a case of bilateral angular cheilitis that is affecting the commissures of her lips. Question What treatment should Dr. Phillips render to address Wendy’s ill-fitting dentures, oral candidiasis, and angular cheilitis? Discussion The problems here are interrelated. Dr. Phillips should advise Wendy to consult with her physician, as her noncompliance with her oral hypoglycemic medications will only increase oral problems such as xerostomia, which will worsen the discomfort Case scenario 3 John is 45 years old and has been a dental patient of Dr. Lee for several years. However, all of John’s appointments have been related to dental emergencies. John sees Dr. Lee only for extractions when “something hurts or is swollen” since he feels he will eventually lose all of his teeth and need dentures like his parents, both of whom lost their teeth at an early age. Most of John’s visits have been single tooth extractions, and at this point he has only eight teeth on the maxillary arch and seven teeth on the mandibular arch. All of John’s teeth have either advanced periodontal disease or non-restorable carious lesions. John has opted to have all of his remaining teeth extracted and immediate dentures fabricated. Given the number of teeth that need to be extracted, John has asked Dr. Lee to refer him to an oral surgeon so he can be “put to sleep” for the surgery. John’s medical history includes having had insulin-dependent type 1 diabetes for many years as well as hypertension and hepatitis C. His compliance with a diabetic diet is poor, and he does not always take his insulin as prescribed. With few teeth available for occlusion and sensitivity among those that remain, John’s diet now consists largely of processed foods high in carbohydrates and sugar. He has an affinity for beverages high in sugar content such as soda and energy drinks. John presents to Dr. Lee’s office for the impressions from which the immediate dentures will be fabricated. When Dr. Lee enters the operatory, he finds John in distress. John is unsure of his surroundings, his skin is warm and dry to the touch, his breathing is labored, and has an acetone or fruity aroma. Conclusion Diabetes and periodontal disease have a bidirectional relationship. Patients with diabetes are twice as likely to develop periodontal disease as those without diabetes, and the presence and severity of periodontal disease correlate with the degree of glycemic control. The extended hyperglycemic state associated
with poorly controlled diabetes can lead to inflammation of the gingiva and periodontal disease. Periodontal manifestations of diabetes include attachment loss, alveolar bone loss, and gingivitis. Other oral manifestations of diabetes include
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