Dental work post-surgery

[Keithl]

I had a deep cleaning yesterday. Cardio said no need to bridge unless they expect a lot of blood. I knew I had 1 tooth that would be an issue so I dropped INR down to about 1.4. Everything went well, I made the mistake of resuming bridging that night and woke up with clots of blood in my mouth. Stopped bridging for today, trying black tea and gauze. Perio said is if it keeps bleeding to come in they have some topical stuff they can put on to stop the bleeding. No luck, GI bleed 2 years ago after colonoscopy and now this. Still think mechanical was the right option for me, but it sure brings its share of effort.

 

[Chuck C]

I had a deep cleaning yesterday. Cardio said no need to bridge unless they expect a lot of blood. I knew I had 1 tooth that would be an issue so I dropped INR down to about 1.4. Everything went well, I made the mistake of resuming bridging that night and woke up with clots of blood in my mouth. Stopped bridging for today, trying black tea and gauze. Perio said is if it keeps bleeding to come in they have some topical stuff they can put on to stop the bleeding. No luck, GI bleed 2 years ago after colonoscopy and now this. Still think mechanical was the right option for me, but it sure brings its share of effort.

Thanks for sharing your experience Keithl. I sure hope that you get the bleeding under control soon.

I'm curious why you bridged if you only brought your INR down to 1.4? Was this the guidance from your cardiologist? I recently had a thyroid procedure for which I was given the option of getting my INR at or below 1.5 without bridging. As I have the ability to tightly control my INR from my experience self testing, I opted to go this route. I brought mine down to 1.4 for the day of the procedure and had it back up to 1.9 the next day and then 2.3 the day after that. No bridging was used. My cardiologist indicated that a brief dip in INR like this has very little risk- clearly not zero. On the other hand, I believe that there is significant risk with bridging, as shown in my links below.

Anyway, in discussing the issue with my thyroid surgeon, he pointed out that there have been studies showing good results with lowering INR and not bridging and that there seems to be a lot of opinions changing in this area give the good results from lowering INR modestly, without bridging.

Thrombotic events and bleeding still happen with bridging. See the opinion piece and study which Iinked below. I expect that this is, at least in part, due to the followng: Warfarin is held, often for 4+ days prior to procedure, bringing INR down to about 1.0. The bridge, typically levenox, or other AC with a short half life, takes over as anti-coagulant, but it must be stopped a day or so prior to the procedure. With the short half life of lovenox, this creates a window during which there may be close to zero anti-coagulation for the procedure and some time afterwards. It would seem that this window of effectively zero anti-coagulation would increase the risk of thrombosis at this time.

The risk of bleeding seems to be during the time that one is doubling up on the warfarin and the lovenox, or other short half life AC. Once one resumes warfarin, they stay on the lovenox until INR is in range typically, but during this time there is risk of bleeding because we are effectively doubling up on anti-coagulation using two different pathways. Also, as there is no INR type measure to evaluate how much of an effect the lovenox is having on anti-coagulation, there is a bit of guesswork. Ideally the lovenox is stopped once INR is in range, but how good are the clinics at this timing? Say INR is 2.5 at the next test, time to stop the lovenox. But, how much time was the patient at INR 2.0-2,5, while doubled up with the lovenox? And, I'd wager that there is a higher risk of bleeding with INR of 1.5-2.0, while still under the full effects of the lovenox.



I found this expert opinion piece published in the Journal of Thoracic and Cardiovascular Surgery of interest relative to the discussion about anti-coagulation management before and after surgery.

".. bridging strategies vary widely among physicians, many of whom tend to overestimate thromboembolic risk. The rush to anticoagulate postoperatively commonly results in increased bleeding."

I found this especially interesting. The bold is mine:

"The estimated perioperative risk of symptomatic thromboembolic events in patients with MHVs who undergo bridging is about 0.7% to 1.2%,6, 8
with higher rates noted for cage-ball valves and tilting disc valves that have since been retired.1
Without bridging, thromboembolic risks are estimated to be about 0.08% to 0.36% "

" We recommend stratifying patients according to thromboembolic risk and bleeding risk, as outlined in Table 1. " Well worth taking a look at in my view.

" Our proposed bridging anticoagulation strategy accounts for current guidelines and allows a more individualized approach to anticoagulation in patients with MHV who undergo noncardiac surgical operations. "

And, of course: " Newer studies are clearly needed .."

https://www.jtcvs.org/article/S0022-5223(18)31859-2/fulltext
This study is also of interest:

" Conclusions: In patients with atrial fibrillation or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postoperative dalteparin bridging to prevent major thromboembolism. "

https://pubmed.ncbi.nlm.nih.gov/34108229/
Anyway, folks facing a procedure, whether dental or other, might want to discuss the above opinion piece and the above linked 2021 study with their medical team and discuss whether bridging or just modestly lowering INR would be the best route. It will be interesting to see what future studies in this area show us.

 

[Keithl]

I assume it was 1.4ish as I checked night before and it was 1.6. In 2 days it dropped from 2.5 to 1.6, so I assume it dropped a bit more 18 hours later when I had the procedure. When I had my GI bleed several docs said for aortic valve I should be fine going about 2-3 days without anything. And they waited 2 days for the bleed to stop before starting heparin in the hospital. I was not going to bridge, but suspected this tooth would be a problem so decided to stop taking my warfarin 3 mornings before procedure. Since I have On-X I don't start bridging until I get near 1.5 so I only had 2 shots before the procedure, morning and night before. Procedure was 1pm. I decided to take a shot the evening of procedure which I am sure did not help, I should have held any warfarin or bridging until the day after. My confidence was that I was not bleeding at all even hours after procedure.

 

[Keithl]

Went back to Perio yesterday afternoon as I was still bleeding. They put some ointment that helps stop the bleeding nd told me not to brush or use that side for 24 hours. This morning all is good. Next time I need to learn to wait to take my bridge shot. Basically whatever procedure I am having the day of nothing in AM and nothing until the next day to give my body time to clot/heal. Today I bridged and and do 1.5 my normal warafirn to get my INR back up.

 

[skier]

• Prior to needing OHS I had considered dental implants for a couple extractions I've had. My thought is that this is probably too invasive and requires too much commitment after Coumadin, and leaning towards bridge instead. Thoughts from those who have faced similar question?

I'd highly recommend implants over a bridge. The biggest downside to the implants is the cost. In the long run, with the bridge, you are damaging perfectly healthy teeth. Eventually, those teeth are more likely to fail. That's what happened to my 30 year-old-bridge. I now need three implants to replace it.

• Which dental procedures require bridging? Do you have to come off Coumadin even for cleanings and fillings? Or only for dental surgical procedures?

My oral surgeon said I don't need to come of Coumadin to have my implants placed, and I just need to test and make sure I'm in the therapeutic range before the implant surgery.

A few more details: I was planning on getting the implants placed before my valve replacement, and the oral surgeon decided to wait until six months after my heart surgery, even though I'd be on Coumadin.

The fear is during the implant healing process (months), they can potentially fail, most likely due to infection. This would require oral surgery to remove the implant and clean up the infection. That's not something you want to do during the six months following heart surgery, so better to wait six months to place the implants.

 

[MdaPA]

The fear is during the implant healing process (months), they can potentially fail, most likely due to infection. This would require oral surgery to remove the implant and clean up the infection.

Just be mindful that if you need to go on antibiotics to pre-medicate or post surgery, it may impact your INR and your healing process. In my wife's case when she had dental/gum work, her INR shot-up and caused bleeding episodes which delayed her healing. See below post:

Needing non-cardiac surgery with a prosthetic heart valve and warfarin intake

 

[skier]

Just be mindful that if you need to go on antibiotics to pre-medicate or post surgery, it may impact your INR and your healing process. In my wife's case when she had dental/gum work, her INR shot-up and caused bleeding episodes which delayed her healing. See below post:

Needing non-cardiac surgery with a prosthetic heart valve and warfarin intake

Wow, thanks for sharing that and your recommendations:

Here are my observations/recommendations after this incident:

1 - Don't listen to or accept anyone who says a procedure is “routine” when you are on blood thinners/have artificial valves.
2 - Question the Dr. re the bleeding risks and if bridging is truly necessary or not.
3 - Know how things like lack of sleep, diet changes, and drugs (antibiotics, pain meds, etc) you will be taking may impact/interaction with your INR to prevent an unexpected bleeding episode.
4 - Make sure all your Dr's (surgeon, PCP, Cardio, INR clinic) are aware of your procedure and all agree to the same plan.

 

[pellicle]

My oral surgeon said I don't need to come of Coumadin to have my implants placed, and I just need to test and make sure I'm in the therapeutic range before the implant surgery.

well I don't even alter my INR for sub-gingival cleans, however if I was going to have dental implants I would absolutely make sure of my INR before this and if it was not below 2.5 I would steer it a bit that way. For drilling into the bone I would totally consult with the dentist and ask, but I'd expect he'll want INR ~1.4 ... entirely doable.

I test weekly and I self dose and my INR is >95% in range and has been so for about 10 years.

1. test and know thyself, back this up with proper weekly records in a spreadsheet with graphs (and I really mean that). >>this includes testing to see what (if any) interaction there is with antibiotics. It is not the same for everyone.
2. my dentist (whom I'll be seeing tomorrow) regularly says "if I didn't know you were on warfarin I wouldn't know you were:

some reading

https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
http://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
notice the emphasis on actual data derived from YOU.

 

[user 15848]

I have a mechanical AVR.

• No presurgery clearance for me.
• The last time I read the guidelines, dental work did not require a change in coagulation therapy. The major risk for dental work is not bleeding but bacteria that might travel to your heart and cause endocarditis.
• Any dental work that involves the possibility of blood (e.g. cleaning) requires prophylactic antibiotics. My cardio recommends it for all dental work.
• At one time antibiotics were required if you had a BAV, but then the recommendations changed.
• For your specific problem that requires the Bentall procedure, ask your cardiologist if implants vs. bridge is a concern and if you need antibiotics..

Thank you for your post, it seems i ll have an extraction next week and was wondering if the warfarin was going to be a problem, i guess will be placed on a full treat of antibiotics not sure if that will have an impact on INR, but will check every 3 days see what is going on, IF the extraction is a go, for now, just dealing with the pain and not doing more root canals at 70

 

[carolinemc]

Thank you for your post, it seems i ll have an extraction next week and was wondering if the warfarin was going to be a problem, i guess will be placed on a full treat of antibiotics not sure if that will have an impact on INR, but will check every 3 days see what is going on, IF the extraction is a go, for now, just dealing with the pain and not doing more root canals at 70

Your dentist will direct you on his/her standards for a cardio patient on Warfarin. Most dentist will help you get premed set up. Good luck.

 

[tom in MO]

Thank you for your post, it seems i ll have an extraction next week and was wondering if the warfarin was going to be a problem, i guess will be placed on a full treat of antibiotics not sure if that will have an impact on INR, but will check every 3 days see what is going on, IF the extraction is a go, for now, just dealing with the pain and not doing more root canals at 70

I'd ask the dentist too. If they said I had to go off warfarin, I'd ask the dentist to contact your cardiologist who should be the one to provide you with instruction as to what to do. Some valves you can go off warfarin for a few days, others you need to bridge the time period with different drugs.

 

[thomas999]

Good thread. I am having a deep cleaning in 2 weeks and debating whether to lower INR, or bridge to avoid bleeding as it is not uncommon for me to bleed with aggressive flossing so I suspect they will draw blood during the deep cleaning. I already have to pre-med. Since I am On-X I was debating getting down from 2.8 closer to 1.5 for the procedure

It's just a little blood if you bleed, it's not that severe. You say you are debating lowering your INR, that shouldn't be a personal decision but a professional one. I have never lowered my INR for dental procedures, and my INR hangs around 2.5 to 3.5. Now I always pre-med with antibiotics, but that's all I do for dental procedures.