Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs



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7 Treating a Patient Taking a Novel Oral Anticoagulant


The INR test is not suitable for assessing coagulation levels in patients taking dabigatran, apixaban or rivaroxaban.26 The effects of dabigatran on coagulation can be qualitatively assessed using the commonly available aPTT (activated partial thromboplastin time) coagulation assay.27 Similarly, the PT (prothrombin time) test can give some indication of the relative levels of anticoagulation with rivaroxaban.28 Although quantitative laboratory tests suitable for the NOACs are not yet widely available, since these drugs provide more predictable anticoagulation9 monitoring is considered less important than for warfarin and is not carried out routinely.

Compared to warfarin, the NOACs exhibit a rapid onset of action (2-4 hours) and have relatively short half-lives (5-13 hours for rivaroxaban, ~12 hours for apixaban and ~13 hours for dabigatran, depending on renal function and age).29-31 Because of these pharmacokinetic properties, it is possible to modify an individual’s anticoagulation status quite rapidly, minimising the period where the anticoagulation activity is therapeutically sub-optimal. Although in development, there are not any simple reversal agents available for the NOACs as yet.32 However, as before, the short half-lives of these drugs allow for the relatively rapid reduction of their anticoagulation effects.

Apixaban (Eliquis) and dabigatran (Pradaxa) are taken twice a day, while rivaroxaban (Xarelto) is most commonly taken once a day, either in the morning or at night. For each of the drugs, a lower dose is indicated for certain patients including those with various levels of renal impairment and in some cases elderly patients.29-31 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 doses.

There are currently no published clinical trials specifically assessing the bleeding risks associated with dental procedures for patients taking the NOACs.



Key Recommendations:

For a patient who is taking a NOAC and requires a dental procedure with a low risk of bleeding complications, treat without interrupting their anticoagulant medication.

(Conditional recommendation; very low quality evidence)

For a patient who is taking a NOAC and requires a dental procedure with a higher risk of bleeding complications, advise them to miss (apixaban, dabigatran)/delay (rivaroxaban) their morning dose on the day of their dental treatment.

(Conditional recommendation; very low quality evidence)

There is a lack of direct clinical evidence and clinical experience to favour either continuing or interrupting NOAC medication for invasive dental treatments. The recommendations given here are based on the balance of likely effects of each option for each dental procedure, the known characteristics of the drugs, such as their short half-lives and rapid onset of action and consensus of expert opinion. They are judged to be conditional recommendations because of the lack of evidence and the fine balance between the potential risks and benefits of the treatment options.

Further details on the development of the recommendations in this guidance can be found in Appendix 1 or at www.sdcep.org.uk.

The estimated risk to the patient of a thromboembolic event resulting from brief NOAC interruption is judged to be extremely small, while the risk of a bleeding complication if the NOAC is continued is likely to be small but also depends on the procedure involved and the individual patient. However, both risks are judged to be uncertain, because of the lack of evidence. Because the potential risks from either continuing or interrupting a patient’s NOAC medication are so finely balanced, the anticoagulant management options, risks and lack of evidence should be discussed with the patient.



For a patient who is taking a NOAC and requires dental treatment that is likely to cause bleeding, with a low or higher risk of bleeding complications (see Table 1):

Discuss with the patient the possible benefits and harms and the balance of risks for continuing or interrupting their NOAC medication in the context of the required dental treatment, when gaining consent (see Sections 7.1 and 7.2).




Since the advice on interruption of medication is for a patient to miss at most a single dose of NOAC, or to delay for several hours, it is not usually necessary to consult with the patient’s medical practitioner first. However, if the dental practitioner or patient has any concerns then they should discuss these with the patient’s general medical practitioner, prescriber or medical specialist.

7.1 Management for Procedures with a Low Risk of Bleeding Complications


The consensus of expert opinion is that it is not necessary to interrupt NOAC medication for dental procedures that are likely to cause bleeding, but which have a low risk of bleeding complications (see Table 1). Because the bleeding risk for these procedures is considered to be low, the balance of effects is in favour of continuing the NOAC treatment without modification, to avoid increasing the risk of a thromboembolic event. Although treating a patient in the morning, as advised, is more likely to coincide with the relative peak of drug concentration, this risk was judged to be outweighed by the importance of being able to deal with a bleeding complication, should it occur, within surgery hours.

For a patient who is taking a NOAC and requires dental treatment that is likely to cause bleeding with a low risk of bleeding complications (see Table 1):

Treat the patient according to the general advice for managing bleeding risk (see Section 4), without advising the patient to miss or delay a dose of their medication.

In addition:

Plan treatment for early in the day to allow for monitoring and management of bleeding complications, should they occur.

Limit the initial treatment area (e.g. perform a single extraction or limit subgingival periodontal scaling to 3 teeth, then assess bleeding before continuing).

Use local haemostatic measures to achieve haemostasis. Actively consider suturing and packing, taking into account all relevant patient factors (see Section 4).


7.2 Management for Procedures with a Higher Risk of Bleeding Complications


The consensus of expert opinion is that patients should be advised to miss (apixaban or dabigatran) or delay (rivaroxaban) a dose of their NOAC prior to dental procedures that are likely to cause bleeding and which have a higher risk of bleeding complications (see Table 1). Because the risk of bleeding complications for these procedures is considered to be higher, the balance of effects is in favour of missing or delaying the pre-treatment NOAC dose. The interruption is only for a short time to minimise the effect on thromboembolic risk. Missing or delaying the morning dose of NOAC will significantly reduce the level of anticoagulation at the time of dental treatment.

For a patient who is taking a NOAC and requires dental treatment that is likely to cause bleeding with a higher risk of bleeding complications (see Table 1):

Advise the patient to miss (apixaban or dabigatran)/delay (rivaroxaban) their morning dose on the day of their dental treatment, and treat according to the general advice for managing bleeding risk (see Section 4).

If the patient usually takes their once a day rivaroxaban in the evening, there is no need to modify their medication schedule prior to the dental treatment.



In addition:

Plan treatment for early in the day to allow for monitoring and management of bleeding complications, should they occur.

Consider carrying out the treatments in a staged manner over separate visits, or seek advice from a more experienced colleague in primary or secondary dental care (see Section 3.1).

Use local haemostatic measures to achieve haemostasis. Actively consider suturing and packing, taking into account all relevant patient factors (see Section 4).

Advise the patient when to restart their medication.

For rivaroxaban (taken once a day), the delayed morning dose may be taken 4 hours after haemostasis has been achieved. The next dose should be taken as usual the following morning. If the patient normally takes their rivaroxaban in the evening, they can take this at the usual time on the day of treatment as long as no earlier than 4 hours after haemostasis has been achieved.

For apixaban or dabigatran (taken twice a day), having missed the morning dose, the patient should take their evening dose of NOAC at the usual time as long as no earlier than 4 hours after haemostasis has been achieved.

Advise the patient to recontact the practice for advice if rebleeding occurs prior to, or after, restarting their NOAC.

The patient should avoid missing subsequent doses of their NOAC, unless absolutely required in an emergency situation to control bleeding.

Although many of the higher risk procedures are likely to be elective, there may be rare occasions when they are required urgently in an emergency situation. In such cases, where the patient has already taken their morning dose of NOAC, it is advisable to delay the procedure until later in the day, where possible, to allow levels of anticoagulation to decrease.


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