My Patient Had a Stroke at 16! Can I Help Them?

A DOCS Education member asks:
I am seeing a 32-year-old male patient who weighs 145 pounds. He presented to the office as an emergency, and hasn’t seen a dentist since 2008. The last time he saw his primary care physician was two years ago. He is currently taking no medications, but is partially paralyzed in half of his body from a stroke he suffered at 16 years old.

I explained to the patient that the emergency treatment will be pulpal debridement on tooth #30 (while #31 maybe will need a RCT and #32 an extraction in the future). At the moment the local anesthesia was administered he started sweating and shaking. After four carpules of local anesthetic, I was barely able to do a sedative filling, because the patient was shaking and repeatedly needed to stand up, saying that he is in pain, but also afraid. I prescribed amoxicillin 500 mg, and ibuprofen 600 mg. Three days after the treatment, he required strong medication, and I prescribed 8 Vicoprofen 7.5 mg.

The question I have is how safe it will be to do Incremental Protocol #1? The patient does not take any medications, and I am assuming that his liver is in good condition. Because he is young but did not see a primary care physician, is a must that he has to see the PCP beforehand. The mother is upset because she cannot understand why he has to see his primary doctor.

Any suggestions for a successful OCS would be appreciated!

A fellow DOCS Education clinician responds:
I would like more information on the stroke as it seems quite atypical. Your instinct is good to get a complete work-up considering that he hasn't been seen in a number of years. It may not reveal much of anything however, you may save a life.

The sweating and shaking could be anxiety and/or pain, or the transient epinephrine reaction. This tooth could be the "hot" tooth of symptomatic irreversible pulpitis that will only settle after an intra-osseous or intra-pulpal injection. Four cartridges is quite a bit for one area, if all were delivered in a similar fashion. Hopefully, you tried other blocks besides the classic Halstead and changed up your anesthetic.

Sedation, if all things are fine, would be helpful here. I worry more about the "standing up" aspect with sedation. Is this a control thing for him? With him on the appropriate monitors, behavior like this will be challenging to say the least and a red flag to many for OCS if the behavior is compulsive.

Considering the press about antibiotic and narcotic prescriptions, you may want to reflect on reviewing the current literature on the topic. Most DOCS courses cover this in great fashion as do a great number of our professional journals.

DOCS Education faculty member, Dr. Jerome Wellbrock, responds:

Your fellow DOCS member has highlighted several areas of concern. I absolutely would demand a complete physical exam and consult with the physician, especially exploring all facets concerning the previous stroke. If you have any concerns before sedating this patient it is entirely acceptable to refer to someone for IV Sedation. If the patient and or his mother are against seeing a physician then I would explain to them that it is in their best interest for both safety and a comfortable sedation appointment. A patient cannot sign away a negligent act by a doctor!

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