Guidelines for Dental Patients on Anticoagulants and Antiplatelet Drugs

Guidelines provided by the Scottish Dental Effectiveness Program in the management of dental patients on anticoagulants and antiplatelet drugs are described.

The Scottish Dental Clinical Effectiveness program has provided a series of guidelines for dental patients on anticoagulants and antiplatelet drugs. This program is initiated by the National Dental Advisory Committee (NDAC), operated by the NHS for Education, Scotland.

The guidelines provided by this program are aimed at highlighting the risks involved in performing dental procedures on patients who are on anticoagulant or antiplatelet drugs. As these drugs increase the clotting time of blood, such patients would bleed for an extended period of time after major dental procedures, resulting in excessive blood loss. In extreme cases, the patient may require blood transfusions as an emergency procedure.

Other Injectable Anticoagulants or Blood thinners
Other injectable anticoagulants approved for use are fondaparinux, lepirudin, bivalirudin, argatroban, danaparoid and drotrecogin alfa

‘Guidelines provided by the Scottish Dental Effectiveness Program in the management of dental patients on anticoagulants and antiplatelet drugs are described.’

Medical Conditions Which Increase Risk of Bleeding during Dental Procedure:

There are certain medical conditions, which have been associated with an increase in bleeding risk and they include:

Liver disease
Chronic renal failure
Chemotherapy performed recently
Idiopathic thrombocytic purpura
Heart failure at an advanced stage
Less severe forms of bleeding disorders

Patients with these medical conditions should be treated with greater care due to higher risk of bleeding. Moreover, dental procedures should be started only after consultation with the physician who treated the patient for the medical condition.

Patient with these medical conditions should not be treated in a clinic but should be treated in a hospital where emergency support is available.

Quiz on Anticoagulants
Anticoagulants, commonly referred to as “blood thinners”, are medications that interfere with the body’s natural blood clotting mechanism. Anticoagulants are necessary if the patient has a deep vein thrombosis (“DVT”), a blood clot in a vital organ such as the heart, brain or liver, or if the patient has a condition that predisposes to blood clot formation such as atrial fibrillation or a hypercoaguability disorder. When a blood vessel is blocked by a clot, the individual could suffer a heart attack, pulmonary embolus or a stroke-all potentially fatal conditions. Anticoagulants also play a vital role in the preventative care of several health conditions. Take this quiz to find out how much you know about anticoagulant medication:

Drugs Which Increase Bleeding Risk:

The following drugs increase the risk of bleeding:

Anti-Coagulants and Anti-Platelet Drugs - These drugs increase the risk of bleeding and combined use of these drugs also pose an increased risk of bleeding.
Non- Steroidal Anti-Inflammatory Drugs - These drugs decrease the functions of the platelet to different degrees.
Cytotoxic Drugs - These drugs are normally used in the suppression of the bone marrow. They result in reduced activity of platelets as well as a decrease in function of the liver, affecting coagulation.
Drugs for the Nervous System - These drugs could increase coagulation time when combined with other antiplatelet drugs.

Patients should be asked about the drugs that they use. Often, some patients may be on anticoagulant drugs without a prescription from a doctor.

Clopidogrel

This medication is an anti-platelet agent, that is, a drug that inhibits the ability of platelets to clump together as part of a blood clot. This medication is prescribed either alone or with other medications for prevention or treatment of stroke and heart attack (which are usually caused by blood clots) in persons who are at high risk.

Arresting Bleeding:

The dentist should have the required skill and expertise to arrest bleeding. Local hemostatic measures include:

Open sockets should be plugged with hemostatic material
Suturing open sockets
Mouthwashes containing tranexamic acid should be used 4 times a day for 2 days.

Arresting bleeding is extremely important and extra care should be extended to those patients who are at an increased risk. While placing hemostatic material or sutures for patients, their medical history and drug intake should be taken into consideration. The time required for the patient to reach emergency should also be factored in while placing the hemostatic material.

Extraction of Tooth
A simple but graphic slide animation that shows you how a tooth is extracted by a dentist under local anesthesia.

A must have kit for a dental practitioner

Collagen sponge, oxidized cellulose like as hemostatic material
Suture kit
Gauze

A patient who is on a single or even dual anticoagulant drugs should be treated with care, lowering the risk of bleeding. The anticoagulant drug therapy should not be interfered without consultation with the patient’s physician as it could lead to thromboembolic event which may be hazardous.

Precautions for Dentists:

Dentists should be extra cautious while treating patients who are on anticoagulant drugs

The bleeding time of such patients will extend more than for patients without anticoagulants. This should be considered while planning the treatment time.
The treatment procedure should be advanced slowly. For example, a single tooth extraction should be performed, the bleeding time and effect on the patient should be observed, before resorting to further extractions.
Ask for help from senior dentists or colleagues about treatment measures
If a patient is on new anticoagulant drugs, then the patient’s physician should be consulted before beginning the dental procedure.
Perform the dental procedure during the morning hours so that the patient is monitored for a period of time before the patient is allowed to go home.
If the patient is at a high risk for bleeding, then anticoagulation drugs may be avoided on the day of the procedure.
If the dental procedure is an emergency and the patient who is at high risk for bleeding has already consumed the anti-coagulant for the day, then the procedure should be delayed till the evening, if possible.
If the patient takes injectable anticoagulants, then the dental procedure should not be planned for the same day but the next.

A dentist should assess the drugs consumed by the patient before starting any procedure and should be wary of prescribing any drugs to avoid cross-reaction. With careful planning and monitoring, patients on anticoagulant and antiplatelet drugs may be treated with minimal risk of complications.

Editor’s Note - Certain anticoagulants like Clopidogrel require 5 to 7 days of stoppage before undertaking any major surgical procedure, whereas popular anticoagulants like aspirin requires 3 days. However if you are on baby aspirin (75mg) stopping it on the morning is adequate. Please consult your dentist and inform them if you are on any long term medication. Be safe for the procedure.

References:

1. http://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf

Source-Medindia