aayisha quddus
Member
Oral Surgery & Warfarin
The risk of significant bleeding in patients on Warfarin
low.Patients on Warfarin might bleed more than normal but
bleeding is easily treated with 'local measures' (packing the
tooth-socket with material that aids blood-clotting and
stitching of the tooth socket).
Warfarin should NOT be discontinued in the majority of
patients requiring dental extractions and biopsies unless
instructed otherwise by their Anticoagulant Clinic.
There is an increased risk of thrombosis in patients who
have temporarily stopped taking their Warfarin (the risk is
small but potentially fatal). Bleeding complications, while
inconvenient, do not carry the same risks as thrombo-
embolic complications (that can lead to permanent
disability or death).
Treatment Algorithm for Warfarinised Patients (British Dental Journal 2003)
Please click here to send any comments via email.
Anti-Platelet Drugs & Oral Surgery
An increasing number of patients are taking “blood thinners”
for various medical conditions.
These drugs interfere with the body’s normal clotting
mechanism. There are 2 main processes by which the body
normally forms a blood clot at the site of tissue injury.
The 1st involves small blood cells called platelets which
clump together at the wound to form a mechanical plug. Thisplug slows the flow of blood through the vessel and forms a
matrix for the next phase of coagulation. During coagulation,
chemicals in the blood interact with each other to fill in the
spaces between the platelets, stabilise the clot, & make it
more solid until the process stops the bleeding.
Anti-platelet drugs such as aspirin, ticlopidine & clopidogrel
target this phase of clot formation by preventing platelets
from sticking together and adhering to blood vessels. These
drugs do this by creating permanent changes in the platelets
which last for the lifetime of the platelet (7 - 10 days). These
effects can only be countered as the body produces new platelets that have not been exposed to the drug.
Anti-coagulant agents such as warfarin inhibit the 2nd phase
of clotting by blocking production of proteins that stabilise
the clot. Warfarin can only affect these blood proteins when
they are being made.
Hæmophilia & Von Willebrand's
Disease & Oral Surgery
Patients with Hæmophilia (Factors VIII & IX
Deficiencies) & Von Willebrand's DiseaseHæmophilia is a group of hereditary genetic disorders that
impair the body's ability to control coagulation (blood
clotting).Hæmophilia A (Clotting Factor VIII deficiency) is the most
common form of the disorder (1 in 5,000 – 10,000 male
births).Hæmophilia B (Clotting Factor IX deficiency) is rarer than Hæmophilia A, occuring in around 1 in about 20,000 –
34,000 male births.Hæmophilia lowers blood plasma clotting factor levels of
the coagulation factors needed for normal coagulation.
When a blood vessel is injured, a clot does form but the
missing coagulation factors prevent fibrin formation, which is
necessary to maintain the blood clot.
A hæmophiliac does not bleed more intensely than a person
without it but can bleed for a much longer time. In severe
cases, even a minor injury can result in bleeding that can last
days - weeks or there is incomplete healing. In areas such
as the brain or inside joints, this can be fatal or permanently
debilitating.
Rare Clotting Factor Deficiencies
& Oral Surgery
Patients with Rare Clotting Factor DeficienciesClotting / Coagulation Factors are proteins in the blood that
control bleeding.
If any of the clotting factors are deficient or defective, the coagulation cascade is blocked. When this happens, the
blood clot does not form & bleeding continues longer than it
should.
Rare clotting factor deficiencies are bleeding disorders in
where clotting factors other than those of Factors VIII & IX
(otherwise known as Hæmophilias) are deficient / defective.
These are Factors I, II, V, VII, X, XI, XII & XIII.
Rare Clotting Factor Deficiencies
& Oral Surgery
Patients with Rare Clotting Factor DeficienciesClotting / Coagulation Factors are proteins in the blood that
control bleeding.
If any of the clotting factors are deficient or defective, the coagulation cascade is blocked. When this happens, the
blood clot does not form & bleeding continues longer than it
should.
Rare clotting factor deficiencies are bleeding disorders in
where clotting factors other than those of Factors VIII & IX
(otherwise known as Hæmophilias) are deficient / defective.
These are Factors I, II, V, VII, X, XI, XII & XIII.
Platelet Disorders & Deficiencies
& Oral Surgery
Patients with Platelet Disorders & DeficienciesPlatelets are cell fragments that function in the clotting / coagulation system.Platelets circulate for 7 - 10 days. About one third are
always transiently sequestered in the spleen.
The platelet count is normally 140,000 - 440,000/μL.
However, the count can vary slightly according to menstrual
cycle phase, decrease during near-term pregnancy
(gestational thrombocytopænia) & increase in response to
inflammatory cytokines (secondary or reactive
thrombocytosis).Platelets are eventually destroyed, primarily by the spleen.Platelet disorders include:
Any of these conditions, even those in which platelets are
increased, may cause defective formation of hæmostatic
plugs & bleeding.
The risk of bleeding is inversely proportional to the platelet
count.
When the platelet count is < 50,000/μL, minor bleeding
occurs easily & the risk of major bleeding increases.
Counts between 20,000 - 50,000/μL predispose to bleeding
with trauma, even minor trauma.
With counts < 20,000/μL, spontaneous bleeding may occur.
With counts < 5000/μL, severe spontaneous bleeding is
more likely.
However, patients with counts < 10,000/μL may be
asymptomatic for years.
Dialysis PatientsThe degree to which kidney, liver & bone marrow disease
interfere with coagulation following oral surgical procedures
is not well understood. Although there are no randomised,
prospective studies, it is unlikely that individuals whose
kidney failure is well managed with dialysis would be at
increased risk for clinically significant bleeding, even from
multiple dental extractions.
In the case of dialysis for Chronic Renal Failure, patients areheparinised for the time they are receiving dialysis, & they
could be anti-coagulated to some degree for several hours
thereafter.Heparinisation, along with chronic anti-coagulation (eg aspirin, warfarin), creates a multi-factorial coagulopathy
that puts a patient at higher risk for bleeding from oral
surgical procedures immediately following dialysis.
Although the half-life of heparin is approximately 4 hours, dialysis is a long & fatiguing procedure, & for this reason
patients are better able to tolerate dental care on a non-dialysis day. On the other hand, the longer a patient is
from their last dialysis, the more likely they are to have a coagulopathy from uræmia
The risk of significant bleeding in patients on Warfarin
low.Patients on Warfarin might bleed more than normal but
bleeding is easily treated with 'local measures' (packing the
tooth-socket with material that aids blood-clotting and
stitching of the tooth socket).
Warfarin should NOT be discontinued in the majority of
patients requiring dental extractions and biopsies unless
instructed otherwise by their Anticoagulant Clinic.
There is an increased risk of thrombosis in patients who
have temporarily stopped taking their Warfarin (the risk is
small but potentially fatal). Bleeding complications, while
inconvenient, do not carry the same risks as thrombo-
embolic complications (that can lead to permanent
disability or death).
Treatment Algorithm for Warfarinised Patients (British Dental Journal 2003)
Please click here to send any comments via email.
Anti-Platelet Drugs & Oral Surgery
An increasing number of patients are taking “blood thinners”
for various medical conditions.
These drugs interfere with the body’s normal clotting
mechanism. There are 2 main processes by which the body
normally forms a blood clot at the site of tissue injury.
The 1st involves small blood cells called platelets which
clump together at the wound to form a mechanical plug. Thisplug slows the flow of blood through the vessel and forms a
matrix for the next phase of coagulation. During coagulation,
chemicals in the blood interact with each other to fill in the
spaces between the platelets, stabilise the clot, & make it
more solid until the process stops the bleeding.
Anti-platelet drugs such as aspirin, ticlopidine & clopidogrel
target this phase of clot formation by preventing platelets
from sticking together and adhering to blood vessels. These
drugs do this by creating permanent changes in the platelets
which last for the lifetime of the platelet (7 - 10 days). These
effects can only be countered as the body produces new platelets that have not been exposed to the drug.
Anti-coagulant agents such as warfarin inhibit the 2nd phase
of clotting by blocking production of proteins that stabilise
the clot. Warfarin can only affect these blood proteins when
they are being made.
Hæmophilia & Von Willebrand's
Disease & Oral Surgery
Patients with Hæmophilia (Factors VIII & IX
Deficiencies) & Von Willebrand's DiseaseHæmophilia is a group of hereditary genetic disorders that
impair the body's ability to control coagulation (blood
clotting).Hæmophilia A (Clotting Factor VIII deficiency) is the most
common form of the disorder (1 in 5,000 – 10,000 male
births).Hæmophilia B (Clotting Factor IX deficiency) is rarer than Hæmophilia A, occuring in around 1 in about 20,000 –
34,000 male births.Hæmophilia lowers blood plasma clotting factor levels of
the coagulation factors needed for normal coagulation.
When a blood vessel is injured, a clot does form but the
missing coagulation factors prevent fibrin formation, which is
necessary to maintain the blood clot.
A hæmophiliac does not bleed more intensely than a person
without it but can bleed for a much longer time. In severe
cases, even a minor injury can result in bleeding that can last
days - weeks or there is incomplete healing. In areas such
as the brain or inside joints, this can be fatal or permanently
debilitating.
Rare Clotting Factor Deficiencies
& Oral Surgery
Patients with Rare Clotting Factor DeficienciesClotting / Coagulation Factors are proteins in the blood that
control bleeding.
If any of the clotting factors are deficient or defective, the coagulation cascade is blocked. When this happens, the
blood clot does not form & bleeding continues longer than it
should.
Rare clotting factor deficiencies are bleeding disorders in
where clotting factors other than those of Factors VIII & IX
(otherwise known as Hæmophilias) are deficient / defective.
These are Factors I, II, V, VII, X, XI, XII & XIII.
Rare Clotting Factor Deficiencies
& Oral Surgery
Patients with Rare Clotting Factor DeficienciesClotting / Coagulation Factors are proteins in the blood that
control bleeding.
If any of the clotting factors are deficient or defective, the coagulation cascade is blocked. When this happens, the
blood clot does not form & bleeding continues longer than it
should.
Rare clotting factor deficiencies are bleeding disorders in
where clotting factors other than those of Factors VIII & IX
(otherwise known as Hæmophilias) are deficient / defective.
These are Factors I, II, V, VII, X, XI, XII & XIII.
Platelet Disorders & Deficiencies
& Oral Surgery
Patients with Platelet Disorders & DeficienciesPlatelets are cell fragments that function in the clotting / coagulation system.Platelets circulate for 7 - 10 days. About one third are
always transiently sequestered in the spleen.
The platelet count is normally 140,000 - 440,000/μL.
However, the count can vary slightly according to menstrual
cycle phase, decrease during near-term pregnancy
(gestational thrombocytopænia) & increase in response to
inflammatory cytokines (secondary or reactive
thrombocytosis).Platelets are eventually destroyed, primarily by the spleen.Platelet disorders include:
- Abnormal increase in platelets (thrombocythæmia)
- Decrease in platelets (thrombocytopænia)
- Platelet dysfunction
Any of these conditions, even those in which platelets are
increased, may cause defective formation of hæmostatic
plugs & bleeding.
The risk of bleeding is inversely proportional to the platelet
count.
When the platelet count is < 50,000/μL, minor bleeding
occurs easily & the risk of major bleeding increases.
Counts between 20,000 - 50,000/μL predispose to bleeding
with trauma, even minor trauma.
With counts < 20,000/μL, spontaneous bleeding may occur.
With counts < 5000/μL, severe spontaneous bleeding is
more likely.
However, patients with counts < 10,000/μL may be
asymptomatic for years.
Dialysis PatientsThe degree to which kidney, liver & bone marrow disease
interfere with coagulation following oral surgical procedures
is not well understood. Although there are no randomised,
prospective studies, it is unlikely that individuals whose
kidney failure is well managed with dialysis would be at
increased risk for clinically significant bleeding, even from
multiple dental extractions.
In the case of dialysis for Chronic Renal Failure, patients areheparinised for the time they are receiving dialysis, & they
could be anti-coagulated to some degree for several hours
thereafter.Heparinisation, along with chronic anti-coagulation (eg aspirin, warfarin), creates a multi-factorial coagulopathy
that puts a patient at higher risk for bleeding from oral
surgical procedures immediately following dialysis.
Although the half-life of heparin is approximately 4 hours, dialysis is a long & fatiguing procedure, & for this reason
patients are better able to tolerate dental care on a non-dialysis day. On the other hand, the longer a patient is
from their last dialysis, the more likely they are to have a coagulopathy from uræmia
