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Anticoagulant therapy and dental practice
A nticoagulant therapy and dental practice
Bruno W. Kwapis* D.D.S., M .S., Belleville, III. The number of dental patients receiving anticoagulant therapy is increasing. O f 60 such patients treated by the author, prolonged bleeding occurred in only three, for whom the only preparation was decreasing the daily dose of antico agulant. This prolonged bleeding was corrected by oral administration of vi tamin Kj. The optimal preparation for patients on long-term anticoagulant treat ment for dental surgery consists of reduc ing the prothrombin time to the lower level of the anticoagulant state while remaining within the therapeutic range. At no time should the dentist assume responsibility for discontinuing antico agulant treatment. Cooperation between the patient’s physician and the dentist is necessary. The introduction of continuous antico agulant therapy for the treatment of thrombo-embolic vascular disorders, such as coronary artery disease, certain types of strokes and venous thrombosis, was a significant achievement in medical prac tice. With this therapeutic principle well established, the number of patients receiv ing such care is constantly increasing. Many of them conduct relatively normal daily activities including seeking dental
attention. Therefore, it is important for members of the dental profession to be familiar with anticoagulant therapy as it applies to these patients. The drugs most commonly used in this country to produce an anticoagulant ef fect are heparin, bishydroxycoumarin (Dicumarol), warfarin sodium (Cou madin Sodium) and phenindione deriva tives. Heparin and a cofactor are used to initiate anticoagulant therapy because they immediately inactivate thrombin. The other anticoagulant drugs act as prothrombin depressants and are used for a long-term effect. When the prothrom bin is diminished, the blood takes longer to clot. The impaired clotting activity is favorable to the prevention of intravascular clots. Anticoagulant therapy is not without danger and must be controlled by the pre scribing physician. He should make peri odic examinations of the patient’s blood to determine the prothrombin time by the Quick test. Normal prothrombin time is between 12 and 17 seconds. During treatment it is desirable to maintain a therapeutic range between one and a half and two times the control time.1 This is accomplished by regulating the dosage of the drug and performing prothrombin time determinations at regular intervals. Although anticoagulant therapy is rela tively safe under these conditions, hemor
K W A P IS . . . V O L U M E 66, FEBRUARY 1963 • 35/173
rhagic episodes can occur. The author The bearer. and others2 have observed patients who Address___ have hemorrhaged spontaneously from Phone_______________ is being treated with the gingiva, indicating an overdose of the anticoagulants which slow down clotting of the blood. anticoagulant drug. of or Most physicians administering these call doctor. drugs issue a card to the patient identify for name and phone number of physician and other vital information. ing him as a potential bleeder (see illus tration). This is of value in case of acci dents or emergency surgery and should be recognized as such by dentists. The bearer is being treated with anticoagulants and Normal dental practice can contribute is taking.____________________________________ to a breakdown of vascular integrity and In case of or subsequent bleeding. Hemorrhage can be call his doctor: Phone:--------------------------induced by trauma and manipulative and N am e:________________________________ surgical procedures during therapeutic Address: hypoprothrombinemia. Tissue injury can This card should be shown to any physician be caused by many dental procedures. or dentist treating this patient. The most obvious are dental extraction 3-58-25M rev. 6 & 8-58-250M 9-60-iOOM__________ and associated oral surgery. Less apparent but equally important are periodontal Identification card issued to patients receiving treatments requiring subgingival scaling, long-term anticoagulant therapy adaptations of bands for silver alloy res torations, deep gingival cavity prepara tions and deep tissue injections of local formed on patients receiving anticoagu anesthetic solutions. lants and no serious hemorrhagic episode occurred. This was gratifying in view of reports4-6 implying that cessation of anti PLAN OF TREA TM EN T coagulant therapy led to recurrent throm The dentist who accepts a patient receiv bosis or embolism. Subsequently, Ziffer7 ing long-term anticoagulant therapy must and Scopp8 reported severe bleeding in consult the patient’s physician before pro patients on prolonged anticoagulant treat viding care that might induce trauma to ment for whom dental extractions had oral tissues. Then a plan of treatment can been performed. Behrman and Wright9 be formulated, based on the physician’s presented their observations of dental pa recommendations and directions. The tients successfully operated on who were treatment plan depends on the physician’s receiving long-term anticoagulant ther experience with anticoagulant therapy, apy. In a recent study Sise10 reported the patient’s prothrombin blood level, the that anticoagulant treatment could be type and dosage of the anticoagulant interrupted for a short time without too drug, the degree of contemplated surgery much risk. and the patient’s general physiological The optimal preoperative preparation condition. of these patients for dental surgery con At the inception of the long-term anti sists of reducing the prothrombin time to coagulant technic in therapy, it was be the lower level of the anticoagulant state lieved that anticoagulant drugs should while remaining within therapeutic range. be withheld prior to dental surgery to This can be accomplished by reducing permit the blood prothrombin to reach a the daily dose of the anticoagulant drug normal level. Askey3 reported instances before dental surgery.11 The same objec in which dental extractions were per- tive can be reached by withdrawing the In case
bleeding, injury,
illness____
a
See ofher side patient's
< A
HEART
ASSOCIATION
SERVI CE
bleeding, injury,
illness
m*
&
OVER I
36/174 • T H E J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
anticoagulant drug a day before surgery and resuming it after the wound has clotted. This method takes advantage of the prolonged action of coumarin drugs. The timing must be adjusted when the shorter acting anticoagulants, such as heparin and phenindione, are used. A third approach is retaining the pa tient on the established daily dosage of the anticoagulant drug and diminishing its effect to the desirable preoperative level by oral administration of vitamin K i for a long enough time to permit the wound to clot. This procedure is valuable for patients who have a high prothrombin time on minimal anticoagulant dosage. All decisions regarding treatment should be based on accurate prothrombin time determinations. The dentist should never assume responsibility for discontinuing the anticoagulant dosage of the patient. Hypoprothrombinemia induced by pro thrombin depressant anticoagulant drugs can be controlled by natural vitamin K, by phytonadione (Mephyton) referred to as vitamin Ki, or by its synthetic ana logues. Vitamin K i has a more prompt action (6 to 10 hours) and a more potent and prolonged effect than its analogues. It is available in 5 mg. tablets for oral use and in emulsion form for intravenous ad ministration. When vitamin K i is used to restore the blood prothrombin to the nor mal level, the patient is re-exposed to the hazards of intravascular clotting that ex isted before anticoagulant therapy. The author provided dental and oral surgery for 60 patients on long-term anti coagulant treatment for thrombo-embolic disorders, the most common of which was coronary artery disease. Fifty-two were ambulatory patients; only eight were hos pitalized. Various methods of preparing these patients for surgery were employed. The anticoagulant therapy was under the supervision of many physicians including a cardiologist, internists, medical resi dents and general practitioners. Within the last year the number of patients re ceiving anticoagulant medication from
general practitioners increased signifi cantly. The oral surgical procedures per formed for these patients were: single and multiple tooth extractions, full mouth extractions with associated alveolectomy in quadrant steps, full mouth extraction of 26 teeth with complete alveolectomy, removal of impacted teeth, excision of hyperplastic tissue, an apicoectomy and an oral biopsy. CO N CLU SIO N S
Operative and postoperative hemorrhage did not present serious problems in pa tients receiving long-term anticoagulant therapy. Prolonged bleeding occurred in three patients for whom the only prepa ration was decreasing the daily antico agulant dose. This was corrected by oral administration of vitamin Kj. There was not always a correlation be tween the degree of hemorrhage and the patient’s prothrombin time. The patient who had a full mouth extraction and an alveolectomy of both jaws exhibited rapid clotting and almost no postoperative bleeding despite a prothrombin time twice that of the control. In contrast, two patients who had single tooth extractions had prolonged bleeding despite prothrom bin times less than one and a half the control. Hospitalization was not a requirement. The decision of whether to hospitalize the patient should depend on: the atti tude of the prescribing physician, the understanding between prescribing phy sician and operating dentist, the patient’s attitude toward a possible postoperative hemorrhagic episode, the skill and ex perience of the dentist, the nature of the anesthesia, the amount and type of sur gery and the physiological condition of the patient. Cooperation between the patient’s phy sician and the operating dentist is impor tant. In addition, the dentist should know the principles of surgery and hemostasis as they apply to oral surgery for patients
KW AP1S . . . V O L U M E 66, FEBRU ARY 1963 • 37/175
who are on anticoagulant therapy. They are: 1. A local anesthetic solution with a vasoconstrictor added should be used. The latter reduces bleeding and permits early clot formation. 2. Lacerating and abrading tissue which exposes greater surface area to bleeding should be avoided. 3. The vascular and friable inflamma tory granulation tissue, as seen in ad vanced periodontal disease, should be excised to reduce the exposed vascular surface area. 4. A Surgicel dental cone is recom mended for each tooth socket. 5. Operative wounds should be closed with no. 000 silk, employing a fine, atrau matic and, possibly, noncutting-edge needle. Suturing of extraction wounds, even in instances of single tooth extrac tions, is recommended. 6. Postoperative analgesia and narcosis are beneficial because they permit appli cation of maximum pressure by intermax illary gauze packs to intraoral wounds with minimal discomfort. 7. Application of external ice packs is of value. 8. Mouthwash hygiene should be de ferred until adequate hemostasis is estab lished. 9. Postural postoperative convalescence is important. The head should be ele vated. 10. A soft or liquid diet for early post operative nutrition is advisable. SUM M ARY
Anticoagulant therapy is a well estab lished method for managing thrombo embolic vascular disorders. The number of patients receiving this care is increas ing. Many of them are ambulatory and may seek dental attention. Anticoagulant drugs inhibit blood clot
ting in varying degrees. Since a number of dental procedures induce hemorrhage, this group of patients should receive pre operative preparation by their physician. Vitamin K i is an antidote to prothrombin depressants and controls excessive hemor rhage. The optimal preparation for pa tients on long-term anticoagulant treat ment for dental surgery consists of re ducing the prothrombin time to the lower level of the anticoagulant state while re maining within the therapeutic range. This objective can be reached by several methods. An accurate preoperative pro thrombin time is an essential guide. With proper control of the patient’s hemostasis potential, dental and oral surgery can be performed safely. Cooperation between the patient’s phy sician and the operating dentist is neces sary. At no time should the dentist assume responsibility for discontinuing anticoagu lant treatment. He should be familiar with the principles of surgery and hemo stasis applicable to patients with hemor rhagic tendencies. 10200 West Main Street
*Associate professor, department of oral surgery, St. Louis University School of Dentistry, St. Louîs, Mo. 1. W right, I. S. Use of anticoagulants in coronary heart disease. Circulation 22:609 Oct. I960. 2. Snîtzer, J. M . Personal communication. 3. Askey, J. M.,- and Cherry, C. B. Dental extraction during Dicumarol therapy. California Med. 84:16 Jan. 1956. 4. Facquet, J.; Husson, A., and Ducrot, J. Retrecissements mitraux emboligenes et medication anticoagulante continue. Presse med. 60:116 Jan. 26, 19S2. 5. Cosgriff, S. W . Chronic anticoagulant therapy in recurrent embolism of cardiac origin. Ann. Int. Med. 38:278 Feb. 1953. 6. I u I loch, J., and W right, I. S. Long-term anticoagu lant therapy; further experiences. Circulation 9:823 June 1954. 7. Ziffer, A . M., and others. Profound bleeding after dental extractions during Dicumarol therapy. New Eng land J. M ed. 256:351 Feb. 1957. 8. Scopp, !. W., and Fredrics, Harry. Dental extrac tions in patients undergoing anticoagulant therapy. O ral Surg., Oral M ed. & Oral Path. 11:470 M a y 1958. 9. Behrman, S. J., and Wright, I. S. Dental surgery during continuous anticoagulant therapy. J.A.D.A. 62:172 Feb. 1961. 10. Sise, H. S., and others. The risk of interrupting long-term anticoagulant treatment. Circulation 24:1137 N ov. 1961. 11. Chamberlain, F. L. Personal communication.
Bruno W. Kwapis* D.D.S., M .S., Belleville, III. The number of dental patients receiving anticoagulant therapy is increasing. O f 60 such patients treated by the author, prolonged bleeding occurred in only three, for whom the only preparation was decreasing the daily dose of antico agulant. This prolonged bleeding was corrected by oral administration of vi tamin Kj. The optimal preparation for patients on long-term anticoagulant treat ment for dental surgery consists of reduc ing the prothrombin time to the lower level of the anticoagulant state while remaining within the therapeutic range. At no time should the dentist assume responsibility for discontinuing antico agulant treatment. Cooperation between the patient’s physician and the dentist is necessary. The introduction of continuous antico agulant therapy for the treatment of thrombo-embolic vascular disorders, such as coronary artery disease, certain types of strokes and venous thrombosis, was a significant achievement in medical prac tice. With this therapeutic principle well established, the number of patients receiv ing such care is constantly increasing. Many of them conduct relatively normal daily activities including seeking dental
attention. Therefore, it is important for members of the dental profession to be familiar with anticoagulant therapy as it applies to these patients. The drugs most commonly used in this country to produce an anticoagulant ef fect are heparin, bishydroxycoumarin (Dicumarol), warfarin sodium (Cou madin Sodium) and phenindione deriva tives. Heparin and a cofactor are used to initiate anticoagulant therapy because they immediately inactivate thrombin. The other anticoagulant drugs act as prothrombin depressants and are used for a long-term effect. When the prothrom bin is diminished, the blood takes longer to clot. The impaired clotting activity is favorable to the prevention of intravascular clots. Anticoagulant therapy is not without danger and must be controlled by the pre scribing physician. He should make peri odic examinations of the patient’s blood to determine the prothrombin time by the Quick test. Normal prothrombin time is between 12 and 17 seconds. During treatment it is desirable to maintain a therapeutic range between one and a half and two times the control time.1 This is accomplished by regulating the dosage of the drug and performing prothrombin time determinations at regular intervals. Although anticoagulant therapy is rela tively safe under these conditions, hemor
K W A P IS . . . V O L U M E 66, FEBRUARY 1963 • 35/173
rhagic episodes can occur. The author The bearer. and others2 have observed patients who Address___ have hemorrhaged spontaneously from Phone_______________ is being treated with the gingiva, indicating an overdose of the anticoagulants which slow down clotting of the blood. anticoagulant drug. of or Most physicians administering these call doctor. drugs issue a card to the patient identify for name and phone number of physician and other vital information. ing him as a potential bleeder (see illus tration). This is of value in case of acci dents or emergency surgery and should be recognized as such by dentists. The bearer is being treated with anticoagulants and Normal dental practice can contribute is taking.____________________________________ to a breakdown of vascular integrity and In case of or subsequent bleeding. Hemorrhage can be call his doctor: Phone:--------------------------induced by trauma and manipulative and N am e:________________________________ surgical procedures during therapeutic Address: hypoprothrombinemia. Tissue injury can This card should be shown to any physician be caused by many dental procedures. or dentist treating this patient. The most obvious are dental extraction 3-58-25M rev. 6 & 8-58-250M 9-60-iOOM__________ and associated oral surgery. Less apparent but equally important are periodontal Identification card issued to patients receiving treatments requiring subgingival scaling, long-term anticoagulant therapy adaptations of bands for silver alloy res torations, deep gingival cavity prepara tions and deep tissue injections of local formed on patients receiving anticoagu anesthetic solutions. lants and no serious hemorrhagic episode occurred. This was gratifying in view of reports4-6 implying that cessation of anti PLAN OF TREA TM EN T coagulant therapy led to recurrent throm The dentist who accepts a patient receiv bosis or embolism. Subsequently, Ziffer7 ing long-term anticoagulant therapy must and Scopp8 reported severe bleeding in consult the patient’s physician before pro patients on prolonged anticoagulant treat viding care that might induce trauma to ment for whom dental extractions had oral tissues. Then a plan of treatment can been performed. Behrman and Wright9 be formulated, based on the physician’s presented their observations of dental pa recommendations and directions. The tients successfully operated on who were treatment plan depends on the physician’s receiving long-term anticoagulant ther experience with anticoagulant therapy, apy. In a recent study Sise10 reported the patient’s prothrombin blood level, the that anticoagulant treatment could be type and dosage of the anticoagulant interrupted for a short time without too drug, the degree of contemplated surgery much risk. and the patient’s general physiological The optimal preoperative preparation condition. of these patients for dental surgery con At the inception of the long-term anti sists of reducing the prothrombin time to coagulant technic in therapy, it was be the lower level of the anticoagulant state lieved that anticoagulant drugs should while remaining within therapeutic range. be withheld prior to dental surgery to This can be accomplished by reducing permit the blood prothrombin to reach a the daily dose of the anticoagulant drug normal level. Askey3 reported instances before dental surgery.11 The same objec in which dental extractions were per- tive can be reached by withdrawing the In case
bleeding, injury,
illness____
a
See ofher side patient's
< A
HEART
ASSOCIATION
SERVI CE
bleeding, injury,
illness
m*
&
OVER I
36/174 • T H E J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
anticoagulant drug a day before surgery and resuming it after the wound has clotted. This method takes advantage of the prolonged action of coumarin drugs. The timing must be adjusted when the shorter acting anticoagulants, such as heparin and phenindione, are used. A third approach is retaining the pa tient on the established daily dosage of the anticoagulant drug and diminishing its effect to the desirable preoperative level by oral administration of vitamin K i for a long enough time to permit the wound to clot. This procedure is valuable for patients who have a high prothrombin time on minimal anticoagulant dosage. All decisions regarding treatment should be based on accurate prothrombin time determinations. The dentist should never assume responsibility for discontinuing the anticoagulant dosage of the patient. Hypoprothrombinemia induced by pro thrombin depressant anticoagulant drugs can be controlled by natural vitamin K, by phytonadione (Mephyton) referred to as vitamin Ki, or by its synthetic ana logues. Vitamin K i has a more prompt action (6 to 10 hours) and a more potent and prolonged effect than its analogues. It is available in 5 mg. tablets for oral use and in emulsion form for intravenous ad ministration. When vitamin K i is used to restore the blood prothrombin to the nor mal level, the patient is re-exposed to the hazards of intravascular clotting that ex isted before anticoagulant therapy. The author provided dental and oral surgery for 60 patients on long-term anti coagulant treatment for thrombo-embolic disorders, the most common of which was coronary artery disease. Fifty-two were ambulatory patients; only eight were hos pitalized. Various methods of preparing these patients for surgery were employed. The anticoagulant therapy was under the supervision of many physicians including a cardiologist, internists, medical resi dents and general practitioners. Within the last year the number of patients re ceiving anticoagulant medication from
general practitioners increased signifi cantly. The oral surgical procedures per formed for these patients were: single and multiple tooth extractions, full mouth extractions with associated alveolectomy in quadrant steps, full mouth extraction of 26 teeth with complete alveolectomy, removal of impacted teeth, excision of hyperplastic tissue, an apicoectomy and an oral biopsy. CO N CLU SIO N S
Operative and postoperative hemorrhage did not present serious problems in pa tients receiving long-term anticoagulant therapy. Prolonged bleeding occurred in three patients for whom the only prepa ration was decreasing the daily antico agulant dose. This was corrected by oral administration of vitamin Kj. There was not always a correlation be tween the degree of hemorrhage and the patient’s prothrombin time. The patient who had a full mouth extraction and an alveolectomy of both jaws exhibited rapid clotting and almost no postoperative bleeding despite a prothrombin time twice that of the control. In contrast, two patients who had single tooth extractions had prolonged bleeding despite prothrom bin times less than one and a half the control. Hospitalization was not a requirement. The decision of whether to hospitalize the patient should depend on: the atti tude of the prescribing physician, the understanding between prescribing phy sician and operating dentist, the patient’s attitude toward a possible postoperative hemorrhagic episode, the skill and ex perience of the dentist, the nature of the anesthesia, the amount and type of sur gery and the physiological condition of the patient. Cooperation between the patient’s phy sician and the operating dentist is impor tant. In addition, the dentist should know the principles of surgery and hemostasis as they apply to oral surgery for patients
KW AP1S . . . V O L U M E 66, FEBRU ARY 1963 • 37/175
who are on anticoagulant therapy. They are: 1. A local anesthetic solution with a vasoconstrictor added should be used. The latter reduces bleeding and permits early clot formation. 2. Lacerating and abrading tissue which exposes greater surface area to bleeding should be avoided. 3. The vascular and friable inflamma tory granulation tissue, as seen in ad vanced periodontal disease, should be excised to reduce the exposed vascular surface area. 4. A Surgicel dental cone is recom mended for each tooth socket. 5. Operative wounds should be closed with no. 000 silk, employing a fine, atrau matic and, possibly, noncutting-edge needle. Suturing of extraction wounds, even in instances of single tooth extrac tions, is recommended. 6. Postoperative analgesia and narcosis are beneficial because they permit appli cation of maximum pressure by intermax illary gauze packs to intraoral wounds with minimal discomfort. 7. Application of external ice packs is of value. 8. Mouthwash hygiene should be de ferred until adequate hemostasis is estab lished. 9. Postural postoperative convalescence is important. The head should be ele vated. 10. A soft or liquid diet for early post operative nutrition is advisable. SUM M ARY
Anticoagulant therapy is a well estab lished method for managing thrombo embolic vascular disorders. The number of patients receiving this care is increas ing. Many of them are ambulatory and may seek dental attention. Anticoagulant drugs inhibit blood clot
ting in varying degrees. Since a number of dental procedures induce hemorrhage, this group of patients should receive pre operative preparation by their physician. Vitamin K i is an antidote to prothrombin depressants and controls excessive hemor rhage. The optimal preparation for pa tients on long-term anticoagulant treat ment for dental surgery consists of re ducing the prothrombin time to the lower level of the anticoagulant state while re maining within the therapeutic range. This objective can be reached by several methods. An accurate preoperative pro thrombin time is an essential guide. With proper control of the patient’s hemostasis potential, dental and oral surgery can be performed safely. Cooperation between the patient’s phy sician and the operating dentist is neces sary. At no time should the dentist assume responsibility for discontinuing anticoagu lant treatment. He should be familiar with the principles of surgery and hemo stasis applicable to patients with hemor rhagic tendencies. 10200 West Main Street
*Associate professor, department of oral surgery, St. Louis University School of Dentistry, St. Louîs, Mo. 1. W right, I. S. Use of anticoagulants in coronary heart disease. Circulation 22:609 Oct. I960. 2. Snîtzer, J. M . Personal communication. 3. Askey, J. M.,- and Cherry, C. B. Dental extraction during Dicumarol therapy. California Med. 84:16 Jan. 1956. 4. Facquet, J.; Husson, A., and Ducrot, J. Retrecissements mitraux emboligenes et medication anticoagulante continue. Presse med. 60:116 Jan. 26, 19S2. 5. Cosgriff, S. W . Chronic anticoagulant therapy in recurrent embolism of cardiac origin. Ann. Int. Med. 38:278 Feb. 1953. 6. I u I loch, J., and W right, I. S. Long-term anticoagu lant therapy; further experiences. Circulation 9:823 June 1954. 7. Ziffer, A . M., and others. Profound bleeding after dental extractions during Dicumarol therapy. New Eng land J. M ed. 256:351 Feb. 1957. 8. Scopp, !. W., and Fredrics, Harry. Dental extrac tions in patients undergoing anticoagulant therapy. O ral Surg., Oral M ed. & Oral Path. 11:470 M a y 1958. 9. Behrman, S. J., and Wright, I. S. Dental surgery during continuous anticoagulant therapy. J.A.D.A. 62:172 Feb. 1961. 10. Sise, H. S., and others. The risk of interrupting long-term anticoagulant treatment. Circulation 24:1137 N ov. 1961. 11. Chamberlain, F. L. Personal communication.