Dental management of patients with cardiovascular conditions

Potential problems with anticoagulant and antiplatelet drugs in patients undergoing dentoalveolar surgery ( including extractions):

Many patients with caridiovascular disorder, including coronary heart disease, cerebrovascular disease, atrial filbrillation and venous thromboembolic disease, take antiplatelet and/ or anticoagulant drugs.

The key issue with patients taking an anticoagulant or antiplatelet drug is the balance between the increases risk of bleeding fromm a wound if the drug is not stopped before surgery. The emphasis in the past has been on minimizing bleeding; however, a thromboembolic event is potentially much more serious( eg s stroke is catastrophic event, whereas bleeding from the mouth , although messy and troublesome, can be easily managed by local measure).

Stroke is a catastrophic event, whereas bleeding from the mouth can be managed bu local measures.

It is essential to ascertain if the patient is taking any anticoagulant or antiplatelet drugs and, if so, which drugs thay are taking, the current dosage and the indication.
Also check if the patient is taking any other medications.

The most commonly used anticoagulant drug is Warfarin. Commonly used antiplatelet drugs are Aspirin, Clopidogrel and Parasugrel. Some complementary medicines, including fish oil, ginkgo biloba and glucosamine, have a weak antiplatelet effect, but this is usually not clinically significant.

Aspirin.

Antiplatelet therapy with aspirin does not usually cause significant bleeding from extraction wounds. For dental alveolar surgery ( including extractions), there is no indication to temporarily cease a patient’s prescribed regular aspirin. Warn patients that they have a slightly higher chance of bruising if aspirin is not ceased, but the risk is minor compared with the risk of embolism if aspirin is ceased.
Local measures can be undertaken to help achieve haemostasis, including infiltration of an adrenaline- containing local anaesthetic, insertion of resorbable pack, and suturing.

If aspirin is to be ceases ( eg for an extensive doft tissue procedure) , it should be stopped at least 7 days before the procedure and restarted 2 days after the procedure. Stopping aspirin for only a few days before the procedure is of no benefit.

Clopidogrel and prasugrel

Clopidogrel or prasugrel is commonly used with aspirin to prevent stent thrombosis for up to 1 year after coronary stent placement. They are also used in patients who have had ischaemic events despite treatment with aspirin or who cannot tolerate aspirin.

Premature discontinuation of dual antiplatelet therapy after placement of coronary stent markedly increase the risk of stent thrombosis, which frequently leads to myocardial infartion or death. Detailed studies indicate th risk can be up to 15% Clopidogrel or prasugrel should not be stopped prematurely without expert advice.

Do not stop clopidogrel or prasugrel without expert advice.

Advise patients who are taking clopidogrel or prasugrel and require dentoalveolar surgery ( including extractions) not to cease the medication. Use local haemostatic measures and counciel patients that they may hae extensive bruising.

Warfarin

It is important that both the patient and their medical pratictioner understand how th patient’s warfarin treatment should be managed in relation to tooth extraction. It is not uncommon for patients to reduce their warfarin dose without consultation or, alternatively, to consult with their medical practitioner who may ( unnecessarily) suggest the traditional course of ceasing anticoagulants for minor surgery.

Management of patients taking warfarin who require minor oral surgery

Before surgery ( for all patients)
• Take a detailed medical history including: warfarin dose, stability of INR, underlying medical conditions and medications, need for antibiotic prophylaxis
• Organize blood test for INR within 24 hours before surgery :
• If INR is less than 2.2 and there are no contraindications, proceed with surgery; tranexamic acid mouthwash is not required.
• If INR is 2.2 to 4.0, proceed with surgery usin the tranexamic acid mouthwash protocol below
• If INR is more than 4.0, do not proceed with sugery and refer patient to their medical practictioner.
Do not cease warfarin.

Tranexamic acid mouthwash protocol ( for patient with INR 2.2 to 4.0)

Day of surgery
• Check INR ( INR must be 2.2 to 4.0)
• Administered antibiotic prophylaxis if indicated
• Obtain a bottle of 4.8% tranexamic acid mouth wash

During surgery ( for extraction of teeth only)

• After teeth have been extracted, irrigate sockets with tranexamic acid mouthwash using a disposable syringr.
• Fill the socket with loosely packed haemostatic agent
• Place one sutere per socket.
• Ask th patient to bite on gauze pack soaked in tranexamic acid mouthwash.

After surgery

• Give the patient tranexamic acid mouthwash with instruction on use ( 10 mL rinsed in mouth for 2 mintutes, 4 times daily for 2 to 5 days)
• Arrange review dental appointment for 2 days after the procedure.

Review appointment ( 2 days after the procedure)

• Check for bleeding , pain, delayed healing or infection, and treat as necessary.

Review the patient again in 1 to 2 weeaks to check healing has occurred.

Other anticoagulant or antiplatelet drugs

Several other anticoagulant and antiplatelet drugs are available ( eg dipyridamole, dabigatran, enoxaparin, rivaroxaban) . Dabigatran and rivaroxaban are increaseingly used oral anticoagulant but , unlike warfarin, there is currently no laboratory test to guid treatment and thay do not have a specific antidote.

If a patient is takng an antiagulant or antiplatelet drug than aspirin, clopigrel , prasugrel ans qarfarin, do not cease it. Consult the patient’s medical practitioner before under taking dentalalveolar surgery ( including extractions). In all cases, use local measure to help achieve haemostasis. If there is spontaneous bleeding , urgent medical attention is requires.

( Therapeutic Guidelines)