This question was submitted to us by a general dentist: Are you concerned about mandibular blocks and possible injury to blood vessels (Inferior Alveolar Artery/Vein) in patients continuing anti-coagulant therapy (Warfarin)? Potential Hematomas? Management?
Dr. Jason Goodchild provided this quick initial response:
For patients on anticoagulant therapy, a careful review of the medical history including consultation with the patient’s physician is warranted. This consultation should include information on the patient’s INR (International Normalized Ratio). Ideally, a recent INR (with 24-48 hrs) is needed in order to ascertain the patient’s bleeding risk during surgery.
The literature is consistent on this issue:
- If the patient’s INR is within the therapeutic range (i.e., less than 3.5), they can receive most dental treatments and should not discontinue anticoagulant therapy.
- If the patient’s INR is less than 3.5, inferior alveolar nerve blocks (IANB) are not contraindicated, but should be done with caution; alternating cycles of administration and aspiration should be used to minimize intravascular injection and potential bleeding.
The best way to avoid complications with anticoagulant patients is proper planning and knowledge of INR status. Invasive dental treatments, including IANB, must only proceed once the INR status of the patient is known and the dentist is prepared to manage potential complications.
Hematomas are a known potential complication of IANB injections. With good technique and knowledge of anticoagulant status, the risk can be minimized. Management strategies include warm compresses, and pain control (trismus). Immediate follow-up is needed, if submandibular swelling occurs or airway patency is compromised, although these should be considered extremely rare with good anticoagulant control.
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