Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs



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3 Assessing Bleeding Risk


Before providing dental treatment for a patient taking anticoagulants or antiplatelet drugs, their bleeding risk should be assessed. This involves consideration of both the likely risk of bleeding associated with the required dental procedure and the patient’s individual level of bleeding risk, which can be affected by the anticoagulants or antiplatelet drugs that they are taking, in addition to their other medical conditions and medications. These issues are addressed in Sections 3.1 and 3.2. Guidance on the management of the patient’s dental treatment based on this risk assessment is presented in Sections 4 to 8.

While the risk of bleeding complications associated with dental treatment for these patients should be taken seriously, it should be noted that existing evidence and clinical experience suggest that serious adverse bleeding events are rare. For example, the incidence of significant bleeding after dental procedures (defined as that requiring an unplanned intervention including repacking and resuturing, or transfusion in extreme cases) for patients who have continued their warfarin therapy perioperatively, is estimated at less than 4%.2


3.1 Which Dental Procedures Have the Highest Bleeding Risk?


Table 1 categorises dental procedures into those that are unlikely, under normal circumstances, to cause bleeding and those that can be expected to cause some level of bleeding. The management of patients taking anticoagulants or antiplatelet drugs whose dental treatment involves procedures from the first category should be straightforward and these patients can be treated according to standard practice, with care taken to avoid causing bleeding (see Section 4). More careful consideration should be given to patients who require procedures likely to result in bleeding (see Sections 4 to 8). Dental procedures that are likely to result in bleeding are further categorised in Table 1 into those with a low risk of post-operative bleeding complications and those that are judged to be more invasive and potentially carry a relatively higher risk of bleeding complications. By bleeding complications we mean prolonged or excessive bleeding or bleeding not controlled by initial haemostatic measures. Note that the use of the term ‘higher risk’ is not intended to suggest that these are high risk dental treatments.

Table 1 is intended to be a guide only and bleeding risk assessment for a patient’s dental treatment is likely to require further judgement on an individual case basis. Before performing a dental procedure that is likely to cause bleeding on a patient taking anticoagulants or antiplatelet drugs, the dentist or dental care professional should use their clinical judgement to determine whether they are sufficiently confident and skilled in the procedure and management of the associated peri-operative bleeding. If in doubt they should seek advice from or refer the patient to a more experienced colleague in primary or secondary dental care. This may be an experienced senior colleague in practice, a speciality dentist/dentist with enhanced skills or senior dental officer (e.g. special care or oral surgery), or for very complex cases, a consultant in primary or secondary dental care. If the dentist needs to seek specialist advice from the hospital dental service, they should be aware that it may take time to receive a reply from a suitably senior member of the hospital dental team.


Table 1 Post-operative bleeding risks for dental procedures

Dental procedures that are unlikely to cause bleeding

Dental procedures that are likely to cause bleeding

Low risk of post-operative bleeding complications

Higher risk of post-

operative bleeding complications



Local anaesthesia by infiltration, intraligamentary or mental nerve blocka

Local anaesthesia by inferior dental block or other regional nerve blocksa,b Basic periodontal examination (BPE)c

Supragingival removal of plaque, calculus and stain

Direct or indirect restorations with supragingival margins

Endodontics - orthograde

Impressions and other prosthetics procedures

Fittings and adjustment of orthodontic appliances


Simple extractions (1-3 teeth, with restricted wound size)d

Incision and drainage of intra-oral swellings

Detailed six point full periodontal examination

Root surface instrumentation (RSI) and subgingival scaling

Direct or indirect restorations with subgingival margins


Complex extractionse, adjacent extractions that will cause a large wound or more than 3 extractions at once

Flap raising procedures:

Elective surgical extractions

Periodontal surgery

Preprosthetic surgery

Periradicular surgery

Crown lengthening

Dental implant surgery

Gingival recontouring

Biopsies


a Local anaesthesia should be delivered using an aspirating syringe and should include a vasoconstrictor, unless contraindicated. Note that other methods of local anaesthetic delivery are preferred over regional nerve blocks, whether the patient is taking an anticoagulant or not.

b There is no evidence to suggest that an inferior dental block performed on an anticoagulated patient poses a significant risk of bleeding. However, for patients taking warfarin, if there are any indications that the patient has an unstable INR (see Section 5), or other signs of excessive anticoagulation, an INR should be requested before the procedure.

c Although a BPE can result in some bleeding from gingival margins, this is extremely unlikely to lead to complications.

d Simple extractions refers to those which are expected to be straightforward without surgical complications.

e Complex extractions refers to those which may be likely to have surgical complications.

3.2 Which Patients Have the Highest Bleeding Risk?


A patient’s individual risk of bleeding complications is dependent on a variety of factors, including the type and combination of anticoagulants or antiplatelet drugs they are taking, their underlying health conditions and other medications that they may be taking. The patient’s medical history and details of the prescribed and non-prescribed medication they are taking should be noted at the start of each course of treatment and checked for any changes at each visit (see Section 3.3).

3.2.1 Bleeding risks associated with different anticoagulants and antiplatelet drugs


There is currently insufficient evidence to directly compare the relative bleeding risks associated with the various anticoagulants and antiplatelet medications, including the newer drugs, for dental patients. According to the clinical trials conducted by the drug manufacturers, incidences of major bleeding events for patients with atrial fibrillation taking dabigatran, apixaban or rivaroxaban were similar or lower than for those taking warfarin.14-16 However, it should be noted that these bleeding rates included spontaneous and procedural bleeding and may not be meaningful for dental treatments.

Patients who are on dual or combination therapies and are taking more than one anticoagulant or antiplatelet drug are likely to have a higher bleeding risk than those on single drug therapies.

The clinical experience of dental professionals suggests that dual antiplatelet medication can lead to prolonged bleeding following an invasive procedure. However, once formed, the clot tends to be reasonably stable. Conversely, clinical experience suggests that for patients taking anticoagulants, blood clots may form more quickly than with antiplatelet drugs but can also be more easily dislodged. The use of sutures at the time of treatment, in addition to haemostatic packing, usually stabilises the wound and may reduce the likelihood of prolonged or subsequent re-bleeding and the need for the patient to return for further treatment.

3.2.2 Bleeding risks associated with other medical conditions


Certain medical conditions are known to be associated with an increased bleeding risk, due to effects on either coagulation or platelet function, and should be taken into consideration when planning dental treatment for any patient. These include liver, kidney and bone marrow disorders.17 Although these effects are not dependent on the patient’s anticoagulation medication, it is especially important that the dentist recognises these as additional risk factors that can contribute to post-operative bleeding complications in patients taking anticoagulants or antiplatelet drugs. It is not possible to give an exhaustive list but the main conditions which could be relevant for patients also being treated with anticoagulants or antiplatelet drugs are shown in Table 2.
Table 2 Main medical conditions associated with increased bleeding risk

Medical condition

Increased bleeding due to:

Chronic renal failure

Associated platelet dysfunction

Liver disease (e.g. caused by alcohol dependence, chronic viral hepatitis, autoimmune hepatitis, primary biliary cirrhosis)

Reduced production of coagulation factors.

Reduction in platelet number and function due to splenomegaly.

Alcohol excess can also result in direct bone marrow toxicity and reduced platelet numbers.


Haematological malignancy or myelodysplastic disorder

Impaired coagulation or platelet function (even in remission).

Recenta or current chemotherapy

Pancytopenia including reduced platelet numbers.

Advanced heart failure

Resulting liver failure.

Mild forms of inherited bleeding disorders including all types of haemophilia and von Willebrand’s disease

Defective or reduced levels of coagulation factors.

Idiopathic thrombocytopenic purpura (ITP)

Reduced platelet numbers.

a Have received chemotherapy or radiotherapy to the head or neck less than three months ago, or total body irradiation less than six months ago.

For medically complex patients such as these, the patient’s general medical practitioner or specialist should be consulted, to establish the extent of the disease in order to assess the likely impact on the bleeding risk for the dental procedure.


3.2.3 Bleeding risks associated with prescribed or non-prescribed medications


In addition to the medical conditions discussed above, a number of different medications can exacerbate a patient’s bleeding risk over and above the effects of the anticoagulants or antiplatelet drugs they are taking. Although not an exhaustive list, groups of drugs to be aware of include those described in Table 3:

Table 3 Main drug groups associated with increased bleeding risk



Drug group

Effect

Other Anticoagulants or antiplatelet drugsa

See Appendix 2 for listings.



Patients can be on dual, multiple or combined antiplatelet or anticoagulant therapies. These patients are likely to have a higher risk of bleeding complications than those on single drug regimes.

Cytotoxic drugs or drugs associated with bone marrow suppressionb

e.g. leflunamide, hydrochloroquine, adalimumab, infliximab, etanercept, sulfasalazine, penicillamine, gold, methotrexate, azathioprine, mycophenolate



These can reduce platelet numbers and/or impair liver function affecting production of coagulation factors.

Non-steroidal anti-inflammatory drugs

(NSAIDs)

e.g. aspirin, ibuprofen, diclofenac and naproxen


Impair platelet function to various extents.

Drugs affecting the nervous system

Selective serotonin reuptake inhibitors (SSRIs)



SSRIs have the potential to impair platelet aggregation and, although unlikely to be clinically significant in isolation, may in combination with other antiplatelet drugs increase the bleeding time.

Carbamazepine

Carbamazepine can affect both liver function and bone marrow production of platelets. Patients most at risk are those recently started on this medication or following dose adjustment.

a Be aware that patients may also be taking non-prescribed aspirin, and this antiplatelet agent can in effect convert a prescribed monotherapy into a dual therapy.

b Patients with inflammatory bowel disease or autoimmune/rheumatological conditions are commonly prescribed these drugs.

For the management of patients taking these additional medications, the patient’s general medical practitioner or specialist could be consulted in order to assess the likely impact on bleeding risk.

Be aware that some herbal and complementary medicines may affect bleeding risk, either on their own or when in combination with other anticoagulants or antiplatelet drugs. These include St. John’s Wort, Ginkgo biloba and garlic.

3.3 Advice for Assessing Bleeding Risk


The following best practice advice is based on clinical experience and expert opinion.

Assess whether the required dental treatment is likely to cause bleeding and, if so, whether it has a low or higher risk of bleeding complications (see Table 1).

Ask the patient about their current or planned use of anticoagulants or antiplatelet drugs and other prescribed and non-prescribed medications, when taking or confirming their medical history.

The patient should have been advised by their prescriber/dispenser about their anticoagulant or antiplatelet drug(s) and the need to inform their dentist.

Dentists should be aware, however, that a patient may not know that their medication is an anticoagulant or antiplatelet drug. A list of anticoagulants and antiplatelet drugs which may be encountered with outpatients in the UK can be found in Appendix 2.

Other medications that can also affect a patient’s bleeding risk are listed in Section 3.2.3.

Be aware that many patients take non-prescribed medications such as aspirin, or other NSAIDs. Patients taking these may have a higher bleeding risk.

Ask the patient whether their anticoagulant or antiplatelet treatment is lifelong or for a limited time.

If the patient is on time-limited medication, it may be possible to delay dental treatment until they have stopped taking the drug(s).

Ask the patient about any medical conditions that they have.

The medical conditions for which anticoagulants and antiplatelet drugs are commonly prescribed in the UK are listed in Appendix 3. If a patient is suffering from one or more of these conditions, they may be taking an anticoagulant or antiplatelet drug.

Patients with prosthetic metal heart valves or coronary stents are at higher risk of a thromboembolic event and must not have their anticoagulant or antiplatelet medication altered, except under direct written instruction from their cardiologist.

Some patients may have other conditions such as kidney or liver disease or bone marrow disorders that can affect their coagulation and platelet function (see Section 3.2.2).

Ask about the patient’s bleeding history (e.g. incidences of bleeding requiring retreatment or a hospital visit, prolonged bleeding from other wounds, spontaneous bleeding, easy bruising etc).

A patient’s previous experience of bleeding in response to invasive dental or surgical procedures or to trauma may be a useful indicator of the likelihood of bleeding complications from the current dental treatment.




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