- Email: [email protected]
Anticoagulants and dental surgery
medical team. Bleeding caused by warfarin is reversed using factor IV or vitamin K. It can require up to 12 hours for this reversal to be accomplished. Fresh frozen plasma or prothrombin complex concentrate can be used for urgent cases. No direct reversal agent is currently available for dabigatran, so adequate diuresis must be maintained to ensure its renal excretion. Hypovolemic patients may have inadequate renal perfusion, which diminishes creatinine clearance. Rate of excretion of dabigatran and timely use of blood products are essential for resuscitation. Fresh frozen plasma is also required for all major hemorrhage situations. Other possibilities for reversal include activated prothrombin complex concentrates, recombinant factor VIIa, or concentrates of coagulation factors II, IX, or X. The surgeon should determine when reversal agents are needed. Dabigatran’s disadvantages include its contraindications for certain groups and conditions, including those under age 18 years and patients with marked impairment whose liver enzyme levels are more than twice normal. Patients taking medications such as phenytoin or carbamazepine should also avoid dabigatran. Care should be taken with patients taking clopidogrel, aspirin, and nonsteroidal anti-inflammatory
drugs (NSAIDs), which increase the risks of bleeding. Other patients for whom dabigatran is contraindicated are those with an increased risk of spontaneous bleeding, those who are pregnant, and those who are breastfeeding.
Clinical Significance.—Dabigatran offers some significant benefits compared to warfarin, such as not requiring routine coagulation monitoring and having set dosing guidelines. As a result, it may be easier to use for the patient and clinician. However, no reversal agent is currently available and this drug is contraindicated for many patients. Dentists should be aware of the specifics of this agent so they are prepared to handle situations that may arise in patients taking dabigatran.
Syyed N, Ansell M, Sood V: Dabigatran (Pradaxaâ): Surgeon’s friend or foe? Br Dent J 217:623-626, 2014 Reprints available from N Syyed, StR, Oral and Maxillofacial Unit, Southern General Hospital, Glasgow, G51 4TF; e-mail: [email protected]
Anticoagulants and dental surgery Background.—Dental surgery for patients taking anticoagulant medications has raised considerable controversy over whether or not to continue these medications in view of the increased risk of bleeding. However, major blood vessels are unlikely to be involved during dental surgery and local hemostatic methods can be readily applied should bleeding occur. Reviews of literature in 1998 and 2000 showed that it is rare to encounter bleeding complications requiring more than local hemostatic measures after dental surgery at therapeutic anticoagulation levels. Should the anticoagulants be stopped or reduced, however, fatal embolic complications can occur. The conclusion of these reviews was that continuous anticoagulation at therapeutic levels should be continued for dental surgery, with local hemostatic measures in place should bleeding occur. An update on these findings with additional literature was prepared. Methods.—Articles were identified in literature searches of the National Library of Medicine PubMed and Scopus databases up to October 10, 2013. Those chosen reported on bleeding complications or thromboembolic events in
patients taking warfarin who underwent dental procedures. For some the warfarin therapy was continued, for some it was altered, and for some it was interrupted. Results.—When warfarin anticoagulation was continued, the risk of a significant postoperative bleeding complication was exceedingly small. More than 99% of the patients had no postoperative bleeding that required more than local hemostatic measures. When warfarin was withdrawn or reduced for dental procedures, 22 embolic complications (0.8% of the 2673 patients included) occurred. Six of these were fatal. Discussion.—Withdrawing or reducing the therapeutic levels of warfarin so a patient can undergo dental procedures carries a small but real risk of embolic complications and pulmonary embolism. The results of these complications can be significant, including permanent morbidity or death. When anticoagulation is continued during dental surgery, no instances of permanent morbidity or death
Volume 60
Issue 3
2015
149
have occurred. Any bleeding complications that have developed have been managed with local hemostatic measures. The evidence supports the continuation of anticoagulants but the dental professional must be aware that some health care professionals still have concerns. 1.
2.
3.
The American College of Chest Physicians (ACCP) states that postoperative bleeding after dental surgery can cause the patient distress and anxiety. Patients may be reassured that the risk of bleeding is exceedingly small and most bleeding complications can be readily managed using local hemostatic measures. Some believe that embolic complications are rare when anticoagulation medication is reduced or withdrawn or that these types of complications develop only with very long warfarin cessation periods. Current evidence indicates that embolic complications have occurred after warfarin interruption of 2, 3, or 4 days. The recommended therapeutic INR levels are 2.0 to 3.0, or 2.5 to 3.5 for patients with mechanical mitral valves. Even briefly suspending warfarin administration reduces the INR to a suboptimal level and exposes the patient to a greater risk for stroke or death while providing little or no prevention against postoperative hemorrhage. Since 2001 the ACCP consensus statements have recognized the risk of hemorrhage after dental surgery in anticoagulated patients is less than the morbidity associated with embolic complications from withdrawing or reducing warfarin. They recommend continuing
warfarin for dental surgery. However, in 2012 the recommendation gave the added option to withdraw anticoagulation for 2 to 3 days before the dental procedure. The studies cited in support of this view do not support it but actually confirm that continuous warfarin is safe and appropriate practice for dental surgery.
Clinical Significance.—The risk of serious and sometimes fatal embolic events is small when anticoagulation agents are reduced or withdrawn. However, this risk is greater than the risk of serious bleeding associated with continuing these drugs. Warfarin anticoagulation should be maintained for patients undergoing dental procedures because the risk of stopping this drug outweighs the risk of any significant bleeding complications associated with its continuation.
Wahl MJ, Pinto A, Kilham J, et al: Dental surgery in anticoagulated patients—stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol 119:136-157, 2015 Reprints available from MJ Wahl, 2003 Concord Pike, Wilmington, DE 19803; e-mail: [email protected]
Pediatric Dentistry The Hall technique Background.—About 20% of US children age 2 to 5 years have untreated dental caries. Among the challenges in pediatric dental caries management are access to care, behavior management, and the need for definitive treatment until the primary teeth are exfoliated. Carious primary molars require proper treatment to prevent oral infections, achieve or maintain proper mastication, and maintain proper space in the arch for the permanent premolars. Stainless steel crowns (SSCs) offer a history of clinical success and work well for two-surface and larger carious lesions in primary molars. SSCs are usually placed after traditional preparation, which consists of use of a local anesthetic, removal of tooth structure as needed, and removal of carious tissue before the SSC is luted in place with glass ionomer cement. SSCs have an average clinical failure rate four
150
Dental Abstracts
times less than that of Class II amalgam restorations. A more conservative approach, the Hall technique, has been used since the 1980s. With this technique, the SSCs are used to seal over caries lesions on primary molars using glass ionomer cement. No caries removal, crown preparation, or use of local anesthetic is involved. As a result, dentists can offer a simple, definitive treatment quickly for pediatric patients. The technique limits anxiety, is noninvasive, and tends to produce a restoration with a relatively long lifespan. As a result, the Hall technique may increase access to care, decrease rates of untreated caries, and still allow for natural tooth exfoliation. The clinical and radiographic success rates of SSCs used to restore primary molars using both the traditional technique and the Hall technique were compared.
drugs (NSAIDs), which increase the risks of bleeding. Other patients for whom dabigatran is contraindicated are those with an increased risk of spontaneous bleeding, those who are pregnant, and those who are breastfeeding.
Clinical Significance.—Dabigatran offers some significant benefits compared to warfarin, such as not requiring routine coagulation monitoring and having set dosing guidelines. As a result, it may be easier to use for the patient and clinician. However, no reversal agent is currently available and this drug is contraindicated for many patients. Dentists should be aware of the specifics of this agent so they are prepared to handle situations that may arise in patients taking dabigatran.
Syyed N, Ansell M, Sood V: Dabigatran (Pradaxaâ): Surgeon’s friend or foe? Br Dent J 217:623-626, 2014 Reprints available from N Syyed, StR, Oral and Maxillofacial Unit, Southern General Hospital, Glasgow, G51 4TF; e-mail: [email protected]
Anticoagulants and dental surgery Background.—Dental surgery for patients taking anticoagulant medications has raised considerable controversy over whether or not to continue these medications in view of the increased risk of bleeding. However, major blood vessels are unlikely to be involved during dental surgery and local hemostatic methods can be readily applied should bleeding occur. Reviews of literature in 1998 and 2000 showed that it is rare to encounter bleeding complications requiring more than local hemostatic measures after dental surgery at therapeutic anticoagulation levels. Should the anticoagulants be stopped or reduced, however, fatal embolic complications can occur. The conclusion of these reviews was that continuous anticoagulation at therapeutic levels should be continued for dental surgery, with local hemostatic measures in place should bleeding occur. An update on these findings with additional literature was prepared. Methods.—Articles were identified in literature searches of the National Library of Medicine PubMed and Scopus databases up to October 10, 2013. Those chosen reported on bleeding complications or thromboembolic events in
patients taking warfarin who underwent dental procedures. For some the warfarin therapy was continued, for some it was altered, and for some it was interrupted. Results.—When warfarin anticoagulation was continued, the risk of a significant postoperative bleeding complication was exceedingly small. More than 99% of the patients had no postoperative bleeding that required more than local hemostatic measures. When warfarin was withdrawn or reduced for dental procedures, 22 embolic complications (0.8% of the 2673 patients included) occurred. Six of these were fatal. Discussion.—Withdrawing or reducing the therapeutic levels of warfarin so a patient can undergo dental procedures carries a small but real risk of embolic complications and pulmonary embolism. The results of these complications can be significant, including permanent morbidity or death. When anticoagulation is continued during dental surgery, no instances of permanent morbidity or death
Volume 60
Issue 3
2015
149
have occurred. Any bleeding complications that have developed have been managed with local hemostatic measures. The evidence supports the continuation of anticoagulants but the dental professional must be aware that some health care professionals still have concerns. 1.
2.
3.
The American College of Chest Physicians (ACCP) states that postoperative bleeding after dental surgery can cause the patient distress and anxiety. Patients may be reassured that the risk of bleeding is exceedingly small and most bleeding complications can be readily managed using local hemostatic measures. Some believe that embolic complications are rare when anticoagulation medication is reduced or withdrawn or that these types of complications develop only with very long warfarin cessation periods. Current evidence indicates that embolic complications have occurred after warfarin interruption of 2, 3, or 4 days. The recommended therapeutic INR levels are 2.0 to 3.0, or 2.5 to 3.5 for patients with mechanical mitral valves. Even briefly suspending warfarin administration reduces the INR to a suboptimal level and exposes the patient to a greater risk for stroke or death while providing little or no prevention against postoperative hemorrhage. Since 2001 the ACCP consensus statements have recognized the risk of hemorrhage after dental surgery in anticoagulated patients is less than the morbidity associated with embolic complications from withdrawing or reducing warfarin. They recommend continuing
warfarin for dental surgery. However, in 2012 the recommendation gave the added option to withdraw anticoagulation for 2 to 3 days before the dental procedure. The studies cited in support of this view do not support it but actually confirm that continuous warfarin is safe and appropriate practice for dental surgery.
Clinical Significance.—The risk of serious and sometimes fatal embolic events is small when anticoagulation agents are reduced or withdrawn. However, this risk is greater than the risk of serious bleeding associated with continuing these drugs. Warfarin anticoagulation should be maintained for patients undergoing dental procedures because the risk of stopping this drug outweighs the risk of any significant bleeding complications associated with its continuation.
Wahl MJ, Pinto A, Kilham J, et al: Dental surgery in anticoagulated patients—stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol 119:136-157, 2015 Reprints available from MJ Wahl, 2003 Concord Pike, Wilmington, DE 19803; e-mail: [email protected]
Pediatric Dentistry The Hall technique Background.—About 20% of US children age 2 to 5 years have untreated dental caries. Among the challenges in pediatric dental caries management are access to care, behavior management, and the need for definitive treatment until the primary teeth are exfoliated. Carious primary molars require proper treatment to prevent oral infections, achieve or maintain proper mastication, and maintain proper space in the arch for the permanent premolars. Stainless steel crowns (SSCs) offer a history of clinical success and work well for two-surface and larger carious lesions in primary molars. SSCs are usually placed after traditional preparation, which consists of use of a local anesthetic, removal of tooth structure as needed, and removal of carious tissue before the SSC is luted in place with glass ionomer cement. SSCs have an average clinical failure rate four
150
Dental Abstracts
times less than that of Class II amalgam restorations. A more conservative approach, the Hall technique, has been used since the 1980s. With this technique, the SSCs are used to seal over caries lesions on primary molars using glass ionomer cement. No caries removal, crown preparation, or use of local anesthetic is involved. As a result, dentists can offer a simple, definitive treatment quickly for pediatric patients. The technique limits anxiety, is noninvasive, and tends to produce a restoration with a relatively long lifespan. As a result, the Hall technique may increase access to care, decrease rates of untreated caries, and still allow for natural tooth exfoliation. The clinical and radiographic success rates of SSCs used to restore primary molars using both the traditional technique and the Hall technique were compared.