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References

Al-Mubarak S, Al-Ali N, Abou Rass M, Al-Sohail A, Robert A, Al-Zoman K, Al-Suwyed A, Ciancio S. Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy. Br Dent J. 2007; 203:1-5
Goodchild J, Donaldson M. An evidence-based dentistry challenge: treating patients on warfarin. Dent Implantol Update. 2009; 20:1-8
Evans IL, Sayers MS, Gibbons AJ Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg. 2002; 40:248-252
Ward B, Miller HS. Dentoalveolar procedures for the anticoagulated patient: literature recommendations versus current practice. J Oral Maxillofac Surg. 2007; 65:1454-1460
Ufer M. Comparative pharmacokinetics of vitamin K antagonists: warfarin, phenprocoumon and acenocoumarol. Clin Pharmacokinet. 2005; 44:1227-1246
Becker W. Postoperative bleeding and oral anticoagulants. Br Dent J. 2007; 203:410-411
Albers G, Dalen JE, Laupacis A, Manning WJ, Petersen P, Singer DE. Antithrombotic therapy in atrial fibrillation. Chest. 2001; 119:194S-206S
Büller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126:401S-428S
Salem DN, Stein PD, Al-Ahmad A, Bussey HI, Horstkotte D, Miller N Antithrombotic therapy in valvular heart disease – native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126:457S-482S
Nematullah A, Alabousi A, Blanas N, Douketis JD, Sutherland SE. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis. J Can Dent Assoc. 2009; 75:41-41i
Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations. Br J Oral Maxillofac Surg. 2000; 38:124-126
Devani P, Lavery KM, Howell CTJ. Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?. Br J Oral Maxillofac Surg. 1998; 36:107-111
Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med. 1996; 158:1610-1615
Blinder D, Manor Y, Martinowitz U, Taicher S, Hashomer T. Dental extractions in patients maintained on continued oral anticoagulant: comparison of local hemostatic modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999; 88:137-140
Liverpool: North West Medicines Information Centre; 2007
Muthukrishnan A., Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations. Br J Oral Maxillofac Surg. 2000; 38:124-126
Blinder D, Manor Y, Martinowitz U, Taicher S. Dental extractions in patients maintained on oral anticoagulant therapy: comparison of INR value with occurrence of postoperative bleeding. Int J Oral Maxillofac Surg. 2001; 30:518-521
Perry DJ, Nokes TJC, Heliwell PS. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Dent J. 2007; 203:389-393
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Dewan K, Bishop K, Muthukrishnan A. Management of patients on warfarin by general dental practitioners in south west Wales, continuing the audit cycle. Br Dent J. 2009; 206:1-7
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A study to assess management of patients on warfarin by general dental practitioners (GDPS) in the west midlands

From Volume 39, Issue 8, October 2012 | Pages 578-587

Authors

Karun Dewan

BDS, MFDS RCSEng, LDS RCSEng, MSc(Prosth Dent), FDS RCS(Rest Dent)

Staff Grade, Department of Restorative Dentistry, Morriston Hospital, Swansea SA6 6NL, UK

Articles by Karun Dewan

Viren Vithlani

BDS, MFDS RCS(Ed)

General Dental Practitioner, AJ Moore and Associate, Long Eaton, Nottingham

Articles by Viren Vithlani

Neil Patel

Specialist Registrar in Orthodontics, Eastman Dental Hospital, 256 Gray's Inn Road

Articles by Neil Patel

Kathy Warren

BDS, LDS RCS(Eng), FDS RCS(Ed), FDS RCS(Eng), DRD RCS(Ed), PhD

Consultant in Restorative Dentistry, School of Dentistry, Birmingham Dental Hospital, St Chad's Queensway, Birmingham B4 6NN, UK

Articles by Kathy Warren

Abstract

Current management protocols for anticoagulated patients undergoing dental procedures are influenced by evidence-based guidelines. These guidelines state that the risk of significant bleeding is low in patients who have a stable INR within a therapeutic range, (2-4). The risks of interruption of anticoagulant therapy is greater than the risk of bleeding. This paper discusses the current practice of general dental practitioners (GDPs) in the West Midlands when treating patients taking warfarin and compares these findings with standard guidelines. A questionnaire was sent to 638 GDPs in West Midlands in 2010, 492 (77%) were returned. This study was carried out three years after a similar study carried out in South West Wales and after the guidance updated by the BNF and NMWIC. Thirty-three (7%) of the respondents did not treat patients on warfarin. The majority of respondents (86%) considered that a dental extraction in a patient on warfarin is a procedure associated with a high risk of bleeding. Surgical implant placement (75%), subgingival debridement (49%) and inferior dental block (40%) administration were also considered by GDPs to be associated with a high risk of bleeding. The majority (88%) of the respondents check the INR of anticoagulated patients before carrying out treatment. Of these, 244 (52%) would do so within 24 hours and 78 (17%) of them within 72 hours. Only 117 (25%) considered 4.0 as the safe upper limit for the INR for performing high-risk procedures.

Clinical Relevance: The findings of this study demonstrate that there is general awareness about how to manage patients on warfarin but uncertainties still exist among general dental practitioners. Further education and training would improve the care of patients on warfarin in a primary care setting.

Article

Oral anticoagulants are effective prophylactic medications in the prevention of life-threatening thrombo-embolic events.1 Warfarin, a competitive inhibitor of vitamin K, is the most commonly prescribed oral anticoagulant in the UK.2 It reduces the risk of thrombo-embolic events in patients with mechanical heart valves, deep vein thrombosis and other hypercoagulable states.1,3,4,5

Since an increasing number of people are on long-term oral anticoagulant therapy, GDPs' awareness of current guidelines on the management of anticoagulated patients in the dental environment is important.6 This should include assessment of the potential problems prior to undertaking a dental procedure that carries a risk of bleeding.4

Warfarin activity is measured and monitored using the International Normalized Ratio (INR).1 This is a measure of the extrinsic pathway of coagulation and is used to measure the clotting tendency of blood.1,–4

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