Give examples dental procedures unlikely to cause bleeding
LA
BPE
supragingival PMPR
orthograde endodontic
impressions
fitting orthodontic appliances
restorations with supra gingival margins
Give examples of higher risk post-op bleeding procedures
complex extractions
adjacent extractions that will cause a large wound or > 3 teeth extracted
implant surgery
periradicular surgery
biopsies
Give examples of low risk post op -bleeding procedures
Simple extractions (1-3 teeth with restricted wound size)
RSD
6PPC
direct or indirect restorations with sub gingival margins
incision and drainage of intra-oral swellings
Patient is taking a DOAC and requires 16 xla , how would you approach this?
treat without interrupting medication
ideally treat early in day
consider staging extensive procedures
strongly consider suturing and packing
Apixaban and dabigatran are usually taken…
2x daily
Rivaroxaban is usually taken…
once a day in morning
edoxaban Is usually taken…
one a day in evening
patient on rivaroxaban requires surgical extraction of 38, how would you manage this?
advise patient to delay morning dose and take 4 hours after haemostasis has been achieved following XLA
patient is on apixaban and dabgatran and requires implant surgery - how would you manage?
advise patient to delay morning dose, then take evening dose as usual
how to manage patient on warfarin prior to extraction
INR must be checked no more than 24 hours before 72 hours if patient is stably anti-coagulated
must be below 4
patients INR is over 4 but they require XLA - how would you manage this?
consider referral if urgent OR
delay tx if non-urgent
give examples of patients with high risk of developing MRONJ
previous MRONJ diagnosis
being treated with anti-resorptive or anti-angiogenic drugs for management of cancer
taken bisphosphonates for > 5 years
taking bisphosphonates and also concurrent treatment with a systemic glucocorticoid
give examples of patients with low risk of developing MRONJ
bisphosphonate use <5 years and not being treated with glucocorticoid
patient has taken denosumab in last 9 months
MRONJ - when to refer and who to refer to
extraction socket not healed at 8 weeks and MRONJ is suspected
refer to oral surgery or special care dentistry
Estimated incidence of MRONJ in cancer patients treated with anti-resorptive or anti-angiogenic drugs
1%
Estimated incidence of MRONJ in osteoporosis patients treated with anti-resorptive
0.01-0.1%
1-10 cases per 10,000
how do anti-resorptive drugs work?
inhibition of osteoclast activity leading to decreased bone resorption and remodelling
