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Creed3
January 6th, 2003, 11:47 AM
Hi Everyone!
I have been waiting to hear from my doctor about what he wants me to do with my coumadin before my dentist appt. This is what he finally told me to do....

Cleanings: Stop coumadin the day before dentist appt. After the appt., start your coumadin again, that day.

Procedures: Stop coumadin three days before appt. and start taking coumadin again after the appt, that same day.

Does this sound right? I know some of you have written that you keep taking your coumadin like you always do, before a dental cleaning. The doctor keeps my INR between 2.0 and 3.0.

Thanks & Take Care!
Gail

Ross
January 6th, 2003, 12:30 PM
Hi silly person!

Continue the Coumadin for simple cleanings. Don't stop for this alone. I've had mine cleaned, drilled, filled, and scaled while on normal coumadin therapy and there has not been any troubles at all. I think your Doc is wrong and you should print out and take the page from Al's site with you. I'm going to Al's site and get you the link for his dental procedures page. ;) The only time you may need to come off the Coumadin is with mulitple teeth extraction or oral surgery. Check the link out below, it's updated!

http://warfarinfo.com/dentalprocedures.htm

MarkU
January 6th, 2003, 12:38 PM
Hi Gail,

You really need to read the recent update that Al Lodwick did to his website and the related thread in this section, discussing the risks of discontinuing Coumadin therapy for dental procedures.

I for one would be very hesitant to discontinue my Coumadin for any routine dental work. The risk of having a stroke is too scary to me.

From the layman's knowledge I have of how Coumadin is processed by the body, I wouldn't think that discontinuing for one day prior to any procedure would have much effect anyway.

Mark

LUVMyBirman
January 6th, 2003, 12:39 PM
Yikes Gail. Listen to Ross!!! You were given incorrect info!

The only time I stopped was when I had my wisdom's pulled. Back when bridging therapy with Lovenox was safe. I have read of others here lowering their INR's and safely carrying out extraction's too. Will have to look into that if that day ever darkens my door again

Ross
January 6th, 2003, 12:39 PM
All dosage changes take 3 days to show a result so stopping a day before isn't going to change much of anything. I wouldn't risk it. :)

Lorraine
January 6th, 2003, 12:48 PM
Hi Gail,

So far all I've had is cleanings since my surgery. I stayed on my Coumadin. I took antibiotics, I believe it was an hour before the procedures. I wouldn't go off the Coumadin if I were you. Did your doctor give you a prescription for antibiotics to take?

I believe others have had procedures done and stayed on their Coumadin too. You also should read what Al posted on January 3rd, 2003. "Risk of Stopping Warfarin for Procedures." Print it out and take it with you to your doctor and the dentist.

I know others have had different procedures so I'm sure they can help you out with their opinion and experiences too. Hope I helped some. Take care.

Ross
January 6th, 2003, 01:17 PM
I was wlking around and cleaning up when I remembered to ask you if you were taking any antibiotics before the appointment. If not, you need to get ahold of the dentist and have him prescribe 2000mg of Amoxicillin or similiar, to be taken 1 hour before your appointment.

Glad you jumped in Lorraine! I nearly forgot that part.

Creed3
January 6th, 2003, 02:06 PM
Yes, my doctor did write me a prescription for amoxicillin. I'm not sure what the dose is. I'll see when I pick it up. I will also be printing off a copy of Al's post. I did read it and that is why when my doctor gave me these instructions, it didn't sound right. I will definately print it and show it to him. My dentist will not give me an appointment until I do what my doctor tells me to do. If my doctor doesn't change his mind, my dentist will not see me if I decide to stay on the coumadin.

Thanks Everyone!
Gail

Ross
January 6th, 2003, 02:26 PM
Just continue the coumadin and don't tell him you took it. It's really too bad that these health care pro's don't have it together when it comes to us rat poison people. :D

Blanche
January 6th, 2003, 03:09 PM
Gail:
I'm sorry you're stuck between the doctor and the dentist. The only answer is that patients must educate their doctors and dentists. Albert's been on coumadin for 12 years and had regular dental visits, including one extraction. Never had a problem and never went off coumadin. There is an article that you might tell your dentist about. It is, "Myths of Dental Surgery in Patients:Receiving Anticoagulant Therapy," M. J. Wahl, Journal of the American Dental Association, January 2000, vol 131, pp77-81.
Al Lodwick quotes this article. I could not find the entire article on the web, but there is an abstract. If you email me through this board, I can email it back to you. The conclusions this study, which involved 950 patients and 2400 surgical patients was
"Serious embolic complications, including death, were three times more likely to occur in patients whose anticoagulant therapy was interrupted than were bleeding complications in patients whose anticoagulant therapy was continued (and whose anticoagulation levels were below or within therapeutic levels.) Interrupting therapeutic levels of continuous anticoagulation for dental surgery is not based on scientif fact, but seems to be based on its own mythology." The study also talks about 526 patients who had 575 interruptions of continuous anticoagulation therapy. "Five suffered serious embolic complications; four of these patients died." You might also check an article from the New York State Dental Association, entitled "Stop the Nonsense Not the Anticoagulants: a Matter of Life and Death" dated November 2002. I hope this link works. www.nysdental.org/publications/full_article-archives.cfm?ID=89

You might want to send these materials to both your doctor and your dentist. Most state dental associations have position papers about interrupting anticoagulation therapy. Your dentist should know of these. I have a feeling that if you present him with articles from his professional peers that he will insist that you continue your Coumadin. To do otherwise in the face of research evidence is clear malpractice.

I wish I could do better for you, but I am not computer savy and am so limited. If you wish, I'll gladly send you the articles above and others that I have. Gail, you have such a positive attitude that I know you will make this work for you. OOPS! I almost forgot, you might also want to use Al Lodwick's newest materials on stopping anticoagulation. www.warfarinfo.com/procedures
Best wishes,
Blanche

Johnny Stephens
January 6th, 2003, 05:23 PM
Hi Gail, I've had a crown replaced while on Coumadin with no difficulty. My dentist has a standing prescription for the 2000 mg of Amoxicillin and I take it one hour before my appointments.

As an aside, I carry this card from the American Heart Association on the suggestion of my cardiologist (it's about the antibiotics, but not the Coumadin):

Wallet Card (http://www.americanheart.org/downloadable/heart/1023826501754walletcard.pdf)

The relevant portion for valvers is about halfway down: "Prophylactic regimens for Dental, Oral, Respiratory Tract, or Esophogeal Procedures."

csutherland
January 6th, 2003, 06:32 PM
My Jerry had every tooth in his head crowned about 2 years before his AVR. Adjustments are still being made in his bite, etc., as well as some grinding, etc. and nothing has ever been said about coumadin. They do insist on him having the handful of pills 1 hr. before every app't though. He also had a checkup and
cleaning by his regular dentist since the AVR. Same deal. Oddly enough, I had rheumatic fever as a small child and about 15 years ago someone discovered that fact on a chart and now I have to take antibiotics every time before seeing the dentist.

I do have a question I'm going to post on another thread about a colonoscopy & coumadin. I read something a while back on here about it but wasn't concerned at the time.

Ross
January 6th, 2003, 07:13 PM
Celia, you may want to inquire about a "Virtual Colonoscopy".
Check this link out!
http://virtualcolonoscopy.med.nyu.edu/vcinfo/whatis.html

Rich
January 6th, 2003, 08:04 PM
Never went off Coumadin except once for an extraction.
There is no reason you should stop it for what your'e having done.

allodwick
January 6th, 2003, 08:30 PM
Any dentist who stops warfarin for a cleaning may as well plan to go to court naked, because that is about how much defense they will have if something happens to you.

There is even research now that almost anything can be done if the INR is less than 4.1

Granbonny
January 7th, 2003, 02:14 PM
No, No, No, Noooooooo....Don't come off of coumadin for a cleaning. I had 2 seperate Peridontist DEEP cleaning..NEVER bled..did not take any invasive needle numbing (Was I brave:p :p ) Went straight to restroom to check and my teeth were just a shining and no sign of blood:D :D :D :D I took 4..500mg of Amox before...Now when I brush NO bleeding.....................Johnny Stephens. Is that you or Steve Martin?????Thanks Al..She told me I have a loose tooth in the back and if I ever want it pulled will check INR first..You are so :cool: :cool: :cool: :cool: What would we ever do without you....Bonnie

Creed3
January 9th, 2003, 09:50 PM
Thanks to everyone! The information and the sites you gave me were great. My doctor told me to fax him the information I had regarding dental cleanings/procedure and coumadin. I just sent it today, so hopefully I will hear something from him by next week. I'm really curious as to what he will say about it. I'll let you all know how things go.

Take Care!
Gail

joy
January 10th, 2003, 07:10 AM
Hi gail, I just started my coumadin, and my new doctor said that if I am going in for any procedure which requires drilling stop the coumadin 3 days before,but go on Lovenox instead. That's all the info I have for you!
Joy

Christine
January 10th, 2003, 11:07 AM
i'm a little differnt than ya'll... before surgery, i've always been premed before dental procedures.. latest being 4 500mg caps one hour before and 3 caps six hours later.. now, my card wants me to take 6 caps one hour before and 3 six hours later.. i've had alot of work done over the years and test showed a past infection hit my valve which I think spead up the stenosis..

but my dentist is very comfortable working with coumadin patients.. he's always ahead of his game so to speak.. i was told that i shouldn't stop or change coumadin unless i'm having major dental work (ie:extractions, gum surgery) - i do bleed alittle longer or quicker, but they know my situation and deal with it by applying pressure and taking their time..

hope that helps..

christine

terry40
January 10th, 2003, 07:51 PM
My PCP and dentist have a copy of that AHA card that was given to me by my cardiologist, inreference to antibiotics,
but this coumadin will be new to me.

Before I had surgery the cardiologist group needed a dental clearance, I also got my bi-annual cleaning, so I won't be due for a while, I'll have to print out the info on Al's site for future refences.

I thought they increase the antibiotic dose, when the valve is replaced with a mechanical prosthesis. Something else for me to check out.

Terry40

Creed3
January 14th, 2003, 01:25 PM
I heard from my doctor today regarding the information I faxed him. He said that that is not the standard of care given. He told me to let my dentist decide whether to leave me on the coumadin. It also sounded like my doctor wanted to talk to me regarding this information, so I made an appt. to see him in one week to discuss this. We'll see where that goes. Does anyone have any comments that I should arm myself with next week? I hope he doesn't decide to bash this site because that would really really upset me and make me very angry. You never really know how doctors will react if they feel like they are being questioned about their care. My doctor has never given me any indication in the past that he would react in a negative manner, but you never know. He has always let me know when he thought something was over his head. I guess we'll see in a week.

Take Care!
Gail

LUVMyBirman
January 14th, 2003, 01:51 PM
Hi Gail,

You wrote: "I hope he doesn't decide to bash this site because that would reallyrealy upset me and make me very angry."

I have a doctor that loves the fact I am involved with the group. So much that he would like me to speak to his post op patients after our conversation. Another said " stay off those boards and chat rooms".

If I want to be neutral.....I always use "a good friend of mine" that has a valve. That way it seems more personal to them. Actually, it was not stretching it too far as my former neighbor in TN was a valver herself. Small world. ;)

I wouldn't stop taking my coumadin for general dental work. I have had a lot completed on the med. Including a root canal. No problem. Extraction's may require other measures. As I did come off and use Lovenox bridging. Now they don't want us doing that. FDA induced warning. But I hear extractions can be carried out on the Coumadin. Catch 22.

Let us know how it works out for you.
Take care

Johnny Stephens
January 14th, 2003, 02:35 PM
Not the standard of care given? I wonder about that, because my dentist, doctor, and cardio who work in 3 different groups were all in synch on it. To take it even a step further, my anticogulation pharmacist called me at work to make sure I was clear on the instruction not to stop my coumadin before the dental work.

With regard to bashing the site, I like Gina's "a friend of mine" approach, because I've also had varying levels of acceptance on information that I present as coming from "an Internet group." Some of the docs (like my cardio) have been very supportive...he said he considers me to be an educated medical consumer because of what I've gleaned here. Other just seem to dismiss it out of hand, but luckily those seem to be in the minority :) .

If he does react angrily to simple questions like this, maybe it's time to go doctor shopping? Just my $.02

Rich
January 14th, 2003, 04:43 PM
I think a lot of doctors are intimidated by the knowledge many of their patients have in this day and age.
Not many years back most of us would simply do what the doctor said without question.
For example my wife and I have done tons of research on statin drugs since she has had so many problems with them.
About a week ago at our cardiologist appt. he told her she knew a lot more about all this than he did..and he has been a heart doctor for a very long time.
Some accept this 'threat' very willingly but others get plain scared that they can't BS their patients any longer.

allodwick
January 14th, 2003, 08:05 PM
Gail, if your cardiologist gets too huffy ask what the standard of care is and where it is published.

Here is a tactic I was ready to use against the other side's expert witness when a lawsuit was settled out of court.

The attorney I was working with was going to question the expert doctor.

What professional body sets the standards for the use of warfarin?

Probable answer (I don't know).

What was the volume number of the standards that body had in place at the time the incident occurred?

Probable answer (I don't know).

What did those standards say about managing a situation like this?

Probable answer (I don't know)

You do not know who sets the standards, what standards were in effect, nor what the standards said yet you call yourself an expert in this field. I'd like to know how you got to be an expert but I'm afraid that it would be just wasting the court's time. I have no further questions.

What effect do you think that would have on a jury. He made his statement but we would have made it seem like he wasn't even worth cross examining him. Just blow him out of the tub.

That is where your doctor would be if he could not define his standard of care.

Blanche
January 15th, 2003, 12:35 PM
Gail:
Doctors seem to automatically disregard information from the net, and sometimes with good reason. There is alot of junk floating about. But, the articles you provided him were reasearch articles, articles from experts in the field, and articles from medical practitioners. You might want to take a copy of the seven articles I sent. There are two research studies published in the Journal of the American Dental Association, two from State Dental Associations, one from an Australian Dental Association, one from practicing oral surgeons who are affiliated with 21 hospitals in the Atlanta Area, and one from the University of Michigan Health System's Anticoagulation Unit. This along with all of Al Lodwick's materials should convince anyone. By the way, when I first gave Albert's doctor materials from Lodwick, I included a copy of his Vita (resume), which certainly shows that Al Lodwick is a recognized expert with a National reputation.

Last week Albert visited a Urologist (one who says he welcomes pro-active patients) for the first time. When Albert mentioned dental work, the Doctor said, "You don't go off your Coumadin, do you?" This doctor knew about all the studies and reasons for staying on Coumadin.

Sorry you have to go through this. Good wishes.

John & Joann
January 17th, 2003, 03:35 PM
We MUST get in on this discussion. Joann has been on coumadin for 31+ years. She NEVER goes off coumadin when she has normal dental procedures done. We have a friend that went off coumadin for a sygmoid and had a massive stroke. 6 years in nursing home before death.

Make certain that you have EXPERT information before you go off coumadin!!!

Joann has survived with mechanical valves for 31 years because of her strong faith, expert advice from physicians, asking questions, and following directions.

Some dentists want you to go off coumadin for THEIR convenience. This recommendation should come from a medical specialist that knows valves and not a dentist or a general physician!

John for Joann
Clicking and freezing in Western Ohio
Florida soon!

ShezaGirlie
January 17th, 2003, 05:53 PM
I just had a wisdom tooth pulled last week and did NOT go off Coumadin. I printed out information on www.warfarinfo.com and took it to my Dentist. He read it and was very interested as he doesn't have many patients on Coumadin. He actually asked me if he could keep the printout. Of course.

So, between my Cardiologist and Dentist I remained on Coumadin for the extraction taking the following doses. My normal dose is 10mg.

A rundown of my INR and dose of Coumadin follows:
Friday ---- INR = didn't test/Coumadin 7.5mg
Saturday - INR = 2.4/Coumadin 7.5mg
Sunday - - INR = 2.1/Coumadin 10mg
Monday -- INR = 1.8/Coumadin 10mg [day of extraction--bleeding
Tuesday - INR = 1.9/Coumadin 10mg -- bleeding
Wednes - INR = 2.9/Coumadin 10mg
Thurs ---- INR = didn't test/Coumadin 10mg
Friday --- INR = 3.7/Coumadin 7.5mg -- bleeding
The reason for the Friday dose at 7.5 was because I started bleeding again.....four days after extraction.
Saturday - INR = didn't test/Coumadin 7.5 -- bleeding
Sunday --- INR = 2.3/Coumadin 10mg
Monday -- INR = didn't test/Coumadin 10mg
Tuesday -- INR = 2.3/Coumadin 10mg [Wed & Thurs = 10mg]
Friday ----- INR = 2.4/Coumadin 10mg [I'm getting there]

Yes, it was a royal pain in the @$$ to keep up with all this and I don't get on well with all these 'health' issues as I never had any before OHS. Mine was emergency and I didn't have a choice of valves as the mechanical ones are the only types installed in my town.

So consider yourselves lucky to be able to study the situation from all avenues before you have to have surgery. That's why I'm sharing... and please listen to John and Joann...and Al because experience counts!

Now where's that bottle of red wine...

allodwick
January 17th, 2003, 06:03 PM
Sheza.. I like your handle. Whenever I teach a class I use the name Sheeza Notwell for my patient.

Ross
January 17th, 2003, 06:17 PM
John for Joann
Clicking and freezing in Western Ohio

Updated 8 PM ET (1Z) 1/18/2003
Broken Clouds, Light Snow 85 %
8 F WNW 6 mph

Ross clicking and freezing in N.E. Ohio! :confused:

Creed3
January 17th, 2003, 09:21 PM
Hi Everyone!
I was able to talk to my PCP about the coumadin the other day. I had to take my little girl to the doc, so we discussed it while I was there. He said that he read over the information I sent him, but it is not the standard of care given for coumadin patients. He said that if he were to tell me to go off the coumadin and something happened, he would be in big trouble because they would come back to him and say that is not the standard of care given in these cases. He also told me that he knew of some cases where patients who went off their coumadin bled so much they bled to death or needed a transfusion. Well, anyway, we talked some more about it and he said that he thinks my situation is above and beyond his training and that my cardiologist should regulate my coumadin. He was very understanding about the whole thing. I talked to my cardiologist and they said that I should not stop taking my coumadin for a dental cleaning. They went on to tell me what some of the options were if I needed to have a procedure done. My cardiologist called my dentist and they are going to talk over what is the best thing for me and to find out what the dentist is comfortable working with. My cardiologist also said that if I were having a procedure, depending on the type of procedure, I may be able to stop coumadin for 3 days at the most, but that is not his preference. I would have to start my coumadin up right away after the procedure. His preference for a procedure (depending on what type) would be for me to stop coumadin but give myself two heparin shots a day. I think she said heparin, I know she didn't say lovenox. I don't remember when or how far in advance he would want me to stop the coumadin and start the shots. After the procedure I would then have to go right back on the coumadin right away.
The nurse at the cardiologist's office told me that I should definately question things that the doctors tell me. She said that this is my health we are dealing with and that my situation is not the norm. She told me that I shouldn't think that my PCP is a bad doctor, he just doesn't have the backround to deal with a special case like mine. Well, I'm going on and on here. I just wanted to let you all know what was happening. Let me know what you think.

Thanks & Take Care!
Gail

djacq
January 18th, 2003, 05:28 AM
Gail,
I am experiencing some of your concerns also.
I respect your PCP acknowledging the need for someone else to manage your Comadin. So many Docs won't acknowledge or are aware of the management for valves.

My cardio is willing to act as a consultant but my PCP is managing my comadin and I am so fearful that very few Docs are familiar with managing anticoag for valve replacement.
It is so hard and I even wonder if cardios' know how to manage valve patients. How many of us are there in the scheme of things?

I am becoming more anal about this everyday but I truly believe it is because I don't have confidence in anyone (except Allodwick) to deal with this. I wish I could go to Allodwick's Clinic!!!!!!!

I am very interested in your progress with this. Good luck.

Donna

Blanche
January 18th, 2003, 05:27 PM
Gail:
You should be so very proud of yourself. You have become a proactive patient by asking questions, obtaining reliable information, and not accepting directions that you know are not correct. I'm sure your doctor is very good at what he does, but he definately should not be regulating anticoagulation because he obviously is over his head. I can not believe that in the face of research evidence and accepted practice he still maintains that going off coumadin is the standard of care. What did he say when you asked him about the articles you provided? Did he tell you where that "standard of care" is published and who developed it and when? Patients bleeding to death and needing transfusions....that is horse puck at the worst or urban legend at best. I can't wait to hear what Al Lodwick has to say about that. I hope you told him that you had research evidence about people who died when they went off coumadin. But all is well now. You have a cardiologist who seems to know what he/she is doing. You will probably be alot better off now that you can be confident in the directions you get. You should probably send your dentist copies of the materials that you have, if you haven't already done so. Three cheers for you, you've done well.
Blanche

allodwick
January 18th, 2003, 07:34 PM
I respect your PCP for saying that he was in over his head. In my experience, the patients who get into the most trouble are those whose doctors do not know when (or are too stubborn) to ask for help.

The other patients who do not get good care are those whose doctors are sarcastic to, or yell at nurses. I remember one incident where a doc was at the hospital before 7AM. One doc asked another, "John, what are you doing here so early?" "Well the nurse called me at 3 AM to tell me a patient was dying, so Idecided to get up early to come see her. But they did not call me back to tell me she actually died." (Sounds noble, eh?) When Dr. John was out of earshot the night nurse said, "When I called him at 3AM he asked, 'What do you want me to do, come down and resurrect her?' There was no way I was going to call him again to tell him that she died and set myself up for more abuse."

Remember, it is not the degree or the specialty that make a person a competent warfarin manager. One cardiologist told me, "I did not not go to med school, residency and do a fellowship in cardiology to be a Coumadin doser. That is the primary care docs job. Unfortunately most of them fail at it." (He is no longer practicing in the same state -- I also heard him yell at a nurse once)

Warfarin has been on the market for about 50 years and there is still about one medical journal article daily about it. Every day we literally learn more about its management and care of patients taking it.

John & Joann
January 19th, 2003, 05:55 AM
P.S.

Joann also uses a Coumadin Clinic. A pharmacist manages her coumadin under the supervision of a cardiologist. He does not have any direct contact.

We are able to do it without supervision, but MUCH prefer this arrangement. Obviously, we will both speak up if something is not correct. This has only happened once in 31 years.

John for Joann
Brrrrrrr in Western Ohio

Granbonny
January 19th, 2003, 06:12 AM
How often does Joann test? Is she ever out of range? BonnieFreezing in the deep south too:p :p

Creed3
January 19th, 2003, 07:59 AM
I really didn't get into a real deep discussion with my PCP. My daughter is the one who had the appt. with him. We talked about the articles I gave him, but he kept saying that was not the normal standard of care usually given. I didn't really get into asking him about showing me documentation on what the standard of care is because he pretty much had already told me he thought this was out of his league. He said that I could continue to get my blood drawn at his office or the hospital and then just have the results sent to UVA for my cardiologist to regulate everything. The nurse at my cardiologist's office said that they don't regulate too many patients who are on coumadin, but the nurse says that I sound pretty proactive and she trusts that I will be very involved in my regulation. I can't imagine not being completely aware and involved. She told me that they had regulated some patients who just wouldn't listen to them at all. When they would tell the patients to go get their INR checked, the patients would just ignore them and get it tested whenever they felt like it. The nurse just wanted to make sure that if she said to get tested, that I go to get tested. She just kept stressing how important it is to keep my INR within the correct range. She also agreed with me when I said that my flu shot threw off my INR levels. My PCP didn't believe me at all when I told him that. I know my cardiologist doesn't feel it is necessary to test at home but I don't think he is totally against it. I think that decision will come with time.

Take Care!
Gail