Page 8 - GP Spring 2022

We should emphasize that oral hygiene is which subsided after the procedure. There 5. Other Considerations and Challenges
essential to prevent bacterial endocarditis was no impact on the risk of arrhythmia and
as poor oral hygiene can act as a source of a negligible effect on mean blood pressure. Several challenges were encountered while
transient bacteremia that could be associat- In this patient’s case, her LVAD coordina- treating this patient. Transportation diffi-
ed with the development of bacterial endo- tor stated that the main concern would be a culties, as the patient utilized Access-A-
carditis. For this patient, we recommend decrease in blood pressure. Thus, the use of Ride and needed to book transportation
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the use of antibiotic prophylaxis prior to all local anesthetic with epinephrine was ac- several days in advance, thereby decreas-
invasive procedures. ceptable with consideration taken to utilize ing flexibility in scheduling appointments.
the lowest effective concentration, constant Several appointments were also canceled
2. Medication Interactions and Side Effects monitoring during the procedure, and tak- due to medical complications the patient
ing precautions to avoid IV injection (i.e., was facing, such as medication changes
Digoxin: Digoxin is being prescribed less aspiration prior to injection). and their side effects (e.g., patient canceled
frequently as the paradigms for managing an appointment due to ongoing inconti-
heart failure and atrial fibrillation have Avoidance of abrupt postural changes to nence resulting from an adjustment of her
shifted to other drug classes. For patients prevent orthostatic hypotension is always antihypertensive medications). This result-
medicated with digoxin, it is always wise warranted. For the restorative phase of ed in a slow delivery of treatment, which
to record baseline pulse rate and rhythm treatment, 1.5 carpules of lidocaine 2% became a challenge in terms of patient mo-
before commencing dental treatment. It is with epinephrine 1:100,000 via maxillary tivation and willingness to continue with
wise to use caution when administering infiltration was used. No complications treatment. The doctor-patient relationship
epinephrine as the most serious side effect were encountered and the treatment was was strengthened by the excellent rap-
of the medication is related to cardiac ar- well-tolerated. port between the patient and the provider,
rhythmia causing excitation. 12 which positively enhanced the patient’s
3. Risk of Prolonged Bleeding: Aspirin compliance with treatment - the impor-
Digoxin toxicity: Digoxin has a low ther- and Warfarin Management tance of this relationship for successful out-
apeutic index as many as 25% of patients comes for these complex patients cannot be
experience some degree of toxicity. The Evidence shows that the concomitant use understated, and providers must be willing
most common side effects are gastrointes- of aspirin and warfarin increases the risk of to invest the time necessary so that these
tinal-related and hypersalivation. 12 bleeding, major bleeding events, ER vis- patients do not simply give up.
its, and hospitalization. The combination
Beta-Blockers. Metoprolol. While treat- of warfarin and aspirin compared to war- Discussion
ing patients medicated with nonselective farin monotherapy showed higher rates of The medical management of this patient
beta-blockers, it is wise to record blood adverse outcomes. However, aspirin and was relatively straightforward: the patient
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pressure and heart rate before administer- warfarin should not be discontinued due was aware of the need for antibiotic pro-
ing local anesthetic-vasopressor formula- to the increased risk of stroke if they are phylaxis and was compliant. As expect-
tions. stopped. The benefits of using aspirin and ed, the use of epinephrine did not present
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warfarin outweigh the risk of prolonged a problem during treatment and despite
Diuretics. It is known that diuretic medica- bleeding, but it is imperative that good lo- hesitancy to treat for some clinicians, no
tions significantly reduce and alter salivary cal hemostatic measures are implemented medical complications, no medication in-
composition which may have an impact on when performing any invasive procedures teractions, and no increased bleeding were
the incidence of dental caries, periodontal to minimize the bleeding risk. encountered during the restorative treat-
disease, and mucosal lesion formation. It ment phase.
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is imperative to manage xerostomia caused It is critical to ask for recent INR results,
by diuretic medications for high-risk car- generally within 24-48 hours, to ensure Conclusions
ies patients. Therapeutic approaches such that the patient is within a reasonable range As poorly controlled comorbidities will ag-
as saliva substitutes, topical agents, and prior to an invasive dental procedure. Sur- gravate heart failure (HF), it is important to
systemic sialogogues are recommended gery is generally acceptable for patients ensure that other systemic diseases in med-
to alleviate xerostomia caused by diuretic on warfarin with an INR below 3. It is ically compromised patients are well-con-
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medications. Frequent hydration will also important to assess potential interactions trolled. This case report demonstrates the
alleviate the condition of xerostomia. when prescribing an antibiotic in patients importance of managing other comorbidi-
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on warfarin. ties in patients with end-stage heart failure
Chronic Use of Inhalers for Asthma and due to the numerous medical complications
COPD. Increased dental caries risk has 4. Selection of Post-operative Analgesia the patient may already be facing. In ad-
been attributed to prolonged use of inhaler and Other Medications dition, it is critical to find clinicians who
medications due to reduced salivary flow are willing to deal with cases involving
and pH. 17 The use of nonsteroidal anti-inflammato- medically compromised patients. Clini-
ry drugs (NSAIDs) for more than 5 days cian hesitation over this patient’s case was
The evidence suggests that the use of lo- may diminish the antihypertensive efficacy identified throughout the treatment related
cal anesthetic (LA) with epinephrine is not of most drug classes used to manage hy- to her multiple medical complications and
contraindicated for patients with a compro- pertension, which includes any of the be- the potential for adverse clinical outcomes.
mised cardiovascular system. Comparing ta-blockers. NSAIDs do not have effects Some clinicians may be hesitant not only
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the use of LA with epinephrine to LA with- on INR but may increase the risk of bleed- about invasive procedures, but also non-in-
out epinephrine, no statistically significant ing while on warfarin. vasive procedures (such as restorations or
difference was found. The use of local dental prophylaxis). In fact, our opinion is
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anesthesia with epinephrine only had a that the greatest challenge for patients that
transient increase in systolic blood pressure are medically compromised is finding cli-

www.nysagd.org l Spring 2022 l GP 8