1. Case 1 Shahinda wahba 5033 Dina bawahab 5090 Wid nahas 5069 Doaa bayumi 5580 Ayat al-hindy Latifa abdulrahman

2. Introduction: Anticoagulants are medicines that help prevent blood clots. They're given to people at a high risk of getting clots, to reduce their chances of developing serious conditions such as strokes and heart attacks.

3. A blood clot is a seal created by the blood to stop bleeding from wounds. While they're useful in stopping bleeding, they can block blood vessels and stop blood flowing to organs such as the brain, heart or lungs if they form in the wrong place.blood clot Anticoagulants work by interrupting the process involved in the formation of blood clots. They're sometimes called "blood-thinning" medicines, although they don't actually make the blood thinner. Although they're used for similar purposes, anticoagulants are different to antiplatelet medicines,

4. Types of anticoagulants The most commonly prescribed anticoagulant is warfarin.warfarin Warfarin and the newer alternatives are taken as tablets or capsules. There's also an anticoagulant called heparin that can be given by injection.heparin

5. Warfarin also known by the brand names Coumadin among others, is an anticoagulant normally used in the prevention of thrombosis and thromboembolism, the formation of blood clots in the blood vessels and their migration elsewhere in the body, respectively. anticoagulant normally used in the prevention of thrombosis and thromboembolism, the formation of blood clots in the blood vessels and their migration elsewhere in the body, respectively

6. How does Warfarin Work Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX, and X, and the anticoagulant proteins C and S.anticoagulant proteins C and S.

7. Heparins Heparin is an injectable anticoagulant that is used to prevent the formation of blood clots in the vessels. It is a highly-sulfated glycosaminoglycan. Heparin works by decreasing the clotting ability of the blood, helping to prevent the formation of clots as well as stopping the further expansion of any existing clots. it is also used to manage and treat blood clots that may occur in the heart, legs and lungs.

8. How does Heparin Work Heparin works by decreasing the clotting ability of the blood, helping to prevent the formation of clots as well as stopping the further expansion of any existing clots. it is also used to manage and treat blood clots that may occur in the heart, legs and lungs.

9. Evaluate safety of dental treatment for patients with Warfarin (Coumadin) : A. Procedures involved low risk of bleeding: Examination, Radiographs, Study Models Safety profile based on INR: INR <1.5-3.5: Safe to proceed in a routine manner. INR >3.5: Can be safely performed with judicious use of local hemostatic measures in many instances

10. B. Procedures involved low-moderate risk of bleeding: Examples Simple restorative dentistry Supragingival prophylaxis Complex restorative dentistry Scaling and root planning Endodontics Safety profile based on INR: INR <1.5-3: Safe to proceed in a routine manner. INR >3: Not advised to do procedures. Need to refer to physician for adjustment of warfarin therapy.

11. C. Procedures involved moderate risk of bleeding: Examples: Simple extraction up to 3 teeth Curettage Gingivoplasty Removal of single bony impaction Crown and bridge procedure Safety profile based on INR: INR <1.5-3.5: Can be safe to proceed with judicious use of local hemostatic measures in some instances. INR > 3.5: Not advised to do procedures. Need to refer to physician for adjustment of warfarin therapy.

12. D. Procedures involved moderate-high risk of bleeding: Examples: Gingivectomy Apicoectomy Minor periodontal flap surgery Placement of single implant Safety profile based on INR: Not sufficient scientific data to draw a conclusion for any INR values. Not advised to do procedures. Need to refer to physician for adjustment of warfarin therapy and evaluate all factors for risk assessment.

13. E.Procedures involved high risk of bleeding: Examples: Full-mouth/Full-arch extractions Extensive flap surgery Extraction of multiple bony impactions Multiple implant placement Safety profile based on INR: Not sufficient scientific data to draw a conclusion for any INR values. Not advised to do procedures. Need to refer to physician for adjustment of warfarin therapy and evaluate all factors for risk assessment. Local hemostatic measures included: Gelatin sponges with silk sutures Systemic, irrigant, and mouthrinse forms of tranexamic acid Vasoconstrictors in local anesthetic Atraumatic surgical techniques

14. Three options for alteration of warfarin (coumadin ) status: Option 1: After consult with physician → 2-3 day cessation of warfarin therapy → determine INR: If INR is unacceptable, defer an additional day → repeat INR → perform dental treatment only when INR is in an acceptable range → resume warfarin therapy on the evening of the same day of dental procedure. If INR is acceptable → perform dental treatment → resume warfarin therapy on the evening of the same day of dental procedure.

15. Option 2: After consult with physician with an unacceptable INR: Discontinue warfarin therapy several days before surgery (or other dental treatment) and substitute heparin anticoagulant therapy or Low molecular weight heparin (LMWH). Heparin then can be discontinue 6-8 hours before surgery or Low molecular weight can be discontinued the day before surgery. Warfarin or heparin or LMWH can be readministered shortly (12-18 hours) after surgery.

16. Option 3: (Not Recommended) After consult with physician, stop warfarin therapy for 4-5 days before performing dental treatment. Warfarin is then resumed after the dental treatment. Not recommended because ↑ risk of thrombotic complications due to underlying disease.