Oral Anticoagulants and Dental Procedures

Transcription

1 Oral Anticoagulants and Dental Procedures Ashley N. Castelvecchi, PharmD; Lamonica N. Crump, PharmD Continuing Education Units: 1 hour This course will discuss the available anticoagulant and antiplatelet therapies available in the United States as well as the recommended management of these agents prior to dental procedures. Conflict of Interest Disclosure Statement The authors report no conflicts of interest associated with this work. ADAA This course is part of the home-study library of the American Dental Assistants Association. To learn more about the ADAA and to receive a FREE e-membership visit ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2009 to 7/31/

2 Overview Anticoagulants and antiplatelets are commonly used for various conditions including the treatment and prevention of cardiac disease, cerebral vascular accident, and thromboembolism, in both the inpatient and outpatient settings. As such, dental professionals will encounter many patients taking these medications. For these patients, several factors should be considered prior to a dental procedure; the indication for anticoagulant or antiplatelet therapy, bleeding risk, and thromboembolic risk must be assessed prior to interruption of therapy. Evaluating the risk versus benefit of continuing therapy can assist in determining if and when it is appropriate to interrupt therapy. Additionally, patients receiving anticoagulant and antiplatelet medications are frequently managed by different healthcare providers and specialists, so it is important to inform other providers if alteration of therapy is warranted, and provide clear instructions and education to both the patient and caregivers. The management of these agents prior to dental procedures can be complex due to the potential to prolong bleeding times, however recent studies and guidelines suggest that these medications can be safely continued for most minor dental procedures. 1-4 Dental professionals should still be prepared to use local measures to manage any excessive bleeding. This course will discuss the available anticoagulant and antiplatelet therapies available in the United States as well as the recommended management of these agents prior to dental procedures. Learning Objectives Upon completion of this course, the dental professional should be able to: Describe the different types of oral anticoagulants and antiplatelets and the mechanisms of action. Evaluate the risks associated with interruption of anticoagulant and antiplatelet medications prior to dental procedures. Identify strategies for bleeding risk reduction and management following dental procedures. Understand the importance of health care professionals in the management of oral health care. Course Contents Glossary Available Anticoagulants Warfarin Aspirin and Antiplatelets Bleeding Complications versus Thromboembolic Complications Dental Treatment Considerations Management of Bleeding Role of Healthcare Professionals Conclusion Course Test References About the Authors Glossary Acute Coronary Syndrome (ACS) A group of conditions involving acute decreased blood flow to the heart, including unstable angina and different types of myocardial infarctions, or heart attacks. anticoagulant/antiplatelet Medications used to prevent clot formation or to prevent a clot that has formed from enlarging; they work by blocking the action of clotting factors or platelets. antifibrinolytic agent A medication that prevents the breakdown of fibrin in blood clots and is used to prevent excessive bleeding. blood clot A thickened mass formed by platelets, which form to stop bleeding, such as at the site of a cut; a clot can also form in a blood vessel, causing decreased blood flow. embolus (i.e. pulmonary embolism) A clot that travels through the blood vessel into a smaller vessel, which obstructs circulation. hemophilia A hereditary disorder, that occurs primarily in males, in which the blood fails to clot normally because of a deficiency or an abnormality of one of the clotting factors. hemostasis A process which causes bleeding to stop. 2

3 International Normalized Ratio (INR) A standardized measure of the prothrombin time (PT), which is used to determine the clotting tendency of blood. The INR is the ratio of a patient s PT to a normal (control) sample, raised to the power of the ISI value for the reagent system used. International Sensitivity Index (ISI) A measure of thromboplastin sensitivity to an international standard. Each lot number of thromboplastin used in prothrombin or INR testing is assigned its own unique ISI value from the manufacturer. Percutaneous Intervention (PCI) A procedure performed to diagnose or treat narrowed cardiac vessels. Includes procedures such as diagnostic catheterization, cardiac revascularization, angioplasty, stent placement. provider Use of this term within this course may indicate a patient s primary physician, cardiologist or anticoagulation clinic. thrombocytopenia A low platelet count which can be hereditary, alcohol or medication induced, or as a result of other disease states or chemical exposures. thrombosis (i.e. Deep vein; cerebral; coronary) Formation of a blood clot that blocks or partially blocks a blood vessel; this may lead to infarction, or death of tissue, due to a lack of blood supply. Available Anticoagulants For many years, vitamin K antagonists and aspirin were the only oral therapies available for prevention of thrombosis. Several new antithrombotic therapies have been developed in recent years. It is important for healthcare providers to stay up-to-date on available treatments, including the mechanism of actions and management of these agents. These newer anticoagulants target a specific stage in the coagulation process, differing from vitamin K antagonists, which effect multiple stages of the process by reducing synthesis of vitamin K dependent factors. The platelet aggregation inhibitors, such as the thienopyridines (i.e. clopidogrel (Plavix )), aspirin/dipyridamole (Aggrenox ), and cilostazole (Pletal ), prevent platelet aggregation and/or platelet activation, inhibiting adhesion of platelets and clot formation. The development of newer generations of antithrombotic agents have been on the horizon targeting convenience and improving clinical outcomes for patients. The Food and Drug Administration (FDA) approved the first oral direct thrombin inhibitor, dabigatran ( Pradaxa ) in October This medication inhibits thrombin from converting fibrinogen to fibrin in the coagulation cascade, thereby preventing formation of a clot. 5 Rivaroxaban (Xarelto ) is a factor Xa inhibitor that blocks the active site of factor Xa to prevent activation of factor Xa in the coagulation cascade. This medication was approved in July 2011 for the prevention of embolism in atrial fibrillation or patients undergoing hip or knee replacements. 6 There are two other oral factor Xa inhibitors in development and pending FDA approval, including apixaban and edoxaban. See Table 1 for complete list of oral agents available in the United States. There is less data regarding management of these newer agents with respect to bleeding risk during dental procedures 2 ; therefore the remainder of this course will focus primarily on vitamin K antagonists and platelet aggregation inhibitors. Warfarin The mainstay in the anticoagulant class for many years has been the vitamin K antagonists, or warfarin (Coumadin ) therapy. Warfarin acts by inhibiting synthesis of the vitamin K-dependent clotting factors II, VII, XI, and X, as well as endogenous anticoagulants protein C and S. 7,8 Vitamin K antagonists are often closely monitored and have a high bleeding risk with a narrow therapeutic range. Standardized measures such as the International Normalized Ratio (INR) are utilized to determine coagulation times in patients receiving warfarin therapy and assist in determining bleeding risk for a patient. For most indications, the target INR range is 2.0 to 3.0; although some patients, such as those with certain types of heart valve replacements, may require a higher target range of 2.5 to 3.5. Subtherapeutic levels can increase the risk of thromboembolic complications, while supratherapeutic levels can increase the risk of bleeding complications. Therefore, patients require frequent monitoring of INR of at least every four weeks, if the INR is therapeutic and stable. 7 3

4 Table 1. Anticoagulant/Antiplatelet Agents available in United States For patients taking warfarin who are undergoing a minor dental procedure, it is recommended to continue warfarin therapy and administer a prohemostatic agent as long as the INR is less than ,9 Minor procedures include those such as prophylaxis, simple extractions, and local anesthetic injections (Table 2). These procedures result in relatively small blood loss and can be managed with local measures. 9 Ideally, dental providers should check the INR within 24 hours prior to the procedure, but up to 72 hours prior to the procedure is acceptable if the patient s INR has been stable. 7,10 If the INR is greater than 4.0, it is recommended to consider postponing the procedure due to increased risk of bleeding. The development of Point-of-Care (POC) devices has proven useful for this purpose to provide immediate INR results, so a dental provider may proceed with the necessary dental treatment. These devices use a fingerstick sample of capillary whole blood or un-anticoagulated venous whole blood. 7 Available POC devices include: Coaguchek XS, Coaguchek XS Plus, INRatio 2, etc. In some cases, such as for certain dental surgeries, it may be appropriate to have partial warfarin therapy interruption, where the patient is instructed to hold warfarin for two or three days prior to the procedure. 2 If the patient is to undergo a procedure associated with higher bleeding risk, such as extensive surgery, root removal, or bone removal, it may be appropriate to hold warfarin therapy for up to five days prior to the procedure. 2,11 The patient s provider or cardiologist should be contacted to assist 4

5 Table 2. Anticoagulant/Antiplatelet Agents available in United States in development of a more extensive plan, which may include using heparin or low molecular weight heparin to bridge the patient during interruption of warfarin therapy. This strategy may be used particularly if the patient is at higher risk for thrombosis. Aspirin and Antiplatelets A few of the more commonly used antiplatelet medications include aspirin (or acetylsalicylic acid, ASA), clopidogrel, and dipyridamole. These agents act to inhibit one or more steps of platelet formation and aggregation, and essentially cause prolongation in bleeding time. Other newer agents, such as the thienopyridines, work to inhibit platelet activation and aggregation, specifically by inhibiting the P2Y12 adenosine diphosphate (ADP) receptor on platelets The thienopyridines include clopidogrel (Plavix ), prasugrel (Effient ), and ticagrelor (Brilinta ). Clopidogrel is approved for treatment of acute coronary syndrome (ACS) as well as reduction of new stroke or myocardial infarction (MI) in patients with a recent stroke, MI, or established peripheral arterial disease. 12 Prasugrel is approved for patients with ACS who are to be managed with percutaneous coronary intervention (PCI), to decrease the risk of thrombotic cardiovascular events. 13 Ticagrelor, has been approved for the same indication as prasugrel, but it is different from prasugrel and clopidogrel in that it reversibly binds to the ADP receptor. 14 Studies which look at postoperative bleeding times associated with continuation or discontinuation of antiplatelets such as aspirin, clopidogrel or dipyridamole, show a low risk of bleeding. 15 Although bleeding time may be prolonged in patients that take antiplatelet agents, it may not be clinically relevant when determining the risk versus benefit of continued treatment with dental procedures. 1 Postoperative bleeding may be controlled with local measures (see Management of Bleeding section). There are few studies evaluating the bleeding risk associated with dental procedures in patients receiving the thienopyridines, either alone or in combination with aspirin. It is also important to note that there are limited studies showing clinically significant bleeding after dental procedures with these agents. 16 Therefore, in most patients, antiplatelet medications should not be discontinued prior to routine dental procedures or minor dental surgeries according to current guidelines and studies. 2,4,10,16 Additionally, if 5

6 there is any concern for bleeding or thrombosis, particularly in those patients receiving any combination of antiplatelets or anticoagulants (ASA/clopidogrel or ASA/warfarin, etc.), it is suggested that the case be reviewed more closely to consider interruption of therapy prior to the dental procedure. 16 If necessary, these medications may be held for seven to ten days prior to a procedure, but only after consulting the patient s provider or cardiologist. 2,16 Bleeding Complications versus Thromboembolic Complications When an anticoagulant or antiplatelet medication is interrupted prior to a dental procedure, there is an increased risk of thromboembolic events. 17 However, if these medications are continued patients are at an increased risk of bleeding, as these agents impair clotting, which may result in postoperative bleeding and complications. Thrombosis is the formation of a blood clot that blocks or partially blocks a blood vessel. Types of thromboses are named by their location including cerebral, deep vein and coronary. Postoperative bleeding complications may lead to infarction or death of tissue due to a lack of blood supply. It is important to first weigh these factors prior to deciding if anticoagulant therapy should be interrupted. Wahl 18 has studied the impact of stopping and continuing anticoagulant therapy in dentistry. The thromboembolic event risk associated with interruption of anticoagulant therapy varies from 0.02 to 1%. According to the several consensus guidelines, anticoagulant and antiplatelet therapy can safely be continued for most minor dental procedures listed in Table 2. 2,4,9,10 It has also been shown that interruption of therapy may put patients at an increased risk for a thromboembolic event. 17 General guidance can be provided using certain assessment tools with regards to bleeding risk and thromboembolic risk, but individual management may vary depending on procedure type and patient characteristics. Several tools have been evaluated to assess the bleeding risk and thromboembolic (i.e. stroke) risk of patients taking anticoagulation therapy. Bleeding risk assessments often account for patient factors such as an age greater than 65 years old, prior gastrointestinal bleeding, history of stroke, history of myocardial infarction, hematocrit less than 30%, creatinine above 1.5mg/dL, and history of diabetes. The final score is provided as low, intermediate, or high bleeding risk. In patients who receive anticoagulant or antiplatelet therapy for atrial fibrillation, a provider may utilize a more extensive assessment tool to evaluate stroke risk. These assessments are referred to as the CHADS2 and CHA2DS2-VASc scores. 2,7 These tools include history of alcohol abuse, renal or hepatic insufficiency, gender, history of diabetes, history of stroke, age range 65 to 74 or greater than 75 years old, history of vascular disease, uncontrolled hypertension or CHF, and history of excessive falls. Dental Treatment Considerations The main discussion at hand is the consideration for interruption of anticoagulants or antiplatelet agents for planned dental treatment. For patients who are receiving warfarin or low-dose aspirin and need to undergo simple extractions or oral surgeries, it is recommended to continue these agents and manage bleeding with hemostatic measures unless the INR is greater than ,2 As previously discussed, if the INR is greater than 4.0, it is recommended to consider rescheduling the procedure. Overall, it is important to consider the bleeding risk that may be associated with the dental procedure (see Table 2) 2,9 and the medication. The recommendation to continue anticoagulant or antiplatelet therapy may be extended to other dental procedures including crowns, bridges, root canals, extraction of limited number of teeth, implants, gingival surgery, and supragingival or subgingival scaling. 19 If the patient is to undergo a procedure associated with higher bleeding risk, such as extensive surgery, root removal, or bone removal, it may be appropriate to hold warfarin therapy for up to five days prior to the procedure. 2,11 It is important to inform the patient s provider, who is managing anticoagulant therapy, when warfarin is going to be held for a procedure. Additionally, if the dental procedure is high risk or the patient is at high risk, it may be advisable to contact the patient s cardiologist prior to interruption of therapy. In patients with liver impairment, alcoholism, kidney failure, thrombocytopenia, hemophilia, or other hemostatic disorders, it is also advisable to consult the patient s physician. 4 6

7 The risk of bleeding associated with dipyridamole/ aspirin is similar to aspirin alone, and although there is less data available, clopidogrel, prasugrel, and ticagrelor may be continued as recommended with warfarin and aspirin therapies. 2,16 Management of Bleeding When a patient is on an anticoagulant or antiplatelet agent, it takes longer for primary hemostasis to occur; subsequently bleeding time is prolonged. 19 These medications can essentially double bleeding times, however the clinical relevance of this is minor. In most cases, hemostatic measures can be utilized to control bleeding, as significant or life threatening bleeding after dental surgery is rare. 1 Clinically significant bleeding following a dental procedure has been defined as bleeding that continues beyond 12 hours, causes the patient to call or return to the dental practice or other provider, results in the development of a large hematoma or bruising within the oral soft tissues, or requires a blood transfusion. 11 As previously mentioned, if a patient is on warfarin therapy, obtaining an INR up to 24 to 72 hours prior to the procedure is advisable. In a study conducted by Wahl 17, the incidence of serious bleeding problems in 950 patients receiving anticoagulation therapy undergoing 2400 individual dental procedures was evaluated. Only 12 patients (<1.3%) experienced bleeding uncontrolled by local measures and none of the patients reported serious harm. Further details of those 12 patients include the use of postoperative antibiotics which may have interacted with warfarin, higher than recommended anticoagulation levels, and use of mouthwash immediately after the procedure. Of note, the use of mouthwash or rinse is contrary to standard advice for 24 hours after a procedure. For many procedures, local measures may safely be used to control any bleeding. Local hemostatic measures may include using gelatin sponges with silk sutures, vasoconstrictors in local anesthetic, and the use of antifibrinolytics. Currently available antifibrinolytic agents in the United States include tranexamic and aminocaproic acid solutions, however their use in dentistry has been controversial and are considered off-label. Tranexamic acid was initially approved in December 1986 for use in patients with hemophilia to reduce or prevent hemorrhage during and after surgical procedures. The tranexamic acid solution for injection has been used in other conditions and to reduce blood loss for those with major surgeries such as cardiac, orthopedic, etc. 20 Tranexamic acid solutions can be expensive and difficult to obtain. An alternative is aminocaproic acid solution, which is also used in the prevention of bleeding during and following procedures. Patients utilizing either agent are encouraged to hold the solution in the mouth instead of using as a mouthwash. The tranexamic acid is used by holding 10 milliliters in the affected area for two minutes prior to the procedure and repeated every two hours postoperatively for six to ten doses. For the aminocaproic acid solution, 10 milliliters should be held in the mouth for two minutes and then the patient should be instructed to expectorate. This may be repeated every six hours for two days after the procedure. 20 After any dental procedure, the patient should be educated on general measures which include: Rest for two or three hours. Avoiding hot liquids, rinsing the mouth, using mouthwash, or eating hard foods for 24 hours. Flossing gently every day, avoid areas where gingival tissue may be sore of bleeding. Avoid chewing on the affected side for at least one to two days. Do not rinse for 24 hours. If antibiotics are required, ensure patient contacts his/her anticoagulation clinic for review of drug interaction with warfarin or other prescription medications therapy. Role of Healthcare Professionals It is important to encourage proper dental hygiene and preventative care to minimize the need for more intensive dental procedures. The dental healthcare team should also be aware of other pre-existing conditions which may result in bleeding complications, such as liver disease, renal disease, thrombocytopenia, hemophilia, etc. In these cases, it may be prudent to contact the patient s provider to discuss options prior to dental procedures, particularly those with higher bleeding risk. Patients should be instructed on proper dental hygiene such as: 7

8 Gently brush teeth, gums with an extra-soft toothbrush after every meal and before bed. May soften toothbrush bristles in warm water. Avoid use of toothpicks Floss gently every day, avoid areas where gums may be sore or bleeding. Conclusion The general class of anticoagulant and antiplatelet medications used in the prevention of thromboembolic diseases can increase a patient s bleeding risk. Bleeding complications do not carry the same risk as thromboembolic complications, as patients who interrupt these medications prior to procedures are at a higher risk for stroke or myocardial infarction. If warfarin interruption is deemed appropriate, depending on the individual patient and/or procedure dynamics, it should be managed by an anticoagulant clinic, cardiologist, hematologist, or primary physician. 2,19 In summary, most dental procedures may be performed without interruption in these types of medications with the use of hemostatic measures to control bleeding if needed. 2,11,19 The practice of using antifibrinolytic rinses, suturing, and pressure can be successful in the treatment of bleeding. It is advisable in the use of warfarin to monitor the patient s INR levels 24 to 72 hours prior to dental procedure. For those patients with INRs greater than 4.0, postpone dental surgical procedures and refer patient to a clinician responsible for their anticoagulation management. 8

9 Course Test Preview To receive Continuing Education credit for this course, you must complete the online test. Please go to and find this course in the Continuing Education section. 1. Anticoagulant medicines are used for the treatment and prevention of. a. cardiovascular disease b. cancer c. asthma d. bronchitis 2. Patients receiving anticoagulant medications are frequently under the additional care of different healthcare providers and specialists. Hemostasis is a hereditary bleeding disorder. a. Both statements are true. b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false. 3. will prevent platelet activation, inhibiting adhesion of platelets and clot formation. a. Vitamin K antagonists b. White blood cells c. Warfarin d. Platelet aggregation inhibitors 4. For most people, the target INR range is from. a b c d Dental procedures such as subgingival scaling and regional injections of local anesthetic are considered risk. a. low b. moderate c. high d. severe 6. Ideally, dental providers should receive an INR within hours prior to the procedure, but up to hours prior if the patient s INR has been stable. a. 12 / 18 b. 18 / 24 c. 24 / 72 d. 36 / The Agent Class for aspirin is a vitamin K antagonist. Aspirin blocks the aggregation of platelets and works to reduce blood viscosity. a. Both statements are true. b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false. 9

10 8. Patients may indicate their dosage of is anywhere from 1mg 10mg. a. Coumadin b. Plavix c. Aspirin d. Pradaxa 9. If the INR is greater than, it is recommended to consider postponing the procedure due to increased risk of bleeding. a. 2.0 b. 3.0 c. 3.5 d In some cases, such as for certain dental surgeries, it may be appropriate to. a. increase anticoagulant b. interrupt anticoagulant therapy c. maintain the regular treatment plan d. None of the above. 11. A few of the more commonly used antiplatelet medication(s) include. a. aspirin b. acetylsalicylic acid c. dipyridamole d. All of the above. 12. A(n) may lead to infarction, or death of tissue, due to a lack of blood supply. a. thrombosis b. embolism c. thrombin d. hematoma 13. When an anticoagulant or antiplatelet medication is discontinued prior to a dental procedure, there is an increased risk of thromboembolic events. According to the several consensus guidelines, anticoagulant and antiplatelet therapy can safely be continued for most minor dental procedures. a. Both statements are true. b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false. 14. Bleeding risk assessments often account for patient factors such as. a. history of diabetes b. prior gastrointestinal bleeding c. history of stroke and/or a history of myocardial infarction d. All of the above. 15. When a patient is on an anticoagulant or antiplatelet agent, it takes for primary hemostasis to occur. a. a shorter time b. a normal amount of time c. a longer time 10

11 16. Clinically significant bleeding following a dental procedure has been defined as. a. bleeding that continues beyond 2 hours b. bleeding that causes the patient to call or return to the dental practice c. bleeding that results in the development of a blood clot d. All of the above. 17. The use of mouthwash is for 24 hours after dental treatment. a. not recommended b. recommended c. standard d. supported 18. Local hemostatic measures may include using. a. gelatin sponges with silk sutures b. vasoconstrictors in local anesthetic c. antifibrinolytics d. All of the above. 19. After any dental procedure, the patient should be educated on such general measures that include to avoid. a. hot liquids b. rinsing the mouth for 24 hours c. eating hard foods for 24 hours d. All of the above. 20. Patients on anticoagulant therapy should be instructed to. a. avoid flossing b. avoid brushing with a soft bristle brush c. avoid toothpicks d. avoid regular dental check ups 11

12 References 1. Jeske AH, Suchko GD, et al. Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment. J Am Dent Assoc Nov;134(11): Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest Feb;141(2 Suppl):e326S-350S. 3. Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management considerations for the patient with an acquired coagulopathy. Part 2: Coagulopathies from drugs. Br Dent J Nov 8;195(9): American Dental Association. Oral Health Topics/Anticoagulant, Antiplatelet Medications and Dental Procedures. Accessed April Pradaxa. Highlights of Prescribing Information. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; January 2012 (Revised November 2012). 6. Xarelto. Highlights of Prescribing Information. Bayer HealthCare AG, Leverkusen, Germany; Janssen Pharmaceuticals, Inc; November Ageno W, Gallus AS, Wittkowsky A, Crowther M, et al. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines. Chest Feb;141(2 Suppl):e44S-88S. 8. Coumadin (warfarin sodium). Highlights of Prescribing Information. Copyright Bristol-Myers Squibb Company; October University of Washington Medical Center, Anticoagulation Services. Suggestions for anticoagulation management before and after dental procedures. April Perry DJ, Nokes TJ, Heliwell PS, et al. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. British Dental Journal 2007, Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management considerations for the patient with an acquired coagulopathy. Part 1: Coagulopathies from systemic disease. Br Dent J Oct 25;195(8): Plavix. Highlights of Prescribing Information. Bridgewater, NJ: Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. December Effient. Highlights of Prescribing Information. Indianapolis, IN: Eli Lilly and Company; September Brilinta. Highlights of Prescribing Information. Wilmington, DE: AstraZeneca; Bridgewater, NJ: Bristol- Myers Squibb/Sanofi Pharmaceuticals Partnership. July Napeñas JJ, Hong CH, Brennan MT, Furney SL, et al. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. J Am Dent Assoc Jun;140(6): Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation Feb 13;115(6): Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med Aug 10-24;158(15): Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. J Am Dent Assoc Jan;131(1): Pototski M, Amenábar JM. Dental management of patients receiving anticoagulation or antiplatelet treatment. J Oral Sci Dec;49(4): Lexi-Comp Online, Lexi-Drugs OnlineTM, Hudson, Ohio: Lexi-Comp, Inc. Accessed May 10,

13 About the Authors Ashley N. Castelvecchi, PharmD Ashley is a Clinical Pharmacy Specialist for the Home-Based Primary Care program at the Veterans Affairs Outpatient Clinic in Greenville, South Carolina. She has a Doctor of Pharmacy from the University of Kentucky and completed a Post-Graduate Year One Clinical Pharmacy Residency at the Veterans Affairs Medical Center in Lexington, Kentucky. Lamonica N. Crump, PharmD Lamonica is a Clinical Pharmacy Specialist at the Veterans Affairs Outpatient Clinic in Greenville, South Carolina. She has a Bachelors of Science and a Doctor of Pharmacy from the University of South Carolina. 13