Winter Park Dentistry- Blood Thinners
Dr. Ramzi Matar (Winter Park Dentistry): Hello everybody, thanks and welcome to this episode of our podcast. We have again with us our guest Dr. Andonis Terezides, introduced to you at the last podcast about the bisphosphonate medications. Today our episode is about blood thinners. You’re obviously an oral surgeon, I think if you didn’t like blood there would be a problem, you deal with blood all the time, so bravo for you, I’m glad somebody has a stomach for it, a lot of people are very glad that you’re there. The reason I want to talk about blood thinners, is because there have been a lot of changes. I see legal ads, every time there’s ten new legal ads on the news, you know there’s some new drug, “have you been on this blood thinner? Known somebody who died on this blood thinner?”, so immediately I called you and said “hey, what’s going on with blood thinners?” and you told me all this stuff and I think all the world needs to know about it. The basic premise is there’s a bunch of new blood thinners out, I wanted you to tell people who are generally on blood thinners, what are they getting treated for, obviously they are important for what they’re been treated for, but they do provide you with road blocks for when you’re doing surgery, so some of the new blood thinners, what are the pros and cons of them. So please tell us a little bit about… Introduce to us what are most patients on blood thinners for.
Dr. Andonis Terezides: In the last five years there’s been an explosion of new medications on the market, and many of those are called blood thinners, and they work a little bit differently that many of the traditional medications that patients have been taking, for instance warfarin or Coumadin is a very common one that many patients have been taking now for fifty or sixty years, aspirin is one as well that patients have been taking for probably more than fifty or sixty years as well. And then over the last thirty years or so, patients have been taking something called Plavix or clopidogrel.
These are three most common ones, the ones that have been most used to and developed or patterned on how to treat patients, and we know what procedures we can do, what procedures we can’t do and how to modify them, but over the last five years there’s been really an explosion in new medications, and the studies are lacking in a lot of the literature, on what we need to do from a dental standpoint. They’ve really only gone into the thing of major surgical procedures in a lot of the literature, and that leaves the smaller procedures in limbo on what we can or can’t do safely for patients. It has prompted the attorneys now, they’ve got a new field of medications they can try new businesses from.
Dr. Ramzi Matar (Winter Park Dentistry): So who are these people that are on them, what are most patients out there on blood thinners for?
Dr. Andonis Terezides: They’re on it for the same reasons they’ve been on before, and that’s for cardiac stents, the coronary artery stents that patients sometimes have after angioplasty, if they’ve suffered a heart attack or a coronary event. They’re on them also for stents, sometimes get placed into the carotid arteries, because of plaques and risks of stroke, they get placed on these medications as well for reasons such as deep vein thrombosis or bloods clots in legs or the extremities, which are a risk for causing something called coronary embolism. And then they’re also on these medications because they might have suffered a stroke in the past, because of one of this pulmonary embolisms, or DVT that has traveled up to the brain.
Dr. Ramzi Matar (Winter Park Dentistry): So most people that are on blood thinners, they know they’re on blood thinners, there’s no secret per se?
Dr. Andonis Terezides: Right.
Dr. Ramzi Matar (Winter Park Dentistry): So things like aspirin and Plavix, we see this all the time, do these really… If somebody comes to you and they’re on aspirin, do you have to stop the aspirin, or Plavix for that matter, what do you do with those?
Dr. Andonis Terezides: For routine things that I do as a surgeon on a day to day basis in the office like place dental implants, perform bone grafts or take out teeth, I don’t stop patients from those medications. There are times where I’ll have to have them modify their regimes, or at least check some lab tests to being with, so that we know that they’re within a safe range before proceeding with the surgery. Aspirin and Plavix rarely ever stop us, and there’s no real test that we do prior to surgery, we just engage based on what local measures are available to us to help with stopping the bleeding, stitches, little things that we can put into the socket, as well as good surgery technique.
And then there is one medication, commonly known as Coumadin or also called warfarin, that one we do test some lab tests, and we like to have lab values from 24 hours before the procedure, it’s a blood test called an INR, and patients are familiar with it because they do it from two to four times a month, to make sure they’re within a therapeutic range for their procedure. The medications that we are talking about, things like Predaxa which is Dabigatran, Tegretol which is rivaroxaban, Ticlid which is ticlopidine, Pletal which is cilostazol, Persantine which is dypiridamole, Prasugrel, Brilinta which is Ticagrerol, Eliquis which is apixaban, very convoluted names. They say they take aspirin, or one of these medications, a blood thinner, but they don’t remember which one. Now that list of three is grown to eight or nine and there is even more still coming on the market, and now we’re at a point what to necessarily do, because we don’t know how to test these medications, some of these medications don’t have reversals, and the doses are the same for patients, so a 110 pound lady and a 250 pound guy take the same amount of medication, so we don’t know how they’re going to react, if it would be the same.
Dr. Ramzi Matar (Winter Park Dentistry): Do this new class… Obviously they’re coming into the market for a reason, are they better for the people with atrial fibrillation, or stents, I mean, they must be coming out because they’re medically better. I realize that from your perspective as an oral surgeon they present challenges, but are they better somehow when patients are taking them?
Dr. Andonis Terezides: That’s what the initial studies and the literature show, and part of it is some patients are not really responding as well, as say to Coumadin or medications that they take, they’re all usually going to be okay with aspirin, but some patients are allergic to aspirin, some patients require some sort of duo play with therapy like aspirin and Plavix, and there is a subset of population, thing that I read on the literature, about 20 to 30 percent of patients don’t necessarily receive the appropriate auto coagulation med, so there is a need in the market to find a better medication, one that’s less hassle for patients, to not have to go and draw blood and have it tested all the time, to stay within the therapeutic range. Yes, the whole studies are showing that most of these medications do serve a better purpose for many patients who are not so well-served with the old fashion medications that we’re used to.
Dr. Ramzi Matar (Winter Park Dentistry): The classic ones… So tell me this then, we have the classic blood thinners, Plavix, Coumadin, aspirin, you have some patients, 20 to 30 percent for whatever reason is not well regulated, they can’t do the INR, they want something a little easier to take, so there’s this whole new list of medications coming out, Predaxa, Eliquis, those are the ones I’ve seen personally, so how do you manage that? What do you do as an oral surgeon, someone comes to you and says “Yes, I’m on Predaxa, I need a tooth out and it’s hurting”? What do you do?
Dr. Andonis Terezides: Well, single tooth, we’ll probably just continue them on their medications the way they are, again a lot of these medications cannot be stopped, if you stop them, even for a day or two, it puts the patient at significant risk for ending up in the hospital, and a significant number of those patients can actually succumb to the sudden stop in their medications and can die. So fortunately a surgeon can do a procedure relatively quick, we have at our disposal a number of things that can help us provide some sort of localized measure to get hemostasis to stop the bleeding. So for most of the routine things that we would treat a patient if they’re stable enough to be treated in our office, we can proceed as planned. If we come across that one patient is on these medications, and they’ve been on it, for whatever reasons they’re not able to stop the medications, because they’ve changed on to another medication, because they’re only within a certain subset on time, following the placement of a new cardiac stent that was only a few weeks prior, and it has to be done, we have surgeons that are able to take a patient to a hospital and at least get them managed in an operating room setting.
Dr. Ramzi Matar (Winter Park Dentistry): That’s the line for you as a surgeon, I mean I can’t go to a hospital clearly but as an oral surgeon, if you say “hey we have a high risk patient, he has a tooth that’s hurting, it’s infected or whatever, we have to do surgery” you can do it in a hospital but clearly that’s the last choice you have, but it sounds like it’s still a bit early, the jury’s still hot on this new medications and well, while they’re great for, I’m sure cardiologists love them, and all the other MDs love them, that’s great, but from a dental point of view it does present some challenges that need to be worked out. I’m glad there’s people like you that love this stuff, you’re a complete dental geek, you love it, I know you’re reading about it all the time, and when I asked you to do this you sent me like a 5 page paper, on all we could talk about, I didn’t even know how to pronounce 60 percent of the words, so I’m glad there’s people like you on my team.
Dr. Andonis Terezides: I’m happy to do so Ramzi, I just want to make it a point for viewers who are watching this, that they should never stop their blood thinners without the express written consent and knowledge of their prescribing physicians. There’s a lot of patients who will come because of the old school mentality where they would just stop their aspirin for a few days before having a tooth taken out, we really as a profession in dentistry we’ve moved away from that because we’ve learned that we can treat patients without necessarily having a lot of serious issues, while they’re still on their blood thinners, which is very important, because we can deal with a little bit of bleeding, but we really can’t deal with a patient who suffers from a stroke or a heart attack caused by the stopping of the medication.
Really, that’s the biggest take-home message, patients need to be able to give us their medication list clearly, have something written down, or at least give us their contact information for their prescribing physician, and then that they shouldn’t stop the medications. If we can do that, we can provide an excellent for patients.
Dr. Ramzi Matar (Winter Park Dentistry): I had no idea that you had patients come to you and say “hey, by the way, I stopped my medication three days ago, I’m ready for surgery” and you’re like panicking that they’re going to have a stroke in your chair, I didn’t even think about that but yeah anybody watching this, please get to your physician, get to your oral surgeon, tell them what’s going on, let them manage it, don’t start doing this at home cookbook dentistry treatment. Thank you for that, I didn’t even mean to ask you that question but again, thanks for having me, thanks for being on the show for me, I appreciate it. Everyone watching this, I hope you learned something, if you know somebody that’s on a blood thinner or could be on a blood thinner maybe having some dental surgery, please send them this video, have them ask us questions or learn… Hope somebody takes something from this. Thank you so much.