3BDS: Anticoagulation and dentistry

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Anticoagulants/ antiplatelets are prescribed to reduce the risk of thrombosis/ potential heart attack, stroke, pulmonary embolisms in patients with:
• Vascular or thromboembolic conditions
• Cardiac conditions
• History of stroke
• Following heart valve replacement surgery. In particular metal heart valve surgery
• Cardiac stents
• Joint replacements
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what diseases can predispose individuals to the risk of a thrombosis with potential heart attack, pulmonary embolism
atherosclerosis, cardiac arrhythmias
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what is the dental aspect when it come to anticoagulants
bleeding- either spontaneous or associated with invasive procedures
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what are the most commonly used anticoagulants
- Vitamin K antagonist ie Warfarin
- Antiplatelet drugs
- Novel Oral Anticoagulants (NOAC)
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how does warfarin work
Inhibits coagulation by antagonizing Vitamin K
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how long does it take for the coagulant effect of warfarin to fully develop
48-72 hours
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what are the limitations of warfarin
narrow therapeutic range, sensitivity to diet and drug interactions and the requirement for frequent monitoring and dose adjustment
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how can the overall effect of oral anticoagulants be measured
by INR
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What is INR
PROTHROMBIN time ratio
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what is the prothrombin time within normal range- what is the INR
INR of approx 1
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what does an INR above 1 indicate
that clotting will take longer than normal
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what is the general management of warfarin
Information required prior to Examination:
• INR assessed within 72 hours of dental procedure
• INR Stable – BNF’s definition. A patient that doesn’t require weekly monitoring and has not got any INR measurements above 4 in the last 2 months
• INR should
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when must the INR be check for a stable INR patient and Unstable INR patient who require weekly monitoring or who have had INR measurements >4 in the last 2 months
stable= no more than 72 hours before appointment
unstable= INR must be checked within 24 hours of dental treatment
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what to do if the patient's INR is 4 or above
inform the patient’s GMP or anticoagulation service and delay treatment, for urgent treatment refer patient to secondary dental care.
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does LA infiltration, intraligamentary, mental or an inferior dental block cause bleeding
no
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when should be patient with warfarin be treated and what is the post operative management
at the beginning of the day, early in the week

post operative management
as normal (no rinsing, chew on the opposite side, no smoking etc)
• NHS 111
• Local A&E department for trauma, pain not relieved by painkillers or haemorrhage
• Pain relief – foll
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when should advise be sought from GMP or anticoagulant clinic
if :
 Unstable INR
 INR >4.0 in last 2 months
 Other disorders of haemostasis
 Renal failure, liver disease or alcoholism
 Patient receiving cytotoxic drugs or radiotherapy
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warfarin activity increases with:
antibacterials
antiepileptics
antifungals
hormones
cardiac drugs
analgesic
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warfarin activity decreases with:
antiepiletics
anti fungal
cardiac drugs
analgesics
oral contraceptives
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warfarin effects can also be influenced by
• Irregular tablet taking
• Diets high in vitamin K (avocado, cabbage, spinach, lettuce, liver etc)
• Alcohol ingestion
• Cranberry juice – enhance effects
• Green T is high in vitamin K
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should the dentist stop warfarin and other vitamin K antagonists and why
no.
• Increase risk of thrombosis outweighs the risk of oral bleeding!
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give some examples of antiplatelet drugs
aspirin and copidogrel
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when is aspirin and clopidogrel used
aspirin= Prophylaxis of cerebrovascular disease or MI
clopidogrel= Used in conjunction with low dose long term aspirin
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give examples of novel oralanticoagulents NOACs
Rivaroxaban – Apixaban – Dabigatran
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when are NOACs given
• Prophylaxis of venous thromboembolism in adults after hip/knee replacement surgery
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what is the general advice for all patient taking anticoagulants and anti platelet drugs
• Plan treatment for early in the day and week
• use appropriate local measures and only
• discharge the patient once haemostasis has been achieved
• if travel time to emergency care is a concern, place particular emphasis on the use of measures to avoid
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Other cards in this set

Card 2

Front

what diseases can predispose individuals to the risk of a thrombosis with potential heart attack, pulmonary embolism

Back

atherosclerosis, cardiac arrhythmias

Card 3

Front

what is the dental aspect when it come to anticoagulants

Back

Preview of the front of card 3

Card 4

Front

what are the most commonly used anticoagulants

Back

Preview of the front of card 4

Card 5

Front

how does warfarin work

Back

Preview of the front of card 5
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