MYTHS OF DENTAL SURGERY IN PATIENTS: RECEIVING ANTICOAGULANT THERAPY

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ABSTRACT
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Background

Continuous anticoagulant therapy with warfarin is administered to prevent a variety of medical complications, including thromboembolisms and stroke. When patients receiving continuous anticoagulant therapy are scheduled for dental surgery, a decision must be made whether to continue or interrupt the anticoagulant therapy.

Methods

The author reviewed the literature, focusing on dental surgery in patients receiving continuous anticoagulant therapy and in patients whose anticoagulant therapy was withdrawn before they underwent dental procedures.

Results

Of more than 950 patients receiving continuous anticoagulant therapy (including many whose anticoagulation levels were well above currently recommended therapeutic levels) who underwent more than 2,400 surgical procedures, only 12 (< 1.3 percent) required more than local measures to control hemorrhage. Only three of these patients (< 0.31 percent) had anticoagulation levels within or below currently recommended therapeutic levels. Of 526 patients who experienced 575 interruptions of continuous anticoagulant therapy, five (0.95 percent) suffered serious embolic complications; four of these patients died.

Conclusions

Serious embolic complications, including death, were three times more likely to occur in patients whose anticoagulant therapy was interrupted than were bleeding complications in patients whose anticoagulant therapy was continued (and whose anticoagulation levels were within or below therapeutic levels). Interrupting therapeutic levels of continuous anticoagulation for dental surgery is not based on scientific fact, but seems to be based on its own mythology.

Clinical Implications

Dentists should recommend that therapeutic levels of anticoagulation be continued for patients undergoing dental surgery. Practitioners should consult with the patient&apos;s physician if necessary to determine his or her level of anticoagulation before performing dental surgery.

Section snippets

INTERNATIONAL NORMALIZED RATIO

Therapeutic levels of warfarin are measured by the international normalized ratio, or INR, or pro-thrombin time ratio, or PTR (the higher the INR or PTR, the greater the anticoagulant effect).1 In 1992, the American College of Chest Physicians reported that its recommended therapeutic range of continuous anticoagulant is an INR between 2.0 and 3.0 for all conditions except artificial heart valves, for which the recommended INR is between 2.5 and 3.5.2 This statement has been endorsed by the

Myth 1

The first myth is that there are many documented cases of serious bleeding problems resulting from dental surgery in patients receiving therapeutic levels of continuous anticoagulation.

More than 2,400 cases of dental surgical procedures (that is, extractions, alveolar surgery and gingival surgery) performed on more than 950 patients receiving continuous anticoagulant therapy have been documented.5, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42

SUMMARY

  • Based on a review of the literature, I conclude that there is no need to withdraw continuous anticoagulant therapy for non-surgical or surgical dental procedures if the patient&apos;s anticoagulation level is within the currently recommended therapeutic range.

  • Dental practitioners should prescribe prophylactic or therapeutic antibiotics only when absolutely necessary for patients, particularly those receiving continuous anticoagulant therapy. Concomitantly administered antibiotics may interact

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    Dr. Wahl is in private general practice, 1601 Concord Pike, Wilmington, Del. 19803.

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