Extracting a non-restorable molar in poorly controlled diabetes
A 54-year-old market trader attends a dental clinic with a grossly decayed lower right first molar. She has had intermittent pain for three weeks and a small buccal sinus with minimal purulent discharge. There is no facial swelling, trismus, dysphagia, or fever. Her medical history includes type 2 diabetes treated with metformin 1 g twice daily and glibenclamide 5 mg daily. Random capillary glucose is 15.1 mmol/L and HbA1c is 9.6%. Blood pressure is 148/92 mmHg. She has no history of hospital admission for diabetes and no symptoms of hypoglycaemia. The tooth is non-restorable. The clinic has local anaesthetic, forceps, chlorhexidine, and amoxicillin but no immediate access to a physician. She asks to have the tooth removed today because she travels for work next week.
1. Decide whether to extract today or defer. Justify your answer.
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The tooth is non-restorable and there is a chronic sinus with minimal discharge but no spreading infection, trismus, dysphagia, or systemic upset. That makes the extraction a drainage procedure rather than an elective one. Deferring is risky: she will travel, may not return, and the infection could progress.
The main concern is poor glycaemic control (HbA1c 9.6%, random glucose 15.1 mmol/L), which impairs healing and increases the risk of infection and dry socket. My decision would be to proceed today, after checking that she has eaten and is not hypoglycaemic, using a morning appointment, effective local anaesthesia, and a minimally traumatic technique. If she had a spreading infection, trismus, fever, or had taken nothing by mouth, I would refer for urgent medical assessment first. As it stands, extraction with clear post-operative instructions and early review is the safer option than leaving a non-restorable infected tooth in a patient who is about to travel.
2. Advise on antibiotics, analgesia, and mouthwash for this patient.
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Antibiotics are not routinely indicated for a localized chronic periapical infection with a sinus and no systemic involvement; the extraction provides drainage. If there is spreading infection or systemic upset, use amoxicillin, but here I would not prescribe routinely. She should continue metformin and glibenclamide, but check glucose before the procedure and ensure she eats afterwards.
For analgesia, paracetamol is preferred; avoid ibuprofen and other NSAIDs where possible because of renal and gastric risk in diabetes, especially if dehydration develops. If a non-steroidal is needed, use the lowest dose for the shortest time, but paracetamol plus codeine may be better. Chlorhexidine 0.12–0.2% mouthwash can be used after 24 hours, not immediately, to reduce plaque. Record the HbA1c and random glucose and advise review by her diabetes team. Avoid aspirin for pain because of bleeding risk.
3. What post-operative advice and referral criteria would you give?
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Post-operative advice: bite on gauze for 20–30 minutes, do not rinse or spit for 24 hours, avoid hot drinks and smoking, maintain oral hygiene, and eat soft food. Check glucose and take usual diabetes medication; if she cannot eat, she needs medical advice about adjusting glibenclamide to avoid hypoglycaemia.
Warning signs: increasing pain, swelling, fever, trismus, dysphagia, persistent bleeding, or a bad taste. Refer to a physician or emergency department if she develops facial swelling, difficulty swallowing or breathing, fever above 38°C, glucose above 20 mmol/L with symptoms, or symptoms of hypoglycaemia. Arrange a review in 48–72 hours, especially given diabetes, to check healing and dry socket. If healing is poor, refer for assessment of glycaemic control. Document that she was advised not to travel without a dental review if pain or swelling develops.