Dental implications - management of the post-infarct patient

Editor, – In writing on the dental implications of the management of the post-infarct patient (Aust Prescr 1996;19:13), Dr R. Woods appears to have selectively quoted from his reference¹ regarding antibiotics and warfarin. He states 'If antibiotics are employed, dentists should be aware that some antibiotics may inhibit the action of warfarin.' This is true for rifampicin, nafcillin, dicloxacillin¹ and griseofulvin.² Dr Woods has not mentioned that Buckley and Dawson¹ also reported potentiation of warfarin by erythromycin, metronidazole, chloramphenicol, quinolones, trimethoprim/sulfamethoxazole, sulfonamides, the imidazole antifungals, some cephalosporins and high intravenous dose penicillin. This latter group includes antibiotics more likely to be prescribed by dentists as the former drugs are not on the Schedule of Pharmaceutical Benefits for dentists.³ Antibiotic potentiation of warfarin has also been referred to in the dental literature.^4,5

A recent review concluded there was probable potentiation of warfarin by paracetamol and by dextropropoxyphene,⁶ and potentiation by aspirin was referred to by Buckley and Dawson.¹ These are common drugs in dentistry. Given the number of patients on long-term anticoagulants, Dr Woods may care to elaborate on these important interactions.

Dentists should be mindful of both potentiation and inhibition of warfarin. The former is a potential dental emergency with respect to haemorrhage, the latter a potential medical emergency. I feel the evidence would lead dentists to be more concerned about potentiation of warfarin rather than inhibition and suspect this is by far the more likely problem that dentists may cause or have cause to deal with.

Rod Marshall
Periodontist
Lecturer in Periodontology
Faculty of Dentistry
University of Queensland
Brisbane, Qld

Dr R.G. Woods, the author of the article, comments:

I appreciate the interest expressed by Dr R. Marshall and his comments. Dr Marshall is quite correct regarding the effects of antibiotics on the action of warfarin in the drug regimens of post-infarct patients.

The matter of drug interactions with warfarin is summarised in Goodman and Gilman.⁷

'The list of drugs and other factors that may affect the action of oral anticoagulants is prodigious and expanding. Any substance or condition is potentially dangerous if it alters (1) the uptake or metabolism of the oral anticoagulant or vitamin K; (2) the synthesis, function, or clearance of any factor or cell involved in hemostasis or fibrinolysis; or (3) the integrity of any epithelial surface.'

Coagulation for those on warfarin is unpredictable. It is usual for the INR to be checked regularly and frequently.

Whether to alter coagulation therapy in anticipation of dental treatment is a decision based on clinical judgment, which should be taken jointly by the medical practitioner managing the case and the dentist. Considerations will include the nature of the proposed treatment, its urgency and the possible consequences of a changed anticoagulant regimen.