76-year-old man for upper dental clearance

Background

• Significant tooth decay and gum disease
• Affecting ability to eat and impacting on QoL
• AF – on Apixaban
• IHD
• OSA – CPAP
• Mycotic AAA – EVAR 2019. On lifelong clopidogrel
• NIDDM – HbA1c – 6.6%
• CKD

Issues

• Recent CVA – Feb 2021. Lacunar infarct of internal capsule and Thalamus.
• 3 previous CVA’s
• Dysphagia due to previous CVA.
• Dentition worsening oral intake and exacerbating symptoms
• Patient very keen for procedure to be done as soon as possible

Discussion

• Elective procedure
• Current evidence recommends elective surgery should occur 9 months post CVA for risk reduction (Perioperative stroke after non-cardiac, non-neurological surgery – BJA Education)

Ongoing ischaemic events on anticoagulation and anti-platelet therapy

• Will the risks be significantly reduced in this patient after 9  months?
• Other options – outpatient dental procedures are done on anticoagulant therapy, can he have some of his teeth out in the community while awaiting full dental clearance?
• Should Neurologist/Haematologist advice should be sought regarding the cause of the CVA’s and management of anticoagulation

Plan:

• Discussion with surgical team:                
  • Further review with regards to symptomatic management options.
  • Happy to extract teeth with uninterrupted clopidogrel therapy
• Liaise with neurologist and haematologist