253

Abstract: Antiplatelet and anticoagulant agents

have been extensively researched and developed as
potential therapies in the prevention and management
of arterial and venous thrombosis. On the other hand,
antiplatelet and anticoagulant drugs have also been
associated with an increase in the bleeding time and risk
of postoperative hemorrhage. Because of this, some
dentists still recommend the patient to stop the therapy
for at least 3 days before any oral surgical procedure.
However, stopping the use of these drugs exposes the
patient to vascular problems, with the potential for
significant morbidity. This article reviews the main
antiplatelet and anticoagulant drugs in use today and
explains the dental management of patients on these
drugs, when subjected to minor oral surgery
procedures. It can be concluded that the optimal INR
value for dental surgical procedures is 2.5 because it
mi ni mi zes the ri sk of ei ther hemorrhage or
thromboembolism. Nevertheless, minor oral surgical
procedures, such as biopsies, tooth extraction and
periodontal surgery, can safely be done with an INR
lower than 4.0. (J. Oral Sci. 49, 253-258, 2007)
Keywords: antiplatelet; anticoagulants; INR; oral
surgery; dentistry.
Introduction
Thrombotic and thromboembolic occlusions of blood
vessels are the main cause of ischaemic events in heart,
lungs and brain (1). Since the observation that thrombi
occluding arteries were rich in platelets, antiplatelet agents
and anticoagulants have been extensively researched and
developed as potential therapies for the prevention and
management of arterial thrombosis (1). Platelet activation
and aggregation is considered to be central to arterial
thrombus production (2). Platelets are the major players
in arterial thrombosis and therefore are attractive targets
in the prevention and treatment of cardiovascular diseases
such as myocardial infarction, cerebral ischemia and
peripheral arterial insufficiency (1).
Even though several antiplatelet and anticoagulant
agents have been developed in recent years, acetylsalicylic
acid (ASA) and warfarin are the standard drugs for
preventing vascular diseases (3).
Antiplatelet and anticoagulant therapies have long been
associated with an increase in the bleeding time and risk
of postoperative hemorrhage. Typically, it is recommended
that the patient stops the therapy 3 days before any surgical
procedure. This article reviews the main antiplatelet and
anticoagulants drugs in use today and explains the dental
management of these patients when submitted to oral
surgery procedures.
Blood clotting
The blood clotting mechanism is initiated by one of two
pathways: intrinsic and extrinsic. In both cases, this is a
cascaded reaction sequence in which inactive factors
become activated and catalyze the formation of products
from precursors, which in turn activate more factors until
the final products are formed. The intrinsic pathway is
initiated by damage, or alteration, to blood independent
of contact with damaged tissue, whereas the extrinsic
pathway is initiated by exposure to factors derived from
damaged tissue (4).
Journal of Oral Science, Vol. 49, No. 4, 253-258, 2007
Correspondence to Dr. Jos M. Amenbar, Rua Padre Anchieta
2285-103 Bigorrilho, Curitiba, PR CEP: 80730-000, Brazil
Tel: +55-41-3013-0054
Fax: +55-41-3013-0054
E-mail: [email protected]
Dental management of patients receiving anticoagulation or
antiplatelet treatment
Mariele Pototski
1)
and Jos M. Amenbar
2)
1)
School of Dentistry, University of Minnesota, St Paul, MN, USA
2)
Department of Oral Medicine, Dental School, Federal University of Paran, Paran, Brazil
(Received 2 June and accepted 15 October 2007)
Review
254
Factor V secreted by the a-granules of activated platelets
binds to activated factor X to produce prothrombin activator,
which in the presence of calcium, catalyzes the formation
of thrombin from prothrombin. Thrombin then catalyzes
the production of fibrin monomer from fibrinogen, which
in the presence of calcium and fibrin stabilizing factor
(factor XIII), forms fibrin threads. Thrombin also binds
to platelet surface receptors and activates serum factor VIII,
which forms complexes with factor IX on the platelet
surface. Activated factors VIII and IX participate in the
activation of factor X via the intrinsic pathway (4).
The blood clot consists of a fibrin mesh containing the
platelet aggregate, as well as entrapped red and white
blood cells. Contraction of the platelet actin myosin fibers
is responsible for retraction of the clot, which occurs
within 20 min to 1 h, further closing the vessel (4).
Historically bleeding time, prothrombin time (PT) and
partial thromboplastin time (PTT), have been the standards
by which clinicians evaluate anticoagulation levels.
Nevertheless, an international normalized ratio (INR) was
introduced in 1983 by the World Health Organization
Committee on Biological Standards to assess patients
receiving anticoagulation therapy more accurately (5).
The INR is calculated from the ratio of the patients PT
and control PT, raised to the power of the international
sensitivity index value (ISI). INR = (patient PT/mean
normal PT)
ISI
. It is a more reliable and sensitive value for
determining the level of anticoagulation because it depends
on the patients blood and on the sensitivity of the
thromboplastin reagent and the assigned ISI value.
Therefore, PT may not be the laboratory value of
importance when evaluating the level of anticoagulation
(5).
A patient with a normal coagulation profile would have
an INR of 1.0. It is recommended that a patient undergoing
invasive treatment should have a PT within 1.5 to 2.0
times the normal value, and this corresponds to an INR
of 1.5 to 2.5 when the ISI is 1.0 (5).
In patients with anticoagulant therapy, an INR between
2.0 and 3.0 is recommended for most indications. Thus,
an INR of 2.5 (range, 2.0 to 3.0) minimizes the risk of either
hemorrhage or thromboembolism (6).
Antiplatelet therapy
Since platelets provide the initial haemostatic plug at
the site of a vascular injury, they are involved in pathological
processes and are an important contributor to arterial
thrombosis leading to myocardial infarction and ischaemic
stroke (7). The most common antiplatelet drugs are
acetylsalicylic acid, clopidogrel and dipyridamole.
Acetylsalicylic acid - ASA
ASA is still the only nonsteroidal anti-inflammatory drug
(NSAID) used in the treatment and prevention of
thromboembolic diseases (3). The antithrombotic action
of ASA depends on the irreversible inhibition of
arachidonate cyclo-oxygenase activity in platelets, thereby
reducing the extent of thromboxane A2 formation that
occurs after activation of phospholipase A2 and release of
arachidonic acid (3). Thromboxane A2 is a strong platelet
agonist, which is an effective inducer of platelet granule
secretion as well as platelet aggregation (3). Available
evidence suggests that a daily ASA dose of 75-150 mg is
recommended for long term prevention of serious vascular
events in high risk patients (8). In clinical situations where
an immediate antithrombotic effect is required (such as
acute myocardial infarction, stroke, or unstable angina),
a loading dose of 300 mg is recommended (8).
Clopidogrel
The antiplatelet activity of clopidogrel is greater than
that of ASA in the secondary prevention of CVA,
myocardial infarction and peripheral arterial insufficiency
(9). Despite its growing popularity, clopidogrel is very
expensive, so it is used only selectively in patients resistant
to treatment with ASA. The antiplatelet effect of clopidogrel
is irreversible and lasts for the life of the platelet (7 to 10
days) (9).
Dipyridamole
Dipyridamole inhibits adenosine uptake in erythrocytes
and endothelial cells. This increases plasma adenosine
levels, which means that there is more available for binding
to the adenosine receptor on the platelet. Adenosine
activates the release of adenylate cyclase, which converts
cyclic adenosine triphosphate (cATP) to cyclic adenosine
monophosphate (cAMP). Dipyridamole also blocks the
enzyme cyclic guanine monophosphate phosphodiesterase
(cGMP), thereby inhibiting the breakdown of cGMP (3).
However, the antiplatelet activity of dipyridamole is less
than that of ASA and ADP receptor blockers. Moreover,
its action on phosphodiesterase is wholly reversible and
ceases about 24 h after the drug is discontinued (10).
Antiplatelet therapy and oral surgery
When platelets are inhibited, it takes longer time for free
blood flow from a cut to stop and for primary haemostasis
to occur, as a consequence, the bleeding time is prolonged
(1). However, the effect on primary haemostasis is minimal
in patients without additional risk factors for impaired
clotting. Antiplatelet medications can double the baseline
bleeding time, but this may still be within or just outside
255
the normal range. It has been reported that only 20% to
25% of patients using ASA have an abnormal bleeding time
(1). Patients taking antiplatelet medications will have a
prolonged bleeding time, but this may not be clinically
relevant because postoperative bleeding after dental
procedures can mostly be controlled using local haemostatic
measures.
Lockhart et al. (11) suggested that postoperative bleeding
is considered to be significant if it conforms to the following
four criteria: the bleeding continues beyond 12 hours; it
causes the patient to call or return to the dental practice
or accident and emergency department; results in the
development of a large haematoma or ecchymosis within
the oral soft tissues; and requires a blood transfusion.
A study investigating stopping versus continuing low-
dose ASA prior to dental extraction was done by Ardekian
et al. (12). Thirty-nine patients taking ASA 100mg daily
were studied. Nineteen continued ASA as normal, while
20 stopped taking ASA seven days before the planned
extractions. A bleeding time test was performed one hour
prior to the procedure. The mean bleeding time was longer
in patients who continued ASA compared to those who
stopped (3.1 min vs 1.8 min, P = 0.004). Although the
difference was statistically significant, none of the patients
who continued ASA had a bleeding time outside the
normal range in this study (2-10 min). Intraoperative
bleeding was controlled in 33 (85%) patients with gauze
packing and sutures. Six patients (2 who stopped ASA and
4 who continued ASA) had tranexamic acid added to the
local packing. At the end of the study, it was observed that
no patient experienced uncontrolled bleeding immediately
after the procedure or in the following week.
There are few published studies on the relative risks of
perioperative bleeding with clopidogrel and dipyridamole.
The pharmacological mechanisms underlying the
antiplatelet action of clopidogrel and dipyridamole suggest
that patients taking these medications will be at no greater
risk of excessive bleeding than those taking ASA (13).
A review of the implications of antithrombotic
medications in dentistry concluded that patients on
clopidogrel should not have the dose altered prior to dental
procedures (13). Based on these reports, it is suggested that
these medications should not be discontinued prior to
dental surgical procedures. On the other hand, if patients
take both ASA and clopidogrel, they should be referred
to a dental hospital or hospital based oral/maxillofacial
surgeon.
Anticoagulation therapy
The goal of anticoagulant therapy is to prevent clot
formation or expansion and Warfarin is the most common
drug used in this therapy (6).
Warfarin
Warfarin is an antagonist of vitamin K, an element
necessary for synthesis of clotting factors II, VII, IX and
X, as well as the naturally occurring endogenous anti-
coagulant proteins C and S. These factors and proteins are
biologically inactive without the carboxylation of certain
glutamic acid residues. This carboxylation process requires
a reduced vitamin K as a cofactor. Antagonism of vitamin
K or a deficiency of this vitamin reduces the rate at which
these factors and proteins are produced, thereby creating
a state of anticoagulation (6).
Warfarin has two functions: anticoagulant activity and
antithrombotic effect. Therapeutic doses of warfarin reduce
the production of functional vitamin K dependent clotting
factors by approximately 30 to 50 percent. A concomitant
reduction in the carboxylation of secreted clotting factors
yields a 10 to 40 percent decrease in the biologic activity
of the clotting factors. As a result, the coagulation system
becomes functionally deficient (6).
Anticoagulation therapy and oral surgery
If warfarin therapy is stopped, it would take about four
days for INR to reach 1.5 in almost all patients and with
this INR, any surgery can be safely performed (14). After
warfarin therapy is restarted, approximately three days will
be needed for the INR to reach 2.0. Therefore, if warfarin
is withheld for four days before surgery and treatment is
restarted as soon as possible after surgery, patients would
have a sub-therapeutic INR for approximately two days
before surgery, and two days after surgery increasing the
risk of thromboembolism (15).
Besides this, independent of the intensity of anti-
coagulation, the perioperative risk of thromboembolism
may be increased due to other factors, in particular a
rebound hypercoagulable state caused by the dis-
continuation of warfarin and the prothrombotic effect of
the surgery itself (16). Consequently, for patients whose
INR returns to normal shortly after stopping warfarin
therapy, it can be assumed that the risk of preoperative
arterial thromboembolism, postoperative arterial thrombo-
embolism, and preoperative venous thromboembolism
will be similar to that which is expected in the absence of
anticoagulation (7).
Wahl (17) studied the impact of stopping the anti-
coagulation therapy in dentistry by reviewing 542
documented cases involving 493 patients, who had
anticoagulation therapy withdrawn prior to a variety of
dental procedures. He reported that four patients
experienced fatal thromboembolic events (2 cerebral
256
thromboses, 1 myocardial infarction, 1 embolus - type not
specified); one patient experienced two non-fatal
thromboembolic complications (1 cerebral embolus, 1
brachial artery embolus) and the majority of patients had
no adverse effects. The incidence of serious thrombo-
embolic complications was 1%. These findings have been
criticized as the duration that the anticoagulant was stopped
was either longer than normal practice (range 5-19 days)
or unknown (18). Although, it cannot be assumed that
st oppi ng t he ant i coagul ant t herapy caused t he
thromboembolic events, there is a risk associated with
the perioperative withdrawal of oral anticoagulants. For
minor procedures such as dental surgery, the risk appears
to vary from 0.02% to 1%.
In another study, Wahl (19) also estimated the incidence
of serious bleeding problems in 950 patients receiving
anticoagulation therapy undergoing 2400 individual dental
procedures. Only 12 patients (< 1.3%) experienced bleeding
uncontrolled by local measures and none of the patients
were reported to have experienced serious harm. Of these
12 patients, seven had higher than recommended
anticoagulation levels; three were given a course of
postoperative antibiotics, which may have interacted with
the warfarin and two were using a placebo mouthwash four
times a day immediately after the procedure, which is
contrary to standard advice to avoid rinsing for the first
24 h.
Bleeding complication vs
thromboembolic complication
Even though continuing the antiplatelet or the
anticoagulation therapy during dental surgical procedures
will increase the risk of postoperative bleeding requiring
intervention, stopping them does not guarantee that the risk
of postoperative bleeding requiring intervention will be
eliminated as serious bleeding can occur in non-
anticoagulated patients (19). Most cases of postoperative
bleeding can be managed by pressure or repacking and re-
suturing the sockets. The incidence of postoperative
bleeding which could not be controlled by local measures
varied from 0% to 3.5% (19,20).
Bleeding complications, while inconvenient, do not
carry the same risks as thromboembolic complications.
Patients are more at risk of permanent disability or death
if they stop antiplatelet or anticoagulation medications
prior to a surgical procedure than if they continue it.
Thromboembolic events, including fatalities, have been
reported after antiplatelet or anticoagulation withdrawal.
Although the risk is low, the outcome is serious. This
must be balanced against the fact that there is no single
report of uncontrollable bleeding when dental procedures
have been carried out without stopping antiplatelet or
anticoagulation medications (21).
It is important to consider the consequences of venous
and arterial thromboembolism, and of bleeding, in addition
to the rates at which these outcomes occur. Six percent of
recurrent episodes of venous thromboembolism are
expected to be fatal (22). A small group of patients with
recurrent events, perhaps 2%, will have serious permanent
disability, though the majority will recover well. The
consequences of arterial thromboembolism are much more
serious; approximately 20 percent of these episodes are
fatal, and 40 percent result in serious permanent disability
(23).
No cases of permanent disability or death, reported as
a consequence of postoperative bleeding associated with
a dental surgical procedure in which the patient continued
oral anticoagulation, were found. The majority of
publications that have considered the risks of stopping
versus continuing anticoagulation or antiplatelet therapy
for dental procedures have concluded that most dental
patients can undergo procedures without stopping their
therapies provided that local haemostatic measures are used
to control bleeding (11,17,21,24,25).
Oral surgery considerations
The activity of anticoagulants is expressed using the
international normalized ratio (INR). For an individual not
taking anticoagulant or antiplatelet drugs, the normal
coagulation profile is an INR of 1.0. The INR must be
measured prior to dental procedures, ideally this should
be done within 24 h before the procedure (21,25-27), but,
for patients who have a stable INR, an INR measured
within 72 h before the procedure is acceptable.
Scientific literature has advocated that minor dental
surgical procedures can safely be carried out with the INR
within the therapeutic range (2.0-4.0) when local
haemostatic measures are used to control bleeding (13,17-
20,24,26,27). However, patients who have an INR greater
than 4.0 should not undergo any form of surgical procedure,
including dental, without consultation with the clinician
who is responsible for maintaining their anticoagulation.
Minor surgical procedures, such as simple extraction of
up to three teeth, gingival surgery, crown and bridge
procedures, supragingival scaling and the surgical removal
of teeth (11,28), can be safely carried out without altering
the anticoagulation or antiplatelet medication dose. If
more than 3 teeth need to be extracted then multiple visits
will be required and the extractions may be planned to
remove 2-3 teeth at a time, by quadrant, or one at a time
in separate visits (24). Scaling and gingival surgery should
initially be restricted to a limited area to assess if bleeding
257
is problematic.
Management of bleeding
According to Scully and Wolff (26), oral procedures must
be done at the beginning of the day because this allows
more time to deal with immediate re-bleeding problems.
Also the procedures must be performed early in the week,
allowing delayed re-bleeding episodes, usually occurring
after 24-48 h, to be dealt with during the working weekdays.
Local anesthetic containing a vasoconstrictor should
be administered by infiltration or by intraligamentary
injection wherever practical (11,26). Regional nerve blocks
should be avoided when possible. However, if there is no
alternative, local anesthetic should be administered
cautiously using an aspirating syringe (30). Local
vasoconstriction may be encouraged by infiltrating a small
amount of local anesthetic containing adrenaline
(epinephrine) close to the site of surgery.
Sockets should be gently packed with an absorbable
haemostatic dressing (11,26) and then carefully sutured.
Resorbable sutures are preferable as they attract less plaque
(26). If non-resorbable sutures are used they should be
removed after 4-7 days (26). Following closure, pressure
should be applied to the socket using a gauze pad that the
patient bites down on for 15 to 30 min. Efforts should be
made to make the procedure as atraumatic as possible
and any bleeding should be managed using local measures.
Scully and Cawson (30) also developed the following
list of instructions that should be given to the patients for
management of the clot in the postoperative period: to look
after the initial clot by resting while the local anesthetic
wears off and the clot fully forms (2-3 h); to avoid rinsing
the mouth for 24 h; not to suck hard or disturb the socket
with the tongue or any foreign object; to avoid hot liquids
and hard foods for the rest of the day; to avoid chewing
on the affected side until it is clear that a stable clot has
formed; if bleeding continues or restarts, to apply pressure
over the socket using a folded clean handkerchief or gauze
pad for 20 min; if bleeding does not stop, the dentist
should be contacted.
Anticoagulants and antiplatelet drugs used in the
prevention of thromboembolic diseases can cause intra-
operative and postoperative hemorrhagic complications.
However, stopping these drugs before a procedure exposes
the patient to vascular problems with the potential for
significant morbidity.
The optimal INR value for dental surgical procedures
is 2.5 because it minimizes the risk of either hemorrhage
or thromboembolism. Nevertheless, minor dental surgical
procedures can safely be done with the INR between 2.0
and 4.0, being aware that local haemostatic measures may
be needed to control bleeding.
Patients who have an INR greater than 4.0 should not
undergo dental surgical procedures, and they must be
referred to the clinician who is responsible for maintaining
their anticoagulation.
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