Guidelines of year 2011 dental management of Patients taking oral anti-coagulants and Aspirin.

2. • 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

3. Review of Stoopler et al. Sept.2015

4. Anticoagulants
Rapidly acting
(parenteral)
Heparin
Indirect Factor
Xa Inhibitors
Slow acting
(oral)
Coumarine
derivatives
Warfarin
Indandione
derivative
Direct
thrombin
inhibitors

5. 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

6. 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

7. Mechanism of
action
Heparin
Potentiates
action of
antithrombin-III
Warfarin
Prevents maturation
of Vit-K dependant
clotting factors

8. Antiplatelets
COX
inhibitors
Aspirin
ADP receptor
inhibitor
ticlopidine clopidogrel
Adenosine
receptor
inhibitors
dipyridamole

9.  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)

10.  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

11.  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.

12.  Simple restorative treatment
 Supragingival scaling
 Local anaesthesia by buccal infiltration,
intraligamentary or mental block
 Impressions and other prosthetics procedures.

13.  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

14.  INR more than 4
 liver impairment and/or chronic alcoholism
 renal failure
 thrombocytopenia, haemophilia or other disorder of haemostasis
 current course of cytotoxic medication.

15.  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

16.  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

17.  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

18.  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

19.  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.

20.  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

21. 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

22. 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

23.  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.

24.  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

25. 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

26.  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

27.  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)