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Pharmacology · patient case question

What is the MOST important precaution before this extraction?

Patient case: Patient who has replaced medications with herbal remedies

Patient: 52-year-old woman presenting for extraction of a non-restorable molar.

Chief complaint: Wants the broken back tooth out.

History: Describes herself as a naturist. Has stopped all prescribed medication and now takes garlic capsules, St John's wort, ginkgo and fish oil daily.

Findings: Non-restorable tooth 19. No other relevant findings on examination.

  1. Anticipate an increased risk of bleeding
  2. Expect a prolonged duration of local anesthesia
  3. No precaution is required — herbal products are inert
  4. Anticipate an increased risk of postoperative infection
Show answer and explanation

Correct answer: A. Anticipate an increased risk of bleeding

  • A. CORRECT. GARLIC inhibits platelet aggregation, as do the other 'G' herbs — ginkgo, ginger and ginseng — along with vitamin E and fish oil. ST JOHN'S WORT is a potent CYP3A4 and P-glycoprotein INDUCER that lowers plasma levels of warfarin, oral contraceptives, benzodiazepines and other drugs, and carries serotonin syndrome risk with tramadol. The dominant surgical concern here is HEMOSTASIS: take a full supplement history, consider discontinuation one to two weeks preoperatively in consultation with her physician, and plan local hemostatic measures.
  • B. There is no established prolongation of local anesthetic effect from these products.
  • C. The assumption that natural means free of interaction is exactly the error this item tests.
  • D. Herbal supplements are not associated with a general increase in infection risk.

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