Extraction request in a hypertensive patient on aspirin after a TIA

Do not carry out an elective extraction today, but do treat the pain.

A reading of 174/104 mmHg exceeds the usual threshold for elective outpatient dental surgery - many services defer elective treatment at ≥160/100 and treat ≥180/110 as a stop - and the combined picture matters more than the number: uncontrolled hypertension, a TIA only eight months ago, a random glucose of 11.8 mmol/L indicating poor diabetic control, and a history of syncope in the dental chair.

Is this an emergency? No. There is no cellulitis, no swelling, no trismus, no dysphagia and no fever, so there is no airway or fascial space threat. A painful necrotic tooth with a periapical lesion is urgent, not an emergency justifying surgery against stage 2 hypertension in a patient with recent cerebrovascular disease.

What to do today.

• Recheck the blood pressure after 15 minutes of rest with a correctly sized cuff, and confirm with a second reading.
• Prescribe paracetamol and arrange same-week medical review for blood pressure control and glycaemic control; send a short letter stating the readings and the planned procedure.
• Book the extraction for a morning appointment once blood pressure is controlled, with monitoring and a plan for the syncope history (supine position, slow position changes).

If pain is severe or swelling develops. Options are an urgent pulpectomy or access to relieve pressure under careful monitoring, or referral to the hospital 20 minutes away with anaesthetic cover. What is not acceptable is a heroic chairside extraction on an uncontrolled hypertensive patient because he asked for it.

Choose on pharmacology, not habit.

• Lidocaine 2% with 1:80,000 epinephrine is the reasonable default. One 1.8 mL cartridge contains 36 mg lidocaine and about 22.5 µg epinephrine. The maximum dose is 4.4 mg/kg, up to 300 mg, which for a 70 kg man is roughly eight cartridges; a single inferior alveolar nerve block plus buccal infiltration of about 2.2 mL is far below that.
• Articaine 4% with 1:100,000 diffuses through bone better for infiltration but is not superior for a mandibular block, and the 4% concentration carries a slightly higher risk of persistent dysaesthesia. No reason to prefer it here.
• Mepivacaine 3% plain avoids vasoconstrictor entirely and is the right choice when epinephrine is genuinely contraindicated (unstable angina, recent myocardial infarction, phaeochromocytoma). It is not a good default for a necrotic molar where haemostasis and depth matter, and it is shorter acting.

The epinephrine question. The 22.5 µg in a cartridge is a fraction of the catecholamine released by the pain and anxiety of an extraction. The real risk in this patient is the endogenous surge from inadequate anaesthesia, not the cartridge; well-controlled anaesthesia with a vasoconstrictor is safer than a painful procedure without one. The important precautions are technique, not avoidance: aspirate in two planes for the block, inject slowly (about 1 mL per minute), use the smallest effective volume, and monitor blood pressure and pulse before, during and after.

Given his anxiety and syncope history, consider anxiolysis and a supine position with slow chair movements rather than adding more adrenaline-releasing stress.

Bleeding on aspirin 100 mg.

• Do not stop the aspirin. Low-dose aspirin for secondary prevention after a TIA is continued through dental extractions. Omitting a day or two does not reliably reduce bleeding and does raise thrombotic risk.
• Local measures: atraumatic extraction, curettage of granulation tissue, a haemostatic socket dressing such as oxidised cellulose or gelatin sponge, a figure-of-eight suture, and 10–15 minutes of firm gauze pressure. Find the bleeding point before adding more dressing. Tranexamic acid 4.8% mouthwash four times daily for two to three days is a useful adjunct where available.
• Advice: no rinsing, spitting, smoking or hot drinks for 24 hours, sleep with the head raised, and return if bleeding restarts.

Medication review before he leaves.

• Metformin: no direct interaction with local anaesthetics or antibiotics, but continue it and address the glucose of 11.8 mmol/L, because poor control impairs healing and increases infection risk. Refer to his physician.
• Amlodipine: no significant interaction, but note that calcium channel blockers can cause gingival hyperplasia if further extractions are planned.
• Analgesia: paracetamol first line. Ibuprofen only in a short course if renal function is normal, and remember NSAIDs can raise blood pressure and blunt antihypertensives; reduce the risk by avoiding them in this patient where possible, and never combine two NSAIDs.
• Antibiotics: amoxicillin-clavulanate is compatible with his medicines; reserve it for spreading infection or as prophylaxis per local protocol, and remember it never substitutes for drainage or removal of the source.
• Documentation: record the blood pressure, the decision to defer, the advice, the physician referral and the review date. The examinable judgement is neither "extract anyway" nor "refuse forever" - it is treat the pain, control the risk, then extract safely.