The coagulation disordered patient in dental practice – specialties

The coagulation-disordered patient in the dentist’s office

Tooth extraction can have serious consequences for patients on anticoagulation. In order to avoid bleeding complications, it must be clarified in the planning phase of the procedure which coagulation disorder is present and how the patient is medicated. The following article provides a practical overview of medicinal anticoagulants and their consequences for dental surgery, as well as recommendations on the surgical procedure for patients with coagulation disorders.

In dental practice there are regular treatment measures that are inevitably associated with bleeding. Patients whose hemostasis is disturbed represent a challenge for the practice. Today, drug-induced anticoagulants are more common in the dentist’s patients than the genetically determined coagulation disorders. A history of coagulation with a few standard questions is of great value in identifying the patients concerned.

The following questions can be asked:

  • Do you have a tendency to bleed? (observed in injuries, operations; tendency to hematomas, extreme menstrual bleeding)
  • Have an inherited clotting disorder?
  • Take anticoagulant medication?
  • Do you have liver disease??

Many patients with coagulation disorders know about their condition; but not always about its importance for the dentist. Treatments in which bleeding is not expected, such as filling therapy, can become a danger for these patients if an anesthetic is performed on the mandibular foramen if the vessel is injured during the injection. Therefore, alternatives should be used if possible, such as intraligamentary anesthesia or infiltration anesthesia.

Genetic hemostasis disorders and liver diseases

  • " alt ="Tab. 1: Overview of coagulation disorders and liver diseases." origsrc ="https://www.zmk-aktuell.de/fachgebiete/allgemeine-zahnheilkunde/story/typo3temp/GB/93976981d0.jpg" style ="cursor: pointer;">
    Tab. 1: Overview of coagulation disorders and liver diseases.

Hemophilia patients are usually well informed about the degree of the disease. However, only in the case of abortive forms with factor VIII or IX residual activity of more than 15% should outpatient dental surgery treatment be started based solely on the patient’s statements. In general, the advice of the treating internist or hematologist should be sought in the case of coagulation disorders from the genetic or hepatic type before treatment with risk of bleeding. Only he can assess whether such treatment can be carried out safely, whether preoperative medication or substitution is required or whether inpatient therapy should be considered.

Anticoagulant medication

The patient population treated with anticoagulant medication is steadily increasing. These patients have a more or less high thromboembolic risk, which is why the anticoagulant therapy should not be interrupted if possible. Since the recommendations for dental therapy of anticoagulated patients have changed significantly in recent years, there is often uncertainty among dentists and general practitioners about the necessary procedure. For these patients, the dentist always has a therapeutic problem if measures have to be taken that are likely to cause bleeding. Depending on the type and strength of the anticoagulation, different treatment regimes must be observed. In anticoagulant therapy, we essentially differentiate four groups of active substances: antiplatelet agents, vitamin K antagonists, direct oral anticoagulants, heparin.

Antiplatelet

To inhibit platelet aggregation, acetylsalicylic acid preparations in doses of 100 to 300 mg / die (Aspirin protect®, Godamed® and others) and P2Y12 antagonists (Iscover®, Ticagrelor®) are used. They cause an irreversible inhibition of platelet aggregation, which regresses within five to seven days after the medication is stopped by newly generated platelets. Patients on monotherapy with a platelet aggregation inhibitor can be treated dentistically without stopping medication.

Dual platelet inhibition is a special case, in which patients are treated with a combination of ASA and a P2Y12 inhibitor. In this case, there is a high risk of subsequent bleeding. If the prescribing doctor considers it justifiable, the dual therapy should be converted into monotherapy. As a rule, the ASA medication is continued while the second medication is paused. The surgical procedure can then be carried out after five to seven days. The dual therapy should be resumed as soon as possible postoperatively, which is usually the case for small and medium-sized dental surgery treatments with good local wound care. d. R. will be possible the following day. Patients after stent implantation or diagnosed with acute coronary syndrome (ACS) regularly receive dual platelet inhibition for a period of six weeks to one year, which must not be interrupted during this time. In these patients, electrical interventions should be postponed until after the end of the dual therapy interval. Survivable surgical interventions under dual therapy should be assigned to a specialist practice or clinic, where a management of the high willingness to bleed is usually possible. The administration of platelet concentrates to remove the inhibition of aggregation is possible, but is rarely necessary in dental surgery and reserved for the clinic.

Vitamin K antagonists

Vitamin K antagonists (VKA) are coumarin derivatives, the best known of which is Marcumar®. These preparations are taken daily by the affected patients according to a schedule determined by the doctor. Coagulation factors IX, X, II and VII have to be carboxylated in the liver depending on vitamin K in order to be effective. Due to their structural similarity, the coumarins occupy the necessary binding site of vitamin K and thus competitively inhibit the formation of these factors. The extent of anticoagulation can be determined using the INR (international normalized ratio). The INR standard value is 1.0. The coagulation activity decreases with increasing value. The therapeutic range is usually between 2.0 and 3.0, with mechanical valve replacement also over 3.0. Almost all outpatient dental surgery can be performed in the therapeutic area (INR
Fig. 1: Development of the plasma level after taking medication.

If pausing the NOAK does not seem justifiable, small dental interventions in the valley mirror can take place, depending on the prescription pattern, i.e. 12 to 18 hours after the last intake (Fig. 1). The shorter the waiting period after the last dose, the more carefully the local hemostasis measures must be taken.

heparin

In particular, low molecular weight heparin is used for temporary thrombosis prophylaxis or for bridging in the case of perioperative changeover from VKA and DOAK. Taking into account the significantly increased risk of bleeding, dental surgical interventions can be carried out in the valley. The short half-life permits relatively good control of the anticoagulation. If the thrombosis prophylaxis is limited in time, elective interventions should be postponed until after the heparinization. If a patient is switched to heparin as part of bridging for surgical intervention, this should not lead to the assumption in the dental practice that there is no longer any particular risk of bleeding. In my experience, heparinized patients even show a higher tendency to bleed than patients with VKA with an INR
Tab. 2: Medicinal anticoagulants and their consequences for dental surgery.

  • Local anesthesia with vasoconstrictor
  • atraumatic procedure (e.g. separation of roots during extractions)
  • Application of local resorbable hemostatic agents that activate the intrinsic coagulation cascade through their surface properties: gelatin sponges (Gelastypt®), ox >Dressing sheets can easily be made in practice using a deep-drawing device and are very effective tools in avoiding them >
  • " alt ="Fig. 2: Lower bandage plate." origSrc ="typo3temp / GB / eb36e58c02.jpg" style ="cursor: pointer;">
  • " alt ="Fig. 3: Tranexamic acid (Cyclokapron®)." origSrc ="typo3temp / GB / c1ef1a375f.jpg" style ="cursor: pointer;">
  • Fig. 2: Lower bandage plate.
  • Fig. 3: Tranexamic acid (Cyclokapron®).

Tranexamic acid (Cyklokapron®) (Fig. 3), in the form of soaked bite pads or mouthwashes, supports postoperatively by inhibiting local fibrinolysis. A practical problem with the use of tranexamic acid arises from the fact that no finished product is available as a mouthwash solution. It is easy to prepare a 5% solution for immediate topical use from the available 5 milliliter Cyclokapron® ampoules (10%). It has proven useful to put the contents of the ampoule in a glass, then to fill the empty ampoule with water and to empty it again into the glass. The resulting 10 milliliters of the 5% solution can now be applied to the wound using a soaked swab or formulated as a rinsing solution and used by the patient four times a day for at least two days.

Accompanying medication of dental surgery

Some medications commonly used in the dental field can increase the risk of bleeding. In particular with analgesia, “coagulation-neutral” should be prescribed. Paracetamol, metamizol and tramadol are particularly suitable (for severe pain). Non-steroidal anti-inflammatory drugs (NSAID) such as ASA and ibuprofen and selective COX-2 inhibitors, so-called coxibes, are contraindicated. Antibiotics also interfere with anticoagulation, especially after prolonged use. They should therefore be used under strict indications and as briefly as possible. Single-shot doses, as recommended in some guidelines in dentoalveolar surgery, however, have no clinically disadvantageous effect on hemostasis.

Conclusion

The outpatient dental surgery treatment of patients with anticoagulation is only possible with sufficient surgical experience. In order to avoid bleeding complications, strict indications, thorough treatment planning with the involvement of the treating (general) doctors, an atraumatic surgical procedure with the most careful local hemostasis as well as postoperative observation in the practice up to the bleeding arrest with subsequent reliable accessibility of the treating dentist are required. Under no circumstances may the anticoagulation be discontinued or modified by the patient or the dentist. If in doubt, the transfer should be made to a specialist practice or clinic.

More about the author of the article: Dr. Uwe Matzen

Unless otherwise stated, pictures: Dr. Uwe Matzen

Related Posts

Like this post? Please share to your friends:
Christina Cherry
Leave a Reply

;-) :| :x :twisted: :smile: :shock: :sad: :roll: :razz: :oops: :o :mrgreen: :lol: :idea: :grin: :evil: :cry: :cool: :arrow: :???: :?: :!: