A patient with an HbA1c of 10% presents wanting Invisalign and a cleaning. She has not seen a dentist in years, consumes sugary and acidic drinks frequently, and you find numerous carious lesions including one moderate-to-severe lesion causing pain. What should you do?

Correct answer: C. Refer her to her physician for diabetes management while beginning disease control

• A. Extraction without addressing the systemic condition or the remaining caries is fragmentary care, and the surgical wound will heal poorly at this HbA1c.
• B. A prophylaxis alone leaves active caries and pain untreated, and six months of observation in a high-risk patient is supervised neglect.
• C. CORRECT. An HbA1c of 10% represents poorly controlled diabetes with substantially impaired wound healing, higher infection risk and accelerated periodontal breakdown. Medical referral is essential. Meanwhile you address the pain and begin caries control — you do not simply wait for the physician.
• D. Orthodontic treatment in a patient with active rampant caries and uncontrolled diabetes would be indefensible. Elective care follows disease control.

Note: Sequence for this patient: (1) manage the acute pain, (2) refer to the physician for glycemic control, (3) caries control with SDF, glass ionomer or interim restorations, plus dietary counselling and high-fluoride paste, (4) definitive restorative once caries risk is falling, (5) periodontal therapy, (6) re-evaluate, and only then (7) discuss the elective orthodontic request. Managing the expectation gap between what she asked for and what she needs is the real skill in this case.