Periodontal+Case++2+Diabetes

Case 2: Kim Case

Our Patient : Kim is a 19 year old college student. She currently attends University of California Riverside where she is majoring in education. She enjoys being outdoors with family and friends. She is from Northern California and is having a hard time adapting to her new life.

Chief complaint : “My lower gums bleed when brushing and they're puffy”

Medical History: As we reviewed the medical history with Kim, she stated she had noticed she was urinating a lot. She said she drank a lot of water because she feels thirsty and gets a dry mouth sometimes, and attributed the frequent urination to that. She said that it had been getting worse lately and she has been having to get up in the night to use the restroom, and she had gone twice while in the waiting room before her appointment. She also stated that she had lost 10 pounds recently and didn't really know why; she had not been exercising more or dieting. She stated she had not been eating very well due to school, and was under some stress, so she assumed the weight loss was due to that. Near the end of the medical history review, Kim stated she was not feeling very well, and was feeling "shaky" and "weak." She stated she had skipped lunch since she was running late. With all of these signs, we decided to check Kim's blood glucose level. It read 55 mg/dL. We gave Kim a protein bar and sent her to her physician to be checked for diabetes. *Type I diabetics do not produce the insulin in order to carry glucose to the body's cells to use for energy, so the glucose builds up in the blood. The only way for the kidneys to filter all the glucose out is through urination, which could explain Kim's frequent urination. With this urination the body not only loses the glucose, but water as well, which can cause dry mouth and thirst (WebMD, 2010). While Kim believed she was urinating so much because of her water intake, it could be that she is losing so much water through the body's need to urinate in order to remove the glucose, that it is the reason why she is drinking so much water. In addition, the diabetes would contribute to her weight loss; since the body expels the sugar through the urine rather than using it for energy, the body begins to break down fat for use for energy, often causing weight loss in the individual (WebMD, 2010). We believe that by urinating twice before her appointment, Kim expelled the glucose from her body, but because she had skipped lunch there was none to replace it, causing her low blood sugar reading. ASA status:

At our first appointment, after reviewing the patient's medical history, and taking her blood glucose level, we determined she could possibly be an undiagnosed diabetic so we placed her as an **ASA III** since there had been no past history of hospitalization for her condition.

We referred her to the physician, and sent a **medical consult** out.



On her next appointment, which was several months later, she told us she had been diagnosed by her physician as a Type I diabetic, and she was able to get on insulin to help her to control her diabetes. Because she is still newly on the medication, and having a difficult time controlling her blood glucose levels her physician instructed us to take her blood glucose readings at each appointment. Her readings were still reading high, between 150 and 173 mg/dL., but they were still under 200 and staying fairly consistent when she was taking her own readings, so we kept her as an **ASA III .**





Assessments:


 * Extra-oral findings**: palpable submandibular lymph node.


 * TMD** : None


 * Max opening**: 48 mm


 * Intra-oral findings**: bilateral linea alba, palatal torus and bilateral mandibular tori.


 * Intra-oral picture**:


 * Gingival description:**

Free - generalized pink with localized red on the maxillary interdental papillae, hyperplastic, firm, and bulbous.

Attached-generalized pink, shiny, with some loss of stippling.


 * Type 1 Diabetes can often have the side effect of gingival enlargement, and diabetic patients are 2-3 times more likely to experience gingval disease. This increased risk is influenced by the increase in glucose in the gingival fluid and blood of diabetic patients; this is believed to affect the microflora of the oral cavity, and increase the severity of the gingival disease (Carranza, 2006).

In addition to the increased glucose levels, polymorphonuclear leukocyte function is impaired in diabetic patients with consistently elevated glucose levels. With the host's "primary defense" impaired, healing time is delayed prolonging infection and increasing the risk for the advancement of the disease (Carranza, 2006).

Our patient has been presenting with fairly high blood glucose levels, and says they have been within the 150-180 range at home as well. With the consistent elevation of glucose in the blood and gingival fluid, and the likely impairment of the immune response, our gingival findings correspond with her diabetic involvement.


 * MBI** 17%


 * BOP** 36 %


 * Probing depths**: Probing depths are generalized 2-5mm.

**Recession**: 23 lingual 1mm, 25 lingual 2mm.


 * MGJ in ** **volvement**: None

**Fremitus:** + 7-10 +1 # 11 & 12 *The +7-10 is normal physiological fremitus as the teeth contact slightly. #11,12 have more contact with opposing teeth #22,21 which is most likely the reason for the +1 fremitus.

**Mobility:**+ 7-12, 21 and 24-25.
 * The gingivodental group of the gingival fibers have been damaged around these teeth in order for the mobility to occur. The damage occurs as a result of the inflammatory response's reaction to bacterial plaque, and as a diabetic, Kim's inflammatory response to the plaque is exaggerated.

**Furcations**: None

**Angles class**: bilateral class I, with overbite and over jet of 3mm, #11, 22 and 12 are in lingual version and #21 is in buccal version.

**Profile**: Mesognathic

**Calculus code**: light-medium Radiographic Interpretation:

The **missing teeth** are 1, 16, 17, 32.


 * Our patient disclosed she had her wisdom teeth removed when she was 16.

Trabecular pattern: consistent with localized opacities on the mandibular that are most likely tori, which correlates with the intra oral findings.
 * Restorations** include occlusal amalgam on #2, occlusal amalgam on #3 and has re-decay we have it on the referral, #4 has an occlusal amalgam, #12 has an occlusal amalgam, # 13 occlusal amalgam but it has decay on the distal and is on the referral form for a DO. #14 has an MO amalgam, #15 occlusal amalgam, # 18 occlusal amalgam, #28 occlusal amalgam, #29 occlusal amalgam, #30 MO amalgam, #31 occlusal amalgam.


 * Lamina Dura**: consistent


 * Alveolar crest**: generalized 1-2mm with localized fuzziness on the lower mandibular, localized 3mm from the CEJ between 20-21 and #28-29, which correlates with the probing depths.

**PDL**: Widening of the PDL on mesial #11, #12, #21 and #25. Distal widening of #21,24,25. Widening of PDL correlates with mal-occlusion She is an **ADA II**, **AAP: generalized slight chronic periodontitis induced by plaque and calculus modified by type I diabetes**. The remainder of pockets are most likely pseudo pockets due to gingival enlargement. Critical thinking: Prognosis:

Based on intra-oral findings, social economic factors, radiographic findings and patient's compliance, the prognosis is good so long as the patient continues to be compliant and keeps up her diligent oral hygiene and control of her diabetes as best as possible. We placed her on a 3 month re-care because even with diligent at-home oral hygiene, she will still need professional cleanings on a regular basis. Once she has better control of her diabetes and the signs of inflammation have diminished, we will re-assess her re-care intervals.

Treatment plan: Soap notes: **Appointment 1 on 5/15/10** S: Pt. is here for her cleaning. O: RMH, P: 100, R: 20, BP: 128/85 A: ASA IV--pending medical consult. P: After reviewing patient's medical history and noticing gingival enlargement at E&I, it was decided to take the patient's blood glucose levels, which read 55 mg/dL. Referred patient to physician, patient stated she would go. NV: Pending for medical consult. **Appointment 2 on 9/15/10** S: Pt is here for her cleaning O: RMH, BP: 119/79, P: 77, R: 17, BGL: 173 at 1:00 pm, ate peanut butter and jelly sandwich for lunch and took insulin. A: ASA III, ADA II, AAP generalized slight chronic periodontitis due to plaque and calculus modified by diabetes typ I, Calculus code: Lt/Med. P: Took FMX 18 films, gathered assessments, DDS exam with referral sent out for #3 occlusal and #13 DO; referral form given to patient, 2nd check-in, nutritional counseling, told patient to start a food diary for 3 days, one day being a weekend day and to keep very detailed records, OHI, focused on Bass technique of brushing. NV: PI, OHI, Rt. mouth scale  **Appointment 3 on 9/22/10** S: Pt. is here for her cleaning. O: RMH, BP: 118/77, P: 75, R: 16, BGL: 150 at 1:00pm, ate chicken Caesar salad and yogurt for lunch and took insulin. A: ASA II, ADA II, AAP generalized slight chronic periodontitis due to plaque and calculus modified by diabetes typ I, Calculus code: Lt/Med. ** Why ASA II on this appointment? Ms. Lesser's question. ** P: PI, OHI, reviewed Bass technique from last visit and introduced C-shape flossing, scaled right side of mouth to completion, reviewed patient's food diary. NV: Left mouth scale, finish nutritional counseling, OHI, fluoride  **Appointment 4 on 10/6/10** S: Pt. is here for her cleaning. O: RMH, BP: 119/78, P: 76, R: 16, BGL: 163 at 1:00pm, ate chicken sandwich with lettuce and tomato for lunch and took insulin. A: ASA III, ADA II, AAP generalized slight chronic periodontitis due to plaque and calculus modified by diabetes typ I, Calculus code: Lt/Med. P: Scaled left mouth to completion, OHI, reviewed flossing technique from last visit, completed *nutritional counseling, applied 5% sodium fluoride varnish with instruction not to eat hard foods or brush for 4 hours; told her to eat softer foods when she eats dinner. NV: 3 month re-care. * We decided to include nutritional counseling in our treatment plan because a healthy diet is a major factor in the control of diabetes. Even though she is on insulin injections, you don't want your body to work harder than it has to to compensate for unhealthy food choices. Because our patient is newly diagnosed, it may be a difficult transition to make. We instructed her on healthy choices she can make that would contain little, if any, sucrose. Cereals such as Cheerios have very little sugar and have added benefits. Sodas should be avoided, but selecting a diet soda would be better than a regular soda because it is made with an artificial sweetener. Wheat Thins are a healthy snack with very little sugar. Carrots as well because they have been proven to be beneficial for your eyesight, and poor eyesight is one of the adverse effects of diabetes. In general, we advised her that it is a good idea to start reading food labels if she hasn't been already. She should avoid foods with high sugar and carbohydrate content. There are several "sugar-free" and "no sugar added" items that taste just as good if not better than the original.

**Diabetes Mellitus:**Uncontrolled Diabetes Mellitus may cause many adverse effects such as susceptibility to infection and poor wound healing. An estimated 15.7 million people have diabetes and almost half are undiagnosed. Type 1 diabetes, formerly known as insulin-dependent diabetes mellitus (IDDM) is an auto-immune disorder which causes destruction of the insulin producing cells in the body (beta cells found in the pancreas). This destruction causes an insulin deficiency. Type 1 diabetes is responsible for 5-10% of all cases of diabetes and occurs most frequently in children and young adults. This type is very unstable, difficult to control and requires insulin injections. Patients with Type 1 diabetes often present with the common symptoms of polydipsia, polyphagia, and polyuria.Common oral manifestations of patients with uncontrolled diabetes include: cheilosis, mucosal drying and cracking, burning mouth and tongue, inadequate salivary flow, higher predominance of //Candida albicans//, and an increased rate of dental caries. Some changes to the periodontium have also been associated with diabetes and include: enlarged gingiva, gingival polyps, abcess formation, periodontitis, and loosened teeth. Because diabetes lowers the body's defense mechanisms, the patient's susceptibility to infection is a major risk factor. This may ultimately lead to destructive periodontitis. The glucose concentration in the gingival fluid and blood of diabetic patients is greater than those without diabetes. This elevated change in glucose levels changes the microflora of the oral environment and may contribute to the severity of the periodontal disease. The susceptibility to infection has been linked to a deficiency in polymorphonuclear leukocytes (PMNs), which are the body's primary defense against periodontal pathogens (Carranza, 2006).

References:

Carranza, F. A., Klokkevold, P. R., Newman, M. G., Takei, H. H. (2006) //Carranza’s clinical periodontology 10th edition.// St. Louis, MO: Saunders Elevier.

WebMD. (2010). //Type I Diabetes.// Retrieved from: http://diabetes.webmd.com/guide/type-1-diabetes