Dental treatments of patients with anemia

In dental and oral surgery, we are seeing more and more patients who have to take antithrombotic pharmaceutical due to medical prescription.


 Dental treatments of patients with anemia
In dental and oral surgery, we are seeing more and more patients who have to take antithrombotic pharmaceutical due to medical prescription. The pharmaceutical are also known as blood thinners or coagulation medications. The use of these medicines is due to the prevention of venous or arterial thromboembolism, as the number of illnesses and deaths in our country is statistically very high. This group of patients represents a risk group for the dentist, so this should be taken into account when preparing the treatment plan and the dental procedures to be performed.
Thrombosis can also appear in the arterial and venous system. The pathomechanism of venous and arterial thrombosis varies, so the treatment and the medications used are different as well.
Coagulation factors play a role in venous thrombosis, whereas thrombocytes (platelets) are the main factors in arterial thrombosis, so therapy is different in this disease pattern. The so-called anticoagulant therapy is used in venous thrombosis. In arterial thrombosis therapy, platelets inhibit thrombosis (platelet activation TAGG).
Dental oral surgery applications for the disease pattern "Anticoagulants - coagulation poverty"
For patients undergoing antithrombotic therapy, we must pay special attention to the practicality and safety of dental oral surgery, as it affects wound healing during treatment and can lead to complications.
Considering this background knowledge, we need to procedure the treatment if the anticoagulant medication is still effective and still allows the patient's outpatient treatment and dental procedure. Nevertheless, we have to take into account a heavy bleeding, but even in this case, there is no risk of thromboembolism.
Tooth extraction, tooth and root removal, apicoectomy, supra and subgingival cleaning, and implant placement may result in increased bleeding during treatment.
The anticoagulants are subdivided into three main groups: the anticoagulants, the antiplatelet agents mentioned above, and the thrombolytics which are intended to dissolve the already formed thrombus. For the long-term treatment, the medications of the first two groups are used, which we will explain later, as we can notice these pharmacopoeias also in the dental clinic. Depending on the stage of treatment of the patient, further aspects must be considered before and after the dental procedure.
The most commonly used anticoagulants are heparin, LMWH and coumarin.

Heparin and LMWH (parenteral use)
For procedures or surgeries scheduled under current guidelines, the patient will receive the last dose rate of LMWH 12 hours prior to surgery and will resume therapy after 12 hours. The dentist uses local hemostasis to prevent major postoperative bleeding. In case of urgent intervention, the effect of heparin can be suspended with protamine sulfate.

For patients treated with coumarin derivatives, we must always request a laboratory test with current INR values prior to oral surgery to verify bleeding and clotting time. According to expert judgment, with an INR value of below 1.89 an oral surgery can be performed without consulting a cardiologist. Based on the results of clinical studies, it can be concluded that an INR between 2 -3.5 a surgery can be performed with good local wound care. During dental treatment, it is recommended to remove up to three teeth. It is of outstanding importance that the closure of the resulting wounds will be executed with sutures in the "Per Primam" method. For larger oral surgeries and high INR values, however, the INR should be temporarily reduced. The cessation of medication is in the responsibility of the cardiologist of the patient always, which the dentist requests in writing from the cardiologist in charge. In urgent cases, the effect of coumarin can be reversed with vitamin K (Konacion i.v.), fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC).
Among the antiplatelet agents, acetylsalicylic acid (ASA) is the most commonly used medication. In addition, several new medications have been marketed in recent years (eg ticlopidine, clopidogrel, dipyridamole). At low doses (up to 100 mg / day) no bleeding complications are to be expected. Patients receiving higher dosages, desmopressin (parenteral or nasal spray) is recommended and a careful local wound care is of tremendous importance as well.

Patients treated with double platelet aggregation (clopidogrel + ASA) tend to develop significant bleeding in oral surgery. Therefore, discontinuation of the medication should be considered prior to surgery, which might result in increasing the risk of thrombosis. The dentist and oral surgeon will always consult with the cardiologist of the patient who needs to decide on the patient's medication.

Novel oral anticoagulants = NOAC
In recent years, in addition to traditional medicines, new types of oral anticoagulants called NOAC (rivoroxaban, edoxaban, apixaban, dabigatran) have been developed. These patients do not require routine coagulation monitoring for their dental and oral surgery. According to the results of clinical studies, there is no cause for significant bleeding during the dental treatment and therefore there is no need to modify the medication. Dental and oral surgery should be performed with local hemostasis and, if possible, the intervention should be timed before taking the medicine.

All groups of medication require careful hemostasis during surgery. The dentist and oral surgeon operates using compresses on the wound, and it uses different absorbent (Spongostan Sponge, Gelaspon) to seal the wound carefully.
verzekenyseg EN

Source: Dental care of patients with anemia, dr. József Szalma and dr. Árpád Joób-Fancsaly, Hungarian Society of Vision, Maxillofacial Surgery and Hungarian Society of Implantology, 2015

Outpatient oral surgery of cardiovascular patients, Nikola Rebeka and dr. Kivroti Kivovics, Hungarian Dentist 2017/4. c.

Log In!