Can I get a dental implant if I take Coumadin?

Coumadin is an anticoagulant (blood thinner), which reduces the formation of blood clots. It does so by blocking the synthesis of certain clotting factors. A reduction in clotting factors will also reduce the chance of any blood clot formation.

Coumadin is predominantly used to prevent heart attacks, strokes and blood clots in veins and arteries as well as around prosthetic devices, such as artificial heart valves. The down side of Coumadin are the prolonged bleeding times. This is of great concern to anyone who needs to undergo minor surgery.
Many patients who take Coumadin get their INR (International Normalized Ratio) and PT (Prothrombin Time) tested on a regular basis. The Prothrombin time (PT) evaluates the ability of blood to clot properly, whereas the International Normalized Ratio (INR) is used to monitor the effectiveness of blood thinning drugs such as Coumadin (or also Jantoven, Marevan and Waran, which are all brand names for the generic Warfarin).

Most dental surgeons will look for the INR assessed a day prior to surgery, to determine whether it is safe to perform any minor oral surgical procedure, however some also consider the PT time along with the INR. Your cardiologist is always the final decision maker, however. Sometimes they will take you off the Coumadin and switch you over to Heparin a few days prior and after the surgery, sometimes they may just take you off for a couple of days. This will really depend on how high your risk of clot formation is and only your cardiologist can make this decision.

So to answer the original title question: As long as you are carefully monitored and prepared by your cardiologist just prior and after the dental implant surgery, you can get dental implants. There are no published studies showing an decrease in success rates of dental implants in patients taking any of the Warfarins.

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A 100 Watt Laser – And My Doctor Says It Won’t Hurt?!?!

It is an unfortunate business practice, but the sale of medical lasers is largely being promoted by their hardware profile: “X” number of watts, “Y” number of pulses at “Z” nanometers etc.  What is unfortunate about this is that it does not really paint a good picture on what the clinical qualities of a laser really are, because this type of advertising does not really address what kind of “tissue interaction” it produces.  This however is ultimately the most important quality of any laser.  I’ll explain…

First and foremost, the power of the laser (usually displayed in Watts) is the true output power in terms of light energy emitted.  This is in direct contrast to a light bulb for instance.  A 60-Watt light bulb will draw 60 Watts of power out of the socket, but only deliver a fraction thereof as light energy, because most of the power drawn gets converted to heat energy.  In a laser the power rating is NOT what it draws out of the electric socket, but rather the light energy it produces.

Another concept that needs to be addressed is that this power claim describing a laser, can often be misleading.  More often than not, a “high-powered” healthcare laser in the 20 – 100 Watt range achieves this kind or output power mostly in a “pulsed” mode.  This means that the laser will be “on” and “off” several hundred or even several thousand times a second and every time it is “on” it emits 100 Watts.  Since this is a pulse train of laser light, it is important to note that the AVERAGE power may only be in the milliwatt range, so there is effectively only less than 1 Watt being absorbed by the tissues.

The last and most important concept which needs to be addressed is that of the power density at the output tip (aka “fluence”).  A 50-Watt laser with an output diameter of 1 cm will have an entirely different effect on tissues than a 6-Watt laser with an output diameter of only a few hundred microns.  The former will have a biostimulatory effect, whereas the latter will be able to cut tissue.

So, as we can see, the advertising profiles of lasers do not really always reflect the clinical relevance.  It is my opinion that this needs to change eventually, so that the tissue interaction is placed into the foreground and not the hardware profile.


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Sinus Augmentation or Sinus Lift Procedure

The Sinus Augmentation of Sinus Lift Procedures are very common bone grafting procedures within the realm of implant dentistry.  Patients are often not quite clear what these procedures actually are, so I would like to

The maxillary sinus on a CT scan 3-D image

The maxillary sinus on a CT scan 3-D image

shed some light on these grafting procedures.  The maxillary sinus is the largest of all sinuses in the head-and-neck area.  It is located just to the inside of the bone in the upper cheek area.  The maxillary sinus starts out as a small air cavity in children and then expands and gets bigger as we grow older.  Once teeth are missing in the back areas of the upper jaw, the sinus will expand even further down towards the jaw ridge from the inside of the jaw bone.  This can be seen on the images on the right, especially the very bottom image, which shows a cross-sectional CT scan slice through the alveolar process of the upper jaw bone.

Now, as the sinus expands, and encroaches upon the alveolar ridge from the inside, you can appreciate that there is a diminishing distance of bone left between the top of the ridge and the floor of the sinus.  If this distance is too small to place one or several dental implants of proper length, we need to perform a sinus lift or sinus augmentation procedure, in order to re-gain this distance.

What is the difference between a “Sinus Augmentation” and a “Sinus Lift Procedure”?  Well, many will use these two terms

A CT Scan Slice through the sinus and alveolar process

A CT Scan Slice through the sinus and alveolar process

interchangeably, however there is a little difference between these two terms.  A “Sinus Augmentation” is a slightly more aggressive procedure, where a window is cut into the bony cheek side wall of the sinus and the sinus membrane is then gently lifted off the sinus floor, until a bone graft is finally placed underneath the lifted membrane.

A Sinus Lift procedure, on the other hand is usually performed right through the hole which is drilled for the implant(s).  No window is cut on the cheek side of the bone.  The Augmentation is usually done, for bigger lifts and the Lift procedure is usually done for smaller lifts.

So when the sinus membrane is finally lifted in either procedure, a bone graft is placed underneath the membrane, which keeps the membrane “tented” up.  For more detailed information on bone grafts see my bone graft post or link to Robert Gougaloff ‘s website.  This bone graft will then “mature” over the next six to 24 months (depending on the type of graft used).  What this

A CT Scan Cross sectional slice from the above image

A CT Scan Cross sectional slice from the above image

has accomplished however, is that the floor of the sinus was effectively “raised” and has thus given us enough room to place one or more dental implants of proper length.

Sinus Augmentations and dental implants can be done in one stage or in two stages, depending on how much residual alveolar bone was left to stabilize the implant.  If it is done in two stages, then the dental implant is usually placed 6 to 12 months following the sinus augmentation, depending on the graft material used.

Sinus Lift Procedures and the placement of dental implants are usually done at the same time, which obviously shortens the treatment time dramatically.  However this can usually be only done if the amount of lift needed is not too excessive.

A video of a Sinus Augmentation procedure can be seen on the following video link: Robert Gougaloff ‘s Sinus Augmentation Video.

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