Tooth Extraction

[pellicle]

The problem with having bleeding in the mouth is that you can't apply a tourniquet or pressure on it for too long

And Super Glue probably isn't easy to apply either

 

[pellicle]

Management of Dental Extractions in Patients taking Warfarin as Anticoagulant Treatment: A Systematic Review​

https://jcda.ca/article/f20

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

 

[MdaPA]

And Super Glue probably isn't easy to apply either

In my wife's case they did apply super "dental" glue after the bleeding started but it did not hold-up to the hydrostatic pressure of the liver clot (kind of like caulking a crack to stop a water leak coming from a basement foundation).

 

[bicuspidrek]

Thank you @pellicle @MdaPA @Chuck C @Protimenow @ATHENS1964 for the input.

I went in again this morning (INR: 2.5) and oral surgeon made a comment on the size of the liver clot. They really were large. He removed them and redid the sutures + gelfoam. He commented there was still slight bleeding and I asked if I could wait around and get him to check in on me some time later. He agreed, and was satisfied that the bleeding was stemmed sufficiently. I held on to the gauze for a good number of hours till dinner.

For now sutures seem to be holding reasonably well, fingers are still crossed.

She then got sick from swallowing the blood. It was a long ordeal but what saved her was renting a portable fluid suction device (like what they use in the dentist office) from a medical supply company. It took a good week or two for the bleeding and liver clots to subside once her INR got temporarily down between 2.0 and 2.5 (normal range for her is 2.5-3.5).

I got disgusted from the constant taste of iron. When you say sick here - I'm hoping it meant disgust versus actuall illness. Did she have her stitches re-done? I had the liver clots over one weekend and I was done with it. :O

Have you had your INR tested since the procedure? I know that you were 2.2 on the morning of your procedure, but with all of the meds that they had you on, it would not surprise me if there was one or more of them interfering with warfarin clearance. You could easily be over 3.0 at this point.

You're right on the money, my INR on the day of initial procedure was 2.4, but climbed rapidly to 3.4 within the third day. For the next few days, I intend to be on top of my INR and be within 1.8-2.2. At least for 2-3 days on this value. I hope I will not require pain meds during the process as it has shown to cause my INR to spike.

Proper scientific control and test case can only be done if he gets another wisdom tooth pulled and goes for INR < 2

I do have 2 more on the other side of my mouth laying in wait. Not looking forward and will be sure to keep up with my oral hygiene in a bid to avoid this as long as I possibly can. And if I can't, I am not bestowed with the wisdom of the experts on what to base my INR on prior surgery.

In my wife's case they did apply super "dental" glue after the bleeding started but it did not hold-up to the hydrostatic pressure of the liver clot (kind of like caulking a crack to stop a water leak coming from a basement foundation).

This is such an apt description of how the liver clot grows.

 

[MdaPA]

I got disgusted from the constant taste of iron. When you say sick here - I'm hoping it meant disgust versus actuall illness. Did she have her stitches re-done?

She got physically sick from swallowing too much blood (called gastrointestinal distress) and passed out. Took her to ER where they gave her protonix to calm her stomach down which she ended up having an allergic reaction to (making a long story short here). All that on top of her bleeding mouth was a complete nightmare. They then had an oral surgeon come in who said there is nothing else to do for her bleeding gums except get her INR down to around 2.0 and give it time to heal. It was while in the ER that she discovered that the fluid suction device was a life saver and they gave her an Rx to rent a portable one to use at home.

 

[dwhist]

In my case, I had a tooth (not a wisdom tooth) extracted. Gauze didn't seem to help much, plus, when the blood seemed to have clotted, when I removed the gauze, the bleeding started again.

I had a cut on roof of my mouth from an overly sharp edge on a tortilla. It would not stop bleeding and after 24 hours I went to ER. Doc said it was close to needing a stitch, but thought we could handle it. I told him I tried the tea bag trick and it did not work. I told him I put it on dry. He said to put tea bag in boiling water for a minute to activate the stuff that would help and when cool, put on cut He said always wet the tea bag or if using gauze, wet it first, otherwise as you saw, it pulls the scab off when you remove the gauze.

 

[Chuck C]

I had a cut on roof of my mouth from an overly sharp edge on a tortilla.

Been there! This seems to happen to me every 2 or 3 years, with a corn chip or tortilla. I get so pissed at myself when it happens: "How long have you been eating now Chuck and this still happens?" Every time it was eating while distracted or eating too fast. I get even madder at myself when I bite my tongue by accident

I think I've had one tongue bite and one tortilla chip cut since being on warfarin, which each caused some bleeding. They took longer to stop than prior to warfarin, but not really an issue.

 

[pellicle]

Hi

I do have 2 more on the other side of my mouth laying in wait. Not looking forward and will be sure to keep up with my oral hygiene in a bid to avoid this as long as I possibly can.

yeah, I had 4 to be removed ... and back then I had a homograft valve so my dentist never gave any ACT a thought.

He did break the root off (x-ray showed how it curled off to the back) and had to chisel it out of the bone.

I personally find this subject interesting and while I know that any experiment involving you is (N = 1) but I still prefer to minimise risks and if bringing the INR to just over 1.5 does that then you should consider it. Do you not have an On-X valve anyway? (note for the casual reader the On-X is on the FDA record as approved down to INR=1.8 "for daily targeting")

Best Wishes

 

[Chuck C]

I had a good discussion with my dentist yesterday about warfarin management for dental procedures.

It turned out that I had more work done than I thought I was getting. I had not one, but two cracked crowns which needed replacement. They were older crowns on #14 and 15. Also, #13 had a cavity on the surface facing #14. Removing #14 gave him perfect access to get to it, so I gave him the green light, even though it was kind of on the 'watch and wait' list. I can't wait to see my bill.

So, I asked him if he typically has his patients on warfarin reduce their INR for tooth extractions. He said that he always tells his patients to check with their cardiologist, but said that typically there is not much bleeding with a simple tooth extraction, so no INR reduction. But, there are tooth extractions and there are tooth extractions. He said that if the tooth to be extracted is impacted, this changes things and could warrant an INR reduction. This would be even more so the case if there was infection to the point where the extraction required removal of some infected bone.

 

[pellicle]

n my wife's case they did apply super "dental" glue after the bleeding started but it did not hold-up to the hydrostatic pressure of the liver clot (kind of like caulking a crack to stop a water leak coming from a basement foundation).

that's interesting to know that they have that in their tool kit (I'm not surprised btw), but I was meaning like "in the field" as I do when I get my own injuries working with steel and sharp plastics here at home.

Such as mounting a solar panel on the shed I built

I relied on this a lot (just to stop me staining all my clothes)

https://cjeastwd.blogspot.com/2021/06/superglue-wound-dressing.html

Life's fun

Best Wishes

 

[pellicle]

Hi

He said that he always tells his patients to check with their cardiologist, but said that typically there is not much bleeding with a simple tooth extraction, so no INR reduction. But, there are tooth extractions and there are tooth extractions. He said that if the tooth to be extracted is impacted, this changes things and could warrant an INR reduction.

good points

its like studies, there are averages and then there are individual situations.

An old poster here Dr Leng (yes an actual doctor, but we know that must be fake because "there are no doctors here") once noted (I think in personal communication) that "Asians tend to be Bleeders and Caucasians tent to be clotters"

I do wonder about the studies actual make up above (that were kindly presented).

Best Wishes

 

[bicuspidrek]

I personally find this subject interesting and while I know that any experiment involving you is (N = 1) but I still prefer to minimise risks and if bringing the INR to just over 1.5 does that then you should consider it. Do you not have an On-X valve anyway? (note for the casual reader the On-X is on the FDA record as approved down to INR=1.8 "for daily targeting")

You are right, I have an On-X valve. I will be sure to target a much lower INR prior any procedures in the future, and definitely with blessings from my cardiologist.

She got physically sick from swallowing too much blood (called gastrointestinal distress) and passed out.

That's horrible, and it definitely must have been a very very rough period for the both of you. Glad that it's in the rear view mirror now! Thanks for sharing about GI distress, I did some light reading on it and am glad that I had not reached that stage.

They then had an oral surgeon come in who said there is nothing else to do for her bleeding gums except get her INR down to around 2.0 and give it time to heal.

Seeing the value of the lower end of INR in recover so I am trying to bring it down to below 2.0 but am struggling at the moment due to a multitude of lifestyle changes that has happened over the months leading to 2024. I had initially managed to establish a relatively stable INR, sitting within the 2.0 - 3.0 range on an almost fixed dosage. My diet then was pretty regular, and I was reasonably healthy.

Towards the later part of the year however, I got back-to-back flus over a three week period- Covid-19 (definitively) and then influenza A (presumably). Fought back from these and starting 2024, I moved to a plant-based diet. My dose requirement shifted only slightly (up to 5.5mg, from 5mg).


I have also come across this article:

Paracetamol at 4 g daily (a dose higher than that used in clinical practice) potentiates the anticoagulant response produced by warfarin.

I was indeed prescribed Paracetamol (500mg) + Codeine Phosphate (8mg) tablets, instructions were to take 2 tablets, 3 times a day. Paying attention only to the Paracetamol component, this equates to 3g of Paracetamol a day. However further instructions state not to exceed 8 tablets within 24 hours. As I was trying to cope with the discomfort stemming from the extraction, and hoping to harvest as much rest as possible (Codeine component of the tablet causes drowsiness in some, until the body gets used to it), I maxed out the 8 tablets within 24 hours dosage guideline, and effectively hitting the 4g/24 hours of Paracetamol limit, which "potentiates the anticoagulant response produced by warfarin."

I will be more mindful of my pain medication consumption in this second stage of recovery.

This wisdom tooth extraction and the medication + diet (mostly liquid) has clearly thrown in a lot of additional variables but because of self-testing, I am in greater control of titrating my dose. It also helped that I had a "large" batch of test strips come in at the right time.

I had a cut on roof of my mouth from an overly sharp edge on a tortilla.

Every time it was eating while distracted or eating too fast. I get even madder at myself when I bite my tongue by accident

I was meaning like "in the field" as I do when I get my own injuries working with steel and sharp plastics here at home.

Haha, pre-warfarin, I slice myself up ever so often that my wife got used to them. Once I cut myself pretty good while helping in some baby foam installation for the brother-in-law. Resorted to super glue and it worked reasonably well enough (probably being on INR 1.0 helped immensely).

Post-warfarin, I have bit my gum + my tongue a couple of times and while scary, it was manageable. Gargling with salt and water helped the recovery slightly.

Nowadays, if my wife sees me grabbing my hand in an odd manner, she'd fiercely ask me "What happened?!" - thinking that I had sliced up myself again. This happened yesterday and the hilarious part was that I was simply drying my finger on my shirt, so it seemed like I was trying to curb a bleed.

 

[pellicle]

she'd fiercely ask me "What happened?!"

I used to get "what have you done now you idiot"

 

[Deepak khanka]

Sorry to hear about your dental complications and thanks for sharing your experience so that others may learn.

Have you had your INR tested since the procedure? I know that you were 2.2 on the morning of your procedure, but with all of the meds that they had you on, it would not surprise me if there was one or more of them interfering with warfarin clearance. You could easily be over 3.0 at this point.

Maybe talk to your cardiologist to see what he thinks of bringing your INR down to around 1.8 for a couple of days until the bleeding is resolved. Staying in that zone briefly might not be much of an issue- just make sure to discuss it with him and get his blessing.

I'm actually going in for dental work myself today. It is just for a replacement of a crown, so not much concern with bleeding and I have not taken any steps to lower my INR for the procedure. I will be taking my 2,000mg of amoxicillin an hour prior. Personally, if I was getting teeth extracted, I would get my cardiologist's blessing to go in with an INR about 1.7 to 1.8, at least for the day of the procedure. My normal range is 2.0 to 3.0, BTW.

Hi
2000mg 1 hr prior to the procedure is this adviced ? or is there pre dosage stage for a day 500 mg x3 . I have some filling work to be done but my dentist has not prescribed anti biotics (UK) I have amoxicillin and I can self medicate but don’t know the pre & post dosage . Any suggestion how many days before and how many days after I need to take antibiotics and how many mg.

 

[pellicle]

Hi
2000mg 1 hr prior to the procedure is this adviced ?

that has been my protocol for some years now

half life of amoxicillin is slated as:

Pharmacokinetics​

​

Absorption: Amoxicillin exhibits stability in the presence of gastric acid and is rapidly absorbed after oral administration, with average peak blood levels typically reached within 1 to 2 hours.​

Elimination: Amoxicillin has an approximate half-life of 61.3 minutes, and about 60% of the administered dose is excreted in the urine within 6 to 8 hours.​

(link)
so basically that's perfect

 

[pellicle]

my protocol

just wanted to add here that by 'my' I mean

1. my surgeon wants this and explicitly said to do this
2. my dentist wants this and ass me each time if I have
3. I think its the right thing to do and I make sure I do it

 

[JLmatus]

I bit my tongue a few years ago while on warfarin and I could not stop the bleeding. I felt like an idiot and really did not want to go to the emergency room. After about 2 hours of trying everything (tea bags, gauze etc), I started googling suggestions. I found a product called "Bleed Stop". It's a powder used to stop bleeding. It is similar to what the military uses on wounds. Put the powder on a piece of gauze and the bleeding stopped within a few minutes. I ordered a few boxes of the stuff to keep on hand for emergencies. I'm not sure if it can be used for a tooth extraction though.

 

[3mm]

2000mg 1 hr prior to the procedure is this adviced ?

This is what my cardiologist and dentist tell me to do.

 

[Sheenas7]

I bit my tongue a few years ago while on warfarin and I could not stop the bleeding. I felt like an idiot and really did not want to go to the emergency room. After about 2 hours of trying everything (tea bags, gauze etc), I started googling suggestions. I found a product called "Bleed Stop". It's a powder used to stop bleeding. It is similar to what the military uses on wounds. Put the powder on a piece of gauze and the bleeding stopped within a few minutes. I ordered a few boxes of the stuff to keep on hand for emergencies. I'm not sure if it can be used for a tooth extraction though.

I also bit my tongue one. It was a nightmare. I was after 2 hours of trying, on my way to hospital when it stopped. Could have used that!

 

[pellicle]

Could have used that!

and that my friend is the great part of this place, rubbing shoulders with people who are in the same "boat of problems" and can share ideas about what worked for them.

But of course, only follow your doctors instructions ;-)

BTW, you didn't happen to know your INR at that time do ya?