Dental management in patients receiving anticoagulation or antiplatelet treatment

DENTAL DENTAL MANAGEMENT IN MANAGEMENT IN

PATIENTS RECEIVING PATIENTS RECEIVING ANTICOAGULATION ANTICOAGULATION OR ANTIPLATELET OR ANTIPLATELET

TREATMENTTREATMENT

IS STOPPING OF THE THERAPY REALLY

REQUIRED IN MINOR DENTAL SURGERY ?

Piti Niyomsirivanich, MD.

CLINICAL SCENARIO

ผู้��ชาย 45 ปี Old CVA with AF with MR S/P MVR on warfarin 22 mg/week INR 3.0

จะถอนฟั�น ทำ�าไงดี� ? หย�ดียา warfarin ก่�อนไปีถอนฟั�น ไปีถอนฟั�นเลย

CLINICAL SCENARIO

ผู้��หญิ�ง 75 ปี Previous STEMI S/P PCI Drug Eluting Stent

เมื่ !อ 6 เดี อนก่�อน

ASA 81 mg/d + Clopidogrel 75 mg/d

จะไปีถอนฟั�น ทำ�าไงดี� หย�ดียา ASA + Clopidogrel ก่�อนไปีถอนฟั�น หย�ดียา ASA ก่�อนไปีถอนฟั�น หย�ดียา Clopidogrel ก่�อนไปีถอนฟั�น ไปีถอนฟั�นไดี�เลย

TUTORIAL IN ORAL ANTITHROMBOTIC THERAPY

ANTITHROMBOTIC DRUGS CATEGORIZED BY PHARMACODYNAMICS

Anti thrombotic drug categories

Generic names and subgroup

Antiplatelet agents COX-1 inhibitor Aspirin

ADP receptor inhibitor: Clopidogrel ,Prasugrel ,Ticlopidine ,Ticagrelor

Gp IIb/IIIa inhibitor Abciximab ,Eptifibatide , Triofiban

Phosphodiesterase inhibitor Cilostazol , Dipyridamole

Vitamin K antagonist Warfarin , Coumarin , Dicoumarol , Phenprocoumon , Acenocoumarol

Factor Xa inhibitor Enoxaparin (SC), Fundaparinux (SC), rivaroxaban(SC)

Direct thrombin inhibitor dabigatran

Thrombolytic drugs tPAAlteplase , Tenecteplase , Reteplase , Streptokinase , UrokinaseAdapted from Cochrane Database Syst. Rev,CD 001820.

OVERVIEW OF CLOT FORMATION

injury

TF ThrombinCoagulation cascade

Collagen vWF

ADP

Thromboxane A2

P2Y12

PAR-1

GP IIb/IIIa

Fibrin platelet aggregation

Xa/Va prothrominase complex


injury


Collagen vWF

ADP

Thromboxane A2

P2Y12

PAR-1

GP Iib/IIIa



CONCEPTS ON EARLY COAGULATION CASCADE

Intrinsic pathway extrinsic pathway

TF/VIIa

XI XIa

IX IXa

XaX X

XII,HMK , PK

Prothrombin(II) Thrombin

Fibinogen(I) Fibrin

PL ,VIIIa Ca PL, Ca

PL ,Va Ca

Adapted from Thromb Haemost 85(6):958-65



TF/VIIa

XI XIa

IX IXa

XaX X

XII,HMK , PK


Fibinogen(I) Fibrin

VKA e.g. warfarin

Inh. II , VII ,IX ,X

PL ,VIIIa Ca PL, Ca

PL ,Va Ca




XI XIa

Xa

XII,HMK , PK

Fibinogen(I) Fibrin

Factor Xa inhibitor : Enoxaparin ,

Fundaparinux

PL ,VIIIa Ca PL, Ca

PL ,Va Ca

TF/VIIaIX IXa



X X



XI XIa

XII,HMK , PK

Fibinogen(I) Fibrin

Direct thrombin inhibitor :

dabigatran

PL ,VIIIa Ca PL, Ca

PL ,Va Ca

TF/VIIaIX IXa


XaX X


CONCEPTS ON THE NEW, CELL-BASED COAGULATION MODEL

Initiation

TF –bearing celle.g. fibroblast TF

Adapted from Thromb Haemost 85(6):958-65Arterioscler Thromb Vasc Biol 2006:26(1):41-8


Initiation


VII

VIIa



Initiation


VIIa

TF/VII complex

X

Xa

IX

IXa



Initiation


VIIa

TF/VII complex

IXa

Xa/Va complex

VaXa



Amplification


VIIa

TF/VII complexVaXa

IXa

Xa/Va complex

prothrombin

Thrombin



AmplificationTF –

bearing celle.g.

fibroblast

TF

VIIa

Va

Xa

IXa

Thrombin



AmplificationTF –

bearing celle.g.

fibroblast

TF

VIIa

Va

Xa

Thrombin

Platelet Activation

VaV

vWF/VIII

VIIIa

IXa

IX

PAR1,PAR4


Thromboxane A2 synthesis


PropagationTF –

bearing celle.g.

fibroblast

TF

VIIa

Va

Xa

Activated Platelet

Va

VIIIa IXa

Intrinsic tenase

X Xa


CONCEPS ON THE NEW, CELL-BASED COAGULATION MODEL

PropagationTF –

bearing celle.g.

fibroblast

TF

VIIa

Va

Xa

Activated Platelet

Va

VIIIa IXa

Intrinsic tenase

XaVa/Xa complex(Prothrombinase)

Fibrinogen Fibrin

Prothrombin Thrombin


PRE-OPERATIVE EVALUATION FOR ANTICOAGULANTS

Bleeding Risk Procedure

Versus

Risk of thromboembolic events

Whether to off anticoagulants ?

PATIENT VERSUS SURGICAL RISK FACTORS

Patient Risk Factors

Prior thromboembolism ?

Mechanical valve ?

AF ?

Surgical Risk Factors

Procedure type ? Quantify Risk of

bleeding ?

Quantify Risk of thromboembolism ?

RISK OF THROMBOEMBOLISM

Michael et al. After discontinue OAT in 169 patients 22% thromboembolic event 7% died

Tulloch and Wright et al. Case Report Discontinue OAT for 8 days before oral surgery Post operative day 2 CVA Post operative day 4 branchial artery emboli

Br Heart J 1970;32:359-364Circulation 1954;9:823-834

RISK OF THROMBOEMBOLISM

Wahl et al. Review > 2400 cases 950 cases continued oral antithrombotic

12 cases experienced post-operative bleeding Which controlled by local measures

Incidence of thromboembolic complication was about 1%

Small but outcome serious !!!

Arch Intern Med 1998;158:1610-1616

RISK OF HEMORRHAGE

Cambell et al. Randomized controlled trial Continue OAT versus withdrawn OAT No significant difference in total blood loss

Madrid and Sanz Systemic review Continue OAT with INR 2-4 and discontinue OAT No significant in post operative hemorrhage

J oral Maxillofac Surg 2000;58:131-135Clin Oral Implants Res 2009;20 Suppl 4:96-106

MEANING OF INR VALUE

Most anticoagulation therapyINR 2.0 - 3.0

Few INR 3.0 - 4.0

Blinder et al. INR value did not significantly influence the

incident of perioperative bleeding (INR 2.0 -4.0)

INR 2.0-4.0 post operative hemorrhage can not be so serious

Int J Oral Maxillo Surg 2008;66:51-57

CONCLUSION

ThromboembolisThromboembolism Riskm Risk

Bleeding Risk

Local control

Small but outcome serious !!! Arch Intern Med 1998;158:1610-1616

CHEST 2012; 141:326-350S

CLINICAL SCENARIO

ผู้��ชาย 45 ปี Old CVA with AF with MR S/P MVR on warfarin 22 mg/week INR 3.0

จะถอนฟั�น ทำ�าไงดี� ? หย�ดียา warfarin ก่�อนไปีถอนฟั�น ไปีถอนฟั�นเลย


injury


Collagen vWF

ADP

Thromboxane A2

P2Y12

PPAR-1

GP Iib/IIIa



ANTIPLATELET

promote

vWFvWF

ASPIRIN ARACHIDONIC ACID METABOLISM

Phospholipid-Arachidonic acid

Phospholipases

Arachidonic acid

Prostaglandin G2

Prostaglandin H2

Tissue Specific Isomerases

COX1

HOX

Arachidonic acid

Prostaglandin G2

Prostaglandin H2

COX2

HOX

Thromboxane A2(Promote Thrombosis)

Prostaglandin D2 Prostaglandin E2 Prostaglandin F2aProstacyclin(inhibit Plt aggregation)

Low dose ASA High dose ASA(Inflammatory dose)

Higher dose block

Adapted from: CHEST 2012; 141(2) (Suppl) : e89S-e119S

Platelets & vascular endothelial cells

Dipyridamole. effects of dipyridamole on NO/cGMP and prostaglandin/cAMP signal transduction in human

platelets.

Adapted from :Aktas B et al. Stroke. 2003;34:764-769

Copyright © American Heart Association, Inc. All rights reserved.

Platelet aggregation Platelet aggregation

DIPYRIDAMOLE.PROMOTE PROSTACYCLIN

promote

CILOSTAZOL PHOSPHODIESTERASE III INHIBITORS

Eur Heart J (2008) 29 (18): 2202-2211.

Vasodilatory stimulating phosphoprotein

THIENOPYRIDINESTICLOPIDINE ,CLOPIDOGREL , PRASUGREL

Eur Heart J (2008) 29 (18): 2202-2211.

ANTIPLATELET AND ORAL SURGERY

Ardekian et al. 39 patients taking ASA 100 mg

19 continued20 stopped

Bleeding time 3.1 min versus 1.8 min (p=0.004)

None of them had prolong bleeding time >10 min

No patient experienced uncontrolled bleeding Antiplatelet should not be discontinued prior to

dental procedureJ Am Dent Assoc 131,331-335

DUAL ANTIPLATELET OR SINGLE ANTIPLATELET?

Nepanas et al. Retrospective study 43 patients who were receiving single or dual

antiplatelet therapy

Twenty-nine patients (67 percent) were receiving dual antiplatelet therapy.

The authors found no differences between patients receiving single or dual antiplatelet therapy for all variables.

J Am Dent Assoc. 2009 Jun;140(6):690-5

COMPLICATION RATES FROM DISCONTINUATION OF ANTIPLATELETE < 6 WKS AFTER PCI W/WO STENT

CHEST 2012; 141:326-350S

CLINICAL SCENARIO





CLINICAL SCENARIO





LOCAL BLEEDING CONTROL

Local anesthesia with vasoconstrictor Local hemostatic material (bonewax ,surgicel) Local hemostatic agent (epinephrine solution )

Suture Pressure Dressing Peridontal pack application Tranexamic acid Mouth wash

Journal of Oral Science,Vol.49,No.4,253-258,2007

TAKE HOME MESSAGE Warfarin

ถ�า INR 2 - 4 ไมื่�ต้�องหย�ดี

ถ�า INR > 4 ไมื่�ต้�องผู้�า/ทำ�าฟั�นทำ�ก่ก่รณี�

Antiplatelets ASA , clopidogrel ,prasugrel , ticlopidine ,

cilostazole , Tegagrelor etc.

ไมื่�ต้�องหย�ดีทำ�ก่รณี� ไมื่�ว่�าจะ on ดี�ว่ย indication primary prevention , secondary prevention , S/P stent ก่&ต้ามื่ ทำ'(ง single หร อ dual antiplatelet

HIGH ALERT DON’T STOP OAT!!!

Warfarin Mechanical valve , Hypercoagulable state

Antiplatelet S/P w Stent [DES , BMS] within 1 years

สุ�ดีทำ�าย

หาก่ INR สุองถ*งสุ�!น' (น บ่�หย�ดีINR เก่�น 4 ให� ผู้�าไมื่�antiplatelet ไซร� อย�าไดี�

หย�ดีเลยบ่�หย�ดีOATไว่� จ'ก่ไดี�

ปีลอดีภั'ย

THANK YOU

Health & Medicine

Dental management in patients receiving anticoagulation or antiplatelet treatment