Clinical Scenario

A 74‐year‐old man attends to your clinic for an emergency appointment. He complains of a painful lump in the gum adjacent to the upper left first molar (#26) that presented 24 hours earlier and is getting worse.

Structured Learning

1. What could have led to this patient having HCV infection?
   • The patient received a blood transfusion in the 1980s
   • This was before the introduction of HCV screening of donated blood in 1991–2
2. The patient requests that the #26 is extracted immediately and does not want any delay. Why is this not advisable?
   • You need further information from his physician regarding the severity/impact of his HCV infection
   • The patient has an increased bleeding risk due to his thrombocytopenia and the likelihood that his HCV infection has also impaired the hepatic synthesis of coagulation factors
   • Antibiotic prophylaxis is mandatory (splenectomised)
3. What could be causing this patient’s thrombocytopenia?
   • The pathophysiology of thrombocytopenia in relation to HCV infection is complex
     

     

   • Hypersplenism may contribute to thrombocytopenia but this patient has had a splenectomy
   • Hence, in his case, contributory factors include:
     • Bone marrow suppression resulting from HCV itself
     • Aberrations of the immune system resulting in the formation of antiplatelet antibodies and/or immune complexes that bind to platelets and facilitate their premature clearance
     • Thrombopoietin (TPO) deficiency secondary to liver dysfunction

4. What laboratory test results would you need before proceeding with the dental extraction?
   • Full blood count to confirm the platelet count
   • Coagulation study to check the prothrombin time/INR and partial thromboplastin time
5. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Reduced co‐operation due to anxiety‐depressive syndrome
     • History of dental anxiety/bad experience of dentistry
     • Alprazolam may impair judgement/cause drowsiness – the patient should not drive and he may not be able to give informed consent
   • Medical
     • Low compliance with medical management with no active antiviral treatment – HCV loads likely to be high
     • Bleeding tendency
     • Increased risk of infection due to the splenectomy
     • Compromised respiratory capacity
     • Risk of a hypertensive crisis (exacerbated by dental anxiety)
     • Drug selection and interactions
   • Dental
     • Poor oral health
     • Acute infection of #26 may prevent effective anaesthesia
     • Lack of regular brushing/mouth cleaning (increases the risk of postoperative infection)
     • Dry mouth as a result of alprazolam
     • Follow‐up jeopardised by patient’s dental history and depressive symptoms
6. The patient requests sedation due to his dental anxiety. What should you consider?
   • In moderate hepatic impairment, benzodiazepines should not be administered (except for lorazepam in liaison with the physician)
   • Benzodiazepines should also be avoided for patients with chronic obstructive pulmonary disease
   • The patient is already taking alprazolam (a benzodiazepine)
   • The use of nitrous oxide may be a better option

7. You are unable to achieve effective anaesthesia to enable extraction of the #26. How would you proceed?
   • Prescribe antibiotics: amoxicillin (full dosage) and metronidazole (reduced dosage) may be prescribed but clavulanic acid and azithromycin should be avoided
   • Incision and drainage should be considered
8. What analgesic would you recommend after extracting the tooth root remains?
   • In moderate hepatic impairment, the recommendation is to use metamizole or paracetamol at reduced dosages (<2 g/24 hours)
   • Non‐steroidal anti‐inflammatory drugs with antiplatelet action should be avoided for this patient due to his tendency to bleed
   • Peripheral thrombocytopenia is an adverse effect of metamizole (unavailable in some countries), which is therefore not recommended when there is baseline thrombocytopenia

General Dental Considerations