Anticoagulation + Dental Work??

[zoolander]

Can a pt get dental procedures on coumadin?

A cardiac pt just got discharged on coumadin for A fib (target INR, 2-3, not therapeutic yet). He just called re: a teeth cleaning and was told he couldn't have his teeth cleaned there while on coumadin.

What's the general policy on teeth cleaning, or dental work in general, on anticoagulation? I thought that teeth cleaning would be less invasive than, say, an extraction, but didn't have a ton of insight on call late Friday night.

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[Dr.SpongeBobDDS]

Weird. It seems like the dentist would have requested a consult rather than just out and out turning him away. Usually a cleaning is pretty atraumatic, but depending on the severity and location of the calculus it can get a little bloody. We are taught at my school to get a consult for EVERY patient on blood-thinners/anti-coagulants even if we are sure nothing will go wrong. Usually it's just a kind of a cover-your-butt formality for the off chance that something does go wrong.

Also, I would be wary of what a patient describes to you as a cleaning. There are "cleanings" that involve little more than rubbing the tooth clean with a tiny rubber cup and then there are "cleanings" that involve surgically flapping the gingival tissue to provide access to root surfaces. Fairly significant difference there. 🙂

 

[Dr.SpongeBobDDS]

Maybe a real dentist or a more experienced student will chime in on this.

 

[DDSSlave]

Lack of a Scientific Basis for Routine Discontinuation of Oral Anticoagulation Therapy Before Dental Treatment


This is a very good article that addresses some of the issues with treating patients on anticoagulants. I am by no means knowledgeable enough to confidently answer this question, but I will echo what was said that if in fact the patient needs deep scaling and root planing, that can result in a lot of bleeding and may be what is concerning the dentist. This article certainly says these patients can be treated without discontinuing meds, but perhaps there's a balance of risk versus the necessity for the procedure. Just some thoughts from a student.

Edit: just realized you might have some difficulty accessing the full article so here's the reference: JADA The Journal of the American Dental Association, November 2003, vol. 134, no. 11,pp. 1492-1497 (6 pages)

 

[UBTom]

While I was on externship at Bellevue Hospital Center in NYC with their OMFS department, the residents tell me their official policy is NOT to discontinue coumadin anticoagulation for a patient, part of the reason being there is a 12-hour danger period of hypercoagulation after abrupt discontinuation.

While I was in clinic in dental school the oral medicine instructors also tells us not to have the patient discontinue anticoagulation therapy if their INR is less than 3... Unless the patient's physician says otherwise.

 

[DrJeff]

While I was in clinic in dental school the oral medicine instructors also tells us not to have the patient discontinue anticoagulation therapy if their INR is less than 3... Unless the patient's physician says otherwise.

Those are the numbers that I go by in my office too, and I've extracted literally over 100 teeth under those parameters without any hemostasis problems over the years.

If the INR is under 3 (and for about 98% of folks on Coumadin therapy it is) essentially any treatment that we do in our offices shouldn't present any coagulation problems.

 

[DrTacoElf]

Those are the numbers that I go by in my office too, and I've extracted literally over 100 teeth under those parameters without any hemostasis problems over the years.

If the INR is under 3 (and for about 98% of folks on Coumadin therapy it is) essentially any treatment that we do in our offices shouldn't present any coagulation problems.

Whats INR?

 

[DrJeff]

Whats INR?

It stands for Intrenational Normalization Ratio. In loose terms, its a standardization that allows a laboratory to determine how "fluid" one's blood is with respect to clotting, and then using the chemicals that the lab does, allow you to compare that to a different labs settings.

Basically, if your blood is clotting "normally" you'll have an INR that is essentially 1.0. If you clot quickly, your INR will be less than 1.0, and if your clotting is delayed, your INR will be greater than 1.0. In sometype of vascular disease managements, you'll want for a patients blood to clot slower than normal to reduce the risk of abnormal clotting and risk of things like strokes. In this case, the patient is often placed on anticoagulant therapy (Coumadin is the most common long term drug for this).

The INR was developed as a standardization "rate" that allows for differences in the types of chemicals that a lab uses to measure "liquidity" of the blood. I.E. a lab in California may use different chemicals than a lab in Massachusetts, and by utilizing the information about chemicals that the manufacturer provides, you can get an INR that is consistant throughout the country.

In most places now the INR value has replaced its predicessors, the PT (Pro Thrombin time), PTT (Partial Pro Thrombin time) and BT (Bleeding Time) as the way that we interpret basic "liquidity" issues of blood.

 

[stoic]

Anacdotally, During my shadowing time in the ER (I'm a premed), I've seen a couple of patients taking coumadin come in after dental cleanings because the oozing around all of the teeth wouldn't stop. Not talking major blood loss here, but enough that their teeth were red. Both cases brought until control with a lot of packed gauze.

 

[DrJeff]

As I love to tell all my patients, when you take a little bit of blood and mix it up in a mouth of saliva, a little blood looks like alot of blood 😉

 

[toothcaries]

my experience is limited (i have 3 patients in my practice on warfarin- 2 CHF patients and a pt with a high risk for pulm embolisms)..so i dont think i am adding anything new..


but...
my understanding is to use an INR of 4.0 as the upper limit for simple oral surgery procedures////and a max of 3.0 for procedures with potential for significant blood loss (ie full mouth extraction with alveoplasty)

if pt is anticoagualted to a high inr...consulting w/ physician about reducing anticoagulation to less than 3.0 would be a good idea..

it's poor practice at best, imo, to request a patient to decrease or stop taking the warfarin without consulting their physician.

 

[irvinekatie]

Maybe someone with experience could help me answer a few questions.

Besides the CHEST guideline, is there any other particular guideline that dentists follow in regards to when it is appropriate to stop anticoagulants for dental procedures? If someone could point me to the source, I would very much appreciate it.

I've seen some dentists who would request to stop coumadin for dental extractions, while some don't. Is stopping coumadin for dental extraction teeth-specific? Thanks!

 

[shabu2]

Maybe someone with experience could help me answer a few questions.

Besides the CHEST guideline, is there any other particular guideline that dentists follow in regards to when it is appropriate to stop anticoagulants for dental procedures? If someone could point me to the source, I would very much appreciate it.

I've seen some dentists who would request to stop coumadin for dental extractions, while some don't. Is stopping coumadin for dental extraction teeth-specific? Thanks!

I would not stop coumadin for emergency extractions of single or even two teeth. Hemostatic measures (gel foam, or avitene with a good figure 8 suture and some pressure) suffice. You could always do a coumadin/lovenox switch for major procedures, but I usually don't worry even when INR is in theraputic range (~3.5) for single tooth ext.

 

[DrJeff]

Maybe someone with experience could help me answer a few questions.

Besides the CHEST guideline, is there any other particular guideline that dentists follow in regards to when it is appropriate to stop anticoagulants for dental procedures? If someone could point me to the source, I would very much appreciate it.

I've seen some dentists who would request to stop coumadin for dental extractions, while some don't. Is stopping coumadin for dental extraction teeth-specific? Thanks!

I think that it goes without saying, that if you have ANY doubt as to how anti-coagulated the patient is, a consult with the patient's physician that's managing their anti-coagulation state is a must.

Most of the time though, when you have a patient that's on anti-coagulation therapy, you'll see that they will regularly let you know that their on anti-coagulation therapy, and atleast in my practice, probably 2/3rds of my anti-coagulation therapy patients will know what their most recent INR value is, so you'll often have a starting point as to what you might expect bleeding wise for that patient.

I will pretty guarentee you that any dentist that's doing "bloody" procedures on a somewhat regular basis(extractions, deep scalings, crown lengthing, perio surgery, etc) will atleast have 1 bleeder in their careers. So thinking through the clotting cascade and what you have at your disposal to manage the bleeder AHEAD of time is always a good thing to mentally review every now and then.

 

[aphistis]

I would not stop coumadin for emergency extractions of single or even two teeth. Hemostatic measures (gel foam, or avitene with a good figure 8 suture and some pressure) suffice. You could always do a coumadin/lovenox switch for major procedures, but I usually don't worry even when INR is in theraputic range (~3.5) for single tooth ext.

I agree. As long as INR is therapeutic, I've always been fine getting hemostasis with local measures (stuffing the socket with gelfoam or surgicel (hemostatic packing materials)), suturing securely, and giving good post-op instructions to the patient.

I've done Lovenox (heparin) bridges two or three times, all at physician request. FYI for the students, it involves the patients switch from their coumadin to home Lovenox injections twice a day, starting about a week before the surgery. On the day of surgery, the patient simply skips the injection, gets the procedure done, and then goes back to taking their coumadin normally. Since heparin has a much shorter half-life than coumadin, using Lovenox minimizes the amount of time their anticoagulation is disrupted.

Lovenox bridging works and can be helpful for bloody full-mouth cases, but it's a pain in the arse ("doc, why do I have to give myself these shots twice a day instead of just taking my pill like normal?") and Lovenox is pretty expensive. For simple procedures, it's safer and easier to just keep them on the coumadin they're already taking, taking care to minimize bleeding, and using local measures to help achieve hemostasis.

 

[Calidental]

I agree. As long as INR is therapeutic, I've always been fine getting hemostasis with local measures (stuffing the socket with gelfoam or surgicel (hemostatic packing materials)), suturing securely, and giving good post-op instructions to the patient.

I've done Lovenox (heparin) bridges two or three times, all at physician request. FYI for the students, it involves the patients switch from their coumadin to home Lovenox injections twice a day, starting about a week before the surgery. On the day of surgery, the patient simply skips the injection, gets the procedure done, and then goes back to taking their coumadin normally. Since heparin has a much shorter half-life than coumadin, using Lovenox minimizes the amount of time their anticoagulation is disrupted.

Lovenox bridging works and can be helpful for bloody full-mouth cases, but it's a pain in the arse ("doc, why do I have to give myself these shots twice a day instead of just taking my pill like normal?") and Lovenox is pretty expensive. For simple procedures, it's safer and easier to just keep them on the coumadin they're already taking, taking care to minimize bleeding, and using local measures to help achieve hemostasis.

Although it is rare what is the feeling you guys have on the provision of regular invasive treatment for a patient with elevated INR. For example, pt attends today for upper arch implants and a week later for lower arch implants. The dual arch treatment could not/would not be completed by the patient/dentist in one session, would you personally send for INR both times?

 

[aphistis]

Although it is rare what is the feeling you guys have on the provision of regular invasive treatment for a patient with elevated INR. For example, pt attends today for upper arch implants and a week later for lower arch implants. The dual arch treatment could not/would not be completed by the patient/dentist in one session, would you personally send for INR both times?

Definitely, and it's actually not all that uncommon. If you've got a sick patient needing a lot of oral surgery, staging the procedure (doing them one arch, or even one quadrant, at a time) is a common technique for managing their treatment needs.

Especially in that situation, though, you need current lab values. Treating someone with a therapeutic INR is doable, but a number of factors can negatively affect someone's coagulation status. If you try to do an arch extraction on someone whose INR is 4.5 because they misunderstood their newly-adjusted coumadin regimen for a few days before the appointment, you could find yourself in deep water fast.

To answer your question, though, I can think of two options. First, it's my understanding that chairside INR devices (similar to Accu-Check units for blood glucose) are available, but I hear they're still pretty expensive. I've never used one myself to know how well they work.

The easier option in an office setting would be to coordinate their appointments with their regularly scheduled labs. These chronically anticoagulated patients have regular INR measurements. If they have blood drawn every month and you can wait that long between appointments, just tell them to get their blood drawn first thing in the morning and bring their results with them to their appointment that afternoon. If you can't wait that long, you can just write "please draw blood and perform a PT/INR, on XYZ date" on a prescription blank and give it to the patient to take to their lab before coming for the appointment.

 

[Calidental]

Definitely, and it's actually not all that uncommon. If you've got a sick patient needing a lot of oral surgery, staging the procedure (doing them one arch, or even one quadrant, at a time) is a common technique for managing their treatment needs.

Especially in that situation, though, you need current lab values. Treating someone with a therapeutic INR is doable, but a number of factors can negatively affect someone's coagulation status. If you try to do an arch extraction on someone whose INR is 4.5 because they misunderstood their newly-adjusted coumadin regimen for a few days before the appointment, you could find yourself in deep water fast.

To answer your question, though, I can think of two options. First, it's my understanding that chairside INR devices (similar to Accu-Check units for blood glucose) are available, but I hear they're still pretty expensive. I've never used one myself to know how well they work.

The easier option in an office setting would be to coordinate their appointments with their regularly scheduled labs. These chronically anticoagulated patients have regular INR measurements. If they have blood drawn every month and you can wait that long between appointments, just tell them to get their blood drawn first thing in the morning and bring their results with them to their appointment that afternoon. If you can't wait that long, you can just write "please draw blood and perform a PT/INR, on XYZ date" on a prescription blank and give it to the patient to take to their lab before coming for the appointment.

Certainly seems the reasonable way to go. Any of you had experiences with a big time bleeder, when you thought the INR was in the desired range?

 

[irvinekatie]

Thanks so much for all your inputs. Would anyone be able to tell me if there's a written guideline that dentists follow regarding anticoagulant and dental procedures? Thanks!

 

[DrJeff]

Certainly seems the reasonable way to go. Any of you had experiences with a big time bleeder, when you thought the INR was in the desired range?

I've had 2 in my career and my partner just had 1 last week. These were patients where it was found out after that they had coagulation issues.

#1 In my residency, simple extraction of 24/25 due to advanced perio on a belived healthy 27 year old. I popped the teeth out, placed a guaze pack, and sent them on their way. Next day they come back into the clinic with literally a gallon sized zip lock bag full of bloody guaze😱 and still oozing extraction sites. Being in a hospital setting, the patient was sent to the lab for a CBC PT/PTT and INR. The INR came back at 5.0 😱 and the white count was off the charts. Voila, I helped diagnosis leukemia (ALL) in a patient.

#2 Also in my residency. I was paged by the ER at about midnight for a patient who had had implants placed in the former #13 and #14 areas earlier that day, They'd been unable to stop bleeding from around the implant sites. Tried all the tricks, still oozing. Sent off for a clotting profile from the lab, and when the lab work came back, we found out that the patient had a previously undiagnosed case of Von Willibrands.

#3 Last week, a semi-irregular patient of my partner(typically shows up every few years mainly for a toothache which historically they then choose to extract) shows up saying that their MD told them that they need to have their teeth cleaned/examined so they can be dentally cleared for surgery for replacement of a now infected, already once replaced heart valve. The patient is on coumadin therapy. The patient comes in and has a routine scaling without any significant note of bleeding. The patient also is noted to need atleast a half dozen teeth extracted to be dentally cleared for surgery, and it's a very real debate that currently on-going about having full mouth extractions given that there is a significant chance that the failed valve may be due to the patient's perio status. The next AM, the patient's MD, whose office is next door to ours, walks in with the patient about 10 minutes after we open, saying that she's been bleeding all night since her cleaning. A half hour of pressure packs, some gel-foam in deep perio pockets and some laser cautery, my partner has the bleeding under control, and later that day we find out that the patient's INR was 4.5 (usually runs 2.5-3.0) because the patient had mistakenly taken twice their normal coumadin dose for the last couple of days😡

The thing is that the longer you practice, the more likely you are to encounter a bleeder. Sometimes they'll be patient's you mighy suspect, often they'll catch you by suprise.

 

[sweetfoi]

if the patient is taking warfarin and she has to do a full mouth extraction and after consulting the physician he refused to stop it
you said that we can use warfarin if the INR is less than 3 if its more do we use the heparin injection as one of you said 2 shots a day instead, so why dont we let her stop warfarin in the first place and use heparin even if the INR is less then 3

 

[ou_jay]

if the patient is taking warfarin and she has to do a full mouth extraction and after consulting the physician he refused to stop it
you said that we can use warfarin if the INR is less than 3 if its more do we use the heparin injection as one of you said 2 shots a day instead, so why dont we let her stop warfarin in the first place and use heparin even if the INR is less then 3

Low molecular weight heparin is very, very expensive, and it has to be injected not swallowed. If the coumadin is working to prevent dangerous clots, but the INR is still in an acceptable range for hemostasis after dental treatment, then there is no reason to use the heparin.

 

[sweetfoi]

so if INR is within three i dont stop warfarin
if its higher i can switch o heparin but what i dont understand is if it has a short half life ,two hours to my knowledge why do i switch a week earlier to extraction and not the day of extraction

 

[aphistis]

so if INR is within three i dont stop warfarin
if its higher i can switch o heparin but what i dont understand is if it has a short half life ,two hours to my knowledge why do i switch a week earlier to extraction and not the day of extraction

You shouldn't be altering medication regimens to treat diseases you're unfamiliar with. Consult the patient's physician to ask for their help. The last thing you want to do is kill a patient, which can result from either excessive (hemorrhage) or insufficient (stroke, pulmonary embolism) anticoagulation.

 

[Aznfarmerboi]

I thought I might give a few insight into anticoagulation therapy.

There should be no discontinuation of Coumadin just because the patient is going to have a dental procedure. If the INR is X < 3.5- 4 depending on INR therapeutic targets, it should be fine. If the INR is above 4, I would probably reduce the next warfarin dose (that should be up to the primary care physcian's discretion).

With that said, I would not recommend switching from Coumadin to Lovenox unless the patient is high risk like having mechanical valves or recent thromboembolic event. Besides the fact that it is expensive and you should always do oral therapy if possible, the half life does not apply here. Warfarin has a long half life and at steady state, changing it to Lovenox wont affect therapy significantly versus holding a day's dose. In addition because of both drugs's significant half life(>30 hours each), it does not affect rescue therapy.

One of the main things that I am concerned about is the interaction between the antibiotics and anticoagulation since most dental procedures require antibiotics prophylaxis. This can be a major problem especially in the elderly population as the interaction can increase the INR significantly (via pharmcokinetics and dynamics). For the most part, the antibiotics is short term and most likely nothing will happen. However I do worry about about the one patient that do slip through the cracks.

Also, do you guys use tranexamic acid mouthwash or aminocaproic acid
mouthwash a lot and how does it relate to this? Do you guys keep this commonly in your practice since we rarely stock or deal with that.

 

[aphistis]

I thought I might give a few insight into anticoagulation therapy.

There should be no discontinuation of Coumadin just because the patient is going to have a dental procedure. If the INR is X < 3.5- 4 depending on INR therapeutic targets, it should be fine. If the INR is above 4, I would probably reduce the next warfarin dose (that should be up to the primary care physcian's discretion).

With that said, I would not recommend switching from Coumadin to Lovenox unless the patient is high risk like having mechanical valves or recent thromboembolic event. Besides the fact that it is expensive and you should always do oral therapy if possible, the half life does not apply here. Warfarin has a long half life and at steady state, changing it to Lovenox wont affect therapy significantly versus holding a day's dose. In addition because of both drugs's significant half life(>30 hours each), it does not affect rescue therapy.

One of the main things that I am concerned about is the interaction between the antibiotics and anticoagulation since most dental procedures require antibiotics prophylaxis. This can be a major problem especially in the elderly population as the interaction can increase the INR significantly (via pharmcokinetics and dynamics). For the most part, the antibiotics is short term and most likely nothing will happen. However I do worry about about the one patient that do slip through the cracks.

Also, do you guys use tranexamic acid mouthwash or aminocaproic acid
mouthwash a lot and how does it relate to this? Do you guys keep this commonly in your practice since we rarely stock or deal with that.

You'll be glad to hear that your information is outdated, then. 🙂 Antibiotic prophylaxis is infrequently indicated for dental treatment, according to the most recent revision of the AHA/ADA guidelines published in 2007. In brief, prophylactic antibiotics are generally no longer indicated unless the patient is status post valve replacement, has a congenital intracardiac structural defect, or has a past history of SBE.