Management of patients on warfarin by general dental practitioners in South West Wales: continuing the audit cycle

The Dilemma of Peri-Procedural Warfarin Management: A Narrative Review

Periprocedural vitamin K antagonist management is a complex process and inherently entails multiple clinical issues. Marked variations have been reported in different aspects of this process. These differences were noted at the clinician and institutional levels owing to the lack of evidence-based data leading to many discrepancies in decision-making. This review aims to address the gap of vitamin K antagonist periprocedural management acknowledged by previously published prescribers’ questionnaires. One of the components of this process is “bridging,” which aims to provide minimal interruption of the anticoagulation period through the use of heparin products. Recent studies showed that bridging is increasing bleeding risk. Secondly, interruption decision relies on the classification of thromboembolism risk which depends on trials that did not include patients with atrial fibrillation. Thirdly, the interruption duration is different among different International normalization ratio levels, which strengthens the difference in the clinical practice of preoperative vitamin K antagonist management. Lastly, the resumption of a vitamin-K antagonist after surgery has many scenarios according to the procedure and patient risk of bleeding. Vitamin-K antagonist periprocedural management is complicated due to individual practice and the lack of strictly implemented institutional standardized protocols to guide, manage and evaluate the process.

Avaliação do nível de conhecimento de cirurgiões-dentistas e graduandos em Odontologia quanto ao manejo de indivíduos em uso de anticoagulantes orais

Resumo Introdução Diante da alta incidência das doenças cardiovasculares, muitos são os pacientes que fazem uso de medicações para prevenção e tratamento dessas desordens. Consequentemente, o número de pessoas em uso de anticoagulantes orais a serem submetidas a tratamento odontológico é crescente e o manejo desses indivíduos requer criteriosa avaliação da condição clínica e do procedimento a ser realizado. Objetivo Avaliar o nível de conhecimento de cirurgiões-dentistas e graduandos em Odontologia quanto ao manejo de indivíduos em uso de anticoagulantes orais a serem submetidos a tratamento odontológico. Material e método Investigação descritiva, quantitativa, de corte transversal, com base em um questionário respondido por 100 indivíduos, sendo 70 cirurgiões-dentistas e 30 graduandos do curso de Odontologia, escolhidos por conveniência, para avaliar o conhecimento sobre o tema proposto. Para comparação das variáveis quantitativas, foi utilizado o Teste t de student, para comparação de duas amostras, e o Teste ANOVA, com pós-teste de Bonferroni, para comparação de três amostras. Resultado Dentre os entrevistados, 74,5% dos cirurgiões-dentistas e 54,2% dos graduandos relataram já ter atendido um paciente que faz uso de anticoagulante oral. Não houve diferença estatística quanto ao desempenho entre profissionais e alunos acerca do manejo odontológico de pacientes em uso de anticoagulantes. Dentre o grupo de cirurgiões-dentistas, os profissionais da cirurgia bucomaxilofacial e os que fizeram residência multiprofissional apresentaram melhor desempenho quando comparados aos clínicos gerais. Conclusão Pôde-se concluir que, para os grupos estudados, o manejo de pessoas em uso de anticoagulantes orais ainda é um desafio.

Dentists' Knowledge, Attitude and Practice in Treating Patients Taking Oral Antithrombotic Medications - A Survey

INTRODUCTION

India lists high on patients suffering from diabetes, hypertension, stroke and myocardial infarction. Hence, a large proportion of the population is on long term Oral Antithrombotic Medications (OAM). Though several guidelines exist on dental management of these patients, previous surveys have shown variation among the dentists.

AIM

The purpose of this study was to assess the knowledge, attitude and practice of dentists in Chennai, India, towards dental management of patients taking OAM using a questionnaire survey.

MATERIALS AND METHODS

The survey was conducted among 256 dentists in Chennai, India using a printed questionnaire containing 16 questions, at their university location. Descriptive statistical analysis was used to analyze the data.

RESULTS

Of the final population of dentists who were included in the survey (n =212), majority of them were aware about drugs such as warfarin and aspirin compared to other newer drugs (dabigatran, rivaroxaban). Most participants took physician's opinion before proceeding with any invasive dental procedure and thromboembolic events were their major concern while treating patients on OAM.

CONCLUSION

The survey revealed dentists are knowledgeable about management of patients on OAM. However, they tend to overestimate the bleeding risk, thus being cautious in their treatment approach. Based on the results of the study, the authors suggest that continuing dental education programs and further training on management of such medically complex patients will be beneficial in order to provide optimum dental care to people taking OAM.

Dental extraction in patients on warfarin treatment

Background

Warfarin is one of the most common oral anticoagulants used to prevent thromboembolic episodes. The benefits of discontinuation of this drug before simple surgical procedures are not clear and this approach could be associated with complications. The aim of this study was to evaluate the risk of bleeding in a series of 35 patients (in cases where the international normalized ratio [INR] is less than 4) following simple tooth extraction without modification of the warfarin dose given to patients.

Methods

Thirty-five patients taking warfarin who had been referred to the Oral and Maxillofacial Department, College of Dentistry, King Saud University, for dental extractions were included in the study. Exclusion criteria included patients with an INR of ≥4 or with a history of liver disease or coagulopathies. No alteration was made in warfarin dose, and the CoaguChek System was used to identify the INR on the same day of dental extraction. Bleeding from the extraction site was evaluated and recorded immediately after extraction until the second day.

Results

A total of 35 patients (16 women and 19 men) aged between 38 and 57 years (mean =48.7) were included in the present study. All patients underwent simple one-tooth extraction while undergoing warfarin treatment. Oozing, considered mild bleeding and which did not need intervention was seen in 88.6% of patients. Moderate bleeding occurred in 11.4% of all cases. The INR of the patients ranged from 2.00 to 3.50, with 77.2% of patients having INR between 2.0 and 2.5 on the day of extraction. No severe bleeding which needed hospital management was encountered after any of the extractions. The patients who suffered moderate bleeding were returned to the clinic where they received local treatment measures to control bleeding. Moderate bleeding occurred only in four patients, where three had INR between 3.1 and 3.5, and one with INR less than 3.

Conclusion

In the present study, we have shown that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.

The dental patient on oral anticoagulant medication: a literature review

Specific diseases and medications may considerably influence the delivery of oral care and the course of dental therapy. The purpose of this literature review is to examine the relationship between oral anticoagulant medication and dental treatment. Electronic and manual searches were conducted for clinical studies in the English literature for the years 1988-2010. The review process provided a total of 110 pertinent literature references, out of which 38 studies dealt with oral anticoagulants and dental treatment. Different treatment strategies relative to dental periprocedural anticoagulation regimens have been identified, and their accompanying thromboembolic and bleeding risks are being presented and discussed. Regarding to what extent a safe and successful dental treatment in patients on anticoagulant medication is feasible, the level of evidence is lacking. Until high-level data are provided, an individualised treatment approach after consultation with the physician of the patient is highly recommended.