Patients on Anticoagulant Therapy and dental treatment protocol

Bleeding and coagulation times

 Clotting time: 5-11 m

 PTT: 30-40 s

 PT: 11-14 s

 TT: 10-14 s

 INR:1

Antiplatelet Drug Therapy

Drugs such as Aspirin, Ibuprofen, and Clopidogrel.

Aspirin irreversibly inhibits platelet cyclooxygenase, preventing synthesis of thromboxane A2, and impairing platelet aggregation.

Antiplatelet drugs are generally prescribed for the prevention of arterial and venous thrombosis in patients with ischemic heart disease, heart valve implants and stents, and in people at risk of suffering cerebrovascular events such as stroke. Since these drugs act by inhibiting platelet function, they have been accepted as adequate antithrombotic treatment . The main antiplatelet drugs marked in Spain are the following:

• Acetylsalicylic acid (ASA) blocks thromboxane A2 production, thereby inhibiting cyclooxygenase activity and consequently platelet aggregation . The effect of this drug upon the platelets is irreversible, and therefore lasts for the full length of platelet life (7-10 days). Low doses (75-100 mg) are generally indicated in cases of chest pain, ischemia, transient ischemic accidents, and during the postoperative period (post-angioplasty / angiography) .

• Clopidogrel bisulfate (Plavix®) inhibits platelet aggregation by blocking ADP binding to its platelet receptor

Because of their potential bleeding effect, antiplatelet drugs are often interrupted during the perioperative period, without adequately evaluating the increased thrombotic risk of this decision. More recent publications suggest that the increase in bleeding risk induced by antiplatelet drugs has been exaggerated, while at the same time the increased thrombotic risk associated with treatment interruption has been underestimated Consequently, although each invasive dental procedure implies a risk of oral bleeding, it is not advisable to interrupt antiplatelet therapy, since the increased risk of thromboembolism could outweigh the risk of bleeding

Dental management

Cessation of low-dose aspirin therapy prior to oral surgery has been controversial.

Studies have shown that patients undergoing minor oral surgery, including implant surgery and third molar extraction, experienced minimal bleeding complications when on low-dose aspirin therapy. These complications were controlled with local measures.

If major surgery must be performed under emergency conditions, desmopressin can be used to reduce the risk of excessive bleeding. This should be done in consultation with the patient’s physician or hematologist.

Dosage Forms & Strengths

injectable solution

•4mcg/mL tablet

•0.1mg

•0.2mg nasal spray

•0.1mg/mL (5mL): Delivers 10mcg/spray

•1.5mg/mL (2.5mL): Delivers 150mcg/spray

Anticoagulation with Coumarin Drugs (Warfarin)

Warfarin is an antagonist of vitamin K, an element necessary for synthesis of clotting factors II, VII, IX and X. It is used in the prevention of thrombosis and thromboembolism.

Potential Medical Problem Related to Dental Care

 Excessive bleeding after invasive dental procedures

Dental management

 Identify patients who are taking anticoagulants/ coumarinIf INR is 3.5 or less, most surgical procedures can be performed.

 Dosage of anticoagulant should be reduced if INR is greater than 3.5 (it takes several days for INR to fall to desired level; confirmation should be obtained by new tests before surgery).

Avoid aspirin or aspirin-containing compounds. Use acetaminophen for postoperative pain control.

Patients undergoing major oral surgery should be managed on an individual basis

The INR will drop to 1.5 within a period of 4 days when warfarin is discontinued.

when the INR reaches 1.5, the surgical procedure can be carried out without an increased risk for bleeding

If the INR is higher than 1.5 after discontinuation of warfarin for 4 to 5 days, a small dose of vitamin K (1 mg IV) should be administered.

If the INR is between 1.7 and 2.0, fresh frozen plasma can be given immediately before surgery.

The INR should be checked the day before the surgical procedure.

After warfarin therapy is resumed, it will take 3 days for the INR to reach 2.0, so warfarin should be started on the night of the procedure, provided that there is no obvious bleeding.

Low-molecular-weight heparin bridging can be considered for major surgery.

Patients treated with oral anti-vitamin K anticoagulants require periodic monitoring, based on the prothrombin time (PT). Since this parameter is somewhat imprecise, use of the INR (international normalized ratio: proportion between patient PT and control PT, standardized and corrected) is currently advised . The recommended anticoagulation levels vary between INR 2-3 for all indications, with the exception of patients with heart valve implants, in which INR should be maintained between 2.5-3.5

In the case of elective surgery, major surgery (over three extractions, implant placement, etc.), INR > 3.5 and other concomitant risk factors, the protocol of choice is to suspend anticoagulation 2-3 days before surgery (depending on the risk of thromboembolism), or to switch to subcutaneous heparin

Regarding the new oral anticoagulant drugs, the data in relation to dental treatment are still limited, since these drugs have only recently appeared on the market. In principle, it seems that there is no need to suspend anticoagulation or modify the dose in the case of operations with a normal or low bleeding risk (simple extractions, operations lasting under 45 minutes)

In the case of major surgery or procedures involving a high bleeding risk (multiple extractions, operations lasting > 45 minutes, head and neck cancer surgery) , the recommendation is to suspend the medication 24 hours before the operation and to reintroduce it after 24 hours, provided good hemostasis has been achieved contrast, Spyropoulus et al. in these cases advises anticoagulant suspension 2-3 days before the operation – though the authors underscore the need to carry out more studies and to investigate the possible effects of these new drugs.

Apart from their rapid action and few interactions, one of the main advantages of the new anticoagulants seems to be that they require no monitorization . Nevertheless, there are situations in which we need to know whether the level of anticoagulation is correct, e.g., in emergency

- Postoperative recommendations

It is recommend to perform all dental surgeries in the morning, in order to be able to resolve any bleeding complications in the course of the day.

The following patient instructions are advised :

• Apply pressure with a piece of gauze for 30-40 minutes

• Avoid oral rinses during the first 24 hours

• Follow a soft and cold diet during the first 24 hours

• Avoid suctioning movements

• Avoid touching the socket region with the tongue or manipulation of the operated zone

The adoption of adequate hemostatic measures is the key to not having to modify the antiplatelet or anticoagulation treatment in most cases. The incidence of postoperative bleeding episodes that cannot be controlled by such measures varies between 0-3.5%

As hemostatic measures, some authors recommend tranexamic acid as. postoperative rinse to stabilize the blood clot, since it inhibits purpose of assessing their effectiveness against bleeding. None of the authors found any given measure to be superior to the rest .

To make a review on hemostatic agents click here👆

In relation to suturing, there are differing opinions regarding the ideal type of suture for minimizing bleeding. Some authors advocate reabsorbable sutures since they do not have to be removed – thereby avoiding trauma and minimizing bleeding risk . In contrast, other investigators prefer non-reabsorbable silk sutures, since they retain much less plaque and therefore greatly lessen the risk of bacterial penetration into the bloodstream This in turn reduces the risk of postoperative complications such as thromboembolic phenomena or infections

For more reading free download

👆Crispian skully's medical proplems in dentistry

👆Dental management of medically compromised patient

👆 Myocardial infarction and dental treatment protocol

👆 Epileptic patient and dental treatment protocol