Painful carious 46 in a poorly controlled diabetic on aspirin

Extraction today is not my preferred plan, and this is a risk judgement rather than an absolute rule.

Why I would defer

• Glycaemic control: HbA1c 9.2% with a random capillary glucose of 13.8 mmol/L means poor control. Hyperglycaemia impairs neutrophil chemotaxis and phagocytosis, collagen synthesis and angiogenesis, so the risk of post-extraction infection, delayed healing and dry socket is materially raised. Elective extractions are generally timed for an HbA1c below roughly 8%.
• Blood pressure: 162/96 mmHg sits above the usual threshold (about 160/100 mmHg) at which elective treatment is postponed. The greater immediate hazard is a further pressor surge under anxiety plus exogenous adrenaline, not the cavity itself.
• No current urgency: There is no swelling, no trismus, no fever and no spreading infection. A chronically infected, painful tooth in a stable patient can safely wait days to weeks.

The aspirin Aspirin 75 mg is secondary prevention after stenting. It should not be stopped for a simple extraction: low-dose aspirin does not cause clinically important bleeding in dental surgery, while interruption carries thrombotic risk. If I had any doubt, I would telephone his cardiologist rather than decide unilaterally.

What I would do instead Recheck the blood pressure after ten minutes of rest, document it, arrange analgesia (paracetamol, with caution about NSAIDs given his blood pressure and renal risk on metformin), and refer to his GP or diabetes team for optimisation while booking him into a morning appointment.

The conversation I would acknowledge the pain first, then explain the specific numbers in his own terms: his sugar reading and blood pressure are both higher than the range where I would choose to operate, and the consequence for him is a higher chance of infection, a dry socket and slow healing, at a time when he cannot afford time off work. I would be explicit that this is a postponement, not a refusal, and give him a date. I would also explain that as a lorry driver, a hypoglycaemic or hypotensive episode after treatment is a driving-safety issue, not just a dental one.

Interim measures

• Regular paracetamol with a written dose schedule; avoid ibuprofen where possible.
• Chlorhexidine 0.12% rinse if he cannot brush the area.
• No antibiotic. There is no swelling, fever or systemic upset; antibiotics would not relieve pain, would not remove the need for extraction, and would add resistance and side-effect risk.
• A written safety-net: return immediately, any hour, if he develops swelling, trismus, fever or difficulty swallowing.

Arrangements

• Recheck blood pressure at the end of the visit and record it.
• Letter or call to his GP/diabetes team requesting review of control and confirmation that his renal function is acceptable for metformin.
• Book a morning appointment, after food and medication, with a responsible adult to drive him home.
• On the day: short appointment, effective anaesthesia with no more than two cartridges of 2% lidocaine with 1:80,000 adrenaline, atraumatic technique, sutures, and a glucose check before he leaves.

This changes the problem from elective surgery to urgent care, and the priorities reorder.

What changes A fluctuant buccal swelling with fever and trismus indicates an acute infection that has breached bone and is spreading through fascia. It is now a source-control problem: the tooth, or the collection, must be dealt with, and antibiotics alone would be inadequate. The poor glycaemic control that made me defer treatment now works against him and raises the risk of progression to a deeper space infection.

What I would do

• Assess for red flags: floor of mouth, submandibular swelling, dysphagia, voice change, drooling, respiratory rate, oxygen saturation.
• Check capillary glucose again; hyperglycaemia with infection may need same-day physician review.
• If the collection is fluctuant and accessible, drainage plus removal of 46 under local anaesthesia is reasonable in a facility with surgical backup, with the patient fasted and warned about hypoglycaemia. If he is systemically unwell or the swelling is not localised, I would refer the same day rather than operate in a clinic.
• Start an antibiotic, choosing with his allergy history and local guidance, and make clear that this is adjunctive to drainage, not a substitute.
• Liaise with his physician about control during the acute episode and confirm renal function before using metformin-compatible prescribing.

The aspirin still stays, and local haemostasis with sutures and topical tranexamic acid replaces any thought of stopping it.