dental management of patients taking oral anti-coagulants and aspirin
TRANSCRIPT
Dental management of patientstaking Oral anticoagulants and Antiplatelet drugs
• Vascular retraction (vasoconstriction) to slow blood loss
Vascular phase
• Adherence of platelets to the vessel wall (endothelium) to form a platelet plug
Platelet phase
• Initiation of the coagulation cascade resulting in the formation and deposition of fibrin to form a clot
Plasmatic phase
Review of Stoopler et al. Sept.2015
Anticoagulants
Rapidly acting (parenteral)
Heparin Indirect Factor Xa Inhibitors
Slow acting (oral)
Coumarine derivativesWarfarin
Indandione derivative
Direct thrombin inhibitors
Conditions for which anticoagulants are prescribed…
1. On urgent basis and for long term:
› Atrial fibrilation
› Deep vein thrombosis
› Cerebral venous thrombosis
› Stroke
› Pulmonary thromboembolism
› Unstable angina and non ST elevation
MI patients
2. In no urgency, treatment is started with oral
anticoagulants alone:
› Prosthetic valves
3. When anticoagulation is needed for brief periods,
Heparin alone is used:
› Cardiac bypass surgery
› Hemodialysis
› DIC
Mechanism of action
Heparin
Potentiates action of
antithrombin-III
Warfarin
Prevents maturation of Vit-K dependant
clotting factors
Antiplatelets
COX inhibitors
Aspirin
ADP receptor inhibitor
ticlopidine clopidogrel
Adenosine receptor
inhibitors
dipyridamole
Lab tests to monitor Anticoagualation activity
aPTT- (N: 33-45 seconds) in heparin therapy it is maintained at
1.5-2 times the normal value
PT- (12-14 seconds) in warfarin, maintained at 1.5-3 times the
control value
BT- normal is < 9min.
INR (international normalized ratio)
INR introduced in 1983 by WHO
Thromboplastic reagents used for prothrombin tests are derived from variety of sources and give different PT results in the same patient
So, each thromboplastin is compared with an international reference preparaion (WHO) so that it can be assigened an ISI
When should the INR be measured before a dental procedure?
An INR check 72 hours prior to surgery is
recommended.
This allows sufficient time for dose modification
if necessary to ensure a safe INR (2- 4) on the day
of dental surgery.
“Safe” listed dental procedures
Simple restorative treatment
Supragingival scaling
Local anaesthesia by buccal infiltration,
intraligamentary or mental block
Impressions and other prosthetics procedures.
Procedures carrying “significant risk of bleeding”
Local anaesthesia by inferior alveolar or
other regional nerve blocks or lingual or
floor of mouth infiltrations.
Subgingival scaling and Root Surface
Instrumentation (RSI).
Crown and bridge preparations
Extractions
Minor oral surgery
Periodontal surgery
Biopsies.
Incision and drainage
of swellings.
Surgical Endodontics
Procedures strictly contraindicated in...
INR more than 4
liver impairment and/or chronic alcoholism
renal failure
thrombocytopenia, haemophilia or other disorder of haemostasis
current course of cytotoxic medication.
Is it safe to discontinue anticoagulants prior to dental surgery?
The risk of thrombosis if anticoagulants are discontinued...???
Reviewed by Wahl et al.(1998), 5/493 patients (1%) had
serious embolic complications
Risk is small but potentially fatal
The risk of major bleeding intra/ post operative if anticoagulants are continued...
Meta analysis of Wahl (2000) concludes that
12/774patients (<2%) had postoperative bleeding
problems that were not controlled by local measures.
Results of the studies of Campbell and Sacco (2006)
supports Wahl’s meta analysis
Guidelines of British Committee for Standards in Haematology (June 2011)
The risk of significant bleeding with a stable INR in the therapeutic
range 2-4 (i.e. <4) is very small
the risk of thrombosis may be increased in patients in whom oral
anticoagulants are temporarily discontinued.
Individuals, in whom the INR is unstable, should be discussed with
their anticoagulant management team
The risk of major bleeding intra/ post operative if antiplatelets are continued...
Ardekian et al. (2000) studied effect of continuing v/s discontinuing
Aspirin before extraction.
None of the patients who continued Aspirin had bleeding time outside
the normal range post op.
Review of Little JW (2002) suggests patients on Aspirin and
clopidogrel should not have dose altered before dental surgical
procedure
Strategy for Management of bleeding
According to Scully and Wolff (2002), oral procedures must
be done at the beginning of the day
Also, the procedures must be performed early in the week,
allowing delayed re-bleeding episodes to be dealt with
during the working weekdays.
LA with a vasoconstrictor should be administered by
infiltration or by intraligamentary injection Local pressure (biting on gauze) site packing with gelatine sponges, absorbable
oxycellulose, microcrystalline collagen and suturing Electrocauterization Topical thrombin powder. Fibrin sealants.
5% tranexamic acid mouthwashes used 4 times a day
for 2 days
Scully and Cawson’s list of instructions for the patients...
1. Patient should be advised to rest for 2-3 hours post
operatively
2. Avoid rinsing of the mouth for 24 hours
3. Not to suck hard or disturb the socket with the tongue or any
foreign object
4. To avoid hot liquids and hard foods for the rest of the day
5. To avoid chewing on the affected side
6. If bleeding continues or restarts, apply pressure using a folded
clean handkerchief for 20mins.
7. If bleeding does not stop then immediately contact the dental
office
Anticoagulants and prophylactic antibiotics.
A single dose of an antibiotic is unlikely to have any
significant effect upon the INR.
Individuals who are prescribed more than a single dose of
antibiotics should have the INR measured 2-3 days after
starting treatment.
Anticoagulants and Analgesics
For post op pain control, Paracetamol is the safest analesic.
Drugs such as aspirin, Ibuprofen, selective COX-2
inhibitors should be avoided to avoid complications of
bleeding
CONCLUSION
Step 1 - Assess the dental procedure to be performed for risk of bleeding. (If no significant bleeding risk – proceed with dentistry.) Step 2 - Assess the anticoagulation status of the patient using INR.
step 3- optimal value of INR is 2.5 but the safe range of INR is 2.0-4.0 for provision of dental treatment
Dental Management Strategy
The use of concomitant medications, including antibiotics,
antifungals, (NSAIDs) and other platelet aggregation
inhibitors may affect a patient’s ability to achieve adequate
haemostasis after a routine dental procedure
References: NHS Integrated Dental Service Local Guidance, July 2013 Atanaska. Management of patients on anti-coagulant therapy
undergoing dentalsurgical procedures. Review article.Journal of IMAB -2013, vol. 19, issue 4, 321-326
Perry DJ. British Committee for Standards in Haematology. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. June 2011
Aframian. Management of dental patients taking common hemostasis altering medications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(suppl:S45.e1-S45.e11)
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