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Management of Patients on the Dental Chair

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Management of Patients on the Dental Chair

  1. 1. Management of Patients on Dental Chairon “Antiplatelets & Anticoagulants” Prepared by: Majd Hasanin
  2. 2. Introduction• High percentage of the patients visiting dental clinics have systemic complications such as “Coagulation problems”, requiring them to undergo treatments, such as being under antiplatelets medications & anticoagulants.• It is the duty of the dentist to know how to manage treating those patients without causing any further harm.. So dentists need to be well acknowledged. Majd Hasanin
  3. 3. Antiplatelets Medications• What is an antiplatelet? Affect clotting by inhibiting platelet aggregation, they do so by a variety of different mechanisms which results in a prolonged ‘bleeding time’. Majd Hasanin
  4. 4. How is clotting process affected?• Platelets provide the initial haemostatic plug at the site of a vascular injury. They are also involved in pathological processes and are an important contributor to arterial thrombosis leading to myocardial infarction and ischemic stroke. Majd Hasanin
  5. 5. Local Anesthesia• Local anesthetics containing a vasoconstrictor should be administered by infiltration or by intraligamentary injection wherever practical.• Regional nerve blocks should be avoided where possible. However, if there is no alternative, the local anesthetic should be administered cautiously using an aspirating syringe. Local vasoconstriction may be encouraged by infiltrating a small amount of local anesthetic containing adrenaline (epinephrine) close to the site of surgery. Majd Hasanin
  6. 6. Which procedures can antiplatelet medications be safely continued?• Those likely to be carried out in primary care will be classified as minor e.g. simple extraction of up to three teeth, gingival surgery, crown and bridge procedures, dental scaling and the surgical removal of teeth. Majd Hasanin
  7. 7. • When more than three teeth need to be extracted multiple visits will be required. The extractions may be planned to remove two to three teeth at a time, by quadrants, or singly at separate visits.• Scaling and gingival surgery should initially be restricted to a limited area to assess if bleeding is problematic. Majd Hasanin
  8. 8. Management of Postoperative Pain• “Paracetamol” is considered a safe over-the-counter analgesic for patients taking antiplatelet medications.• “Aspirin” at analgesic doses and non-steroidal anti-inflammatory drugs “(NSAIDs)” e.g. ibuprofen are considered less safe and should be avoided if possible. Majd Hasanin
  9. 9. Drug Interactions• “NSAIDs” should be used with caution in combination with “Clopidogrel”. They can damage the lining of the gastro- intestinal tract leading to bleeding. Majd Hasanin
  10. 10. Anticoagulant• What is an Anticoagulant?• (an"tih-ko-AGu-lant) is a drug that helps prevent the clotting (coagulation) of blood. These drugs tend to prevent new clots from forming or an existing clot from enlarging. They dont dissolve a blood clot. Majd Hasanin
  11. 11. • Anticoagulants are also given to certain people at risk for forming blood clots, such as those with artificial heart valves or who have atrial fibrillation (Atre-al fib"rih-LAshun). Majd Hasanin
  12. 12. As a Medication• Anticoagulants are given to people to stop thrombosis (blood clotting inappropriately in the blood vessels). This is useful in primary and secondary prevention of deep vein thrombosis,pulmonary embolism, myocardial infarctions and strokes in those who are predisposed. Majd Hasanin
  13. 13. Medications• Heparin.• Warfarin (Coumadin) This is the main agent used in the U.S. and UK• Acenocoumarol and phenprocoumon This is used more commonly outside the U.S. and the UK• Brodifacoum Rat poison, not used medically• Phenindione Majd Hasanin
  14. 14. Heparin• It is a biological substance, usually made from pig intestines. It works by activating antithrombin III, which blocks thrombin from clotting blood. Heparin.• Can be used in vivo (by injection), and also in vitro to prevent blood or plasma clotting in or on medical devices. Majd Hasanin
  15. 15. Major pharmaceutical Heparin recall due tocontamination• In March 2008 major recalls of Heparin were announced by pharmaceuticals due to a suspected and unknown contamination of the raw Heparin stock imported from China.• The U.S. Food and Drug Administration was quoted as stating that at least 19 deaths were believed linked to a raw Heparin ingredient imported from the Peoples Republic of China, and that they had also received 785 reports of serious injuries associated with the drug’s use. According to the New York Times: Problems with heparin reported to the agency include difficulty breathing, nausea, vomiting, excessive sweating and rapidly falling blood pressure that in some cases led to life-threatening shock. Majd Hasanin
  16. 16. Warfarin• Warfarin is a synthetic derivative of coumarin, a chemical found naturally in many plants.• It is the drug of choice for oral antithrombotic therapy. Majd Hasanin
  17. 17. Contraindications of using warfarin• Known bleeding tendency, including thrombocytopenia (platelets < 80 x 109/l) and liver disease• Hemorrhagic stroke• Uncontrolled severe hypertension• Pregnancy• Continuing alcohol abuse• Non-compliant patients• Active peptic ulcer Majd Hasanin
  18. 18. Articles & Researches• Several researches & articles & studies have been done regarding the management of anticoagulants prior to dental minor & major procedures.. Majd Hasanin
  19. 19. British Journal of Oral and Maxillofacial Surgery (2002) 40, 248–252© 2002 The British Association of Oral and Maxillofacial Surgeonsdoi: 10.1054/bjom.2001.0773, available online athttp://www.idealibrary.comI. L. Evans,* M. S. Sayers,* A. J. Gibbons,* G. Price,* H. Snooks,† A. W.Sugar* Majd Hasanin
  20. 20. British Journal of Oral and Maxillofacial Surgery (2002) 40, 248–252© 2002 The British Association of Oral and Maxillofacial Surgeonsdoi: 10.1054/bjom.2001.0773, available online at http://www.idealibrary.comI. L. Evans,* M. S. Sayers,* A. J. Gibbons,* G. Price,* H. Snooks,† A. W. Sugar*• A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalized Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions.• Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). Majd Hasanin
  21. 21. British Journal of Oral and Maxillofacial Surgery (2002) 40, 248–252© 2002 The British Association of Oral and Maxillofacial Surgeonsdoi: 10.1054/bjom.2001.0773, available online at http://www.idealibrary.comI. L. Evans,* M. S. Sayers,* A. J. Gibbons,* G. Price,* H. Snooks,† A. W. Sugar*• Continuing warfarin when the INR is 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding.• As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered. Majd Hasanin
  22. 22. Guidelines for the management of patients on oral anticoagulantsrequiring dental surgeryBritish Committee for Standards in HaematologyAddress for correspondence:BCSH SecretaryBritish Society for Haematology100 White Lion StreetLondonN1 9PFe-mail: bcsh@b-s-h.org.ukWriting group: Perry DJ1, Nokes TJC2, Heliwell PS3 Majd Hasanin
  23. 23. Guidelines for the management of patients on oral anticoagulantsrequiring dental surgeryBritish Committee for Standards in HaematologyWriting group: Perry DJ1, Nokes TJC2, Heliwell PS3• Key recommendations:1- The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4 (i.e. <4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued.• Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extraction (grade A level Ib). Majd Hasanin
  24. 24. Guidelines for the management of patients on oral anticoagulantsrequiring dental surgeryBritish Committee for Standards in HaematologyWriting group: Perry DJ1, Nokes TJC2, Heliwell PS32- For patients stably anticoagulated on warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their anticoagulant regimen (grade C, level IV). Majd Hasanin
  25. 25. Guidelines for the management of patients on oral anticoagulantsrequiring dental surgeryBritish Committee for Standards in HaematologyWriting group: Perry DJ1, Nokes TJC2, Heliwell PS33- The risk of bleeding may be minimized by: a. The use of oxidized cellulose (Surgical) or collagen sponges and sutures (grade B, level IIb). b. 5% tranexamic acid mouthwashes used four times a day for 2 days (grade A, level Ib). Tranexamic acid is not readily available in most primary care dental practices. Majd Hasanin
  26. 26. Guidelines for the management of patients on oral anticoagulantsrequiring dental surgeryBritish Committee for Standards in HaematologyWriting group: Perry DJ1, Nokes TJC2, Heliwell PS3 4- For patients who are stably anticoagulated on warfarin, a check INR is recommended 72 hours prior to dental surgery (grade A, level Ib). 5- Patients taking warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesia following dental surgery (grade B, level III). Majd Hasanin
  27. 27. As a General Rule• For minor surgery, no adjustment of anticoagulation is undertaken if the International Normalized Ratio is less than 4.0, if local haemostatic methods and tranexamic acid mouthwashes are used.• For major surgery, warfarin is stopped preoperatively and low- molecular-weight heparin is used. For emergency surgery, partial reversal of anticoagulation with low-dose parenteral vitamin K is obtained. Majd Hasanin
  28. 28. Conclusion• There are discrepancies regarding wither to with-hold the anticoagulant or continue it normally.• The patient MUST be referred back to his/her physician in- order to decide as he/she will be more aware of the patient’s case & medical status.• You as a dentist have NO authority or right to stop any anticoagulant drug ESPECIALLY when it is taken systemically. Majd Hasanin
  29. 29. Thank You Majd Hasanin

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