Start practicing

Medical Emergencies · patient case with 3 questions

Medically complex patient presenting with erosion and lethargy

Patient: Male, 58 years old

Chief Complaint: Sensitive upper front teeth and a persistent sour taste.

Background: Type 2 diabetes. Long-standing reflux symptoms, worse at night. Recently referred to a nephrologist.

Current Findings: Cupped, smooth erosive lesions on the palatal surfaces of the maxillary anterior teeth. He appears lethargic, describes low mood and slowed thinking, and has a fine white crystalline deposit visible on the skin of his face, trunk and limbs.

Laboratory: HbA1c 8.2%

Question 1

GERD results from dysfunction of which structure?

  1. The upper oesophageal sphincter
  2. The lower oesophageal sphincter
  3. The ileocaecal valve
  4. The pyloric sphincter
Show answer and explanation

Correct answer: B. The lower oesophageal sphincter

  • A. Upper oesophageal sphincter dysfunction produces oropharyngeal dysphagia — difficulty initiating a swallow, coughing, nasal regurgitation — not acid reflux disease.
  • B. CORRECT. The lower oesophageal sphincter normally maintains tone that prevents gastric contents entering the oesophagus. When it is weak or relaxes inappropriately, acid refluxes upward. The dental consequence is a characteristic PALATAL erosion pattern on the maxillary anterior teeth — the surfaces the refluxate reaches first.
  • C. The ileocaecal valve separates small from large bowel and has no role in reflux.
  • D. The pyloric sphincter guards the gastric outlet into the duodenum. Its dysfunction causes gastric outlet obstruction or dumping, not reflux.

Note: Erosion pattern reads the aetiology: PALATAL maxillary anterior erosion points to intrinsic acid (reflux, vomiting, eating disorder); FACIAL/labial erosion points to extrinsic acid (citrus, carbonated drinks, wine, swimming pools).

Permanent page for this question

Question 2

Which HbA1c range represents POORLY controlled diabetes?

  1. 8.0–8.5%
  2. 6.0–6.5%
  3. 5.0–5.5%
  4. 7.0–7.5%
Show answer and explanation

Correct answer: A. 8.0–8.5%

  • A. CORRECT. The general glycaemic target for most non-pregnant adults is an HbA1c below 7%. A value of 8.0–8.5% corresponds to an average blood glucose of roughly 183–197 mg/dL and represents poor control, with the associated impairment of neutrophil function, delayed wound healing and heightened infection risk that matter for surgical dentistry.
  • B. 6.0–6.5% falls in the PREDIABETES band (5.7–6.4%), with 6.5% being the diagnostic threshold for diabetes.
  • C. 5.0–5.5% is a NORMAL, non-diabetic value (normal range is below 5.7%).
  • D. 7.0–7.5% is at or just above target — imperfect control, but not the answer when a clearly poor value is offered.

Note: Carry the landmarks: <5.7% normal · 5.7–6.4% prediabetes · ≥6.5% diagnostic of diabetes · <7% the usual treatment target · ≥8% poor control. Routine dentistry proceeds; defer elective surgery and consult the physician when control is poor.

Permanent page for this question

Question 3

The patient reports slowed mental state and low mood, and has white frost-like deposits on the face, trunk and extremities. What is the MOST likely underlying condition?

  1. Addison disease
  2. Hepatitis B
  3. Systemic lupus erythematosus
  4. End-stage renal disease
Show answer and explanation

Correct answer: D. End-stage renal disease

  • A. Addison disease causes HYPERpigmentation — bronzing of skin and diffuse oral mucosal pigmentation — together with fatigue, weight loss and hypotension. The colour change runs in the opposite direction.
  • B. Hepatitis B causes jaundice, fatigue and right upper quadrant discomfort. Jaundice is a YELLOW discolouration; it is not a surface crystalline deposit.
  • C. SLE presents with a malar butterfly rash, photosensitivity, arthralgia, serositis and oral ulceration — an erythematous rash, not a white crystalline deposit.
  • D. CORRECT. The white crystalline deposit is URAEMIC FROST — urea crystallising on the skin as sweat evaporates, seen when blood urea is grossly elevated in advanced renal failure. It occurs alongside uraemic encephalopathy, which produces exactly the slowed cognition and depressed mood described. The recent nephrology referral fits.

Note: Dental implications of end-stage renal disease run wide: bleeding tendency from platelet dysfunction, anaemia, treat on the day AFTER dialysis (not the same day, because of heparinisation), avoid the arteriovenous fistula arm for blood pressure, avoid nephrotoxic drugs including NSAIDs, and adjust doses of renally cleared agents.

Permanent page for this question

Practice patient cases Medical Emergencies study notes