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Managing Patients on Anticoagulants Who Require Oral Surgical

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Managing Patients on Anticoagulants Who Require Oral Surgical Gingival Hyperplasia Related to Calcium Channel Perio & Implant Centers The Team for Jochen P. Pechak, DDS, MSD of the Monterey Bay (831) 648-8800 Blockers and Other Medications and Conditions mobile app: www.GumsRusApp.com in Silicon Valley (408) 738-3423 web: GumsRus.com alcium channel blockers are named for their ability to block the movement of calcium across mechanical channels in heart and artery walls. This causes vasodilation which reduces blood pressure. They are also used to treat angina Cand fast irregular heart rhythms. There are at least eleven channel blockers with different generic and trade names, which can be quite confusing. Nifedipine (Procardia) has the highest reported incidence of gingival hyperplasia, followed tm by diltiazem (Cardizem), amlodipine PDL (Norvasc) and verapamil (Calan). Switching to a different drug in the PerioDontaLetter same class like isradipine (Dynacirc), Medications Which Cause Jochen P. Pechak, DDS, MSD, Periodontics, Implant & Laser Dentistry Summer or reducing the dose of amlodipine to Gingival Overgrowth 5 mg, has been reported to reduce the hyperplasia. Calcium Channel Blockers Trade Name Other drugs that frequently cause (Listed in Order of Reported From Our Office Managing Patients on hyperplasia are cyclosporine, an Frequency of Overgrowth) to Yours... immunosuppressant, and phenytoin Nifedipine Adalat, Nifecard, Procardia, Tenif Anticoagulants Who Require (Dilantin), an anticonvulsant. As dentists, we are challenged with Orthodontic treatment also sometimes Diltiazem Cardizem, Dilacor, Diltiamax, the management of the many medical Oral Surgical Procedures results in hyperplasia. (See below.) Tiazac conditions and the various medications Amlodipine Lotrel, Norvasc which our patients are taking. This current issue of The or most dental patients on therapy is hardly ever needed Verapamil Covera-HS, Calan, Verelan PerioDontaLetter addresses the anticoagulants, no change in because most lasers seal the blood Felodipine Plendil management of patients on Fmedication is necessary prior to vessels. anticoagulant medications when oral undergoing oral surgery. Many patients with atrial Nitrendipine Baypress Discontinuing anticoagulation surgical procedures are indicated. fibrillation, artificial heart valves, medications before dental surgery Nicardipine Caardene Page 3 contains a chart comparing and clotting disorders are receiving oral anticoagulants — medications creates a far greater risk of serious, anticoagulant therapy to prevent Manidipine Manyper which retard or inhibit the coagulation and potentially fatal events than the strokes and embolisms. Nimodipine Nymalize of the blood, thereby reducing fibrin risk inherent in the bleeding Figure 4. Severe gingival formation and preventing clots from associated with the surgical With warfarin (Coumadin), the hyperplasia durimg orthodontics. Nisoldipine Sular forming and growing — and oral procedure. prothrombin time can be adjusted to For periodontal therapy with the an International Normalized Ratio Isradipine Dynacirc antiplatelets — medications which prevent platelets from clumping and laser, adjustment of anticoagulant (INR) of 3.0 before minor dental also prevent clots from forming and Immunosuppressants growing. Cyclosporine Neoral, Sandimmune, Restasis The back page addresses gingival Figure 1. The FDA has hyperplasia related to calcium Tacrolimus Protopic, Prograf warned that stopping channel blockers and other anticoagulants in medications and conditions Sirolimus Rapamune patients with heart stents It also contains a chart showing the various medications which contribute before dental surgery Anticonvulsants to gingival overgrowth. greatly increases the risk Figure 5 The same patient after Phenytoin Dilantin, Phenytek We hope you find this information of stent thrombosis, completion of orthodontics and helpful. As always, we welcome your heart attack, and/or crown lengthening. Sodium valproate Depakote, Depakene, Stavzor comments and questions. death. PDL tm Dr Pechak is a board certified Periodontist embracing the evolution of better options with a focus of minimally invasive techniques for gum disease, oral 21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] Jochen P. Pechak, DDS, MSD surgery and dental implants, Implant Supported Dentures. As a CE provider for the State of California, he lectures and hosts educational events to Dentists, 516 W. Remington Drive • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] dental teams and the community of Dental Hygienists He is the Founder and Director of a chapter of the Seattle Study Club network, as well as our Hygiene Diplomate, American Board of Periodontology Study Club. Please contact us if you wish to be a part of our continued education series, in which CEU are earned. mobile app: GumsRusApp.com • website: GumsRus.com • Dr. Pechak’s direct email: [email protected] surgery, below 2.4 for larger surgeries, With these medications, aspirin Those patients who have had a stent three months after the stent was feverfew, ginkgo biloba, vitamin E, indicated before adjusting and below 2.0 for full mouth and NSAIDS like ibuprofen and in a coronary artery usually take a placed. All stent patients should and fish oil. anticoagulant medications. extractions. Patients taking warfarin naproxen double the risk of a major combination of aspirin and clopidogrel continue on 81 mg aspirin daily for a For localized bleeding after surgery, See the chart below for a should avoid aspirin and NSAIDS bleed and should be avoided. (Plavix) or prasugrel (Effient) to lifetime. Gelfoam, Avitene, and Surgicel are comparison of anticoagulant and like ibuprofen, naproxen, and Commonly, those individuals at prevent reclotting of the stent. The antiplatelet drugs with their Numerous herbal medicines and helpful. metronidazole, which may increase moderate risk of heart attacks are FDA has warned that discontinuing mechanism of action. In all cases, consultation with the the INR. taking aspirin daily. Daily aspirin use this dual drug therapy greatly increases natural dietary supplements also have Newer anticoagulant drugs are now seldom, if ever, should be adjusted the risk of stent thrombosis, heart anticoagulant effects, including garlic, patient’s prescribing physician is being prescribed to replace warfarin before dental surgery, as doing so may attack, and/or death. for prevention of strokes or blood cause a rebound increase in blood Elective procedures with a high clotting in patients with atrial clotting, which in turn increases the risk of bleeding should be postponed fibrillation. These include dabigatran risk of myocardial infarction, stroke, until the dual platelet therapy is (Pradaxa), rivaroxaban (Xarelto), or death by 37%, and continues over completed, usually six to 12 months Comparison of Oral Anticoagulants apixaban (Eliquis), and edoxaban time. (Sundstrom et al, Circulation, after placement of the drug-eluting (Savaysa). The INR test does not work September 26, 2017). stent. Medication Mechanism of Action with these medications, and monitoring Other medications which affect Antiplatelet medication, including is not currently possible. Since these platelet aggregation include dual antiplatelet therapy, should not be Warfarin (Coumadin) Inhibits formation of vitamin K- new agents have a predictable effect, clopidogrel (Plavix), prasugrel interrupted for simple single or dependent clotting factors and the effect is short term, monitoring (Effient), ticagrelor (Brilinta) and multiple tooth extractions and minor Adjust INR to 2.4 or below for most is not necessary. ticlopidine (Ticlid). oral surgery. Doganay et al, JADA, surgeries For larger surgeries, these Normal platelet aggregation returns February, 2018 medications can be stopped 36 hours only when new platelets are produced Patients with stable heart disease, Dabigatran (Pradaxa) Directly inhibits thrombin before and resumed one day after, five to nine days after stopping or who have a bare metal stent, can with physician approval. antiplatelet drugs. often stop the dual platelet therapy Edoxaban (Savaysa) All of these medications directly inhibit Rivaroxaban (Xarelto) Factor Xa. With physician approval, Apixaban (Eliquis) stop for 36 hours before surgery and resume one day after. Comparison of Oral Antiplatelets Medication Mechanism of Action Aspirin Inhibits cyclooxygenase 1 and 2 Stay on for almost all procedures Cilostazol (Pletal) Inhibits platelet phosphodiesterase III Blood Clot Blocking Coronary Artery Vorapaxar (Zontivity) Inhibits PAR I Clopidogrel (Plavix) Inhibit P2Y12 component of ADP Prasugrel (Effient) receptors Figure 2. Daily aspirin use seldom, if ever, Figure 3. Bleeding on probing is increased by Ticagrelor (Brilinta) Do not discontinue if taking after a should be adjusted before dental surgery, as anticoagulant medications, but is not caused Ticlopidine (Ticlid) cardiac stent that can cause a rebound increase in blood by them. clotting, which in turn increases the risk of myocardial infarction, stroke, or death by Avoid taking NSAIDS, like ibuprofen and naproxen, with all these medications. 37%, and continues over time PerioDontaLetter, Summer surgery, below 2.4 for larger surgeries, With these medications, aspirin Those patients who have had a stent three months after the stent was feverfew, ginkgo biloba, vitamin E, indicated before adjusting and below 2.0 for full mouth and NSAIDS like ibuprofen and in a coronary artery usually take a placed. All stent patients should
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