Restorative with medical Flashcards
** toothache discussion - unrestorable tooth 6 mins **
Unrestorsble 26 requiring XLA / patient taking warfarin
- Introduce self and designation
- Ask about INR , when it was last checked and what were the values (need to be in the last 24h , 72h id pt is stably coagulated)
- ** Explain why the tooth cannot be extracted today **
- ’ due to the high risk of bleeding as a result of warfarin , the values recommended for carrying out an extraction are not met ‘
- there are issues with not having at least 3 months worth of INR values
** refer to relevant guidelines
**
1. SDCEP ; INR needs to be below 4 and tested in the last 24h ( 72h if pt anticoagulation is stable in the last 3 months) + SIGN guidelines
2. BNF says that a stable patient wouve be one who does not require weekly monitoring and who has not had any INR measurements above 4 in the last 2 months
- we have a local policy in the GDH that INR should be below 3.5 to carry out an extraction
** Explain again that we cannot proceed with extraction today **
** Deal with the patient pain **
- Analgesia
- Pulp extirpation
- Sedative dressing
- if urgent treatment required ; refer to secondary care
- Do not give antibiotics as there is no systemic involvement
** Ask if the patient understands the explanation and if they have any questions **
Ask if they understand and which option would they like and rebook extraction and ask if they have any questions
- Ask to see GP for tests
- Cannot recommend NSAIDs as can interact with warfarin
- Be careful with metronidazole
- Cannot do XLA today but as there is a bleeding risk and warfarin blocks vit K which makes clotting factors resulting in less clotting factors and higher bleeding risk if INR is above 4
** Bisphosphonates / 6mins **
Discussion of MRONJ and XLA risks before patient starts therapy
-
Explain that we aim to get her dentally fit which means prevent and remove any source of infection
- Introduce yourself and designation
- Explain that alendronic acid is bisphosphonate drug which is an anti-resorptive drug which stops bone resorption by slowing down bone remodelling
** Explain mode of action of bisphosphonate drugs **
- Reduce bone turnover
- Accumulate in sites with high bone turnover = jaw
- Used to reduce complications and symptoms of bone disorders
** Explain relevance of bisphosphonates to dentistry : **
- Risk of poor wound healing following an extraction ( in cancer pts its 5%) , still at risk even if stopping the drug
- Signs and symptoms include pain, delayed healing soft tissue infection , swelling , numbness , parasthesia , exposed inside or outside of mouth (cheek) , but may be asymptomatic
- Need to remove any teeth of poor prognosis prior to therapy
- Need to keep good OHI to prevent further infection
- Reduced turnover of bone and reduced vascularity may cause death of bone - osteonecrosis which is specifically named MRONJ in this case
** Risk of MRONJ in osteoporosis **
- Low risk 0-0.1% risk
( in cancer it is 1%)
** making a clinical diagnosis **
- Chronic periapical periodontitis ( area of infection associated with the left back tooth)
- Gross caries in tooth 36 ( tooth too decayed and cannot be restored)
** Discuss treatment options **
XLA is the only option as tooth not restorable and the decay is below the gumline , if tooth is kept there would be risk of MRONJ when beginning therapy
** Ask if pt got any question **
