Dental management in patients receiving anticoagulation or antiplatelet treatment

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Dental management in patients receiving anticoagulation or antiplatelet treatment

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  • Figure 6. Model summarizing effects of dipyridamole on NO/cGMP and prostaglandin/cAMP signal transduction in human platelets. Dipyridamole inhibits cGMP-specific PDE V, thereby causing increased NO/cGMP-evoked VASP serine 239 (Ser239) and 157 (Ser157) phosphorylation. Dipyridamole also enhances the inhibitory effects of NO/cGMP-mediated signaling on platelet activation. As measured by VASP phosphorylation, only NO/cGMP, but not prostacyclin/cAMP signaling, is affected by dipyridamole under therapeutically relevant conditions. PKA indicates cAMP-dependent protein kinase; PKG, cGMP-dependent protein kinase.
  • Dental management in patients receiving anticoagulation or antiplatelet treatment

    1. 1. DENTALDENTAL MANAGEMENT INMANAGEMENT IN PATIENTSPATIENTS RECEIVINGRECEIVING ANTICOAGULATIONANTICOAGULATION OR ANTIPLATELETOR ANTIPLATELET TREATMENTTREATMENT IS STOPPING OF THE THERAPY REALLY REQUIRED IN MINOR DENTAL SURGERY ? Piti Niyomsirivanich, MD.
    2. 2. CLINICAL SCENARIO  ผู้ชาย 45 ปี  Old CVA with AF with MR S/P MVR  on warfarin 22 mg/week INR 3.0  จะถอนฟัน ทำาไงดี ?  หยุดยา warfarin ก่อนไปถอนฟัน  ไปถอนฟันเลย
    3. 3. CLINICAL SCENARIO  ผู้หญิง 75 ปี  Previous STEMI S/P PCI Drug Eluting Stent เมื่อ 6 เดือนก่อน  ASA 81 mg/d + Clopidogrel 75 mg/d  จะไปถอนฟัน ทำาไงดี  หยุดยา ASA + Clopidogrel ก่อนไปถอนฟัน  หยุดยา ASA ก่อนไปถอนฟัน  หยุดยา Clopidogrel ก่อนไปถอนฟัน  ไปถอนฟันได้เลย
    4. 4. TUTORIAL IN ORAL ANTITHROMBOTIC THERAPY
    5. 5. ANTITHROMBOTIC DRUGS CATEGORIZED BY PHARMACODYNAMICS Anti thrombotic drug categories Generic names and subgroup Antiplatelet agents COX-1 inhibitor Aspirin ADP receptor inhibitor: Clopidogrel ,Prasugrel ,Ticlopidine ,Ticagrelor Gp IIb/IIIa inhibitor Abciximab ,Eptifibatide , Triofiban Phosphodiesterase inhibitor Cilostazol , Dipyridamole Vitamin K antagonist Warfarin , Coumarin , Dicoumarol , Phenprocoumon , Acenocoumarol Factor Xa inhibitor Enoxaparin (SC), Fundaparinux (SC), rivaroxaban(SC) Direct thrombin inhibitor dabigatran Thrombolytic drugs tPA Alteplase , Tenecteplase , Reteplase , Streptokinase , Urokinase Adapted from Cochrane Database Syst. Rev,CD 001820.
    6. 6. OVERVIEW OF CLOT FORMATION injury TF Thrombin Coagulation cascade Collagen vWF ADP Thromboxane A2 P2Y12 PAR-1 GP IIb/IIIa Fibrin  platelet aggregation Xa/Va prothrominase complex
    7. 7. OVERVIEW OF CLOT FORMATION injury TF Thrombin Coagulation cascade Collagen vWF ADP Thromboxane A2 P2Y12 PAR-1 GP Iib/IIIa Fibrin  platelet aggregation Xa/Va prothrominase complex
    8. 8. CONCEPTS ON EARLY COAGULATION CASCADE Intrinsic pathway extrinsic pathway TF/VIIa XI XIa IX  IXa XaX X XII,HMK , PK Prothrombin(II)  Thrombin Fibinogen(I)  Fibrin PL ,VIIIa Ca PL, Ca PL ,Va Ca Adapted from Thromb Haemost 85(6):958-65
    9. 9. CONCEPTS ON EARLY COAGULATION CASCADE Intrinsic pathway extrinsic pathway TF/VIIa XI XIa IX  IXa XaX X XII,HMK , PK Prothrombin(II)  Thrombin Fibinogen(I)  Fibrin VKA e.g. warfarin Inh. II , VII ,IX ,X PL ,VIIIa Ca PL, Ca PL ,Va Ca Adapted from Thromb Haemost 85(6):958-65
    10. 10. CONCEPTS ON EARLY COAGULATION CASCADE Intrinsic pathway extrinsic pathway XI XIa Xa XII,HMK , PK Fibinogen(I)  Fibrin Factor Xa inhibitor : Enoxaparin , Fundaparinux PL ,VIIIa Ca PL, Ca PL ,Va Ca TF/VIIaIX  IXa Prothrombin(II)  Thrombin Adapted from Thromb Haemost 85(6):958-65 X X
    11. 11. CONCEPTS ON EARLY COAGULATION CASCADE Intrinsic pathway extrinsic pathway XI XIa XII,HMK , PK Fibinogen(I)  Fibrin Direct thrombin inhibitor : dabigatran PL ,VIIIa Ca PL, Ca PL ,Va Ca TF/VIIaIX  IXa Prothrombin(II)  Thrombin XaX X Adapted from Thromb Haemost 85(6):958-65
    12. 12. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Initiation TF –bearing cell e.g. fibroblast TF Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    13. 13. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Initiation TF –bearing cell e.g. fibroblast TF VII VIIa Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    14. 14. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Initiation TF –bearing cell e.g. fibroblast TF VIIa TF/VII complex X Xa IX IXa Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    15. 15. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Initiation TF –bearing cell e.g. fibroblast TF VIIa TF/VII complex IXa Xa/Va complex VaXa Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    16. 16. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Amplification TF –bearing cell e.g. fibroblast TF VIIa TF/VII complex VaXa IXa Xa/Va complex prothrombin Thrombin Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    17. 17. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Amplification TF – bearing cell e.g. fibroblas t T F V I I a V a X a IXa Thrombin Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    18. 18. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Amplification TF – bearing cell e.g. fibroblas t T F V I I a V a X a Thrombin Platelet Activation VaV vWF/VIII VIIIa IXa IX PAR1,PAR4 Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8 Thromboxane A2 synthesis
    19. 19. CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL Propagation TF – bearing cell e.g. fibroblas t T F V I I a V a X a Activated Platelet Va VIIIa IXa Intrinsic tenase X Xa Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    20. 20. CONCEPS ON THE NEW, CELL-BASED COAGULATION MODEL Propagation TF – bearing cell e.g. fibroblas t T F V I I a V a X a Activated Platelet Va VIIIa IXa Intrinsic tenase Xa Va/Xa complex (Prothrombinase) Fibrinogen  Fibrin Prothrombin  Thrombin Adapted from Thromb Haemost 85(6):958-65 Arterioscler Thromb Vasc Biol 2006:26(1):41-8
    21. 21. PRE-OPERATIVE EVALUATION FOR ANTICOAGULANTS Bleeding Risk Procedure Versus Risk of thromboembolic events Whether to off anticoagulants ?
    22. 22. PATIENT VERSUS SURGICAL RISK FACTORS  Patient Risk Factors  Prior thromboembolism ?  Mechanical valve ?  AF ?  Surgical Risk Factors  Procedure type ?  Quantify Risk of bleeding ?  Quantify Risk of thromboembolism ?
    23. 23. RISK OF THROMBOEMBOLISM  Michael et al.  After discontinue OAT in 169 patients  22%  thromboembolic event  7%  died  Tulloch and Wright et al.  Case Report  Discontinue OAT for 8 days before oral surgery  Post operative day 2  CVA  Post operative day 4  branchial artery emboli Br Heart J 1970;32:359-364 Circulation 1954;9:823-834
    24. 24. RISK OF THROMBOEMBOLISM Wahl et al.  Review > 2400 cases  950 cases continued oral antithrombotic  12 cases experienced post-operative bleeding  Which controlled by local measures  Incidence of thromboembolic complication was about 1% Small but outcome serious !!! Arch Intern Med 1998;158:1610-1616
    25. 25. RISK OF HEMORRHAGE  Cambell et al.  Randomized controlled trial  Continue OAT versus withdrawn OAT  No significant difference in total blood loss  Madrid and Sanz  Systemic review  Continue OAT with INR 2-4 and discontinue OAT  No significant in post operative hemorrhage J oral Maxillofac Surg 2000;58:131-135 Clin Oral Implants Res 2009;20 Suppl 4:96-106
    26. 26. MEANING OF INR VALUE  Most anticoagulation therapy INR 2.0 - 3.0  Few INR 3.0 - 4.0  Blinder et al.  INR value did not significantly influence the incident of perioperative bleeding (INR 2.0 -4.0)  INR 2.0-4.0 post operative hemorrhage can not be so serious Int J Oral Maxillo Surg 2008;66:51-57
    27. 27. CONCLUSION ThromboembolismThromboembolism RiskRisk Bleeding Risk Local control Small but outcome serious !!! Arch Intern Med 1998;158:1610-1616
    28. 28. CHEST 2012; 141:326-350S
    29. 29. CLINICAL SCENARIO  ผู้ชาย 45 ปี  Old CVA with AF with MR S/P MVR  on warfarin 22 mg/week INR 3.0  จะถอนฟัน ทำาไงดี ?  หยุดยา warfarin ก่อนไปถอนฟัน  ไปถอนฟันเลย
    30. 30. OVERVIEW OF CLOT FORMATION injury TF Thrombin Coagulation cascade Collagen vWF ADP Thromboxane A2 P2Y12 PPAR-1 GP Iib/IIIa Fibrin  platelet aggregation Xa/Va prothrominase complex
    31. 31. ANTIPLATELET promote vWFvWF
    32. 32. ASPIRIN ARACHIDONIC ACID METABOLISM Phospholipid-Arachidonic acid Phospholipases Arachidonic acid Prostaglandin G2 Prostaglandin H2 Tissue Specific Isomerases COX1 HOX Arachidonic acid Prostaglandin G2 Prostaglandin H2 COX2 HOX Thromboxane A2 (Promote Thrombosis) Prostaglandin D2 Prostaglandin E2 Prostaglandin F2a Prostacyclin (inhibit Plt aggregation) Low dose ASA High dose ASA(Inflammatory dose) Higher dose block Adapted from: CHEST 2012; 141(2) (Suppl) : e89S-e119S Platelets & vascular endothelial cells
    33. 33. Dipyridamole. effects of dipyridamole on NO/cGMP and prostaglandin/cAMP signal transduction in human platelets. Adapted from :Aktas B et al. Stroke. 2003;34:764-769 Copyright © American Heart Association, Inc. All rights reserved. Platelet aggregationPlatelet aggregation
    34. 34. DIPYRIDAMOLE. PROMOTE PROSTACYCLIN promote
    35. 35. CILOSTAZOL PHOSPHODIESTERASE III INHIBITORS Eur Heart J (2008) 29 (18): 2202-2211. Vasodilatory stimulating phosphoprotein
    36. 36. THIENOPYRIDINES TICLOPIDINE ,CLOPIDOGREL , PRASUGREL Eur Heart J (2008) 29 (18): 2202-2211.
    37. 37. ANTIPLATELET AND ORAL SURGERY  Ardekian et al.  39 patients taking ASA 100 mg 19 continued 20 stopped Bleeding time 3.1 min versus 1.8 min (p=0.004) None of them had prolong bleeding time >10 min No patient experienced uncontrolled bleeding  Antiplatelet should not be discontinued prior to dental procedure J Am Dent Assoc 131,331-335
    38. 38. DUAL ANTIPLATELET OR SINGLE ANTIPLATELET?  Nepanas et al.  Retrospective study  43 patients who were receiving single or dual antiplatelet therapy  Twenty-nine patients (67 percent) were receiving dual antiplatelet therapy.  The authors found no differences between patients receiving single or dual antiplatelet therapy for all variables. J Am Dent Assoc. 2009 Jun;140(6):690-5
    39. 39. COMPLICATION RATES FROM DISCONTINUATION OF ANTIPLATELETE < 6 WKS AFTER PCI W/WO STENT
    40. 40. CHEST 2012; 141:326-350S
    41. 41. CLINICAL SCENARIO  ผู้หญิง 75 ปี  Previous STEMI S/P PCI Drug Eluting Stent เมื่อ 6 เดือนก่อน  ASA 81 mg/d + Clopidogrel 75 mg/d  จะไปถอนฟัน ทำำไงดี  หยุดยำ ASA + Clopidogrel ก่อนไปถอนฟัน  หยุดยำ ASA ก่อนไปถอนฟัน  หยุดยำ Clopidogrel ก่อนไปถอนฟัน  ไปถอนฟันได้เลย
    42. 42. CLINICAL SCENARIO  ผู้หญิง 75 ปี  Previous STEMI S/P PCI Drug Eluting Stent เมื่อ 6 เดือนก่อน  ASA 81 mg/d + Clopidogrel 75 mg/d  จะไปถอนฟัน ทำำไงดี  หยุดยำ ASA + Clopidogrel ก่อนไปถอนฟัน  หยุดยำ ASA ก่อนไปถอนฟัน  หยุดยำ Clopidogrel ก่อนไปถอนฟัน  ไปถอนฟันได้เลย
    43. 43. LOCAL BLEEDING CONTROL  Local anesthesia with vasoconstrictor  Local hemostatic material (bonewax ,surgicel)  Local hemostatic agent (epinephrine solution )  Suture  Pressure  Dressing  Peridontal pack application  Tranexamic acid  Mouth wash Journal of Oral Science,Vol.49,No.4,253-258,2007
    44. 44. TAKE HOME MESSAGE  Warfarin  ถ้ำ INR 2 - 4 ไม่ต้องหยุด  ถ้ำ INR > 4 ไม่ต้องผ่ำ/ทำำฟันทุกกรณี  Antiplatelets  ASA , clopidogrel ,prasugrel , ticlopidine , cilostazole , Tegagrelor etc.  ไม่ต้องหยุดทุกรณี ไม่ว่ำจะ on ด้วย indication primary prevention , secondary prevention , S/P stent ก็ตำม ทั้ง single หรือ dual antiplatelet
    45. 45. HIGH ALERT DON’T STOP OAT!!!  Warfarin  Mechanical valve , Hypercoagulable state  Antiplatelet  S/P w Stent [DES , BMS] within 1 years
    46. 46. สุดท้ำย หำก INR สองถึงสี่นั้น บ่หยุด INR เกิน 4 ให้ ผ่ำไม่ antiplatelet ไซร้ อย่ำได้ หยุดเลย บ่หยุดOATไว้ จักได้ ปลอดภัย
    47. 47. THANK YOU

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