For a 64‑year‑old woman on metoprolol, metformin, trazodone, chlorhexidine mouthwash and topical hydrocortisone undergoing a simple tooth extraction, is antibiotic prophylaxis required, are there any anesthetic restrictions, and is an epinephrine‑containing local anesthetic safe?

Pre-operative Management for Tooth Extraction in a 64-Year-Old Woman on Metoprolol

For this patient undergoing simple tooth extraction, antibiotic prophylaxis is NOT required, epinephrine-containing local anesthetic is safe with dose limitation, and no anesthetic restrictions are necessary beyond standard monitoring.

Antibiotic Prophylaxis: NO

• Routine antibiotic prophylaxis is NOT indicated for simple tooth extractions in healthy patients without cardiac risk factors. 1

• The 2007 American Heart Association guidelines dramatically restricted endocarditis prophylaxis recommendations, eliminating prophylaxis for most patients undergoing dental procedures. 2

• This patient's medication list (metoprolol, metformin, trazodone, chlorhexidine mouthwash, topical hydrocortisone) does not include any immunosuppressive agents or conditions requiring prophylaxis. 3

• If prophylaxis were indicated (which it is not for this patient), amoxicillin 2g orally 1 hour before the procedure would be first-line, or clindamycin 600mg orally for penicillin allergy. 2

Epinephrine-Containing Anesthetic: YES, with Caution

Epinephrine-containing local anesthetic is safe but requires dose reduction due to metoprolol therapy.

• Non-selective beta-blockers can inhibit the vasodilatory effect of epinephrine, potentially leading to hypertensive reactions and reflex bradycardia. 4 While metoprolol is a selective β1-blocker (less risk than propranolol), caution is still warranted.

• Reduce epinephrine concentration to 1:100,000 or 1:200,000 and limit total dose. 2 The guideline for patients with hypertension recommends reducing epinephrine dose when using local anesthesia. 2

• Lidocaine or mepivacaine with reduced epinephrine can safely be used. 2

• Monitor blood pressure before and during the procedure, as metoprolol indicates underlying cardiovascular disease. 2

Anesthetic Restrictions: NO Major Restrictions

• Standard amide local anesthetics (lidocaine, mepivacaine, articaine) are safe. 2 Allergy to amide local anesthetics is extremely rare. 2

• No contraindications exist with metformin, trazodone, or topical hydrocortisone for dental local anesthesia.

• Avoid excessive epinephrine as discussed above due to beta-blocker interaction. 4

Specific Antibiotic Considerations (If Needed)

If antibiotics were required (e.g., for infection or high-risk cardiac condition):

• First-line: Amoxicillin 875mg twice daily for 5-7 days 1
• Penicillin allergy: Clindamycin 300-400mg three times daily for 5-7 days 1
• Avoid: Metronidazole has no indication here and can interact with other medications 4

Additional Considerations

• Metformin does not require discontinuation for simple tooth extraction; it is not nephrotoxic and poses no direct surgical risk. 2

• Chlorhexidine mouthwash (already prescribed) should be continued or used 0.12% twice daily for 7-10 days post-extraction to reduce infection risk. 2, 1

• Local hemostatic measures (pressure, sutures if needed, tranexamic acid mouthwash) are sufficient for bleeding control in this patient. 2

• Schedule morning appointment to minimize stress and allow better blood pressure control. 2

Common Pitfalls to Avoid

• Do not withhold epinephrine entirely—it provides superior hemostasis and anesthesia; simply reduce the dose. 2

• Do not prescribe prophylactic antibiotics based on outdated endocarditis guidelines; the 2007 AHA recommendations eliminated this for most patients. 2

• Do not extract more than 3 teeth at one time if bleeding concerns arise, though this patient has no specific bleeding risk. 5