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Oral Surgery · patient case with 3 questions

Medically complex man requesting extraction of a painful tooth

Patient: Male, 56 years old

Chief complaint: “This tooth kept me awake all night. I want it out today.”

Background: Type 2 diabetes. Prostate cancer treated 2 years ago. Currently taking warfarin, bisphosphonates and antihypertensive medication.

Vital signs / labs: INR 2.4

Current findings: Non-restorable tooth with symptomatic irreversible pulpitis. Patient is insistent that it be removed at this visit.

Question 1

You explain that the tooth cannot simply be taken out today. The principal reason is:

  1. His type 2 diabetes
  2. Bisphosphonate therapy and the associated risk of medication-related osteonecrosis of the jaw
  3. His previous chemotherapy
  4. His antihypertensive medication
Show answer and explanation

Correct answer: B. Bisphosphonate therapy and the associated risk of medication-related osteonecrosis of the jaw

  • A. Diabetes impairs healing and matters, but it is not the reason the extraction cannot proceed as a routine procedure.
  • B. CORRECT. BISPHOSPHONATES are the standing concern. Extraction is the single strongest local trigger for MEDICATION-RELATED OSTEONECROSIS OF THE JAW (MRONJ). Risk depends on route and duration — intravenous, high-dose oncology regimens carry far greater risk than oral therapy for osteoporosis — so the drug, dose, route and duration must all be established, and the patient consented specifically to this risk.
  • C. The history describes treated prostate cancer, not active chemotherapy. Note that antiresorptive therapy is frequently given in prostate cancer for bone metastases, which raises the suspicion this is high-dose IV therapy.
  • D. Antihypertensives are not a barrier to extraction.

Note: Establish route and duration before deciding. IV antiresorptive therapy for malignancy carries substantially higher MRONJ risk than oral therapy for osteoporosis.

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Question 2

Which value tells you whether his anticoagulation is within a range compatible with a simple extraction?

  1. The platelet count
  2. The bleeding time
  3. The INR
  4. The partial thromboplastin time (PTT)
Show answer and explanation

Correct answer: C. The INR

  • A. Platelet count assesses primary haemostasis and is not what warfarin affects.
  • B. Bleeding time is an obsolete, poorly reproducible test no longer used for this purpose.
  • C. CORRECT. Warfarin inhibits vitamin K–dependent factors (II, VII, IX, X) and is monitored by the INR. His INR of 2.4 sits within the usual therapeutic window, and simple extractions are generally safe with local haemostatic measures at an INR up to roughly 3.5.
  • D. PTT monitors the intrinsic pathway and is used for unfractionated HEPARIN, not warfarin.

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Question 3

Which additional laboratory value would best inform your assessment of his healing capacity?

  1. Serum creatinine
  2. Serum calcium
  3. HbA1c
  4. Total cholesterol
Show answer and explanation

Correct answer: C. HbA1c

  • A. Creatinine matters for drug dosing but is not the key healing predictor in this scenario.
  • B. Serum calcium is not the relevant marker here, though it is worth noting bisphosphonates can lower it.
  • C. CORRECT. HbA1c reflects average glycaemic control over roughly the preceding three months and is the single best predictor of impaired wound healing and infection risk in a diabetic surgical patient. Combined with bisphosphonate exposure, poor glycaemic control compounds the osteonecrosis concern.
  • D. Cholesterol has no bearing on surgical healing.

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Practice patient cases Oral Surgery study notes