Tooth Extraction

[Redone]

Hello Everyone!
I am likely going to need a tooth extraction next week due to a vertical and horizontal fracture of a molar. My cardiologist doesn't think I need to be concerned about dropping my INR down. The Coumadin Clinic I go to hasn't made any recommendations either, but I'll get more advice this Friday when I go. I've had two OHS in less than 9 months due to a blood infection I had last April. I understand the recommended pre-medication requirements of 2000mg before the procedure. My concern is bleeding too much. Had anyone had an extraction while maintaining an INR of 2.5? Should I be concerned?

 

[ATHENS1964]

Follow the doctor's instructions regarding the antibiotic, my opinion is apart from 2 mg one hour before you also have 1mg every 12 hours for the next 1-2 days. Of course, I say again, follow their instructions.
Regarding INR, it depends on the difficulty of extracting the tooth, if it's an easy case you won't even have stitches and you won't have almost any bleeding, the doctor also has hemostatic sponges that provide very good hemostasis ROW > Dental > Common Oral Surgery - RESORBA®
If it's a difficult case as photo you might have a little bleeding, but nothing special.

 

[Eva]

My oral surgeon was happy with me if I went to the low level of my range, which I did by dropping my warfarin a bit two night before.

 

[dick0236]

I try to keep my INR between 2.8-3.5 at all times. I have had several teeth pulled over the years and have never experienced a bleeding problem. It does take a little longer to stop the bleeding when I have had teeth pulled.....but nothing unusual. Also, I have never held warfarin or "bridged" prior to dental work.

 

[Redone]

I try to keep my INR between 2.8-3.5 at all times. I have had several teeth pulled over the years and have never experienced a bleeding problem. It does take a little longer to stop the bleeding when I have had teeth pulled.....but nothing unusual. Also, I have never held warfarin or "bridged" prior to dental work.

Thank you for your feedback. I figured based on what I've read that it was ok. I usually keep my INR at 2.5 so it should be ok.

 

[Redone]

Follow the doctor's instructions regarding the antibiotic, my opinion is apart from 2 mg one hour before you also have 1mg every 12 hours for the next 1-2 days. Of course, I say again, follow their instructions.
Regarding INR, it depends on the difficulty of extracting the tooth, if it's an easy case you won't even have stitches and you won't have almost any bleeding, the doctor also has hemostatic sponges that provide very good hemostasis ROW > Dental > Common Oral Surgery - RESORBA®
If it's a difficult case as photo you might have a little bleeding, but nothing special.

Thank you for your feedback. I appreciate it! I think I'll be all set with an INR of 2.5 and will get the oral surgeon's recommendations on antibiotics after the procedure.

 

[Redone]

My oral surgeon was happy with me if I went to the low level of my range, which I did by dropping my warfarin a bit two night before.

Yes, I have had to do this before so I'll see if the coumadin clinic recommends doing so. Thank you!

 

[Chuck C]

I would not expect much significant bleeding from a tooth exraction. It sounds like your cardiologist is right to not have you drop your INR. If it were me, I would probably drop it near the low end of my INR range, but stay in range. I'm at 2.0 to 3.0. I'd probably target 2.0 to 2.3 for the procedure if it were me, but think you'll do just fine regardless.

 

[carolinemc]

Hello Everyone!
I am likely going to need a tooth extraction next week due to a vertical and horizontal fracture of a molar. My cardiologist doesn't think I need to be concerned about dropping my INR down. The Coumadin Clinic I go to hasn't made any recommendations either, but I'll get more advice this Friday when I go. I've had two OHS in less than 9 months due to a blood infection I had last April. I understand the recommended pre-medication requirements of 2000mg before the procedure. My concern is bleeding too much. Had anyone had an extraction while maintaining an INR of 2.5? Should I be concerned?

Usually, they like you to premed with biotics before and after a dental procedure. I did not have to skip my warfarin for it either. Just use the cotton gauze that the dentist gives you and keep in for two to three hours. You will be fine.

 

[Protimenow]

I had an extraction a few years ago, and it took a LONG time, and a lot of gauze to stop the bleeding.

I saw on a forum, years ago, how one person who had an extraction was able to get the bleeding to stop, but as soon as the gauze was removed, it started again.

Bleeding from an extraction is not always a trivial thing but, as was said earlier, it may also depend on which tooth is extracted.

And, as mentioned earlier, premedication with Amoxicillin is a must.

Good luck with your extraction.

 

[Redone]

Usually, they like you to premed with biotics before and after a dental procedure. I did not have to skip my warfarin for it either. Just use the cotton gauze that the dentist gives you and keep in for two to three hours. You will be fine.

Yes, I always pre-medicate before the dentist even if they're just looking. After what I went through last year with the blood infection and two open heart surgeries I don't take any chances. I'm sure the oral surgeon will have me on antibiotics for a few days, perhaps a week after the extraction. Thank you for you response!

 

[Redone]

I would not expect much significant bleeding from a tooth exraction. It sounds like your cardiologist is right to not have you drop your INR. If it were me, I would probably drop it near the low end of my INR range, but stay in range. I'm at 2.0 to 3.0. I'd probably target 2.0 to 2.3 for the procedure if it were me, but think you'll do just fine regardless.

It makes sense to drop the INR down to 2.0. I usually stay at 2.5, which is the clinics magic number for me. It's a molar so hopefully there won't be too much bleeding, but we'll see

 

[Redone]

I had an extraction a few years ago, and it took a LONG time, and a lot of gauze to stop the bleeding.

I saw on a forum, years ago, how one person who had an extraction was able to get the bleeding to stop, but as soon as the gauze was removed, it started again.

Bleeding from an extraction is not always a trivial thing but, as was said earlier, it may also depend on which tooth is extracted.

And, as mentioned earlier, premedication with Amoxicillin is a must.

Good luck with your extraction.

I can imagine! That's why I figured I'd check in with the experts. I'm having a molar extracted and hope it's an easy removal. Years ago I had a tooth removed and fragments of the tooth had to be dug out causing a divot in the gum tissue. I hope it's not that much of a nightmare. Thank you for your feedback!

 

[pellicle]

Hi

My cardiologist doesn't think I need to be concerned about dropping my INR down. The Coumadin Clinic I go to hasn't made any recommendations either, but I'll get more advice this Friday when I go.

my advice would be based on the fact that you are home testing. But as I see the mention of the Circus Clowns (aka Coumadin Clinic) I suspect you aren't.

#1 make sure your dentist knows your INR before the prodedure.

I would want to manage my INR down to the low end (assuming you have an aortic position modern bileaflet valve like a St Jude, an On-X, and ATS ...) and perhaps even present to the dentist with an INR just under 2.0 (anything between 1.4 and 1.9).

IFF you were self testing this would be as simple as slowing down for road works in your car (because you'd know how to lift your foot off the pedal or apply the controls to your cruise control to lower your speed to the new temporary limit). But this is the gift of being at a clinic, they leave you happless and unempowered.

Below is a typical example of bureaucratic circus

https://www.abc.net.au/news/2015-01...ment-of-myo-moriaty-who-bled-to-death/6017146

The inquest heard Ms Moriarty was regularly tested by her doctor to see how quickly her blood clotted.​

​

Dr Colgan told the inquest he did not discuss those test results with her doctor before the procedure, and instead relied upon what Ms Moriarty told him about her condition.​

​

"I had no feeling of that need.... She was an intelligent and articulate patient," he said.​

some words in there bother me, like "regularly tested" ... weekly is regularly, monthly is also regularly, yearly is also regularly, so what was the frequency of that regularity? Clearly some miscommunication went on and I'm quite sure that no medical practitioner will be held liable for her death. At most there will be an undertaking to ensure that "process is addressed". Cold comfort for her IMO.

I recommend you lower your INR or at least make sure its not at like 3.0 when you go in.

If you can't do those things then, as mentioned by Protime, take the gauze seriously and if you experience bleeding continue into the next day call your dentist.

To my mind this is a perfect example of how a clinic makes things harder and why bridging is deemed necessary for patients (aka INR handling incompetence and bureaucratic miscommunication, compounded with potentials of delays in the processing of lab tests).

FYI an article on good management style

https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
best of luck with the extraction, I know they suck.

 

[pellicle]

also well worth a read about "informed consent" ... and the presumption of how well informed a patient is or can be

https://www.abc.net.au/news/2019-02...ing-informed-consent-daily-conundrum/10782248

 

[Redone]

Hi


my advice would be based on the fact that you are home testing. But as I see the mention of the Circus Clowns (aka Coumadin Clinic) I suspect you aren't.

#1 make sure your dentist knows your INR before the prodedure.

I would want to manage my INR down to the low end (assuming you have an aortic position modern bileaflet valve like a St Jude, an On-X, and ATS ...) and perhaps even present to the dentist with an INR just under 2.0 (anything between 1.4 and 1.9).

IFF you were self testing this would be as simple as slowing down for road works in your car (because you'd know how to lift your foot off the pedal or apply the controls to your cruise control to lower your speed to the new temporary limit). But this is the gift of being at a clinic, they leave you happless and unempowered.

Below is a typical example of bureaucratic circus

https://www.abc.net.au/news/2015-01...ment-of-myo-moriaty-who-bled-to-death/6017146

The inquest heard Ms Moriarty was regularly tested by her doctor to see how quickly her blood clotted.​

​

Dr Colgan told the inquest he did not discuss those test results with her doctor before the procedure, and instead relied upon what Ms Moriarty told him about her condition.​

​

"I had no feeling of that need.... She was an intelligent and articulate patient," he said.​

some words in there bother me, like "regularly tested" ... weekly is regularly, monthly is also regularly, yearly is also regularly, so what was the frequency of that regularity? Clearly some miscommunication went on and I'm quite sure that no medical practitioner will be held liable for her death. At most there will be an undertaking to ensure that "process is addressed". Cold comfort for her IMO.

I recommend you lower your INR or at least make sure its not at like 3.0 when you go in.

If you can't do those things then, as mentioned by Protime, take the gauze seriously and if you experience bleeding continue into the next day call your dentist.

To my mind this is a perfect example of how a clinic makes things harder and why bridging is deemed necessary for patients (aka INR handling incompetence and bureaucratic miscommunication, compounded with potentials of delays in the processing of lab tests).

FYI an article on good management style

https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
best of luck with the extraction, I know they suck.

 

[pellicle]

@Redone nothing seems to have been added to my comment in your reply.

 

[Redone]

Hi,
Thank you for the information and articles. I'm shocked about Moriarty. I agree on the INR and lowering it. Thankfully, I've had extractions before. It's hard to believe I have nice teeth with all the issues I've had. Before OHS, St. Jude, due to Bicuspid Aortic Valve and aneurysm having a tooth removed was no big deal. Now after last year it's a very big deal. 4 weeks after surgery # 2 in August, 2022 I had two root canals. After coming off the antibiotics I was loaded with and a little over a month after OHS I experienced unbelievable pain in two teeth. The one they want to remove had a root canal and internal abcess (dead roots and tissue) not the pussy kind thankfully but still a concern. I was told by the Endodontists not to crown the tooth right away, but wait and come back 6 months later. To me it appears the vertical fracture goes right up into the gum. The extraction hasn't been scheduled yet.

Thank you for your feedback. I appreciate it

 

[jeffp]

#1 make sure your dentist knows your INR before the prodedure.
….
I would want to manage my INR down to the low end (assuming you have an aortic position modern bileaflet valve like a St Jude, an On-X, and ATS ...) and perhaps even present to the dentist with an INR just under 2.0 (anything between 1.4 and 1.9).
……
I recommend you lower your INR or at least make sure its not at like 3.0 when you go in.

A lot more than just INR goes into wound clotting. Platelet function contributes to a good deal of bleeding control in wounds with flow stasis (like those sutured or packed).

An anecdotal story…I had a cracked molar root that necessitated the tooth come out. Dentist removed the tooth but couldn’t get the root fragment. Sent me to an oral surgeon the following week. He had a fun time digging, but did finally get it out and prepped the site for a bone graft (eventually had an implant done after it all healed).
Yeah, I spit out some blood with the hourly oral rinsing and gauze pack follow-ups for the first day or so.

Here’s the INR part: as I have a mechanical mitral valve (St Jude) my range is 2.5-3.5. I usually aim for right in the middle. Dentist and cardiologist were both fine with continued normal warfarin dose. Was 2.8 for the first bit of dental fun, 3.0 for the 2nd. Never had enough prolonged bleeding for the dentist or myself to be at all concerned. I had some nasty slices just with daily living over the years post-op. If pressure for 15 minutes didn’t stop it, I’ve had one episode of stitches.

To bleed out after 2 concurrent tooth extractions, I’d think she’d have had some significant blood dyscrasia going on, maybe something like VonWillibrand’s or such.

Short of a review of medical records, I suspect a lot of what we hear is conjecture.

 

[pellicle]

A lot more than just INR goes into wound clotting. Platelet function contributes to a good deal of bleeding control in wounds with flow stasis (like those sutured or packed).

agreed ... I was trying not to complicate my answer.

Short of a review of medical records, I suspect a lot of what we hear is conjecture.

agreed. So I didn't (or I don't think I did).