Anticoagulants and Antiplatelets Flashcards

1
Q

What is blood clotting and how does a blood clot form?

A
  • Process triggered naturally in response to damage to blood vessels from injury or invasive procedures
  • Platelets within blood become activated locally
  • Leads to increased tendency to adhere to each other and to damaged blood vessel endothelium (primary haemostasis)
  • Inactive coagulation factors converted to active forms
  • Leads to production of protein fibrin from fibrinogen
  • Fibrin stabilises primary platelet plug by cross-linking platelets to each other and to damaged blood vessel wall
  • Prevents further blood loss (secondary haemostasis)
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2
Q

What do antiplatelets do?

A
  • Interfere with platelet aggregation by reversibly or irreversibly inhibiting various steps in platelet activation for primary haemostasis
  • Reduce ability of blood to form clots
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3
Q

What do anticoagulants do?

A
  • Inhibit production or activity of factors required for coagulation stage
  • Impair secondary haemostasis
  • Reduce ability to coagulate
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4
Q

Why are anticoagulants or antiplatelet drugs prescribed if they lead to increased bleeding risk?

A
  • Atherosclerosis and cardiac arrhythmias have risk of thrombosis
  • Thrombus (blood clot) blocks BV at site of formation or thromboembolism
  • Can lead to heart attack, pulmonary embolism or stroke
  • AC or AP reduce this risk
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5
Q

What are dental procedures unlikely to cause bleeding?

A
  • LA by infiltration, intraligamentary or mental nerve block
  • LA by IANB or other nerve blocks
  • BPE
  • Supragingival removal of plaque, calculus or stain
  • Direct or indirect restorations with supragingival margins
  • Endodontics - orthograde
  • Impressions and other prosthetic procedures
  • Fitting and adjustment of ortho appliances
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6
Q

What are dental procedures with low risk of post-op bleeding complications?

A
  • Simple extractions (1-3 teeth with restricted wound size)
  • Incision and drainage of intra-oral swellings
  • Detailed 6 point full periodontal exam
  • sub-gingival PMPR
  • Direct or indirect restorations with subgingival margins
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7
Q

What are the dental procedures with higher risk of post-op bleeding complications?

A
  • Complex extractions
  • Adjacent extractions that will cause large wound or more than 3 at once

Flap raising procedure inc;

  • Elective surgical extractions
  • Periodontal surgery
  • Preprosthetic surgery
  • Periradicular surgery
  • Crown lengthening
  • Dental implant surgery
    /
  • Gingival recontouring
  • Biopsies
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8
Q

What patients do you NOT interrupt anticoagulant or antiplatelet therapy for?

A
  • Patients with prosthetic metal heart valves or coronary stents
  • Patients who have had pulmonary embolism or deep vein thrombosis in last 3 months
  • Patients on anticoagulant therapy for cardioversion
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9
Q

What is the general advice for tx to all patients taking anticoagulants or antiplatelet drugs that require dental treatment likely to cause bleeding?

A
  • Plan treatment early on in day and week
  • Pre-treatment instructions dependent on drug
  • Treat atraumatically
  • Use local measures and only discharge once patient achieved haemostasis
  • Post-treatment advice and emergency contact details
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10
Q

What are the most common DOAC direct oral anticoagulant drugs?

A
  • Apixaban
  • Dabigatran
  • Rivaroxaban
  • Edoxaban
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11
Q

For low bleeding risk dental procedures what should you advise patient to do with morning dose of DOAC?

A
  • Treat without interrupting medication
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12
Q

For high bleeding risk dental procedures what should you advise patient to do with drug schedule when taking DOAC?

A
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13
Q

What are the main examples of Vitamin K antagonist?

A
  • Warfarin
  • Acenocoumarol
  • Phenindione
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14
Q

What to do if patient is taking Vitamin K antagonist?

A
  • Check INR no more than 24hrs before procedure (up to 72hrs if patient is stably anticoagulated)
  • If INR below 4 = treat without interrupting medication
  • Limit initial treatment area and staging extensive or complex procedures
  • Suturing and packing
  • If INR above 4 delay invasive treatments or refer if urgent
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15
Q

What are the main injectable anticoagulants?

A
  • PARIN
    /
  • Dalteparin
  • Enozaparin
  • Tinzaparin
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16
Q

What to do if patient is on prophylactic (low) dose of injectable anticoagulant?

A
  • Treat without interrupting medication
  • Limit initial treatment area and staging extensive or complex procedures
  • Suturing and packing
17
Q

What to do if patient is on treatment (higher) dose of inhectable anticoagulant?

A
  • Consult with prescribing clinician for more info
18
Q

What are the main examples of antiplatelet drugs?

A
  • Aspirin
  • Clopidogrel
  • Dipyridamole
  • Prasugrel
  • Ticagrelor
19
Q

What to do if patient is taking aspirin alone?

A
  • Treat without interrupting medication
  • Limit initial treatment area and staging extensive or complex procedure
  • Local haemostatic measures
20
Q

What to do if patient is taking Clopidogrel, Dipyridamole, Prasugrel or Ticagrelor single or dual therapy (in combo with aspirin)?

A
  • Treat without interrupting medication
  • Expect prolonged bleeding
  • Limit initial treatment area
  • Consider staging extensive or complex procedures
  • Suturing and packing
21
Q

What to do if patient is on anticoagulant and antiplatelet combo?

A
  • Consult with prescribing clinician in order to assess impact of the drug combo and bleeding risk