Anticoagulant Case

Anticoagulant Case
A Literature Review

The Amelodentineers

Diana Haripersaud

Amit Ramharacksingh

Racquel Lutchmedial

Nicoli Rajcoomar

Vanesha Sewalia

Nadeline Gaffoor






Gerodontology

School of dentistry

The University of the West Indies



June 21, 2018

 Anticoagulant Case

TABLE OF CONTENTS


1. INTRODUCTION 2

2. LITERATURE REVIEW 4

3. DISCUSSION 16

4. RECOMMENDATIONS 22

5. CONCLUSION 23

6. REFERENCE 24

APPENDIX 26

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 Anticoagulant Case

INTRODUCTION


A 77 year old male patient of Indo-Caribbean descent, presented at a dental clinic with pain in
his lower right first premolar tooth. His medical history revealed he had a deep vein thrombosis 1
year ago and angina on exertion. He was taking nifedipine, Crestor®, Warfarin® and aspirin
tablets. His vital signs were normal with a blood pressure of 135/78 mmHg, a pulse rate of 70
beats per minute. He had a letter of clearance from his General Practitioner, which stated that he
was fit to undergo an extraction at a dental clinic after he stopped the Warfarin® two days prior
to the extraction and then use Clexane® until he restarts the Warfarin® one day after any
extraction. The patient complied with the GP’s recommendations. As part of an oral examination,
the extra-oral examination was within normal limits, with no lymphadenopathy. The patient had
most of his natural dentition. Radiographs and clinical examination revealed that tooth #44 had
recurrent caries (see Appendix 1). Other clinical findings included: fractured teeth, missing teeth,
and defective restorations. The patient wanted to extract tooth #44 and replace the soon to be
extracted #44 together with the missing #36 and #37 with a removable partial denture. As part of
the treatment plan, tooth #44 was extracted and bleeding persisted longer than five minutes.
However, haemostasis was achieved followed by closure with a suture. A day after the extraction
of tooth #44, the patient returned to the dental clinic with a haematoma (see Appendix 2).

In the case presentation, the male geriatric patient had recurrent caries in his lower right first
premolar presenting with pain and thereby compromising his quality of life prompting him to
seek dental care. Furthermore, it is important to note that he was medically compromised and
that any dental treatment risked complications. This literature review seeks to rationalize the
treatment performed on a case-specific patient from a systematic approach by assessing the
patient attendance, patient medical and dental history, diagnoses, treatment options,
complication, pre-treatment, intra-treatment, post-treatment and dental follow-up.

Gerodontology is a branch of dentistry that deal with the diagnosis, management and treatment
of dental related issues that occur in older patients. Population aging may be due of cutting edge
technologies and increased accessibility in health procedures and management, or the possibility
of the public being educated on the benefits of self-care and proper hygiene, however, it is
certain that the availability of approved and tested medications and supplements have accounted
for such phenomena (Balkaran et al., 2018). In Trinidad and Tobago population aging is apparent
(see Appendix 3). It is suggested that people are more likely to visit dentists as they become
older and it is important that dentists are aware of the possible complications that can occur when

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treating patients with certain medical conditions or who are taking certain medications
(Jainkittivong, Aneksuk and Langlois, 2004). There are the occurrence of an increasing geriatric
population that seek dental care. The most common oral conditions among older people are tooth
loss, dental caries, periodontitis, dry mouth and oral precancer/cancer, which can compromise
older people’s quality of life (Thomson and Ma, 2014). This has many public health implications
which include methods of prevention, establishment of local dental treatment and management
guidelines, restorative dentistry, palliative dentistry and social awareness.

The objectives of the literature review pertaining to the presented case are: to illustrate key
findings in the history and oral examination, to determine the side effects of the patient’s
medication being used, to determine a comprehensive investigation of the patient, to underscore
the current guideline of the use of Warfarin in dental extractions, to discuss the management of
bleeding in the dental clinic and what measures could be used, to determine the most likely cause
of patient’s haematoma, to suggest palliative treatment interventions to alleviate the patient’s
symptoms of soreness and pain and to suggest restorative dental treatment options after dental
extraction.

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LITERATURE REVIEW
Gerodontology
In the last decade we have witnessed a constant increase in the elderly population. The most
significant increase will take place in developed countries where the number of the senior
citizens will reach 1.7 billion by 2050 (Mercel and Better, 2015). According the the WHO,
several countries are creating adapted policies in order to deal with the challenge of the “Grey
Tsunami”. The reasons of this trend come as a consequence of several factors: better health
conditions; improvement of health services; broader access to education; better nutrition in
quality and quantity; creation of psychological support; broadly promoted oral hygiene (Mercel
and Better, 2015). Since geriatric dentistry is not a priority in the basic educational syllabus, the
profession is not able to face a growing minority of atypical or unusual persons looking for
prosthodontic treatment that present outstanding features or variations from the normality
(Mercel and Better, 2015). Edentulism is a popular thought when considering geriatric patients.
However, it is now far less common than incremental tooth loss, irrespective of age. The
incremental loss of teeth during aging presents more of a problem for the dental profession,
because the piecemeal loss of teeth can result in the drifting of adjacent teeth and the
overeruption of opposing units, thus complicating prosthodontic rehabilitation at a later date
(Thomson and Ma, 2014). Chronic dry mouth occurs in a substantial proportion of older people,
affecting their speaking, enjoyment and ingestion of food, and denture wearing. About one in
five older people suffers from dry mouth because of their compromised salivary buffering
(Thomson and Ma, 2014). Higher rates of dry mouth are seen in those taking medications such as
antidepressants, respiratory agents, opiate containing analgesics or antihypertensive drugs. This
can explain why Dental caries is the major oral problem among older people. Steady increases in
both the absolute and relative numbers of older people—together with increases in tooth
retention into old age—pose particular challenges for the oral care system (Thomson and Ma,
2014).

Patient Assessment

Frequently, a comprehensive and well-taken patient History is important because of its

importance in diagnostic value. The medical history must be accurate, concise, and systematic.
The patient assessment is initiated by the patient demographics. A patient’s age, gender, ethnicity,
and employment status are vital in determining risk factors for certain ailments, and determining
the personalized treatment options. For example, hypertension, type 2 diabetes and cardiac
disease are highly prevalent in Trinidad and Tobago, and Indo-Trinidadians are the most affected

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ethnic group regardless of gender and among these individuals the peak prevalence of these
conditions is between 51 and 60 years, particularly for hypertension (Chadee et al., 2013).
Evidently, the patient that attended the dental clinic for pain is of Indo-Caribbean ethnicity and
over the age of 60, therefore if his medical history was not provided, one can assume that his risk
for hypertension, type 2 diabetes and/or cardiac disease are significantly high. 



The chief complaint states in the patient’s own words the reason for the visit. The patient that
attended the clinic presenting complaint was pain in the lower right premolar region. After the
chief complaint is noted, a history of the chief complaint is gathered to determine the details of
the problem to which the patient is seeking dental care. The past medical history determines the
previous health status of the patient to the current date, such as, It is used to assess conditions
such as bleeding disorders, cardiorespiratory disorders, endocrine disorders, neuromuscular
disorders, gastrointestinal disorders, endocrine disorders, infectious diseases, immunological
disorders, allergies and medication usage and previous hospital admissions (Ganda, 2013). This
information gathered from the past medical history can determine the patient’s risks, the need for
referral or consultation, complications of pre-treatment and post-treatment, and drug interactions
(Fragiskos, 2007). The patient experienced Angina on exertion. Angina pectoris is considered a
clinical syndrome that is characterized by temporary ischemia in part of or all of the
myocardium, resulting in diminished oxygen supply (Fragiskos, 2007). An episode of angina
pectoris presents as brief paroxysmal pain posterior to the sternum, may be precipitated by
fatigue, extreme stress, or a rich meal, and subsides within 2–5 minutes after rest and the use of
vasodilators. Furthermore the patient had a history of a deep vein thrombosis one year prior to
seeking treatment. These are vital in determining treatment options for the patient.

A family history is taken to determine the health status of immediate family members. This can
determine whether certain a familial disease pattern exists. Presence of diseases with a strong
hereditary component or tendency for familial clustering should noted; they include: coronary
artery disease, heart disease, diabetes mellitus, hypertension, cardiovascular accidents, asthma,
allergies, arthritis, anemia, cancer, kidney disease, or psychiatric illness (Ganda, 2013). A social
history is also vital to assess the quality of life of a patient and their socioeconomic background.
The review of systems is then investigated systematically to determine unestablished medical
conditions the patient may have failed to mention in the past medical history.

Simultaneously while investigating a patient’s history, the health provider should note the
patient’s general appearance and their ability to interact and respond to questions or instructions,
difficulties in gait, any expressions or pain or discomfort. Observations of that hands can also
suggest conditions the patient may have that are yet to be diagnosed, such as splinter

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hemorrhages of the fingernails which can be associated with infective endocarditis or finger
clubbing which is associated with chronic cardiopulmonary diseases. After noting a patient’s
general appearance, a patient’s vital signs should be recorded. The National Institute for Health
and Clinical Excellence (NICE) guideline for hypertension states that BP readings showing a
difference of 15mmHg or more between both arms is often associated with underlying peripheral
vascular or cardiovascular or cerebrovascular disease, as well as increased cardiovascular and
all-cause mortality (Ganda, 2013). A threshold of <140/90mmHg is considered adequate in
patients between 65–79 years of age and a systolic blood pressure (SBP) threshold of 140–
145mmHg is reasonable for patients 80 years and older (Ganda, 2013).

As part of a comprehensive extra-oral examination of a patient, the head and neck region should
be inspected and palpated for any lumps or bumps due to lymph node enlargement unilaterally or
bilaterally (Ganda, 2013). An assessment of motor and sensory responses of facial tissues noting
any abnormalities, as well as, assessment of the temporomandibular joint for proper function is
then done. An intra-oral examination is then assessed to ensure the soft tissues within the oral
cavity are within normal range. This is followed by charting of the patient dentition, clinical
investigation, radiographic investigation and specialty dental investigations such as electric pulp
test and thermal tests if deemed necessary. It is contraindicated to do thermal and electoral
sensitivity tests on teeth that are symptomatic.

After gathering information from the patient assessment, the health care provider can request
appropriate laboratory tests such as fasting blood glucose levels and HbA1C for patients at risk
or have diabetes, prothrombin time and partial thromboplastin to assess clot formation in patients
with suspected or known bleeding disorders, International Normalized Ratio for patients on
warfarin that have prosthetic heart valves or risk of thromboembolism (Ganda, 2013). A specific
treatment plan is formulated and then relayed to the patient with various treatment options and
the associated risks per treatment option. Any suspected or confirmed medical conditions that are
high risk should prompt the issuance of a medical clearance letter with details of the treatment
that the patient must forward to their medical practitioner to make possible adjustments to
current medication usage, drug interactions or recommend precautions a dental professional
should utilize prior to and during treatment.


Medication

It is imperative to confirm that a patient is compliant with their medication usage. It is also
important to assess the drug-drug interactions between the drugs that the patient is taking and the

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 Anticoagulant Case

anesthetics, analgesics, antibiotics, antivirals, or antifungals used or prescribed in the dental

setting as many of the drugs typically used in dentistry are substrates, inducers, or inhibitors of
the CYP450 enzyme system and can be associated with adverse drug-drug interactions (Ganda,
2013). The case patient was on Nifedipine, Crestor®, Warfarin® and Aspirin.

Nifedipine

Nifedipine is calcium channel blocker used to treat hypertension and chronic stable or
vasospastic Angina and reduce the risk of fatal and nonfatal cardiovascular events, primarily
strokes and myocardial infarctions (Wynn, Meiller and Crossley, 2010). It is used as an adjunct
for comprehensive cardiovascular risk management.

Mechanism of action - it inhibits calcium ions form entering the “slow channels” or select
voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization,
producing a a relaxed coronary vascular smooth muscle and coronary vasodilation (Wynn,
Meiller and Crossley, 2010). It increases myocardial oxygen delivery in patients with vasospastic
angina and reduces peripheral vascular resistant producing a reduction in arterial blood pressure.

It has been contraindicated to patients that experience hypersensitivity on usage. Symptomatic

hypotension with or without syncope can rarely occur with the use of immediate release
nifedipine in hypertensive emergencies and it is neither safe nor effective that can result in
adverse events such as, death, CVA, acute myocardial infarction and stroke have been reported
(Wynn, Meiller and Crossley, 2010).

Drug-drug interactions - patients must avoid concomitant use of nifedipine with grapefruit juice.
Antihypertensives, calcium channel blockers, CYP1A2 substrates, fosphenytoin, hypotensive
agents, magnesium salts, neuromuscular-blocking agents, alcohol, Alpha1-blockers, -Azole
antifungal agents, and cyclosporine potentiates the effects of nifedipine. Barbiturates, calcium
salts, carbamazepine and CYP3A4 inducers decreased the effects of nifedipine. Nifedipine also
decreases the effects of clopidogrel and quinidine.

Rosuvastatin 

Crestor® (Rosuvastatin) is an antilipemic agent and HMG-CoA reductase inhibitor to treat
dyslipidemias and used with dietary therapy for hyperlipidemia to reduce elevations in total
cholesterol, LDL-C, apolipoproteins B, nonHDL-C and triglycerides in patients with primary
hypercholesterolemia. It also is used to treat primary prevention of cardiovascular disease by
reducing the risk of stroke, myocardial infarction in patients without clinically evident coronary
heart disease or lipid abnormalities but with the criteria of and increased risk of cardiovascular
disease as a result of being older than 50 years of age in males and 60 in females, hsC-Reactive

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 Anticoagulant Case

Protein more than or equal to 2mg/L and the presence of at least one additional cardiovascular
disease risk factor such as hypertension (Wynn, Meiller and Crossley, 2010). Furthermore is is
used as an secondary prevention for cardiovascular disease by slowing down the progression of
atherosclerosis.

Mechanism of action - it inhibits 3-hydroxy-3methyglutaryl coenzyme A reductase, which is the

rate limiting enzyme in cholesterol synthesis. This results in a compensation increase in the
expression of LDL receptors on hepatocyte membranes and the stimulation of LDL catabolism
(Wynn, Meiller and Crossley, 2010).

Aspirin

Aspirin is an antiplatelet salicylate that is used to treat mild-to- moderate pain, inflammation and
fever, as well as, to prevent and treat myocardial infarction and acute ischemic strokes. If a
patient is at risk for thrombosis, aspirin should not be withdrawn for dentistry (Ganda, 2013).

Mechanism of action - it irreversibly inhibits cyclooxygenase-1 and -2 enzymes (COX-1 and

COX-2) via acetylation, which results in the decreased formation of prostaglandin precursors. It
also irreversibly inhibits the formation of thromboxane A2 platelets, producing and inhibitory
effect on platelet aggregation (Wynn, Meiller and Crossley, 2010).

It is contraindicated in patients sensitive to salicylates and other NSAIDs. It is also

contraindicated in patient with asthma, rhinitis, nasal polyps, acquired or inherited bleeding
disorders and 3rd trimester of pregnancy. NSAIDs also excessively increase the risk of
gastrointestinal bleeding, when combined with warfarin. This is an important issue, particularly
in the elderly and patients on anticoagulant therapy, including patients on low-dose/81mg aspirin
(Ganda, 2013).

Drug interactions - It is important to avoid concomitant use of aspirin with the influenza virus
vaccine and ketorolac. Aspirin potentiates that effects of alendronate, anticoagulants, carbonic
anhydrase inhibitors, collagenases, corticosteroids, heparin, salicylate, thrombolytic agents,
valproic acid, and vitamin K agonists. Antidepressants, antiplatelet agents, calcium channel
blockers, ketorolac, influenza virus vaccine, NSAIDs, serotonin reuptake inhibitors, loops
diuretics, omega-3-acid esters and norepinephrine reuptake inhibitors potentiate the effects of
aspirin. Aspirin decreases the effects of ACE inhibitors, loop diuretics, non-selective NSAIDs
and Probonecid. Efficacy of apririn may be reduces by corticosteroids and nonselective NSAIDs.

Coumadin

Warfarin (Coumadin) is an anticoagulant and vitamin K antagonist used in the prophylaxis and

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treatment of thromboembolic disorders and as an adjunct to reduce the risk of systemic embolism
after myocardial infarction. It is usually indicated with patients that have recently had a deep
vein thrombosis. Warfarin is a racemic mixture of “R” and “S” forms, where the S form is primarily
metabolized by CYP2C9. The R form is metabolized by CYP1A2 and CYP2C19 (Ganda, 2013).

Mechanism of action - hepatic synthesis of coagulation facts II, VII, IX and X, as well as
proteins C and S, require the presence of vitamin K (Wynn, Meiller and Crossley, 2010). Active
vitamin K is oxidatively converted to an inactive form which subsequently reactivated by
vitamin K epoxide reductase complex 1 (VKORC1) to produce clotting factors (Wynn, Meiller
and Crossley, 2010; Weltman et al., 2015)). Warfarin competitively inhibits the subunit 1 of the
multi-unit VKOR complex thus depleting functional vitamin K reserves and thereby reducing
synthesis of active clotting factors (Wynn, Meiller and Crossley, 2010; Weltman et al., 2015)). -
anticoagulant used to reduce blood clot formation by blocking the formation of vitamin K-
dependent clotting factors.

It has been contraindicated on patients that are hypersensitive to warfarin, have hemorrhagic
tendencies, aneurysms, any recipient of CNS surgery, pericarditis, bacterial endocarditis, history
of warfarin-induced necrosis, pregnancy patients and alcoholics. The use of augmentin an
tetracyclines are also contraindicated because they potentate the effects of Warfarin therapy.
Augmentin can very easily wash out the intestinal bacterial flora, impairing vitamin K
absorption, thereby resulting in a higher incidence of diarrhea and other gastrointestinal
symptoms such as gastric bleeding compared with amoxicillin alone (Ganda, 2013). The
systemic -azole antifungals and griseofulvin promote bleeding in the presence of Coumadin. The
use the topical antifungals is imperative.

Administration - Anticoagulation therapy utilizes an initial intravenous heparin due to its

immediate action, and it is used in a hospitalized setting to stabilize a patient experiencing an
acute thrombotic episode (Ganda, 2013). Once the acute state is under control, warfarin is started
orally. IV heparin is withdrawn when the therapeutic level of coumadin is reached and the patient
is discharged allowing the blood thinning therapy can be completely maintained using warfarin
(Ganda, 2013).

Drug Interactions - Inhibitors decrease the effects of warfarin while inducers potentiate the
effects of warfarin.

CYP1A2 inhibitors (Ganda, 2013): acyclovir (Zovirax), allopurinol (Zyloprim), amiodarone
(Cordarone), amitriptyline (Elavil), anastrozole (Arimidex), caffeine, cimetidine (Tagamet),
ciprofloxacin, clarithromycin, diltiazem, duloxetine (Cymbalta), enoxacin (Penetrex),

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erythromycin, flouroquinolones, fluvoxamine, furafylline, grapefruit juice, imipramine

(Tofranil), interferon, isoniazide (Niazid), ketoconazole, levofloxacin, lomefloxacin (Maxaquin),
methoxsalen (Oxsoralen), mexiletine (Mexitil), mibefradil (Posicor), norfloxacin, ofloxacin, oral
contraceptives, paroxetine (Paxil), propranolol (Inderal), ritonavir, tacrine (Cognex),
thiabendazole, ticlopidine (Ticlid), verapamil (Calan), and zileuton (Zyflo).

CYP1A2 inducers (Ganda, 2013): barbiturates, beta-naphthoflavone, broccoli, Brussels sprouts,

charcoal-broiled foods, insulin, methylcholanthrene, modafinal (Provigil), nafcillin (Novaplus or
Nafcillin), nicotine, omeprazole, phenytoin (Dilantin), primidone (Mysoline), rifampin (Rifadin),
and tobacco smoking.

CYP2C9 inhibitors (Ganda, 2013): amiodarone (Cordarone), anastrozole (Arimidex), cimetidine

(Tagamet), diclofenac (Voltaren), disulfiram (Antabuse), fenofibrate (Tricor), fluconazole,
flurbiprofen, fluvastatin (Lescol), fluvoxamine (Luvox), isoniazide (Niazid), itraconazole
(Sporanox), ketoconazole, ketoprofen (Orudis), lovastatin (Mevacor), metronidazole,
miconazole, oxandrolone (Oxandrin), paroxitine (Paxil), phenylbutazone (Zolandin), probenicid
(Benemid), ritonavir (Norvir), sertraline, sulfamethoxazole-trimethoprim (Bactrim),
sulfinpyrazone (Anturane), sulfonamides, teniposide (Vumon), trogltazon (Rezulin),
voriconazole, and zafirlukast (Accolate).

CYP2C9 inducers (Ganda, 2013): barbiturates, carbamazepine, phenobarbital (Solfoton),

rifampin (Rifadin), and secobarbital (Seconal).

CYP2C19 inhibitors (Ganda, 2013): allicin-garlic derivative, amitriptyline (Elavil),

carbamazepine (Tegretol), chloramphenicol (Chloromycetin), cimetidine (Tagamet), felbamate
(Felbatol), fluconazole, fluoxetine, fluvoxamine (Luvox), esomerprazole, imipramine (Tofranil),
indomethacin (Indocin), itraconazole (Sporanox), ketoconazole, lansoprazole—most potent PPI
inhibitor, meclobemide (Aurorix), modafinal (Provigil), omeprazole, oral contraceptives,
oxcarbazepine (Trileptal), pantoprazole (Protonix), paroxetine (Paxil), PPIs, probenicid
(Benemid), rabeprazole (Aciphex), ritonavir (Norvir), sertraline (Zoloft), ticlopidine (Ticlid),
tolbutamide (Orinase), topiramate (Topamax), troglitazone (Rezulin), and voriconazole.

CYP2C19 inducers (Ganda, 2013): carbamazepine, norethindrone (Aygestin), phenobarbital

(Solfoton), phenytoin (Dilantin), prednisone (Deltasone), rifampin (Rifadn), and valproic acid
(Depakote).

Warfarin Dental Guidelines - (See Appendix 4). Warfarin is administered in doses sufficient to
increase the prothrombin time to 2–2.5 times above the normal level (normal range: 11–12 s),

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thus delaying or preventing the intravascular coagulation of blood (Fragiskos, 2007). There is an
increased risk of prolonged postoperative bleeding, which is often difficult to control. An INR
value must be between 2 and 3 if the anticoagulation therapy is indicated for prophylaxis of
venous thrombosis or atrial fibrillation, and INR range 2.5–3.5 if it is indicated for patients with
prosthetic heart valves (Fragiskos, 2007). It was suggest that the INR levels determine whether to
continue the use of warfarin with local hemostatic agents if it is within therapeutic range or
postponing warfarin to make dose adjustments if INR exceeds 3.5 or 4.0 (Carter et al., 2003;
Randall, 2005; Khalil and Abdullah, 2014). However in recent studies, uncomplicated dental
extractions or minor osteotomies can often be performed at an INR 2.0-3.0 and for extensive
surgical procedures the INR should be 1.6–1.9, so that the risk of bleeding is reduced (Fragiskos,
2007; Al-Mubarak et al., 2007; Weltman et al., 2015). The dentist must never reduce the oral
anticoagulant without close consultation of the treating physician (Fragiskos, 2007).

Heparin

Heparin is an anticoagulant used in the prophylaxis and treatment of thromboembolic disorders.

Mechanism of action - it potentiates that action of antithrombin III and thereby inactivates
thrombin as well as activated coagulation factors IX, X, XI, XII and plasmin. It also prevents the
conversion of fibrinogen to fibrin (Wynn, Meiller and Crossley, 2010).

Treatment Options

Treatment can become more difficult dependent on the more debilitated a patient becomes or the
restriction of treatment due to financial obligations. The clinician needs to adjust from a “treat
everything” philosophy to treating and restoring what is necessary for patients to function
comfortably (Thomson and Ma, 2014). Thomson and Ma further suggested that it is important
that the initial treatment provided for geriatric patients can be modified in the future to allow
easier maintenance. Oral implants have shown to improve quality of life for older edentulous
patients, the shortcoming of oral implants is that it can also rapidly become a burden to those
who are unable to receive satisfactory maintenance. Furthermore, a viable treatment option is to
do nothing and refer to a colleague better suited for geriatric dental treatment. Prior to treatment,
the patient must comply with the instructions that was given by the physician and understand the
risks of treatment.

Restorative

The patient’s radiograph illustrated recurrent caries on tooth #44, inferior to a restoration and
extending into the pulp canal and as a result caused pulpal pain. Extensive loss of coronal tooth
tissue leads to problems with retention of subsequent restorations, weakening of tooth structure,

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and challenges of obtaining a coronal seal (Mitchell, Mitchell and McCaul, 2014). The tooth
appeared to be restorable as the radiopacity is about 1mm above the level of crestal bone. Since
the periodontal bone support was sufficient, if the tooth is functional, depending on what were
the opposing teeth present, a pulpectomy was a viable option. This will provide adaptability for
future dental treatment. However, costs play an important role on the decision for restorative
dental treatment and the fact that the patient treatment request trump all other treatment options
as long as they understand the pros and cons of the options presented.

Exodontia

After anesthesia is achieved using a 25-gauge long needle administering local anesthetic at the
right inferior alveolar nerve the extraction can continue. The simple extraction of a mandibular
premolar should require mandibular universal forceps (no. 151 forceps). The operator position
should be in front of and to the right of the patient. For mandibular right premolars, the mandible
is stabilized by the four fingers on the submandibular area and the thumb is placed on the
occlusal surface of the molars of the same side. Buccolingual force is applied for extraction of
these teeth and the final extraction movement is outwards and downwards (Fragiskos, 2007). 



The management of post-operative bleeding is important (see appendix 5). Once a tooth has been
removed, pressure should be placed on the buccal and lingual/palatal surfaces of the alveolus
around the socket to reduce the alveolus expansion from the extraction (McCormick, Moore and
Meechan, 2014). A piece of sterile gauze is then place over the socket with digital pressure. In
many cases, this firm pressure will allow initial haemostasis to be achieved. Tranexamic acid can
be effective in the control of post-operative bleeding. The British Committee for Standards in
Haematology advise that patients on oral anticoagulants requiring dental surgery can be
prescribed 5% tranexamic acid mouthwash, to be used as a rinse, four times daily, for two days
post-operatively. The patient should be given verbal and written post-operative management of
the extraction site, as well as, an emergency contact number and an appointment for follow-up.

Complications of Treating the Case Patient

Dentists frequently encounter medically compromised patients. Patients taking medications,
whether prescription or over-the-counter, consideration must be given to their therapeutic effects,
and also to potential drug interactions and side effects (Mace and Rickford, 2015). Drugs which
affect hemostasis may require additional precautions with a dental procedure that might cause
bleeding. Depending on the patient’s medical condition and the stress involved in a given
procedure, the potential exists for development of a medical emergency, thus, all dentists and

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dental office staff must be prepared to recognize and treat adverse responses using appropriate
emergency equipment and appropriate current drugs when necessary (Mace and Rickford, 2015).

Angina Pectoris

Ensure proper history, appropriate referral and consultation with the patient’s physician.
Consider sedation techniques for complicated procedures. Limit the amount of local anesthetic
containing 1:100,000 epinephrine (vasoconstrictor) to a maximum of 2 carpules. Consider the
use of anesthesia without vasoconstrictor. During treatment if the patient develops chest pain:
stop dental treatment, administer 0.5mg sublingual GTN, administer Oxygen via oxygen mask is
available, place patient to a upright seated position and if no relief within 2-5 minutes, suspect
myocardial infarction and call for emergency paramedics.

Hypertension

Ensure proper history, appropriate referral and consultation with the patient’s physician. It is
important to note that hypertensive drugs are associated with xerostomia, salivary glad swelling,
lichenoid type reactions and gingival hyperplasia (Wynn, Meiller and Crossley, 2010). Vital signs
should be assessed at every visit. Limit the amount of local anesthetic containing 1:100,000
epinephrine to a maximum of 2 carpules. Dentists should consider the use of anesthesia without
vasoconstrictor and also sedation techniques for complicated procedures.

Post-operative Bleeding

Haemostasis involves: vasoconstriction–vascular contraction smooth muscle in the walls of
blood vessels; Platelet plug formation–adhesion, interaction and aggregation of platelets;
Coagulation cascade–clotting factors in the extrinsic, intrinsic and common pathways lead to the
formation of fibrin (McCormick, Moore and Meechan, 2014). Post-extraction haemorrhage may
be categorized in relation to timing: Primary haemorrhage – the bleeding occurs at the time of
the surgery; Reactionary haemorrhage – 2–3 hours after the procedure as a result of cessation of
vasoconstriction; Secondary haemorrhage – up to 14 days after the surgery (McCormick, Moore
and Meechan, 2014). The haemorrhage may also be classified according to the site affected: soft
tissue; bone; vascular (McCormick, Moore and Meechan, 2014).

Haemorrhagic diatheses may occur due to disorders of coagulation, either due to deficiency of
certain coagulation factors or the presence of anticoagulants in the blood, which often occurs
when the patient takes anticoagulant medication for years for therapeutic or preventive purposes
(Fragiskos, 2007). A haematoma is a frequent postoperative complication due to prolonged
capillary haemorrhage, resulting in blood accumulating within the buccal tissue and diffuses in
areas of the least resistance ultimately ending within the submucosal region (Fragiskos, 2007).

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Therapeutic management of a haematoma consist of placing cold packs extraorally during the
first 24hrs, and then heat therapy to help it to subside more rapidly. There are also
recommendations for the administration of antibiotics to avoid suppuration of the hematoma, and
analgesics for pain relief (Fragiskos, 2007). There are no clinically significant increased risk of
postoperative bleeding complications from invasive dental procedures in patients on either single
or dual antiplatelet therapy (Morimoto, Niwa and Minematsu, 2008, Napeñas et al., 2013;
Weltman et al., 2015). A sufficient hemostasis can be obtained in most cases of tooth extraction
under anticoagulant therapy with warfarin (INR <3.0) and antiplatelet drugs (Morimoto, Niwa
and Minematsu, 2008; Fragiskos, 2007; Al-Mubarak et al., 2007; Napeñas et al., 2013; Khalil
and Abdullah, 2014; Weltman et al., 2015). Patients taking warfarin can safely undergo dental
extractions without any change of regimen if an effective local hemostatic agent or hemostatic
methods are used (Al-Belasy and Amer, 2003; Carter and Goss, 2003; Carter et al., 2003;
Morimoto, Niwa and Minematsu, 2008; Khalil and Abdullah, 2014).

Other Complications

Perioperative complications Post-Operative complications
Fracture of the crown of the adjacent tooth or Trismus
luxation of the adjacent tooth
Soft tissue injuries Hematoma
Fracture of the alveolar process Ecchymosis

Fracture of the mandible Edema

Broken instrument in tissues Postextraction granuloma

Dislocation of the temporomandibular joint Fibrinolytic alveolitis (dry socket)
Subcutaneous or submucosal emphysema Infection of wound
Hemorrhage Disturbances in postoperative wound healing
Displacement of the root or root tip into soft
tissues
Nerve injury eg. Facial Nerve Palsy as a result
of nerve block
Ischemic event eg. CVA or MI
Table 1: List of complications from simple exodontia (Adapted from: Fragiskos, 2007)

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 Anticoagulant Case

Post-exodontia Restorative Treatment 


Removable prosthodontics

Removable partial denture (RPD) is a cost-effective, minimally invasive procedure to replace
missing teeth that can either be acrylic based or metal based. Many patients require replacement
of missing teeth and associated structures to enhance appearance, improve masticatory
efficiency, prevent unwanted movement of teeth (overeruption/drifting), and/or improve
phonetics(Campbell et al., 2017). The steps involved in RPD-related therapy include the
evaluation of abutment teeth, abutment tooth position, abutment preparation, adapting the RPD
metal framework, relating the edentulous areas to the metal framework, communication with the
laboratory, patient education for home care and maintenance, and regular professional recall
(Campbell et al., 2017).



Fixed Prosthodontics

Conventional bridges are a viable option for tooth replacement that have good aesthetics,
however are costly and require a moderate destruction of sound tooth structure. The steps
involved in conventional bridges include the type of retainer, the selection of abutment teeth, the
assessment of retention, the assessment of support, the taper and parallelism, the selection of
pontics and patient education for home care and maintenance (Mitchell, Mitchell and McCaul,
2014).

Implant Prosthesis 

Implantology is based on the principle of osteointegration—a direct functional and structural
connection between a load-carrying titanium implant with bone with no intervening connective
tissue (Mitchell, Mitchell and McCaul, 2014). There are few contraindications for dental implant
treatment, which include: history of periodontal disease, radiotherapy to the jaw bone, untreated
intraoral pathology or malignancy, untreated periodontal disease, uncontrolled drug or alcohol
abuse, recent MI or CVA or valvular prosthesis surgery, intravenous bisphosphonate therapy and
smoking. Socket size and morphology such as alveolar bone loss is one of the key factors that
influence the decision making with respect to the timing of implant placement following tooth
extraction (Serio et al., 2014). Standard panoramic and periapical x-rays should be taken or a
cone beam computed tomography can be used to acquire images in a buccolingual dimension to
accurately identify anatomical landmarks such as the mental foremen in the case of replacing
tooth #44, and to assess the bone quality (Serio et al., 2014). Implant prostheses are quite
expensive and takes a long time for final delivery. Although, it is a viable esthetic option that can
positively influence the quality of life in older patients, implant maintenance and costs
contraindicate treatment in some older patients (Thomson and Ma, 2014).

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 Anticoagulant Case

DISCUSSION


What findings in the history and oral examination are of interest? 


With Reference to Chadee et al. in the literature review, the case patient’s age (77), gender (male)
and ethnicity (Indo-Caribbean) are vital in determining risk factors for certain ailments, and
determining the personalized treatment options. The patient that attended the clinic presenting
complaint was pain in the lower right premolar region, followed by a history of the chief
complaint to determine the details of the problem to which the patient is seeking dental care and
therefore initiate possible treatment options, as well as, complications. 



The patient experienced Angina on exertion; the dentist must be able to follow the steps for
treatment highlighted in the literature review. Furthermore the patient had a history of a deep
vein thrombosis one year prior to seeking treatment. These are vital in determining treatment
options with the consultation of a physician and adhering to various protocols before, during and
after the occurrence of related medical emergencies. Nifedipine is used as an adjunct for
comprehensive cardiovascular risk management. Crestor® (Rosuvastatin) is used as an adjunct
for comprehensive cardiovascular risk management. Aspirin is used as an adjunct for
comprehensive cardiovascular risk management. If a patient is at risk for thrombosis, aspirin
should not be withdrawn for dentistry (Ganda, 2013). Warfarin (Coumadin) is usually indicated
with patients that have recently had a deep vein thrombosis. Used an adjunct for comprehensive
cardiovascular risk management. Heparin is an low molecular weight anticoagulant used a a
bridging therapy if a patient has an INR value > 3.5. The case patient’s BP was 135/78 mmHg
with a pulse rate of 70bpm indicative of a controlled blood pressure and the likelihood of
medication compliance.



The head and neck region should be inspected and palpated for any lumps or bumps due to
lymph node enlargement unilaterally or bilaterally (Ganda, 2013). An assessment of motor and
sensory responses of facial tissues noting any abnormalities, as well as, assessment of the
temporomandibular joint for proper function is then done. The patient’s extra oral examination
were within normal limits, with no lymphadenopathy. This is suggestive that active infections
and tumors are absent. An intra-oral examination and dental charting is then assessed to ensure
the soft tissues and teeth within the oral cavity are within normal range. This intra-oral
examination and dental charting are all part of clinical investigations that can help develop a
working diagnosis. Radiographic and clinical examination illustrated tooth #44 with recurrent

16
 Anticoagulant Case

caries, and other clinical findings: fractured teeth, missing teeth and defective restorations.
Radiographic and clinical investigations confirm a diagnosis and influences the treatment plan.

What are the side effects of the medication being used?


Nifedipine Side effects - More than 10% of individuals experience side effects that occur in the
cardiovascular system as flushing and peripheral edema, central nervous system as dizziness and
headaches and the gastrointestinal system and nausea and heartburn. Less than 10% of of
individuals experience side effects such as, palpitations, transient hypotension, fatigue, mood
changes, insomnia, vertigo, dermatitis, pruritus, urticaria, diarrhea, abdominal camps, tremors,
dyspnea and diaphoresis. In dentistry, Nifedipine has been reported to cause 10% incidence of
gingival hyperplasia after 1-9 months with a dosage of 30-100mg/day (Wynn, Meiller and
Crossley, 2010). This side effect is resolved after discontinuation and reappear with
remedication.



Crestor Side effects - more than 10% of individuals experience neuromuscular and skeletal
myalgia. Less than 10% of individuals experience headaches, dizziness, nausea, abdominal pain,
constipation, threefold increase in hepatic ALT, arthralgia and hypersensitivity syndrome.



Aspirin Side effects - increased risks of hemorrhage. The most common adverse effect of
NSAIDS is gastric toxicity, and older adults and patients with a history of peptic ulcer disease
are at highest risk for this adverse side effect (Ganda, 2013). Prostaglandins also produce
compounds that protect the gastric lining. Once absorbed, NSAIDS inhibit prostaglandin
synthesis in the gastric mucosa and subsequent distribution to the gastrointestinal wall. Other
adverse effects are dose-related. Hypotension, tachycardia, dysrhythmias, edema, fatigue,
insomnia, coma, headache, angioedema, urticaria, hyperglycemia, acidosis, hyperkalemia,
hypernatremia, dyspepsia, dehydration, acid reflux, duodenal ulcerations, vomiting, anemia,
coagulopathy, thrombocytopenia, hemolytic anemia, hepatoxicity, rhabomyolosis, tinnitus,
interstitial nephritis papillary necrosis, proteinuria, renal failure, asthma, dyspnea, respiratory
alkalosis and anaphylaxis are potential and life-threatening side effects that can occur with
usage. In dentistry, aspirin may prolong hemostasis.



Warfarin Side effects - Bleeding is the major adverse effect; in particular for dental surgery.
Haemorrhages may occur at any site and is highly variable dependent on the patient. Angina,
chest pain, edema, haemorrhagic shock, hypotension, syncope, valor and vasculitis are are
possible cardiovascular side effects. In the central nervous system: coma, dizziness, fatigue,
fever, headaches, malaise and stroke are possible side effects. Other side effects include:

17
 Anticoagulant Case

alopecia, bullies eruptions, dermatitis, pruritus, urticaria, abdominal pain, anorexia,

gastrointestinal bleeding, mouth ulcers, nausea, altered taste sensation, hematuria,
agranulocytosis, anemia, leukopenia, retroperitoneal haematoma, jaundice, dyspnea,
osteoporosis, gangrene syndrome and anaphylactic reactions.



Heparan Side effects - Bleeding is the major adverse effect; in particular for dental surgery.
Haemorrhages may occur at any site and is highly variable dependent on the patient. Chest pain,
hemorrhagic shock and thrombosis are possible cardiovascular side effects. In the central
nervous system: chills, fever and headaches are possible side effects. Other side effects include:
alopecia, dermatitis, purpura, urticaria, abdominal pain,, mouth ulcers, nausea, and anaphylactic
reactions.

How would this patient be investigated? Be very detailed in the written presentation?

The health care provider can request appropriate laboratory tests such as fasting blood glucose
levels and HbA1C for patients at risk or have diabetes, prothrombin time and partial
thromboplastin to assess clot formation in patients with suspected or known bleeding disorders,
INR for patients on warfarin that have prosthetic heart valves or risk of thromboembolism
(Ganda, 2013). Firstly, a complete blood count with differential is needed to establish a baseline
with respect to the patient and to quantify the patient’s platelet count. HbA1c is done to gain
insight into the patient’s diabetic status, as diabetes can affect wound healing and can predispose
the patient to infection. Pt/Ptt is imperative to establish the patient’s coagulation capability. INR
is done to monitor the patient’s warfarin therapy. Lastly, recent ECG results should be available
to ascertain the patient’s baseline cardiac status and to rule out history of MI.

Discuss the current guidelines on the use of Warfarin® in dental extractions.


Refer to appendix 4 for guidelines. According to the British Society for Haematology Warfarin
Guidelines (Keeling, Tait and Watson, 2016) Warfarin should be stopped for 5 days before an
elective procedure if anticoagulation needs to be discontinued. Patients with venous
thromboembolism more than 3 months earlier can be given post-operative prophylactic dose
LMW heparin rather than bridging therapy. Patients at very high risk of recurrent venous
thromboembolism, such as previous venous thromboembolism whilst on therapeutic
anticoagulation who now have a target INR of 3·5, and patients who have had venous
thromboembolism less than 3 months previously should be considered for bridging. The patient
was advised by a physician to stop the Warfarin® two days prior to the extraction and then use
Clexane® until he restarted the Warfarin® one day after any extraction. It is possible that the
INR of the case patient was >3.5 and therefore was placed on anticoagulant bridging therapy. 




18
 Anticoagulant Case

According to the Warfarin and Heparin Protocols and suggested Dental Guidelines (Ganda,
2013), always consult with the patient’s M.D. to determine whether warfarin can be stopped
prior to the surgical procedure explaining the extent of surgery planned and the bleeding
expected. For some of the planned major procedures, warfarin can be temporarily stopped for 2-5
days without a risk to thrombosis. The Coumadin in such cases is restarted the evening of the
surgical procedure or the next day, depending on when the patient typically takes the Coumadin.
Trauma should be kept to a minimum in all cases, and the INR should ideally be checked on the
day of the treatment. Aspirin, NSAIDS, alcohol, liver disease, kidney disease, and other bleeding
disorders can increase the risk of bleeding in patients on Coumadin and heparin. Uncomplicated
oral surgical procedures can be performed without altering the Coumadin dose in patients with
an INR less than 3. Minimal trauma during surgery, absorbable sutures, and local hemostats will
additionally help. It is likely that in the medical clearance letter, the dentist described with detail
the proposed treatment of the extraction which is considered a “major procedures” because of the
increased risk for bleeding, tissue trauma, associated local inflammation, and/or infection. Thus,
the physician permitted an extraction at a dental clinic after stopping Warfarin® 48hrs prior to
the extraction and then use Clexane® until he restarts the Warfarin® one day after any
extraction. There were no indication of trauma being kept minimally and also there were no
mention of INR being checked on the day of treatment. The patient was not advised to stop
aspirin treatment and therefore could influence post-operative haemorrhaging. It is likely that the
INR value was >3 and the only local hemostatic method used after extraction were sutures.

Discuss the management of bleeding in the dental clinic and what measures could be used.

Haemostasis management is important (see Appendix 5). Bleeding is usually treated by cleaning
and irrigation of the site - this is also used to remove granulation tissue and remove any tissue
irritants. Once a tooth has been removed, pressure should be placed on the buccal and lingual/
palatal surfaces of the alveolus around the socket to reduce the alveolus expansion from the
extraction (McCormick, Moore and Meechan, 2014).A piece of sterile gauze is then place over
the socket with digital pressure. In many cases, digital pressure will allow initial haemostasis to
be achieved. However, it was not achieved with the case patient. Local anesthetic with
vasoconstrictor can be re-administered to prevent more bleeding from occurring. However, local
anaesthetic is limited maximum of 2 carpules if it contains epinephrine.



The British Committee for Standards in Haematology advise that patients on oral anticoagulants
requiring dental surgery can be prescribed 5% tranexamic acid mouthwash post-operatively.
Other, haemostatic agents such as gel foam or surgical can be used as well to manage bleeding.
Management of bleeding by primary wound closure (suturing) is another method of managing

19
 Anticoagulant Case

bleeding. This was the hemostatic method of choice by the dentist which appeared to promote
haemostasis. An additional option with excessive bleeds or arterial bleeds, is to use ligation and
electrocautery methods of managing bleeding. After haemostasis is achieved, the patient should
be given verbal and written post-operative management of the extraction site, as well as, an
emergency contact number. An appointment should be made for follow-up and continuation of
treatment.

Therapeutic management of a haematoma consist of placing cold packs extraorally during the
first 24hrs, and then heat therapy to help it to subside more rapidly. There are recommendations
for the administration of antibiotics to avoid suppuration of the hematoma, and analgesics for
pain relief (Fragiskos, 2007). The dentist should prescribe 5% tranexamic acid mouthwash
rinses, four times daily, for two days post-operatively. Tranexamic acid forms a reversible
complex that displaces plasminogen from fibrin resulting in the inhibition of fibrinolysis as well
as inhibiting the proteolytic activity of plasmin (Wynn, Meiller and Crossley, 2010).

What is the most likely cause of patient’s haematoma and why?


The patient appeared to have a purplish-red discoloration extending from the lateral border of the
the right side of the jaw to the inferior border and submandibular space, consistent of a
haematoma. A haematoma is a frequent postoperative complication due to prolonged capillary
haemorrhage, resulting in blood accumulating within the buccal tissue and diffuses in areas of
the least resistance ultimately ending within the submucosal region (Fragiskos, 2007). A
sufficient hemostasis can be obtained in most cases of tooth extraction under anticoagulant
therapy with warfarin (INR <3.0) and antiplatelet drugs (Morimoto, Niwa and Minematsu, 2008;
Fragiskos, 2007; Al-Mubarak et al., 2007; Napeñas et al., 2013; Khalil and Abdullah, 2014;
Weltman et al., 2015). Uncomplicated dental extractions or minor osteotomies can often be
performed at an INR 2.0-3.0 (Fragiskos, 2007; Al-Mubarak et al., 2007; Weltman et al., 2015). It
is likely that the case patient INR value was greater than 3.5 or 4.0 and therefore it warranted that
his medication be adjusted for his dental extraction. Instead, at the time of dental extraction, he
was on low molecular weight heparin and aspirin. Heparin potentiates that action of antithrombin
III and thereby inactivates thrombin and activated coagulation factors IX, X, XI, XII and
plasmin, and also prevents the conversion of fibrinogen to fibrin (Wynn, Meiller and Crossley,
2010). Aspirin potentiates that effects of anticoagulants, by irreversibly inhibits the formation of
thromboxane A2 platelets, producing and inhibitory effect on platelet aggregation (Wynn,
Meiller and Crossley, 2010). Aspirin can increase the risk of bleeding in patients on Coumadin
and heparin.



Following the extraction, bleeding persisted longer than five minutes. However, haemostasis was

20
 Anticoagulant Case

achieved followed by closure with a suture. The dentist used a physical method of achieving
haemostasis via primary wound closure there is the possibility that the surrounding capillaries
were hemorrhaging and the blood was diffusing into soft tissue spaces. Furthermore, it is likely
that the use of local anesthetic contained 1:100,000 epinephrine and thereby the effects of the
vasoconstrictor wore off after the dismissal of the patient.

What palliative treatment interventions would you suggest to the patient to alleviate his
symptoms of soreness and pain?

If Pain is present, it is advisable to prescribe analgesic medicaments to manage the pain.
Acetaminophen, COX2 NSAIDs and nonselective NSAIDs can potentiates the effects of
warfarin. Acetaminophen a central PGE inhibitor can be used to treat mild to moderate pain for
persons also taking warfarin. The dosage is 500-1000mg every 4-6 hours. Tramadol is the
analgesic-opioid of choice for pain with person that also take warfarin. It is used to treat
moderate-severe pain. this dosage is 50-100mg every 4-6 hours and not to exceed 400mg/day.



Assuming this question refers to prior to treatment received. Since the recurrent caries appear to
extend into pulp approximately 1mm above crestal bone, the option for conventional root canal
therapy can be considered as a optional palliative treatment intervention.



If referred to post-treatment the patient received. Pain usually presents after resolution of local
anesthetic and peaks at 24-48 hours post-treatment. Extra-oral cold compress during the first 24
hours can be used too reduce inflammation which can result in pain. This is followed by heat
therapy to hasten the alleviation of the haematoma. To treat the post-treatment pain, it is
important to isolate the cause of the pain and then remove the isolated cause accordingly.
Tramadol should be prescribed until the pain resolves.



What restorative dental treatment would you suggest following the extraction?

Firstly, all post-exondontia restorative treatment options must be comprehensively explained to
the patient so that they can make an informed decision on the treatment they want. The patient
wanted to replace the soon to the extracted #44 together with the missing #36 and #37 with a
removable partial denture. The patient can be informed that it possibility to add #46 to the
removable partial denture as from the radiograph it appears to be absent. The dentist should also
give the options for fixed prosthodontics with the option of metal, ceramic or PFM bridges
together with its costs and complications. Furthermore, an option for implantology can be given
if the patient falls within a suitable criteria as mentioned in the literature review. 


21
 Anticoagulant Case

RECOMMENDATIONS
Dentists undergo an oath prior to professional practice. As an aide-memoire of the dental oath,
dentist vow to avoid the twin traps of over treatment or therapeutic nihilism and undertake the
responsibility to not treat disease but to treat a sick human being. Recommendations to promote
and encourage optimal geriatric dental practices and research include:

• Encourage local medical and dental associations to create guidelines for dental treatment that
are tailored for the needs within the Caribbean, with periodic follow-up reports, which will
allow for effective treatment planning that cater to the general needs of Caribbean geriatric
folk and the option of the amendment of the Caribbean-based dental guidelines if follow-up
research deem it necessary.

• Introduce an accredited postgraduate/specialty programme in gerodontology that

incorporates prosthodontics and special needs of geriatric patients. This is to allow for
advanced training of Dentist to provide optimal treatment and management on geriatric
dental patients.

• Establish regular continued dental professional education courses for Dentists with annually
updated guidelines for treating geriatric patients.

• Promote public health research of geriatric dental patients within the Caribbean, with themes
such as, medical health and medication usage, incidence and prevalence of dental diseases,
and follow-up studies on restorative and palliative dental treatment.

• Develop additional elective courses within the undergraduate dental programme for students
who exhibit interests in a particular sub-specialty within dentistry. For example, an
advanced gerodontology elective or restorative geriatric dentistry elective. One can argue
that it is already taught within the undergraduate DDS programme, however, increased
exposure to this subfield will allow for better consolidation of information taught and the
possible exposure to updated or future treatment modalities.


22
 Anticoagulant Case

CONCLUSION
A 77 year old male patient of Indo-Caribbean descent, presented at a dental clinic with pain in
his lower right first premolar tooth. The patient wanted to extract tooth #44 and replace the soon
to be extracted #44 together with the missing #36 and #37 with a removable partial denture. The
case did not present with all of the treatment assessment however, the medical complications
were documented. The patient likely fit a specific criteria within the warfarin and heparin
protocols and suggested dental guidelines, and therefore the physician permitted an extraction at
a dental clinic after stopping Warfarin® 48hrs prior to the extraction and then use Clexane® until
Warfarin® is restarted one day after any extraction. It is likely that that patient would be given all
possible treatment options and opted for exodontia. There were no indication of trauma being
kept minimally and also there were no mention of INR being checked on the day of treatment.
The patient was not advised to stop aspirin treatment and therefore could influence post-
operative haemorrhaging. It is likely that the patient had and INR value >3. The dentist
proceeded to extract tooth #44 and noted that the bleeding persisted for more than 5 minutes,
where the dentist then achieved perceived haemostasis via primary wound closure with a suture.
The details of the treatment the patient received were not mentioned and a day later he presented
to the dentist with a haematoma surrounding the region where the extraction occurred.

A haematoma is a frequent postoperative complication due to prolonged capillary haemorrhage.

Aspirin can increase the risk of bleeding in patients on Coumadin and heparin. There is the
possibility that the surrounding capillaries were slowly hemorrhaging and the blood was
diffusing into soft tissue spaces. Furthermore, it is likely that the use of local anesthetic
contained 1:100,000 epinephrine and thereby the effects of the vasoconstrictor wore off after the
dismissal of the patient. Therapeutic management of a haematoma consist of placing cold packs
extraorally during the first 24hrs, and then heat therapy to help it to subside more rapidly. The
haemostatic agent, 5% tranexamic acid mouthwash, can be prescribed as a rinse, four times daily,
for two days post-operatively as part of therapeutic management of the haematoma. Pain
presented before or after treatment can by treated preferably with Tramadol 50-100mg every 4-6
hours and not exceeding 400mg/day until the pain resolves. After resolution of the haematoma
and healing of the alveolar socket, the patient will be able to continue his elected treatment to
replace his selected missing lower teeth: #36, #37 and #44 with a removable partial denture. 


23
 Anticoagulant Case

REFERENCE
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postoperative bleeding of patients maintained on oral anticoagulant therapy. British Dental
Journal, 203(7), pp.E15-E15.
2. Al-Belasy, F. and Amer, M. (2003). Hemostatic effect of n-butyl-2-cyanoacrylate (histoacryl)
glue in warfarin-treated patients undergoing oral surgery. Journal of Oral and Maxillofacial
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12. Keeling, D., Tait, R. and Watson, H. (2016). Peri-operative management of anticoagulation
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Extractions in Patients on Oral Antithrombotic Therapy. Journal of Oral and Maxillofacial
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491-499.
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oral anticoagulants requiring dental surgery. British Dental Journal, 203(7), pp.389-393.
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Warfarin. Dental Update, 32(7), pp.414-426.
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Periodontics. 4th ed. Ohio: Lexicomp.
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Dental Journal, 35, pp.3-8.
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and Abrahamyan, L. (2015). Management of Dental Extractions in Patients taking Warfarin
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Hudson, Ohio: Lexi-Comp.

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 Anticoagulant Case

APPENDIX
Appendix 1

Figure 1: periapical radiograph of the lower right premolar region illustrating recurrent caries on
tooth #44 inferior to a dental restoration extending into the pulp tissue.



Appendix 2

Figure 2: clinical colored photograph of the extra-oral region of the Patient presenting with a
purplish-red discoloration extending from the lateral border of the the right side of the jaw to the
inferior border and submandibular space.

26
 Anticoagulant Case

Appendix 3

Figure 3. Population structure, by age and sex, Trinidad and Tobago, 1990 and 2015

(Pan American Health Organization. (2015). The United Nations Department of Economic and
Social Affairs, Population Division. Revision 2015, New York.)

Appendix 4
A. Warfarin and Heparin Protocols and suggested Dental Guidelines (Ganda, 2013)
1. Consult with the patient’s M.D. to determine whether warfarin can be stopped prior to the
surgical procedure explaining the extent of surgery planned and the bleeding expected.
2. Amalgams, composites, cleanings, scaling root planing, and endodontic or prosthodontic
procedures are considered “minor procedures” because the bleeding is minimal.
3. Gum surgery, extractions, sinus lifts, and so on are considered “major procedures” because of
the increased risk for bleeding, tissue trauma, associated local inflam- mation, and/or
infection.
4. In most patients, when the PT/INR is in the therapeutic range, amalgams, composites,
cleanings, and endodontic and prosthodontic procedures can be done without stopping the
Coumadin. The bleeding is minimal and can be controlled by adequate pressure or local
hemostats.
5. For some of the planned major procedures, when warfarin can be temporarily stopped
without a risk to thrombosis per M.D., it is usually stopped 48 hours prior to the surgical
procedure. Occasionally, some physicians may want you to stop the Coumadin five days
prior to the planned surgical procedure. The Coumadin in such cases is restarted the evening

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of the surgical procedure or the next day, depending on when the patient typically takes the
Coumadin. So always confirm through patient communication if warfarin (Coumadin) intake
is occurring in the evening or morning hours.
6. If the patient’s PT/INR has always been in the therapeutic range in the past, you can proceed
without confirming the PT/INR prior to surgery. You will, however, need to confirm the PT/
INR prior to major surgery for those patients with a pre-treatment PT/INR above the
therapeutic range.
7. Trauma should be kept to a minimum in all cases, and the INR should ideally be checked on
the day of the treatment.
8. For patients with an increased risk for thrombosis, heparin is the bridging blood- thinning
medication used during the period prior to and immediately following the dental procedure.
The M.D. will then decide whether IV heparin or low molecular weight heparin (LMWH)
will be used. For anticoagulation conversion from Coumadin to IV heparin, the patient is
hospitalized. On the day of admission, the Coumadin intake is stopped and the PT/INR plus
APTT are constantly monitored. IV heparin is started q6h when the INR drops below 2. The
IV heparin dose is progressively increased to compensate for the Coumadin washout and
maintain adequate blood thinning. Heparin ultimately takes over the anticoagulation process
from Coumadin. When complete, Coumadin washout has been achieved and the PT/INR
attains baseline level (1.0). At this point, IV heparin is the only anti- coagulant that supports
the blood thinning. Always confirm that the PT/INR is normal before you begin the surgical
procedure. The major surgical procedure is done 6 hours after the last IV heparin dose. Once
adequate hemostasis is achieved post surgery, IV heparin is restarted. The APTT is monitored
to regulate the IV heparin dose. When the patient is stable postoperatively, Coumadin is
restarted by mouth on the evening of the procedure or the next day. The PT/INR and the
APTT are now monitored. As the PT/INR rises, the IV heparin dose is progressively
decreased. The dropping APTT will reflect the heparin washout. The entire process from start
to finish takes approximately seven days.
9. For anticoagulation conversion from warfarin to LMWH, no hospitalization is needed. The
patient injects the LMWH subcutaneously (SC). The APTT is not monitored with LMWH
use. The M.D. will decide the Coumadin washout and LMWH protocols, prior to the surgery.
10. Enoxaprine (Lovenox) is the most common LMWH preparation prescribed and it is injected
twice daily. Planned major surgical procedures in patients on Lovenox should be done 18–24
hours (six half-lives) after the last intake of the drug. The patient usually skips the Lovenox
subcutaneous injection on the evening prior to and the morning of the surgery. Lovenox is
restarted the evening of or the next day, depending on the thrombosis risk status of the
patient. Patients with a higher risk will restart the Lovenox on the evening following the

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procedure, once hemostasis has occurred. Once the patient is stable with the LMWH,
Coumadin is restarted by mouth and then the PT/INR is monitored. When the PT/INR is in
the therapeutic range of 2–3, the LMWH is withdrawn.
11. Aspirin, NSAIDS, alcohol, liver disease, kidney disease, and other bleeding disorders can
increase the risk of bleeding in patients on Coumadin and heparin.
12. Uncomplicated oral surgical procedures can be performed without altering the Coumadin
dose in patients in INR <3. Minimal trauma during surgery, absorbable sutures, and local
hemostats will additionally help. Tranexamic acid mouthwash can also provide hemostatic
support.
13. For emergency dental surgery it is best to rely on an INR test that is no more than 1week old.
14. Intrapapillary and intraligamentary injections are far safer than regional block anesthesia in
patients with an INR above the therapeutic range. Regional block anesthesia can cause
bleeding into the facial spaces, which can precipitate airway obstruction.
15. Intramuscular injections are administered very cautiously in the following populations:
patients on anticoagulants, cirrhosis patients, and patients with Crohn’s or Celiac disease
associated malabsorption of vitamin K. It is best to avoid.

B. British Society for Haematology Warfarin Guidelines (Keeling, Tait and Watson, 2016)
1. Warfarin should be stopped for 5 days before an elective procedure if anticoagulation needs to
be discontinued.
2. Patients with venous thromboembolism (VTE) more than 3 months earlier can usually be
given post-operative prophylactic dose low molecular weight heparin (LMWH) rather than
bridging therapy.
3. Patients at very high risk of recurrent VTE, such as patients with a previous VTE whilst on
therapeutic anticoagulation who now have a target INR of 3·5, and patients who have had
VTE less than 3 months previously should be considered for bridging.
4. Patients with atrial fibrillation who have a CHADS2 (Congestive failure; Hypertension; Age
≥75 years; Diabetes mellitus; prior Stroke, TIA or thromboembolism) score of ≤4 and who
have not had a stroke or transient ischaemic attack (TIA) in last three months should not
receive bridging.
5. Patients with a bileaflet aortic mechanical heart valve (MHV) with no other risk factors do
not require bridging whilst it should be considered in all other MHV patients.
6. We recommend that postoperative bridging is not started until at least 48h after high bleeding
risk surgery.

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Appendix 5

Figure 4: Management of Post-operative Haemorrhage (McCormick, Moore and Meechan,

2014).

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