Coumadin, and thrombus formation

More ......

Aust Dent J. 2003 Jun;48(2):89-96; quiz 138. Related Articles, Links

Current concepts of the management of dental extractions for patients taking warfarin.

Carter G, Goss AN, Lloyd J, Tocchetti R.

Oral and Maxillofacial Surgery Unit, Royal Adelaide Hospital, Adelaide Dental Hospital and The
University of Adelaide, South Australia.

BACKGROUND: Controversy has surrounded the correct management of patients therapeutically
anticoagulated with warfarin who require dental extractions. The risk of bleeding must be weighed up
against the risk of thromboembolism when deciding whether to interfere with a patient's warfarin
regimen. An improved understanding of the importance of fibrinolytic mechanisms in the oral cavity
has resulted in the development of various local measures to enable these patients to be treated on
an outpatient basis. METHODS: A review of the literature was undertaken. This was supplemented by
the authors' clinical trials and extensive clinical experience with anticoagulated patients.
RESULTS: Various protocols for treating patients taking warfarin have been reviewed and summarized
and an overview of the haemostatic and fibrinolytic systems is presented. A protocol for management
of warfarinized patients requiring dental extractions in the outpatient setting is proposed.
CONCLUSIONS: Patients therapeutically anticoagulated with warfarin can be treated on an ambulatory
basis, without interruption of their warfarin regimen provided appropriate local measures are used.

Publication Types: Review Review, Tutorial

PMID: 14649397 [PubMed - indexed for MEDLINE]

**********

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course we
are aware that most dental extractions and most dental procedures do not require interruption of
anti-coagulation therapy.

1. Do you agree?

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for dental
extraction(s), will develop a thrombus?

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

4. During what time frame would the sequelae (thrombus) develop?

Joel M. Eichen D.D.S.

--
Joel M. Eichen, . Philadelphia PA

DISCLAIMER FOLLOWS:

*********

Dental health-related material is provided for information purposes only and does not necessarily
represent endorsement by or an official position of the SciMedDentistry gang or any other official
agency either actual or fictitious or Steve Mancuso.

Advice on the treatment or care of an individual patient should be obtained through consultation
with a dentist who has examined that patient or is familiar with that patient's dental history.

STANDARD DISCLAIMER

Harefuah. 2003 Sep;142(8-9):621-3, 645, 644. Related Articles, Links

[Self testing and self management of oral anticoagulants with warfarin]

[Article in Hebrew]

Nadav L, Schwartz J.

Hematology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Oral anticoagulation therapy has been shown to be effective for the prevention and treatment of
thromboembolic events in various clinical settings. Since the biological effects of coumarin
derivatives are extremely variable, both inter-individually and intra-individually, under-dosage as
well as over-dosage are frequently observed, and can only be prevented by frequent laboratory
testing of anticoagulation intensity, and consecutive dose adjustment if necessary. Several studies
have shown that self-testing and self-management of oral anticoagulation therapy might improve the
quality of anticoagulation, and reduce the incidences of bleeding complications and thromboembolic
events. Recently, portable INR-monitors are available, which allow more convenient and thus more
frequent control of oral anticoagulation. This review presents several aspects and current studies
on the results of patient self-testing and self-management of oral anticoagulation therapy.

Publication Types: Review Review, Tutorial

PMID: 14518167 [PubMed - indexed for MEDLINE]

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course we
are aware that most dental extractions and most dental procedures do not require interruption of
anti-coagulation therapy.

1. Do you agree?

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for dental
extraction(s), will develop a thrombus?

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

4. During what time frame would the sequelae (thrombus) develop?

Joel M. Eichen D.D.S.

--
Joel M. Eichen, . Philadelphia PA

DISCLAIMER FOLLOWS:

*********

Dental health-related material is provided for information purposes only and does not necessarily
represent endorsement by or an official position of the SciMedDentistry gang or any other official
agency either actual or fictitious or Steve Mancuso.

Advice on the treatment or care of an individual patient should be obtained through consultation
with a dentist who has examined that patient or is familiar with that patient's dental history.

STANDARD DISCLAIMER

1: N Y State Dent J. 2002 Nov;68(9):24-6. Related Articles, Links

Comment in: N Y State Dent J. 2003 Jan;69(1):7.

Stop the nonsense not the anticoagulants: a matter of life and death.

Alexander R, Ferretti AC, Sorensen JR.

Many dental patients have medical problems that require the administration of oral anticoagulants to
prevent catastrophic or life-threatening thromboembolic events. Examples include patients with
medical conditions such as atrial fibrillation, mechanical heart valves, recent pulmonary embolism,
stroke, deep vein thrombosis, anticardiolipin syndrome and coronary artery disease. The oral
anticoagulant used most commonly in these instances is Coumadin. Stopping the administration of
Coumadin to perform routine dental procedures can be life threatening. Many physicians and dentists
believe these patients may not have routine dental procedures, including cleanings and uncomplicated
extractions, while on Coumadin for fear of serious postoperative bleeding. No scientific evidence
exists to support removing these patients from Coumadin to perform routine dental procedures and
uncomplicated extractions, provided the patient's level of anticoagulation is within therapeutic
range. Science clearly indicates that in the case of routine dental work, including uncomplicated
extractions, the risk of a patient on Coumadin having a life-threatening thromboembolic event if the
anticoagulant therapy is stopped is three- to five-times greater than the risk of the patient having
postoperative bleeding that cannot be controlled with local measures.

PMID: 12442730 [PubMed - indexed for MEDLINE]

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course we
are aware that most dental extractions and most dental procedures do not require interruption of
anti-coagulation therapy.

1. Do you agree?

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for dental
extraction(s), will develop a thrombus?

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

4. During what time frame would the sequelae (thrombus) develop?

Joel M. Eichen D.D.S.

--
Joel M. Eichen, . Philadelphia PA

DISCLAIMER FOLLOWS:

*********

Dental health-related material is provided for information purposes only and does not necessarily
represent endorsement by or an official position of the SciMedDentistry gang or any other official
agency either actual or fictitious or Steve Mancuso.

Advice on the treatment or care of an individual patient should be obtained through consultation
with a dentist who has examined that patient or is familiar with that patient's dental history.

STANDARD DISCLAIMER

1: Clin Appl Thromb Hemost. 2000 Apr;6(2):90-3. Related Articles, Links

Simple and safe method to prepare patients with prosthetic heart valves for surgical dental
procedures.

Russo G, Corso LD, Biasiolo A, Berengo M, Pengo V.

Department of Clinical and Experimental Medicine, Thrombosis Center, University of Padova School of
Medicine, Italy.

Temporary discontinuation of high-intensity oral anticoagulant treatment is not recommended in
patients undergoing dental surgery. This policy is not based on solid data from randomized clinical
trials but on expert consensus. The alternative, i.e., to continue treatment and treat patients with
tranexamic acid mouthwash, often is not applicable. A prospective cohort study was carried out to
evaluate bleeding and thromboembolic complications in patients bearing prosthetic heart valves and
registering International Normalized Ratio (INR) values between 2.0 and 4.5, who underwent dental
procedures after a 2-day suspension of warfarin treatment. One hundred four consecutive patients
receiving high-intensity anticoagulation underwent 123 dental procedures after 2 days' warfarin
withdrawal. No major bleeding complications occurred in the week after the procedure; minor bleeding
requiring local measures occurred in two patients. No thromboembolic events and no cases of
bacterial endocarditis were recorded in the 3 months after the procedure. A mean decrease in INR by
approximately 1.0 U (from 2.95+/-0,59 to 1.87+/-0,46) occurred after 2 days' warfarin suspension.
Seven days after reinitiation of warfarin, INR values returned to the therapeutic range in 90% of
cases. The calculated average time spent at INR less than 2.0 (critical value) was 28 hours. Two
days' warfarin suspension is a simple and safe policy for patients with prosthetic heart valves
undergoing dental surgery.

PMID: 10775029 [PubMed - indexed for MEDLINE]

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course we
are aware that most dental extractions and most dental procedures do not require interruption of
anti-coagulation therapy.

1. Do you agree?

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for dental
extraction(s), will develop a thrombus?

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

4. During what time frame would the sequelae (thrombus) develop?

Joel M. Eichen D.D.S.

--
Joel M. Eichen, . Philadelphia PA

DISCLAIMER FOLLOWS:

*********

Dental health-related material is provided for information purposes only and does not necessarily
represent endorsement by or an official position of the SciMedDentistry gang or any other official
agency either actual or fictitious or Steve Mancuso.

Advice on the treatment or care of an individual patient should be obtained through consultation
with a dentist who has examined that patient or is familiar with that patient's dental history.

STANDARD DISCLAIMER

This puppy is almost six years old!

Joel

***

1: Arch Intern Med. 1998 Aug 10-24;158(15):1610-6. Related Articles, Links

Comment in: Arch Intern Med. 2003 May 26;163(10):1242.

Dental surgery in anticoagulated patients.

Wahl MJ.

Department of Dentistry, Christiana Care Health Services, Wilmington, Del, USA.

Continuous oral anticoagulant therapy has been used to decrease the risk of thromboembolism for more
than half a century, prolonging the lives of thousands of patients. Many physicians recommend
interrupting continuous anticoagulant therapy for dental surgery to prevent hemorrhage. In reviewing
the available literature, there are no well-documented cases of serious bleeding problems from
dental surgery in patients receiving therapeutic levels of continuous warfarin sodium therapy, but
there were several documented cases of serious embolic complications in patients whose warfarin
therapy was withdrawn for dental treatment. Many authorities state that dental extractions can be
performed with minimal risk in patients who are at or above therapeutic levels of anticoagulation.
There are sound legal reasons to continue therapeutic levels of warfarin for dental treatment.
Although there is a theoretical risk of hemorrhage after dental surgery in patients who are at
therapeutic levels of anticoagulation, the risk appears to be minimal, the bleeding usually can be
easily treated with local measures, and this risk may be greatly outweighed by the risk of
thromboembolism after withdrawal of anticoagulant therapy.

Publication Types: Review Review, Tutorial

PMID: 9701094 [PubMed - indexed for MEDLINE]

***

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course we
are aware that most dental extractions and most dental procedures do not require interruption of
anti-coagulation therapy.

1. Do you agree?

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for dental
extraction(s), will develop a thrombus?

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

4. During what time frame would the sequelae (thrombus) develop?

Joel M. Eichen D.D.S.

--
Joel M. Eichen, . Philadelphia PA

DISCLAIMER FOLLOWS:

*********

Dental health-related material is provided for information purposes only and does not necessarily
represent endorsement by or an official position of the SciMedDentistry gang or any other official
agency either actual or fictitious or Steve Mancuso.

Advice on the treatment or care of an individual patient should be obtained through consultation
with a dentist who has examined that patient or is familiar with that patient's dental history.

STANDARD DISCLAIMER

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course we
are aware that most dental extractions and most dental procedures do not require interruption of
anti-coagulation therapy.

1. Do you agree?

Depends on blood loss risks.

Quoted message said:

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for
dental extraction(s), will develop a thrombus?

Depends on the anticoagulation and the underlying comorbid condition.

Quoted message said:

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

Ditto.

Quoted message said:

4. During what time frame would the sequelae (thrombus) develop?

Ditto.

Quoted message said:

Joel M. Eichen D.D.S.

Sorry I can't be of more help. Perhaps if you describe a specific scenario, I can help you
understand better the cardiovascular issues behind anticoagulation.

Humbly,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
heartmdphd.comheartmdphd.comOpen ↗

Thanks for your reply. I understand your answer. We answer questions at sci.med.dentistry and
without specifics its extremly difficult to offer up the right information.

Sincerely,

Joel M. Eichen D.D.S.

***

You replied:

MD/PhD said:

Joel M. Eichen D.D.S. said:

Here is a hypothetical question currently being discussed in our dental study groups. Of course
we are aware that most dental extractions and most dental procedures do not require interruption
of anti-coagulation therapy.

1. Do you agree?

Depends on blood loss risks.

Quoted message said:

2. What is the likelhood that a patient, who is interrupted from anticoagulation therapy for
dental extraction(s), will develop a thrombus?

Depends on the anticoagulation and the underlying comorbid condition.

Quoted message said:

3. What would be the sequelae of the thrombus formation and how would that be determined and
treated?

Ditto.

Quoted message said:

4. During what time frame would the sequelae (thrombus) develop?

Ditto.

Quoted message said:

Joel M. Eichen D.D.S.

Sorry I can't be of more help. Perhaps if you describe a specific scenario, I can help you
understand better the cardiovascular issues behind anticoagulation.

Humbly,

Andrew

--
Joel M. Eichen, . Philadelphia PA

DISCLAIMER FOLLOWS:

*********

Dental health-related material is provided for information purposes only and does not necessarily
represent endorsement by or an official position of the SciMedDentistry gang or any other official
agency either actual or fictitious or Steve Mancuso.

Advice on the treatment or care of an individual patient should be obtained through consultation
with a dentist who has examined that patient or is familiar with that patient's dental history.

STANDARD DISCLAIMER

Joel M. Eichen D.D.S. said:

Thanks for your reply. I understand your answer. We answer questions at sci.med.dentistry and
without specifics its extremly difficult to offer up the right information.

Sincerely,

Joel M. Eichen D.D.S.

You are welcome :-)

Humbly,

Andrew
--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
heartmdphd.comheartmdphd.comOpen ↗