anticoagulants and antiplatelets

Question 1

how would you treat a patient taking anticoagulants or anti-platelets requires dental treatment that is unlikely to cause bleeding?

Answer 1

standard procedure - care to avoid bleeding

Question 2

how would you treat a patient taking anticoagulants or anti-platelets requires dental treatment that is likely to cause bleeding?

Answer 2

if medication is time limited delay non-urgent invasive treatment
consult with pt clinician
plan treatment for early in day and week
only discharge when achieve haemostasis
advise paracetamol for pain relief
pre and post treatment advice

Question 3

which patients should you not interrupt anticoagulant or anti-platelet therapy?

Answer 3

prosthetic heart valve/coronary stent
pulmonary embolism or DVT in last 3 months
cardioversion

Question 4

for a patient taking a daily oral anticoagulant DOAC explain how you would treat for low risk bleeding procedure

Answer 4

treat according to advice
treat without interrupting medication
treat early in day
limit initial treatment area
consider suture and packing

Question 5

for a patient taking daily oral anticoagulant DOAC apixaban or dabigatran explain how you would treat for higher risk bleeding procedure

Answer 5

miss morning dose of apixaban or dabigatran
treat early in day and according to advice
suture and packing
advice when torestart meds

Question 6

for a patient taking daily oral anticoagulant DOAC rivaroxaban or edixaban explain how you would treat for higher risk bleeding procedure

Answer 6

delay rivaroxaban or edixaban delay RElay
treat early in day and according to advice
suture and packing
advice when torestart meds

Question 7

how should you treat a patient taking warfarin or another vitamin K antagonist with an INR below four

Answer 7

treat without interrupting their anticoagulant medication

Question 8

when should INR be checked before treatment?

Answer 8

ideally no more than 24hrs before but if their INR is stable up to 72hrs is acceptable

Question 9

what do you do if pt INR is greater than or equal to 4?

Answer 9

inform pt anticoagulation service or GP
delay invasive dental treatment until INR reduced
if treatment urgent - refer to secondary dental care

Question 10

how should you treat a patient with an INR less than 4?

Answer 10

treat according to general advice for managing bleeding risk

Question 11

for all warfarin patients, how should you plan treatment and manage post op.

Answer 11

consider limiting initial treatment
stage treatment
suture and pack

Question 12

how do you treat a patient taking prophylactic low dose of low molecular weight heparin?

Answer 12

treat without interrupting medication

Question 13

what do you do if you are unsure if patient is taking prophylactic - low or treatment - high dose of heparin OR if patient is taking high dose heparin?

Answer 13

consult with clinician prescribing

Question 14

should you interrupt antiplatelet therapy in patients taking single or dual anti platelet drugs?

Answer 14

no - treat with general advice for managing bleeding risk

Question 15

how should you plan to treat a patient taking aspirin ?

Answer 15

consider limiting initial treatment area
treat in staged manner for higher risk bleeding
use local haemostatic measures to achieve haemostasis
be aware bleeding may be prolonged

Question 16

when a patient takes anticoagulant and anti platelet combined, what should you do for either high or low risk procedure?

Answer 16

consult prescribing physician top assess impact of drugs and medical condition on bleeding risk

Question 17

what should you always be cautious of when prescribing to a patient on anticoagulants/antiplatelets?

Answer 17

drug interactions

Question 18

give two examples of anti platelet drugs?

Answer 18

clopidogrel
aspirin

Question 19

give two examples of DOAC

Answer 19

apixaban
dabigatran

Question 20

what do anticoagulants and antiplatelets do?

Answer 20

reduce the ability of blood to form clots, or
coagulate

Question 21

summarise the coagulation cascade

Answer 21

1 damage to blood vessels activates platelets locally
2 platelets adhere to eachother and endothelium
3 coagulation factors activated and lead to fibrin protein production
4 fibrin stabilises primary platelet plug bu cross-linking platelets each other and endothelium

Question 22

what is primary haemostasis?

Answer 22

when platelets adhere to eachother and endothelium

Question 23

what is the activated cross-linking form of fibrinogen

Answer 23

fibrin

Question 24

what is secondary haemostasis

Answer 24

fibrin stabilises primary platelet plug by cross-linking platelets each other and endothelium

Question 25

give two examples of patients at risk of thrombosis?

Answer 25

cardiac arrhythmia atherosclerosis

Question 26

what is a thromboembolism?

Answer 26

when a blood clot travels to a different critical site from where it was formed

Question 27

what is the mode of action of warfarin?

Answer 27

inhibits vitamin k dependent modification of prothrombin

Question 28

what do apixaban, rivaroxaban and edoxaban inhibit?

Answer 28

factor 10a

Question 29

what does dabigatran inhibit?

Answer 29

thrombin

Question 30

what is involved ion assessing bleeding risk - 2 things

Answer 30

patients individual level of bleeding risk risk of bleeding associated with procedure

Question 31

give 3 examples of unlikely to cause bleeding procedure

Answer 31

BPE LA impressions

Question 32

give 3 examples of low risk bleeding procedure

Answer 32

simple extractions - 1-3 teeth 6PPC RSD

Question 33

give 3 examples of high risk bleeding complications

Answer 33

complex extractions e.g. 8s or >3 teeth flap raising procedure e.g. periodontal surgery biopsies

Question 34

what medical conditions are associate with increased bleeding risk?

Answer 34

liver kidney and bone marrow disorders liver disease chronic renal failure haematological malignancy

Question 35

what is pancytopenia

Answer 35

deficiency of all three cellular components of the blood (red cells, white cells, and platelets).

Question 36

give 3 drug categories affecting bleeding risk

Answer 36

anticoagulants anti platelet - can be non- prescribed aspirin NSAIDs- affect platelet function

Question 37

give an example of herbal medicine affecting bleeding risk

Answer 37

st johns wort

Question 38

give three questions to ask when assessing bleeding risk

Answer 38

anticoagulant or antiplatelets if treatment is limited or for lifetime - could delay bleeding history - previous experience

Question 39

what are the 4 components of suturing kit

Answer 39

needle holders tissue forceps scissors suture material

Question 40

why plan treatment for pt at increased bleeding risk early in day and week

Answer 40

to allow time for the management of prolonged bleeding or rebleeding episodes, should they occur.

Question 41

what should you advise for pain relief for pt with bleeding risk

Answer 41

paracetamol

Question 42

what drug interactions increase bleeding risk for most antiplatelets and anticoagulants

Answer 42

NSAIDS - ibuprofen and aspirin

Question 43

what drug will reduce anticoagulant effect of most anticoagulants

Answer 43

carbamazepine

Question 44

give 3 indications for anticoagulant or anti platelet therapy

Answer 44

DVT or pulmonary embolism prosthetic replacement heart valve coronary stent

Question 45

why does missing or delaying DOAC dose significantly reduce the level of anticoagulation and what minimises the period low anticoagulation levels?

Answer 45

due to short half lives of DOAC rapid onset of action of DOAC

Question 46

how long should patient taking DOAC wait after haemostasis is achieved before taking their next dose?

Answer 46

at least 4 hrs

Question 47

how do you limit initial treatment area?

Answer 47

perform a single extraction or limit root surface debridement to three teeth, then assess bleeding before continuing