Warfarin, diabetes and two teeth to remove before a flight
Mr Chan, 58, attends for the extraction of two teeth: 46, grossly carious with a recurrent periapical radiolucency and tender to percussion, and 37, which has a 9 mm pocket and grade II mobility. He has had type 2 diabetes for 12 years; his HbA1c was 8.4% one week ago. He also has atrial fibrillation managed with warfarin 4 mg daily, and his last INR, taken three days ago, was 3.2. His other medication is amlodipine 5 mg, and he takes ibuprofen 400 mg occasionally for knee pain. He has no allergies, smokes 15 cigarettes daily, and has never had a tooth removed. Today he is afebrile with no swelling or trismus. Blood pressure is 158/94 mmHg. He is travelling for work next week and asks whether both teeth can be taken out at this appointment.
1. What further assessment or investigation would you arrange before starting treatment, and why?
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INR - the result is three days old. Current guidance (for example SDCEP) accepts simple extraction at an INR of 3.5 or below, with an INR taken within 24 to 72 hours. Three days sits at the very edge of that window, so I would repeat the INR on the day; if it is above 3.5 I would defer and speak to the anticoagulation clinic. I would not stop warfarin, bridge with low molecular weight heparin, or give vitamin K for a simple extraction: the thrombotic risk of interrupting anticoagulation is greater than a bleed I can control locally.
Blood pressure - 158/94 is below the usual 160/100 threshold for deferring elective care, but it should be repeated after five minutes of rest and with an appropriately sized cuff. If it stays at or above 160/100 I would refer to his GP before proceeding.
Glycaemia - HbA1c 8.4% means poor control. That is a risk factor for infection and delayed healing, not a contraindication. I would not delay treating a tender, infected tooth for it, but I would check a capillary glucose if he looks unwell and write to his GP or diabetes team.
The 37 - its indication is periodontal and elective. Before removing it I would confirm that periodontal treatment cannot retain it; otherwise the priority is the infected 46.
I would also record the INR value and date, and check the rest of his medication list for anything else affecting bleeding.
2. Would you extract both teeth at this visit? Give your reasoning, including the local anaesthetic and local haemostatic measures you would use.
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Decision: extract 46 today, defer 37.
Reasons to treat 46 now: it is symptomatic with a periapical radiolucency, and removing the source of infection is definitive. Delay risks an acute flare while he is away.
Reasons to defer 37: it is elective and not infected. Taking both sides leaves bilateral sockets, a bilateral soft diet, and no comfortable side to chew on. If bleeding starts he cannot tell which side it is coming from, and a delayed bleed while travelling is hard to manage and he cannot return for review. One tooth also shortens the appointment and reduces the cumulative local anaesthetic dose in a hypertensive patient.
A single-visit approach is defensible if the patient prefers it, provided the INR is 3.5 or below, the technique is atraumatic, sockets are sutured, a haemostatic dressing such as oxidised cellulose is placed, and tranexamic acid 4.8% mouthwash is prescribed. I would document that discussion.
Anaesthesia - buccal infiltration plus intraligamentary injection for 46. An inferior alveolar block is not absolutely contraindicated at a therapeutic INR, but where infiltration will do I would avoid it, because a pterygomandibular space haematoma in an anticoagulated patient is difficult to manage.
Local haemostasis - minimise trauma, curette gently, place haemostatic gauze, suture, and have him bite on gauze for 20 minutes before he leaves. Check the socket before discharge.
3. What would you prescribe, what would you tell him about analgesia and antibiotics, and what aftercare advice would you give given his travel plans?
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Analgesia - paracetamol 1 g four times daily, maximum 4 g in 24 hours, for up to three days, after checking for liver disease and other paracetamol-containing products.
I would specifically not prescribe ibuprofen or any NSAID, and would tell him to stop his occasional ibuprofen. NSAIDs potentiate warfarin both pharmacodynamically (platelet inhibition) and pharmacokinetically (protein-binding displacement, rising INR), and carry a gastrointestinal bleed risk in exactly this patient.
Antibiotics - none. Warfarin, diabetes and atrial fibrillation are not indications for prophylaxis, and there is no spreading infection: no swelling, no trismus, no fever, no systemic upset. Prescribing amoxicillin without an indication adds resistance and Clostridioides difficile risk with no benefit. Antibiotics would only be an adjunct if there were systemic signs of spreading infection, alongside drainage or extraction.
Aftercare - written and verbal: bite firmly on gauze for 20 minutes; no rinsing, spitting, smoking, hot drinks or strenuous exercise for 24 hours; soft diet; do not poke the socket. If bleeding occurs, apply gauze pressure for 20 minutes; if it continues, attend an emergency department. Give a contact number.
Travel - explain that a stable clot should form within 24 to 48 hours and a slight ooze is normal, that he should not fly or travel while actively bleeding, and that 37 will be completed on his return.