Guidance on the management of dental treatment for a patient taking an anticoagulant or antiplatelet drug(s), based on the assessment of the bleeding risk (see Section 3), is presented in the form of general advice in Section 4, with specific advice for the different drug groups in Sections 5 to 8.
The management of intra- and post-operative bleeding is the responsibility of the primary care practitioner who provides the dental treatment and they should take the appropriate steps to avoid bleeding complications. Practitioners should however be aware of the local arrangements for access to emergency care for the very rare occasions where bleeding cannot be controlled in the primary care setting.
4.1 Haemostatic Measures
The arrest of bleeding is a core skill for primary dental care and the dental practitioner should have the necessary equipment and skills to perform appropriate local haemostatic measures competently for dental procedures likely to cause bleeding. These include packing any open sockets with haemostatic material and placing sutures.18 Suturing may be used to stabilise the clot, packing material and wound margins, unless it is likely to cause further trauma.
For all patients taking anticoagulants or antiplatelet drugs, haemostasis should be achieved using local measures prior to the patient being discharged from care. Active consideration should be given to suturing and packing, taking into account all relevant patient factors. These may include the drug or drug combination that the patient is taking, other medical conditions or medication that may impact on bleeding, and the travel time for the patient to access emergency care if required (see Sections 3.2.1, 3.2.2 and 4.2). Failure of initial haemostasis will necessitate packing and suturing at a later time.
Patients taking aspirin alone are unlikely to have a higher risk of bleeding complications than non-anticoagulated patients and may not require suturing.
The dental practitioner should have available2:
Haemostatic packing material (e.g. oxidized cellulose, collagen sponge)
Suture kit (needle holders, tissue forceps, suture material, scissors)
Some guidelines recommend the use of tranexamic acid mouthwash as an additional haemostatic measure. However, there is insufficient evidence to indicate any additional benefit when used in conjunction with other haemostatic measures for dental procedures.2 Tranexamic acid is not included in the List of Dental Preparations in the British National Formulary (BNF)19 and therefore cannot be prescribed on the NHS. In addition, tranexamic acid is not available as a mouthwash so has to be prepared and prescribed off licence. Based on these considerations, this guidance does not advise primary care practitioners to prescribe tranexamic acid for dental procedures. However, if tranexamic acid is prescribed by the patient’s medical practitioner then it should be used in addition to local measures.
4.2 Management of Patients in Remote and Rural Locations
Patients living in remote and rural locations may have to travel for longer to access primary care dental treatment, or secondary care in those very rare circumstances when a severe bleeding complication occurs. The individual circumstances should be taken into consideration for patients in remote and rural settings and particular emphasis should be placed on the use of measures to avoid complications (e.g. limiting the initial treatment area, staging treatment and haemostatic measures). In addition, extended post-operative monitoring of the patient prior to discharge is advisable. As with all patients, attitude to risk and the consequences of bleeding complications should be discussed and given due consideration when agreeing treatment.
4.3 Contacts and Referrals
If there is a lack of clarity regarding a patient’s medical condition or their medication, in order to assess their bleeding risk and to inform treatment planning, consult with the patient’s general medical practitioner, cardiologist or other medical specialist.
By following the recommendations in this guidance, dentists should be able to treat the vast majority of patients in primary care. If necessary, colleagues in primary or secondary dental care could be consulted for advice on treatment. This may be a more experienced senior colleague in practice, a speciality dentist/dentist with enhanced skills or senior dental officer (e.g. special care or oral surgery), or in very complex cases, a consultant in primary or secondary dental care (see Section 3.1).
For exceptional cases, if there is concern about whether a patient can be treated safely in primary care, before any referral is made the first contact would be a colleague in secondary care to discuss the most appropriate management for the patient. This will avoid unnecessary or inappropriate referral and will ensure that the patient is referred to the most suitable service. If referring a patient, details of the patient’s anticoagulation medication should be included in the referral.
4.4 General Advice for Managing Bleeding Risk
The following best practice advice is based on clinical experience and expert opinion.
For a patient who is taking an anticoagulant or antiplatelet drug(s) and requires dental treatment that is unlikely to cause bleeding (see Table 1):
Treat the patient following standard procedures, taking care to avoid causing bleeding.
For a patient who is taking an anticoagulant or antiplatelet drug(s), and requires dental treatment that is likely to cause bleeding, with a low or higher risk of bleeding complications (see Table 1):
If the patient has another relevant medical condition(s) or is taking other medications that may increase bleeding risk (see Sections 3.2.2 and 3.2.3), consult with the patient’s general medical practitioner or specialist, if required, for more information in order to assess the likely impact on bleeding risk.
If the patient is on a time-limited course of anticoagulant or antiplatelet medication, delay non-urgent, invasive dental procedures where possible until the medication has been discontinued.
If the medication is being taken in preparation for an elective surgical procedure it may be possible, in a dental emergency, to interrupt the drug treatment in liaison with the surgical consultant.
Patients with acute deep vein thrombosis or pulmonary embolism may be taking high dose apixaban or rivaroxaban for the first 1 to 3 weeks of treatment. It would be advisable to delay any dental procedures likely to cause bleeding until the patient is taking the standard dose.
Plan treatment for early in the day and week, where possible, to allow time for the management of prolonged bleeding or rebleeding episodes, should they occur.
Perform the procedure as atraumatically as possible, use appropriate local measures (see Section 4.1) and only discharge the patient once haemostasis has been achieved.
If travel time to emergency care is a concern, place particular emphasis at the time of the initial treatment on the use of measures to avoid complications (e.g. limiting the initial treatment area, staging treatment, haemostatic measures and post-treatment monitoring).
Advise the patient to take paracetamol, unless contraindicated, for pain relief rather than NSAIDs such as aspirin, ibuprofen, diclofenac or naproxen.
Provide the patient with written post-treatment advice and emergency contact details. Printable post-treatment advice sheets are available at www.sdcep.org.uk.
Follow the specific recommendations and advice given in Sections 5 to 8 for the management of patients taking the different anticoagulants or antiplatelet drugs.