Potential Drug Interactions
- make sure anything you give doesn’t interact with current drugs
- one example would be her ==atorvastatin and azole antifungals for angular chelitis
Potential Emergencies todo
-
managing hypoglycaemia
- shes high HbAC
- Also takes insulin nightly
- timing of insulin
- probably don’t mess with it
- timing of insulin
-
INR according to foo = 3.5
Extraction
- LA
- LUxate
- Elavete
- Forceps
- suture
CAMBRA RECALLS
- 3 months or 6 months
- radiographs every yewar
- OHI reinforce
Double check this if you have time later todo
This is an excellent question. The hospitalization history adds two critical layers of risk that must be managed on top of the complex medication list we already discussed.
Here are the specific dental precautions you must take, broken down by condition.
### 1. 🩸 Precautions for TIA History (4 years ago)
The patient's TIA is a major warning sign.1 It's directly related to their **hypertension** and **atrial fibrillation**. Our primary goal is to **prevent a stroke (CVA)** during dental treatment.
The main triggers for a CVA in a dental chair are uncontrolled high blood pressure and anxiety.
- **Pre-Operative BP Monitoring:** You **must** take the patient's blood pressure and pulse at the _beginning of every single appointment_.
- **Baseline:** Document their "normal" reading.
- **"No-Go" Threshold:** If their BP is acutely elevated (e.g., $>180/110 \text{ mmHg}$), elective dental care should be deferred, and the patient referred for urgent medical review. Their "moderately controlled" hypertension is a yellow flag.
- **Stress and Anxiety Reduction:** This is a medical necessity, not just a comfort.
- **Appointments:** Schedule short, morning appointments when the patient is less fatigued.
- **Communication:** Clearly explain procedures to reduce fear of the unknown.
- **Pharmacology:** Consider anxiolysis, such as oral diazepam the night before and/or nitrous oxide sedation during the procedure.
- **Anesthetic with Vasoconstrictor (Epinephrine):**
- **Use it, but limit it.** The anxiety and pain from _inadequate_ anesthesia will cause the patient's own body to release a flood of endogenous epinephrine, which is far more dangerous than a controlled dose.
- **The "Cardiac Dose":** Limit to a maximum of **2 cartridges** of 1:100,000 epinephrine ($0.036 \text{ mg}$ total).
- **Technique:** Always use an aspirating syringe to prevent intravascular injection.
- **Anticoagulation Management (Warfarin):**
- The TIA and A-fib are _why_ the patient is on Warfarin. This medication **must not be stopped or altered** without consulting their cardiologist, as the risk of a stroke is high.
- **INR Check:** For _any_ procedure with a bleeding risk (including deep scaling, extraction, or biopsy), you must have an INR reading taken within the last 24-72 hours.
- **Safe Range:** Since their target range is 2.5-3.0, you can generally proceed if the INR is **$\le 3.5$**.
- **Local Measures:** Even with a safe INR, you must use local hemostatic measures (e.g., sutures, oxidized cellulose, tranexamic acid mouthwash) for any extraction.
### 2. ☢️ Precautions for Radiotherapy History (12 years ago)
This is a critical diagnostic question. The _only_ thing that matters is **where the radiation was delivered.**
#### **Step 1: Confirm the Field of Radiation**
You must ask the patient or, preferably, consult their oncologist: **"Was the radiation field limited to your breast/chest, or did it include your neck or jaw?"**
You must then proceed based on one of these two scenarios.
---
#### **Scenario A (Most Likely): Radiation was to the Chest/Axilla ONLY**
If the radiation was for breast cancer and did _not_ include the head and neck, then:
- The radiation history itself carries **no direct risk** to dental treatment.
- **BUT...** The patient _already_ has a major risk of osteonecrosis from a different mechanism: **Alendronate (Bisphosphonate) therapy.**
- In this case, you will manage the patient for **MRONJ (Medication-Related Osteonecrosis of the Jaw)**, not osteoradionecrosis (ORN). The precautions are similar but the pathophysiology is different. All invasive procedures (extractions, implants) are high-risk and must be preceded by a discussion of MRONJ risk.
---
#### **Scenario B (Less Likely, but Critical): Radiation INCLUDED the Head & Neck**
If the patient had (for example) metastasis to cervical lymph nodes and the radiation field included any part of the mandible or salivary glands, this is a **lifelong, severe risk.**
- **Risk:** **Osteoradionecrosis (ORN)**. The radiation has permanently damaged the blood supply to the bone. Any trauma (like an extraction) can cause the bone to die, leading to a non-healing wound that may require surgical removal of parts of the jaw.2 This risk _never_ goes away.
- **Primary Goal:** **AVOID ALL EXTRACTIONS. FOREVER.**
- Prioritize root canal therapy or coronectomy (intentionally removing the crown and leaving the root) over extraction, even on seemingly non-restorable teeth.
- **If Extraction is Unavoidable:**
- This requires a formal consultation with their radiation oncologist.
- The patient may require a course of **hyperbaric oxygen (HBO) therapy** before and after the extraction to improve vascularity and reduce ORN risk.3
- Aggressive antibiotic prophylaxis is mandatory.
- **Xerostomia:** If the salivary glands were in the field, the patient will have severe, permanent xerostomia. This compounds the drug-induced xerostomia from their _other_ meds (Omeprazole, Salbutamol, Tiotropium), placing them in the **highest possible risk category for rampant caries and candidiasis.** They will require intensive prevention (e.g., 3-month recalls, high-fluoride custom trays).
### Summary: The Compounding Problem
This patient presents a "perfect storm" of compounding risks.
1. **Risk of Bone Death:** You have two separate, major risks for osteonecrosis: **Alendronate (MRONJ)** and potentially **Radiation (ORN)**. You must first determine if the ORN risk exists. If it does, that patient's jaw is _extremely_ vulnerable.
2. **Risk of Impaired Healing:** You have two risks for poor post-op healing: **Prednisone** (immunosuppression, delayed healing) and **Diabetes** (poorly controlled, HbA1c 8.9%). The Prednisone will also mask the early signs of an infection.4
3. **Risk of Bleeding:** You have the anticoagulant **Warfarin** combined with the myelosuppressive potential of **Methotrexate** (which can cause thrombocytopenia).
Given this complexity, any invasive procedure would require extremely careful planning, likely in consultation with their GP, oncologist, and/or cardiologist.
Would you like to walk through the specific step-by-step protocol for a single procedure, such as an extraction, for this patient (assuming the radiation was chest-only)?