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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