Treatment with Heparin

10.2 Treatment with Heparin

Section I: Clinical Scenario and Dental Considerations

Clinical Scenario

A 55‐year‐old woman presents to you concerned about her deteriorating oral health and ‘crumbling teeth’. Most recently, the upper right second premolar (#15) has lost a filling and feels sharp. It is cutting her tongue, causing bleeding. She has not been able to find a dentist who will see her as they have all refused care due to her medical history.

Medical History

  • Alport syndrome
    • Chronic renal failure (chronic kidney disease stage 5, patient not suitable for renal transplant and undergoing haemodialysis)
    • Visual impairment (yellow flecks/dots behind the retina)
    • Hyperparathyroidism (parathyroidectomy 1  year ago)
    • Osteoporosis (no plan for bone‐altering medications)
    • Secondary hypertension
  • Kartagener syndrome
    • Primary ciliary dyskinesia
    • Bronchiectasis
    • Situs inversus totalis and dextrocardia
    • Partial hearing loss
  • Chronic obstructive pulmonary disease
  • Osteoarthritis
  • Chronic pain
  • Gastro‐oesophageal reflux disease
  • Depression
  • Anxiety, difficulties sleeping and restless legs syndrome
  • Breast carcinoma (diagnosed 2 years ago; surgical treatment only as medical comorbidities posed high risk for chemotherapy; reviewed annually)


  • Dalteparin 5000 IU injection (every second day in own home; native/tissue arteriovenous fistula)
  • Folic acid
  • Cinacalcet
  • Calcium/ vitamin D
  • Amlodipine
  • Amoxicillin/clavulanic acid
  • Azithromycin
  • Prednisolone (10 mg daily)
  • Fluticasone/salmeterol (inhaler)
  • Tiotropium bromide (inhaler)
  • Salbutamol (inhaler and nebuliser solution)
  • Methadone
  • Paracetamol
  • Pantoprazole
  • Metoclopramide
  • Citalopram
  • Diazepam
  • Temazepam
  • Pramipexole

Dental History

  • Irregular dental attender
  • Stopped attending regularly due to competing medical issues and difficulties with access
  • Brushes her teeth twice daily, flosses teeth once weekly. Dexterity still satisfactory
  • Consumes lollies to pass the time during haemodialysis, and sips on 5 cups of coffee with sugar during day. Recommended lemonade and sugary/fatty foods by her doctors and dietician in order to maintain energy and weight

Social History

  • Independent ability for activities of daily living have rapidly declined over past 2 years. Increased dependence on adult son and ex‐husband (good relationship remains)
  • Lives alone, divorced, frequently visited by son who acts as primary carer
  • Driven in private car to appointments by son or ex‐husband
  • Tobacco consumption: 10 cigarettes/day for the past 30 years
  • Alcohol consumption: nil
  • Walks slowly with walking stick; wheelchair required for long distances
  • Patient does not have a telephone due to her hearing impairment; she provides the telephone numbers of her son and ex‐husband in the contact details

Oral Examination

  • Primary concerns
    • #27: carious retained roots; tender on buccal palpation
    • #15: lost restoration
    • 0.5 cm diameter superficial traumatic ulcer of the tongue caused by the sharp #15
  • Multiple other decayed and defective heavily restored teeth (Figure 10.2.1)
    • #14: large glass‐ionomer restoration with fractured margins
    • #17: stabilised with temporary restoration, residual subgingival caries present
    • #26: metal underlay of porcelain‐fused‐to‐metal crown only (no porcelain remaining)
    • #36: distal caries, large amalgam restoration
    • #46: distal caries, large amalgam restoration with fractured margins
    • #47: carious/fractured amalgam restoration
  • Soft deposits present in all quadrants
  • Generalised mild chronic periodontal disease
    Photos depict multiple other decayed and defective heavily restored teeth (S).

    Figure 10.2.1 Multiple other decayed and defective heavily restored teeth.

Radiological Examination

  • Orthopantomagram and periapical radiographs undertaken (Figure 10.2.2)
  • Lost restoration: #15
  • Carious retained root: #27
  • Caries: #17 (residual decay underneath restoration), #36 (distal), #46 (distal) and #47 (distal)
  • Mild horizontal bone loss ~10%

Structured Learning

  1. Why is this patient receiving dalteparin on alternate days?
    • Dalteparin is a low molecular weight heparin (LMWH) and is given as a single‐bolus dose with its mechanism of action lasting up to 4 hours
    • In this patient it is indicated for prevention of thrombosis during haemodialysis
    • This ensures that the vascular access (arteriovenous fistula) remains patent
    • In some countries, unfractionated heparin (UFH) is still preferred to enable haemodialysis instead of LMWH (e.g. United States) – it is given as a bolus dose at the start of dialysis and followed by either a continuous or hourly intermittent infusion
  2. Why is it important to differentiate whether a patient is on UFH or LMWH?
    • UFH and LMWH have different pharmacological effects and clinical indications
    • Hence their impact on dental treatment differs (Table 10.2.1)
    • For this patient, elective dental treatment should be planned on the day following dialysis so that the effects of heparin administration have declined
  3. Why does this patient have renal failure?
    • This patient has Alport syndrome, a genetic condition characterised by kidney disease, hearing loss and eye abnormalities
    • People with Alport syndrome experience progressive loss of kidney function
  4. What is the impact of Kartagener syndrome on the dental management of this patient?
    • Kartagener syndrome is an autosomal recessive genetic primary ciliary dyskinesia disorder, comprising the triad of situs inversus (positioning of some or all of the vital organs reversed or mirrored), chronic sinusitis and bronchiectasis
    • The signs and symptoms vary but may include frequent lung, sinus and middle ear infections beginning in early childhood
      Photos depict (a) Periapical radiograph upper right quadrant showing fractured number 15 (S). (b) Periapical radiograph upper left quadrant showing retained root number 27 (S). (c) Periapical radiograph lower left quadrant showing distal caries number 36 (S). (d) Periapical radiography lower right quadrant showing distal caries number 47 (S).

      Figure 10.2.2 (a) Periapical radiograph upper right quadrant showing fractured #15. (b) Periapical radiograph upper left quadrant showing retained root #27. (c) Periapical radiography lower right quadrant showing distal caries #47. (d) Periapical radiograph lower left quadrant showing distal caries #36.

    • This patient is taking multiple medications to maintain airway patency including high‐dose steroids
    • Steroid prophylaxis will need to be considered for invasive dental procedures (see Chapter 12.1)
  5. You note the superficial traumatic ulcer of the tongue caused by the sharp #15, which is bleeding continuously. The patient reports it has been bleeding all night and she woke in the morning to find her pillow soaked with blood. How would you manage this?
    • Apply pressure and use local haemostatic agents such as tranexamic acid 5% mouthwash applied directly to the tongue
    • Place a temporary dressing/adjust the #15 to avoid further trauma
    • Liaise with the physician to alert them to the persistently bleeding tongue ulcer and obtain their advice
    • Check when the last dose of dalteparin was given and when the next dose is planned – the physician may delay the next dose or if bleeding is significant, and urgently review the patient in a hospital setting
  6. Can reversal agents for LMWHs be used by the medical team to reduce the bleeding from the tongue?
    • Protamine sulfate given by slow infusion results in partial reversal of LMWH
    • It is considered if patients are suffering significant haemorrhage following recent (<12 hours) administration of a therapeutic dose of LMWH
  7. The patient also complains of discomfort from the retained roots in the upper left second molar (#27) region which has been associated with swelling in the past. She requests antibiotics. What factors should you consider?

    Table 10.2.1 Unfractionated heparin and low molecular weight heparin – different approaches when undertaking dental procedures associated with bleeding risk.

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    Unfractionated heparin (UFH)
    • Most patients on UFH are hospitalised and will be placed on warfarin/a direct oral anticoagulant (DOAC) once discharged
    • Elective dental treatment should be delayed until heparin treatment has ceased
    • Treat dental emergencies as conservatively as possible, in consultation with medical specialist
    • If urgent invasive dental treatment cannot be delayed, it should be undertaken at least 6–8 h after injection of UFH or on the following day when its effects have ceased (prior to the next dose of UFH, which may be delayed by the medical team to enable dental treatment)
    • Consider the need to confirm the aPTT, anti‐Xa factor assay and platelet counts
    Low molecular weight heparin (LMWH)

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Nov 6, 2022 | Posted by in Implantology | Comments Off on Treatment with Heparin

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