Warfarin must be monitored to ensure it is working effectively and being used safely. The dose may also need to be adjusted based on a patient’s diet and current medications. Warfarin therapy may be prescribed for patients with certain types of irregular heartbeat, blood clots in the legs or lungs, and patients who have certain medical device implants such as artificial heart valves.Ī patient’s warfarin dose depends on many factors, including the patient’s age, overall health and genetic makeup. Warfarin (also known by the brand names Coumadin and Jantoven) is a blood thinner prescribed to prevent and treat blood clots. The FDA wants to ensure patients and health care providers use these devices safely. INR test meters and test strips are medical devices regulated by the U.S. The INR is used by patients and physicians to determine if warfarin dosing is appropriate. The meter reads the test strip, measures how long it takes the blood to clot, and provides the result based on a standardized calculation in the form of the International Normalized Ratio, or INR. A test strip is inserted into the meter, and then a lancet (a medical pricking needle) is used to obtain blood which is applied to the test strip. The meter has a screen that displays results, and an opening for meter-specific test strips. To avoid the needles becoming barbed and tearing tissues, they should be used once only for each mucosal or skin puncture.An INR test meter is a portable, battery-operated meter, used to monitor patient response to warfarin. Local anaesthetics should be given cautiously avoiding venepuncture. Aspirin and non-steroidal anti-inflammatory drugs may also increase the risk of bleeding. Prolonged use of broad spectrum antibiotics should be avoided as it may change the effectiveness of warfarin by altering gut microflora compromising availability of vitamin K. Where the operative site is infected the use of antibiotics should be restricted to a preoperative prophylactic dose and postoperative antibiotics should be discontinued as soon as reasonable. For extensive surgery the assistance of the physician supervising coagulation therapy is required to assist in determining whether a change of coagulation therapy is indicated. Preferably surgery should be performed in the morning to facilitate postoperative observation. 6 In most cases of dento-alveolar/oral surgery, including simple extraction of teeth, bleeding can be controlled in a reasonable time by minimising the extent of surgery to one site or quadrant, and using firm sutures or firm postoperative packs over the wound. The INR should be checked before surgery.įor routine conservative dental treatment including scaling, changing an established warfarin regimen is not justified. If an interaction is considered likely or if the effect of any prescribed medication is not known, the dentist should consult the doctor supervising the patient's anticoagulant therapy. 5Medications including antibiotics such as metronidazole, herbal remedies and alcohol may unpredictably alter the INR. The dentist should also consider possible drug interactions with warfarin. 2īefore dental treatment a thorough medical history should be obtained including details of any condition likely to be treated with warfarin. However, before deciding if warfarin therapy should be interrupted the risk of perioperative or postoperative bleeding must be balanced against the risk of thromboembolism. The possibility of postoperative bleeding in patients taking warfarin concerns dentists. 4 However dentists should still be cautious before they remove teeth where the INR exceeds 3. 3A small study has suggested that with appropriate local measures to reduce bleeding, teeth may be removed by simple extraction with an INR of 2-4. Oral surgery can be completed safely with an INR from 1.5 to 2.5. Gingival bleeding can indicate a raised INR. 2 The risk of bleeding increases exponentially as the INR rises. Patients receiving treatment for deep vein thrombosis have a lower target range than those with prosthetic heart valves. The desirable INR range for patients depends on the condition being treated. 1 A normal coagulation profile has an INR of 1.0. The activity of warfarin is expressed using the international normalised ratio (INR). Indications for anticoagulation are increasing, and dentists will be consulted by patients taking warfarin. Warfarin is an anticoagulant which inhibits synthesis of the vitamin K-dependent coagulation factors II, VII, IX and X.
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