Dental Treatment for Patients on Blood Thinner

Blood thinners do not affect most dental procedures.  However, blood thinners can have an effect on blood clotting during dental surgery.  Depending on the medication, the dosage and the extent of dental surgery, bleeding can be a concern.  The low level of aspirin use for blood thinning is rarely a concern.  However, stopping aspirin use the day before dental surgery is usually recommended. 

Warfarin use presents the most common potential bleeding problems that dentists encounter.  Stopping coumarin medication prior to dental treatment is controversial.  Since it takes 48 to 72 hours for warfarin to be effective, it must be stopped 2-3 days before treatment, which puts the patient at risk for serious blood clotting complications.   So the risk-benefit has to be determined, that is, uncontrolled bleeding verses blood clot formation in the vessels.

Warfarin should not be stopped for most dental procedures including most extractions and implant placements.  But with any dental surgery, a consultation with the patient’s physician and a recent INR blood test should be reviewed.  Usually an INR up to 2.5 is acceptable and safe for dental surgery, thus coumarin does not need to be stopped or lowered.  With a common sense approach, I ask my patients if they clot, that is, the bleeding stops, in a reasonable amount of time with direct pressure on a skin cut.  During dental surgery, treatment can be done to enhance clotting, such as, the use of clotting agents, stitches, bone grafts and membranes.  Bone grafts and membranes preserve bone in an extraction site as well as reduce bleeding.

Last year I saw a dental phobic 57-year–old patient Todd, who was taking warfarin for deep venous thrombosis from poor circulation in his lower legs and thighs.  He was in severe pain from a split lower left molar and needed an extraction.  After consulting with his physician and determining his INR was 2.2, Todd continued his normal warfarin regime.  With conscious sedation, his tooth was removed and a bone graft and membrane were placed with no bleeding complications.  He was comfortable throughout the procedure with no memory of the event.  Eight weeks later, a root replacement titanium implant was placed under conscious sedation with him continuing his warfarin use.  Just as during his first treatment, Todd had no bleeding problems and happily had no memory of the implant procedure.   4 months later, an implant crown was fabricated and placed with the same great results.

While a risk-benefit assessment, bleeding verses clotting, must be made for each patient, dentist can perform most dental treatments safely for patients taking warfarin without the need for stopping warfarin therapy.     

Enjoy Life and Keep Smiling!

George Malkemus has had a Family and Cosmetic Dental Practice in Rohnert Park for over 27 years at 2 Padre Parkway, Suite 200. Call 585-8595, or email info@ malkemusdds.com.  Visit Dr. Malkemus’ Web site at http://www.malkemusdds.com

Antibiotics and Your Heart

If you have had to take antibiotics prior to dental treatment because of your heart condition, you may not need to any more.  The recent guidelines from the American Heart Association recommend not taking antibiotics prior to dental treatment in most heart condition cases.  You should contact your cardiologist, physician, and dentist to see if you should stop or continue.

For decades, the American Heart Association [AHA] recommended that patients with certain heart conditions take antibiotics shortly before dental treatment.   This was done with the belief that antibiotics would prevent infective endocarditis [IE], an infection of the heart’s inner linings or valves.  The idea was bacteria in the mouth could enter the blood stream during dental treatment and travel to the heart.  It was thought that with a heart murmur, turbulence in the blood flow caused by the heart valve would allow the bacteria to eddy out and start a growth on the valve – not a good thing.  However, a growing body of scientific evidence has shown this is not the case.

The scientific evidence shows that the risks of taking preventive antibiotics out weigh the benefits for most patients.  The risks include adverse reactions to antibiotics and development of drug-resistant bacteria.  Adverse reactions range from upset stomach, nausea and diarrhea to allergic reactions such as hives or life threatening anaphylactic shock.  Allergic reactions to medications, as well as, foods, environmental substances including insect bites and stings can occur after years of never being allergic.  If you have redness, swelling or itchiness after taking medication, stop future pills and call your doctor.  If you have accelerating symptoms especially difficulty breathing, seek immediate emergency help, i.e., call 911.  Use an epi-pen if available, which is found in some emergency kits or carried by people who are allergic to bee stings.

The over use of antibiotics causing the development of drug-resistant bacteria is another reason the AHA guidelines have changed.   Drug-resistant bacteria are formed from antibiotic use.  The inappropriate use of antibiotics increases the risk of drug-resistant forms and prevents their effectiveness when antibiotics are really needed.

Scientists also found no compelling evidence that taking antibiotics before a dental procedure prevents IE in patients who are at risk of developing a heart infection.  There is actually more exposure to bacteria from their mouths during basic daily activities such as eating, drinking, brushing or flossing.  People with gum disease are at a much higher risk of having bacteria enter their bloodstream and causing infective endocarditis and heart disease. So a person’s best defense against IE is preventing gum disease through good oral hygiene, brushing and flossing, healthy diet, and regular professional cleanings with a registered dental hygienist.

A bacterial infection of the gums, called periodontal disease, can affect the entire body.  Gum disease is correlated with heart disease, diabetes, strokes, ulcers and pre-term births.  Bacteria that build up between the tooth and gum can enter into the bloodstream when gums bleed. These bacteria can travel throughout the body and cause serious health problems. Periodontal disease can be prevented with good oral health habits; such as, brushing and flossing, and regular professional cleanings.                                                     

                                                                                                                            AHA Guidelines: Who Should Take Prophylactic Antibiotics Before Dental Treatment

The AHA guidelines state that patients who have taken prophylactic antibiotics routinely in the past, but no longer need them include people with mitral valve prolapse, rheumatic heart disease, calcified aortic stenosis, or most congenital [present from birth] heart conditions.

Certain heart conditions still require pre-medication with antibiotics in patients who would have the greatest danger of a bad outcome if they developed a heart infection.  Preventive antibiotics before a dental procedure are advised for the following patients:

-Artificial heart valves

-A history of infective endocarditis

-Certain specific, serious congenital heart conditions

-A cardiac transplantation that develops a problem in a heart valve

If you have any of these heart conditions, you should consult your cardiologist for the use of antibiotics prior to dental procedures.

The new recommendations apply to any dental procedures that could involve possible bleeding in the gums or oral tissues.  Antibiotic use prior to dental treatment is not necessary for an examination or x-rays, but is mandatory for teeth cleanings and oral surgery treatment like extractions.

The AHA guidelines emphasize that maintaining optimal oral health and practicing oral hygiene are more important in reducing the risk of infective endocarditis than is the taking antibiotics before a dental visit.   So keep brushing and flossing and have regular dental cleanings.

ENJOY LIFE AND KEEP SMILING!

George Malkemus has a Family and Cosmetic Dental Practice in Rohnert Park at 2 Padre Parkway, Suite 200. Call 585-8595, or email info@ malkemusdds.com.  Visit Dr. Malkemus’ Web site at malkemusdds.com

George A. Malkemus, DDS

Dentist in Rohnert Park
2 Padre Parkway Suite #200
Rohnert Park, CA 94928

MalkemusDDS.com Phone: (707) 585-8595