Now What Do I Do?

You have just finished a very busy week in your dental practice and it is approaching 5:00p.m. on Thursday afternoon (or Friday afternoon?) And you are looking forward to a relaxing weekend. The phone rings and your receptionist informs you that Mrs. Smith, a long-standing patient, needs to be seen on an emergency basis complaining of severe pain and swelling

that started several months ago, but has become severe in the last 24 hours. She is then scheduled to be the last appointment of the afternoon. When Mrs. Smith arrives, a problem-focused evaluation demonstrates severe carious lesion associated with tooth number 14 with acute periapical pathology causing a vestibular space infection and abscess. The tooth is non restorable and in need of immediate extraction. Further evaluation demonstrates notable ecchymosis of both arms and dorsal surfaces of the hands. Upon further evaluation and questioning Mrs. Smith states that she was recently diagnosed with non-valvular atrial fibrillation and is now taking Eliquis. Lots of questions now need answers. Can I refer the patient to the oral surgeon today? Is the treating physician available for consultation regarding the use of the anticoagulant medication? Can the anticoagulant medication be stopped? Is it necessary to stop the medication prior to the extraction and what are the risks to the patient?

The old adage that an “ounce of prevention is worth a pound of cure” quickly comes to your mind and you’re wondering if you have that “ounce of prevention” currently in your office.

This article is not intended to be an extensive treatise on the types of medications currently used, indications, contraindications, effects, or complications of the use of anticoagulant therapies, however, there are some basic treatment protocols and supplies that need to be in every dental office that engages in minor oral surgical procedures, especially, extractions, as more and more patients are on anticoagulation therapy.

Briefly, indications for anticoagulation therapy include nonvalvular atrial fibrillation, deep vein thrombosis, recent hip or knee replacement surgery, ischemic stroke, myocardial infarction, pulmonary embolism, and unstable angina. All of these have their own challenges adding to the now complicated extraction, with possible incision and drainage.

Categories for anticoagulants are basically divided into four groups. The first group is Coumadin or Warfarin. This is a vitamin K antagonist, and it works by limiting the availability of Vitamin K to produce clotting factors 2, 7, 9, and 10. Coumadin requires a significant amount of monitoring and follow-up of the patient at least once monthly. There are also a significant number of medications and foods that can interfere with the effect of Coumadin, significantly a number of antibiotics that are commonly used in dental practice. These include Bactrim/Septra, Diflucan, Ciprofloxacin, and Biaxin. We have all seen patients on coumadin therapy. While this continues to be a common anticoagulant the newer medications that are now available are safer, have a faster onset and shorter half-life, and require less monitoring. The second category of anticoagulants are factor 10a inhibitors. These include many of the newer anticoagulants likely to be used by patients seen in the dental office including Eliquis, Savaysa, Arixtra, and Xarelto. The third category is direct thrombin inhibitors. The only one likely to be seen in the office from this category is Pradaxa as most of the medications in this category need to be given parenterally. The last group of anticoagulants fall into the Heparin category and this group is rarely if ever seen in the dental office.

Multiple Studies have supported no change in anticoagulation therapy is necessary prior to minor oral surgical procedures if the patient is in therapeutic range. The risk of altering the anticoagulation therapy far outweighs the risk of minor bleeding which generally can be managed with local measures.

What are those local measures and how can we be prepared in our office to manage this scenario?

The first step of management is consultation with the patients cardiologist or prescribing physician if at all possible. If the patient is on coumadin a recent INR value is mandatory. Current studies support minor oral surgical procedures on patients if their INR value is below 3.5. Most physicians try to maintain the INR range somewhere between 3.0 and 3.5. INR monitoring is not necessary with the newer anticoagulant medications.

What supplies do we need to have in our office for extraction of teeth for patients on anticoagulation therapy? These may include any and all of the following and all are readily available from any of the major dental suppliers.

1. Gel foam. This can be placed in the extraction site directly and may be saturated with saline and an antibiotic if desired prior to application.

2. Collagen. There are multiple forms and brand names of collagen (generally bovine in origin) available, either in the form of plugs, sponges or tape, that can be placed directly into the extraction site as well. Microfibrillar collagen (Avitene) is a superb product that enables hemostasis, but it is also quite expensive.

3. Surgicel is another commonly used resorbable product.

4. During the extraction if there are any obvious bleeding areas chemical or electrical cautery may be used but bear in mind that most of the time these patients simply generally “ooze” from the surgical sites and cautery is not the management of choice.

5. Topical thrombin. This can be reconstituted and collagen sponges, plugs, tape, gel foam or Surgicel can be saturated in the topical thrombin and applied directly into the surgical wound.

6. Mechanical pressure also plays a significant role in hemostasis for these patients. This includes placement of slowly resorbable or non-resorbable sutures over the hemostatic agent of choice approximating the wound margins or at least applying pressure to the wound margins.

7. Postoperatively Tranexamic acid mouthwash should also be prescribed. Patients need to be aware that this prescription will only be available at a hospital pharmacy or compounding pharmacy. They should also be told that they can saturate their gauze in the Tranexamic acid mouthwash and apply it over the wound with direct pressure rather than using it as a mouthwash.

8. The last thing to remember is that Mrs. Smith will have less bleeding in your office then later that night once the local anesthetic with its vasoconstrictor has dissipated and has been metabolized. Take a good hard look at the area prior to discharge because things will be worse later on!

9. If indicated, ask for the help of the hematologist or physician. I have had several patients that required additional hematological workup to control the bleeding.

Much more information is available on the ADA website and in professional journals on how to manage these patients that are on anticoagulant therapy. These are some of the items needed to have the “ounce of prevention” in your office and send your patient home well cared for and happy and hopefully you have avoided a 1:00 a.m. rendezvous with Mrs. Smith in your office!

Dr Ken Baldwin ADA Delegate

RANDON JENSEN

MARIE CHATTERLEY

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