Six to eight millimetre pockets, a DOAC, and a flight in three weeks
Mr T is 58, last saw a dentist three years ago, and books for 'a clean before I go overseas'. He smokes 20 cigarettes a day, has type 2 diabetes with an HbA1c of 9.1% checked last month, and takes apixaban 5 mg twice daily for atrial fibrillation plus amlodipine 10 mg. He has had no radiographs since 2021. BPE: 17/16 = 4*, 26/27 = 4, 11/21 = 3, 37/36 = 3, 47/46 = 2, with generalised marginal bleeding. Probing on the upper right molars gives 6–8 mm with 4 mm recession, grade II furcation involvement on 16, mobility grade I, and bleeding on probing at 68% of sites. There is heavy supragingival calculus and staining. He wants the whole mouth done today, in one appointment, and leaves for a six-month contract in Australia in three weeks.
1. Interpret the BPE, state what further assessment is needed before treatment, and give your provisional periodontal diagnosis and risk assessment.
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What the BPE is telling you. Codes 0–2 are safe; code 3 means a pocket of 3.5–5.5 mm; code 4 means a pocket of 5.5 mm or more and always needs a full six-point pocket chart plus radiographs of that sextant. The star records furcation involvement. So 17/16 (4*) and 26/27 (4) are the priority, 11/21 and 37/36 (3) need charting, and 47/46 (2) reflects calculus rather than pocketing. One code per sextant hides the worst site, so do not plan from the BPE alone.
Further assessment. A full six-point chart with recession and attachment loss, bleeding and plaque scores, mobility, furcation and suppuration; periapicals of the molars and bitewings for crestal bone and caries; a medication review including renal function if any dose change is contemplated; and a social history covering smoking quantity, quitting history, alcohol and oral hygiene.
Diagnosis and risk. Generalised periodontitis, likely Stage III given 6–8 mm pockets with furcation involvement and mobility, with Grade C progression risk driven by 20 cigarettes a day and an HbA1c of 9.1% (about 76 mmol/mol). Both are modifiable and both blunt the treatment response: smoking roughly doubles attachment loss and impairs healing, and poor glycaemic control is bidirectionally linked with periodontitis.
Plan in principle. Cause-related therapy with oral hygiene instruction and professional mechanical plaque removal, re-evaluation at 6–8 weeks, root debridement of residual pockets, then risk-based maintenance. Tell him honestly that the trip changes the plan, not the need for it.
2. How do you manage the apixaban, and what do you do about his request for full-mouth debridement in one visit?
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Do not stop his apixaban. That is a prescriber decision, not yours. Stopping an anticoagulant carries stroke risk.
Bleeding risk reasoning. Subgingival instrumentation is a low-to-moderate bleeding risk procedure. Most guidance is to continue the anticoagulant, with the option of delaying or missing the morning dose on the day only for higher-risk procedures, after discussion with the prescriber and with renal function known. INR monitoring does not apply to apixaban.
Practical measures. Book an earlier appointment and ask whether he has taken that morning's dose, since DOAC levels peak 2–4 hours afterwards. Use firm gauze pressure and consider tranexamic acid 4.8% mouthwash, 10 mL four times daily for two to five days, if oozing persists. Avoid NSAIDs; recommend paracetamol. Prefer infiltration to an inferior alveolar nerve block where possible because of haematoma risk, and check that your scope and employer policy authorise you to give local anaesthetic - if not, plan the appointment with the dentist.
The one-visit request. Splitting the mouth into right and left sides a week apart gives better haemostasis, better comfort and better quality than rushing the whole mouth. Explain the trade-off in terms he cares about: a single hurried visit is more likely to leave deposits behind and to provoke bleeding, and he will be on a plane in three weeks.
Before he goes. Give him a written diagnosis and treatment summary, a referral to a dentist or periodontist in Australia, a hygiene regimen, written post-operative bleeding advice, and a re-assessment plan for his return. Record that the bleeding risk was discussed.
3. How do you address his smoking and his glycaemic control in a single appointment, given he is leaving the country in three weeks?
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Ask, advise, help. Ask permission first: 'Can I ask what you think about your smoking?' rather than opening with a warning. At 20 a day he knows it is harmful; what changes behaviour is linking it to something he cares about - his gums, his healing, the cost over six months abroad. Give brief advice and offer cessation support: Quitline 0800 778 778, text and phone support, nicotine replacement, or varenicline through his GP. Record that advice was given and whether he accepted a referral.
Do not bundle everything. He came for a clean and he leaves in three weeks. Pick two or three changes he is most likely to act on - smoking, a GP review of his diabetes, and a simple interproximal cleaning routine - and let the rest wait. A patient who feels ambushed stops listening.
Glycaemic control. You do not manage his diabetes, but you can state clearly that his gum condition and his HbA1c affect each other, and that a GP review before he travels is worthwhile. With his consent, write to his GP.
Motivational style. Use open questions, affirmations, reflections and summaries. Ask 'how important is this to you, and how confident are you?' rather than 'you need to quit'. If he says he will not stop, accept it, keep the relationship and revisit it next time - the goal is that he comes back at all.
Risk communication. Frame the perio message in his terms: with his current smoking and glucose control, the treatment you do in the next three weeks will achieve less and relapse faster than it would otherwise. That is honest and it is motivating, without being a threat.