Medical Emergencies · patient case question
Which consideration is MOST important for this patient's dental management?
Patient case: Rheumatoid arthritis with a prosthetic mitral valve
Patient: Female, 62 years old
Chief complaint: “I need a tooth taken out.”
History: Rheumatic fever in childhood. Mechanical mitral valve replacement six years ago. Rheumatoid arthritis managed with weekly methotrexate. Warfarin, stable.
Findings: Non-restorable tooth #14 with a chronic apical abscess. No acute swelling. Reduced grip strength and limited manual dexterity.
Show answer and explanation
Correct answer: C. Some dental procedures will require antibiotic prophylaxis
- A. Progression of her rheumatoid disease is a real medical issue but it is not the governing consideration for this dental appointment.
- B. Hospital care is not required for a routine extraction in a stable outpatient. Her INR should be checked within 24 to 72 hours and, if therapeutic, warfarin is CONTINUED with local haemostatic measures.
- C. CORRECT. A PROSTHETIC HEART VALVE is one of the four AHA categories that still require antibiotic prophylaxis, alongside previous infective endocarditis, unrepaired or recently repaired cyanotic congenital heart disease, and cardiac transplant with valvulopathy. Prophylaxis is indicated for procedures involving gingival manipulation, the periapical region, or perforation of oral mucosa — an extraction qualifies. Amoxicillin 2 g orally, one hour before.
- D. Vasoconstrictors are not contraindicated. A limited dose of epinephrine is safe and desirable in stable cardiac patients, because good anaesthesia reduces endogenous catecholamine release.
Note: Note the deliberate contrast with a SUCCESSFULLY REPAIRED tetralogy of Fallot with no residual defect, which needs NO prophylaxis after the first six months. Prosthetic material in the valve position is a different category.
Practice Medical Emergencies questions Medical Emergencies study notes