Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs



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8 Treating a Patient Taking an Injectable Anticoagulant


The low molecular weight heparins (LMWHs), dalteparin (Fragmin), enoxaparin (Clexane) and tinzaparin (Innohep) are administered parenterally by subcutaneous injection rather than orally as for the other anticoagulants discussed, and although used in limited patient groups, they may still be encountered in a primary dental setting. Patients taking LMWHs may include pregnant women with indications for anticoagulation and patients with venous thrombosis with a background of cancer. These drugs may be administered once or twice a day at either prophylactic or therapeutic doses.33-35 Like the NOACs, these drugs have a short onset of action and short half-lives.

There is a lack of direct clinical evidence regarding the dental treatment of patients taking injectable anticoagulants, including the LMWHs. Furthermore, patients taking these drugs are likely to have varied conditions and drug regimes such that further information is required to make a reasonable judgement on the management of their dental treatment.

For a patient who is taking an injectable anticoagulant and requires dental treatment that is likely to cause bleeding (see Table 1):

Consult with the patient’s general medical practitioner or specialist to establish the patient’s medical condition and medication regime in order to assess the likely impact on bleeding risk for the dental procedure. If necessary seek advice from, or refer to, a more experienced colleague in primary or secondary dental care (see Section 3.1).

Note that patients are often given heparin or one of the LMWHs during kidney dialysis. The effects of these are relatively short-lived but where possible dental treatments likely to cause bleeding should be delayed until the following day.

9 Drug Interactions Between Anticoagulants or Antiplatelet Drugs and Other Medications


There are a large number of documented interactions between anticoagulants or antiplatelet medications and other prescription drugs. The current BNF (available at www.medicinescomplete.com ) or individual drug Summary of Product Characteristics (SPC) sheets (available on the electronic Medicines Compendium (eMC) website; www.medicines.org.uk) should be consulted for complete listings.

For the purposes of this guidance, only the interactions between anticoagulants or antiplatelet medications and drugs that are available in the BNF Dental Practitioner’s Formulary are considered. These interactions are listed in Appendix 4.


10 Research and Audit

10.1 Recommendations for Research


There is a particular need for high quality research to improve the evidence base in the following areas:

the effect of the Novel Oral Anticoagulants (NOACs) on bleeding complications following invasive dental procedures;

the effect of the newer antiplatelet drugs (prasugrel, ticagrelor) on bleeding complications following invasive dental procedures.

10.2 Recommendations for Audit


Topics for audit and review that could improve safety for dental patients taking anticoagulants or antiplatelet drugs include:

the accuracy and completeness of medical history records;

compliance with recommendations within the guidance, for example the use of haemostatic measures.

Appendix 1. Guidance Development


The Scottish Dental Clinical Effectiveness Programme

The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative of the National Dental Advisory Committee (NDAC) and operates within NHS Education for Scotland (NES).

The NDAC comprises representatives of all branches of the dental profession and acts in an advisory capacity to the Chief Dental Officer. It considers issues that are of national importance in Scottish dentistry and also provides feedback to other bodies within the Scottish Government on related, relevant healthcare matters.

SDCEP was established in 2004 under the direction of the NDAC to give a structured approach to providing clinical guidance for the dental profession. The programme’s primary aim is to develop guidance that supports dental teams to provide quality patient care. SDCEP brings together the best available information that is relevant to priority areas in dentistry, and presents guidance on best practice in a form that can be interpreted easily and implemented. The guidance recommendations may be based on a variety of sources of information, including research evidence, guidelines, legislation, policies and expert opinion as appropriate to the subject. SDCEP guidance takes a variety of forms to suit the diverse topics being addressed.

Recognising that publication of guidance alone is likely to have a limited influence on practice, SDCEP also contributes to the research and development of interventions to enhance the translation of guidance recommendations into practice through its participation in the TRiaDS (Translation Research in a Dental Setting) collaboration (www.triads.org.uk).

SDCEP is funded by NHS Education for Scotland and has made important contributions to the implementation of the Scottish Government’s Dental Action Plan, which aims to both modernise dental services and improve oral health in Scotland.



The Guidance Development Group

A Guidance Development Group (GDG), comprising individuals from a range of branches of the dental and medical professions and a patient representative, was convened to develop and write this guidance.



Garry Sime (Chair)

Senior Dental Officer and Specialist in Special Care Dentistry, NHS Tayside

Carol Armstrong

Dental Tutor Therapist, UHISOHS, NHS Dumfries & Galloway

Dean Barker

Consultant in Restorative Dentistry/Honorary Clinical Senior Lecturer, University of Aberdeen Dental School and Hospital

Adrian Brady

Consultant Cardiologist, NHS Greater Glasgow & Clyde; Associate Professor, University of Glasgow

Patricia Green

Patient Representative and Anticoagulation Europe (ACE) Local Patient Contact, Aviemore

Steven Johnston

Salaried Dental Officer, Public Dental Service, NHS Orkney

Douglas Kennedy

Consultant in Oral & Maxillofacial Surgery, NHS Tayside

Clare Marney

Consultant in Oral Medicine, Dundee Dental Hospital and School

Steve McGlynn

Specialist Principal Pharmacist (Cardiology), NHS Greater Glasgow & Clyde; Honorary Senior Teaching Fellow, University of Strathclyde

Namita Nayyer

Specialty Registrar in Oral Surgery, Dundee Dental Hospital and School

Avril Neilson

Consultant in Oral Surgery, Dundee Dental Hospital and School

Gillian Nevin

General Dental Practitioner, Coupar Angus; Assistant Director of Postgraduate GDP Education, Dundee Dental Education Centre

Christine Randall

Senior Medicines Information Pharmacist and UKMi Representative, North West Medicines Information Centre, Liverpool

Simon Randfield

General Practitioner, NHS Forth Valley

Petrina Sweeney

Senior Lecturer/Honorary Consultant in Special Care Dentistry, University of Glasgow Dental School

Campbell Tait

Consultant Haematologist, NHS Greater Glasgow & Clyde

Liz Theaker

Consultant in Oral Medicine, Dundee Dental Hospital and School

John Wall

General Dental Practitioner, Perth

The GDG would like to thank Anne Littlewood, Trials Search Co-ordinator, Cochrane Oral Health Group, for performing the literature searches that underpin the development of this guidance.

The Programme Development Team

The GDG works closely with the Programme Development Team, which provides project management and administrative support and is responsible for the methodology of guidance development.



Jan Clarkson*

Professor of Clinical Effectiveness, University of Dundee; SDCEP Director

Douglas Stirling*

Programme Manager – Guidance and Programme Development

Michele West*

Research and Development Manager – Guidance Development and Lead for Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs

Samantha Rutherford

Research and Development Manager – Guidance Development

Linda Young*

Research and Development Manager – Evaluation of Implementation

Catalina Martin*

Research Assistant

Margaret Mooney*

Administrator

Liz Payne

Administrator

*directly involved in the development of this guidance

Guidance Development Methodology

SDCEP endeavours to use a methodology for guidance development that reflects that used to develop high quality guidelines. It aims to be transparent, systematic and to adhere as far as possible to international standards set out by the AGREE (Appraisal of Guidelines for Research and Evaluation) Collaboration (www.agreetrust.org). Details of SDCEP guidance development methodology are available at www.sdcep.org.uk.

Following the TRiaDS framework for translating guidance recommendations into practice36 the views of general dental practitioners on current practice, attitudes to the management of patients taking anticoagulants or antiplatelet drugs and preferred content of this guidance were obtained via telephone interviews. Patient experiences and views were obtained via a questionnaire posted online and distributed through local anticoagulation clinics. This research was used to inform the scope and content of the guidance and the strategy for identifying evidence.

For this guidance, a comprehensive search of MEDLINE, EMBASE and CINAHL was conducted by the Trials Search Co-ordinator of the Cochrane Oral Health Group on the 6th October 2014 and of the Cochrane Database of Systematic Reviews and the Cochrane Database of Abstracts of Reviews of Effects on the 10th October 2014. Potentially eligible articles were identified independently by two reviewers from the list of titles and abstracts retrieved. An article was considered potentially eligible if it met all of the following criteria:



  1. The article was a systematic review or a guideline. An article would be included as a systematic review, if it included a methods section, a search of 1 or more electronic databases and a table of included studies.

  2. The article referred to (i) anticoagulants or antiplatelet drugs and (ii) bleeding or thromboembolic risk in the context of dental treatment.

Where insufficient evidence relevant to dental treatments was obtained, the search results from broader searches were queried using individual anticoagulant terms. The details of all of the searches can be found at www.sdcep.org.uk.

Additional manual searching of guideline repositories and other resources, and follow up of citations from relevant articles found through the systematic searching was also carried out. Other sources of evidence identified by GDG members were also considered, taking relevance and methodological quality into account.

A list of clinical questions related to the scope of the guidance was compiled by members of the GDG and eligible articles which were relevant for each question were identified. For the development of this guidance SDCEP used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess and rate the quality of evidence (www.gradeworkinggroup.org) For guidelines, the AGREE II instrument was used, in addition to GRADE, to assess the methodological quality of the retrieved articles (www.agreetrust.org).

The synthesised evidence was summarised and distributed to the GDG to inform and facilitate the development of the recommendations for the guidance. Where authoritative evidence was unavailable, the GDG was asked to make recommendations based on current best practice and expert opinion, reached by consensus. The process for development of recommendations also followed the GRADE approach, with considered judgements based on the quality of evidence, the balance of risks and benefits, the values and preferences of the patients, and the limitations and inconveniences of the treatment.

A four week external consultation was initiated on February 10th 2015. The consultation draft was made available through the SDCEP website and notification of this was sent to a wide range of individuals and organisations with a particular interest in this topic. To obtain feedback from the end-users of the guidance, a small number of dentists were contacted directly to evaluate the guidance, and all dentists, dental therapists and dental hygienists in Scotland notified that the consultation draft was available for comment. All comments received through the consultation process were considered by the GDG and the guidance amended accordingly prior to publication.

For this guidance, a review of the topic will take place in 2018, and, if this has changed significantly, the guidance will be updated accordingly.

Further information about SDCEP and guidance development is available at www.sdcep.org.

Steering Group

The Steering Group oversees all the activities of the SDCEP and includes representatives of guidance development groups and the dental institutions in Scotland. For up-to-date membership of the Steering Group, refer to the SDCEP website (www.sdcep.org.uk).



Conflict of Interest

All contributors to SDCEP are required to declare their financial, intellectual and other relevant interests. At each group meeting, participants are asked to confirm whether there are any changes to these. Should any potential conflicts of interest arise, these are discussed and actions for their management agreed. All declarations of interest and decisions about potential conflicts of interest are available on request or at www.sdcep.org.uk.


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