MH and medications Flashcards
what are anticoagulant and anti-platelet drugs?
- agents that reduce the ability of blood to form clots or coagulate
Name 3 antiplatelet drugs and describe how platelets work
- aspirin
- dipyridamole
-clopidogrel
interfere with platelet aggregation by reversibly or irreversibly inhibiting various steps in platelet activation required for primary haemostasis
name 3 anticoagulant drugs and describe how they work
- warfarin
- acenocoumarol
- phenindione
work by inhibiting the vitamin k dependent modification of prothrombin and other coagulation factors, which is required for their normal function, and this results in impairment to secondary haemostasis
Name 3 NOACs, describing how they work and why they’re preferred to older anticoagulants
- apixaban
- dabigatran
- rivaroxaban
Apixaban and rivaroxaban inhibit factorXa of the coagulation cascade
- dabigatran inhibits factor thrombin directly
they produce a more predictable level of anticoagulation
what dental procedures are high risk of post-operative bleeding
- Xla of 3 teeth or more
-Xla of adjacent teeth causing a large wound
-Complex extractions - flap raising procedures
- gingival recontouring
- biopsies
what should you as a dentist consider to assess a patients bleeding risk
- consideration the likely risk of bleeding associated with the required procedure
- consideration of the patients individual bleeding risk
Discuss in detail how to assess bleeding risk
- assess whether the dental treatment is a low risk or high risk for bleeding complications
- ask pt about current or planned use of anticoagulant or antiplatelet drugs and other prescribed/non prescribed medications when confirming MH
- be aware pt may be taking aspirin or NSAIDs - higher bleeding risk
- ask pt if AC or AP medication is for a limited time or lifelong
- ask about their medical conditions (kidney liver or bone marrow disorders can affect coagulation and platelet function)
- ask about pt’s bleeding history
what should the dental practitioner have available to achieve haemostasis
- absorbent gauze
- haemostatic packing material (oxidized cellulose, collagen sponge)
- suture kit
how do you manage a patient taking an anticoagulant or antiplatelet drug that requires dental treatment that is unlikely to cause bleeding
treat the patient following standard procedures taking care to avoid causing bleeding
A patient is taking an anticoagulant and requires dental treatment that is likely to cause bleeding with a low or high risk of bleeding complications. The patient is on a time limited course of anticoagulant -what should you do
- delay non urgent, invasive dental procedures where possible until the medication has been discontinued
- if medication is being taken in prep for surgery, may be possible to interrupt the drug treatment in liaison with surgical consultant
- pt’s with acute deep vein thromobsis or pulmonary embolism may be taking high dose apixaban or rivaroxaban for the first 1-3 weeks of tx. Delay dental procedures until pt is taking standard dose
A patient is taking an anticoagulant and requires dental treatment that is likely to cause bleeding with a low or high risk of bleeding complications. what day/time should you plan treatment for
- early in the day and early in the week - allow time for the management of prolonged bleeding or re-bleeding episodes should they occur
A patient is taking an anticoagulant and requires dental treatment that is likely to cause bleeding with a low or high risk of bleeding complications. Before they leave the surgery post extraction, what should you do
- ensure bleeding has stopped - use appropriate local measures and only discharge once the patient has achieved haemostasis
- advise to take paracetamol for pain relief rather than NSAIDs such aspirin, ibuprofen, diclofenac or naproxen
- provide pt with written post treatment advice and emergency contact details
what is INR
- international normalised ratio test which measures the time taken for a clot to form in a blood sample, relative to a standard
a patient is taking warfarin or another vitamin k antagonist with an INR below 4 - how should you treat
treat without interrupting their anticoagulant medication
a patient is taking warfarin or another vitamin k antagonist - when should you check their INR
- ideally no more than 24 hours before procedure
- if pt has stable INR no more than 72 hours before is acceptable
a patient is taking warfarin or another vitamin k antagonist - the INR is above 4, what do you do
- inform the pts GMP or anticoagulation service and delay tx until INR has been reduced to less than 4. For surgent tx, refer to secondary dental care
a patient is taking warfarin or another vitamin k antagonist - how should you structure tx with high risk of post-op bleeding
- consider limiting initial tx area and then assess bleeding before continuing
- carry out tx in staged manner over separate visits
- use local haemostatic measures and consider suturing and packing
how should you treat a patient who is taking single or dual antiplatelet drugs
treat without interrupting their antiplatelet medication
what should you consider if the pt is taking dual antiplatelet drugs or an antiplatelet other than aspirin
- be aware of prolonged bleeding time when tx planning
- limit initial tx area
- carry out high risk bleeding complication procedures in a staged manner
- use local haemostatic measures to control bleeding
when can the delayed morning dose of rivaroxaban be taken
4 hours after haemostasis has been achieved. The dose after that can be taken as usual the following morning
when can patients take their missed dose of apixaban or dabigatran again
- take evening dose at normal time as long as it is no earlier than 4 hours after haemostasis has been achieved
For a patient taking an injectable anticoagulant that requires dental treatment likely to cause bleeding, what do you do
- consult with patients GMP or specialist to establish the pt’s medical condition and medication regime in order to assess the likely impact on bleeding risk for procedure
