Quality Resource Guide
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Guidelines for Consultation With and/or Referral to a Physician 1st Edition
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www.metdental.com
Medical Condition
Implications for Dental Care
When to Consult/Refer
What to ask for and how to use information received
BLEEDING DISORDERS
Congenital Bleeding Disorders:
Inherited conditions affecting
coagulation. For example: von Wil-
lebrand disease, Hemophilia.
-
Increased risk for bleeding
-
Patient may present with signs of
submucosal bleeding such as petechiae,
ecchymoses or hematomas
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Patient with a diagnosis of a congenital
bleeding disorder
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Possible undiagnosed bleeding disorder,
suggested by a history of excessive bleed-
ing or the presence of petechiae, ecchymo-
ses or hematomas
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Specific diagnosis.
-
Laboratory tests: Indicate severity of disease - may include activated
partial thromboplastin time (aPTT), prothrombin time (PT), thrombin
time (TT) and platelet count.
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How managed: for example, patients with type 1 von Willebrand
disease or hemophilia may be receiving desmopressin therapy.
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Precautions needed for procedures involving bleeding: for example,
factor VIII replacement in severe hemophilia; desmopressin, ami-
nocaproic acid, or factor VIII with von Willebrand factor in von Wil-
lebrand disease. Avoid aspirin and other NSAIDS. Block anesthetic
injections can lead to hematoma and respiratory compromise.
Anticoagulant therapy:
Patients taking anticoagulants to
reduce the risk of a thromboem-
bolic event (
e.g.
stroke, myocardial
infarction).
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Increased risk for bleeding
-
Patient may present with signs of
submucosal bleeding such as petechiae,
ecchymoses or hematomas
-
Unclear history of taking anticoagulants
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Patients taking warfarin/coumadin
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If planning major surgery with significant
bleeding expected
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Specific anticoagulant being taken, dose, and indication.
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Antiplatelet therapy (aspirin, clopidrogrel): Usually no changes to
antiplatelet therapy indicated
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.
-
Warfarin: Obtain recent prothrombin time/INR. Most dental proce-
dures, including most extractions, can be performed with INR ≤ 3.5
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- If over 3.5, consult with the physician to reduce warfarin dose.
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Heparin: Typically used for a limited time only. Defer elective proce-
dures where significant bleeding expected.
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Direct factor XA inhibitors (rivaroxaban, apixaban, edoxaban) and
direct thrombin inhibitors (dabigatran): Evidence to date suggests
that most dental procedures, including most extractions, can be
performed without modifying these medications
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.
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For all of the above: Expect and be prepared to locally manage
some increase in bleeding - If planning major surgery, discuss
benefits and risks (thromboembolic event) of dose reduction with
physician and patient, and follow-up with the patient after surgical
procedures.