Blood thinners and dental treatment

The drugs

Bleeding risk by procedure (Table 1)

DOACs — apixaban, dabigatran, rivaroxaban, edoxaban

Low bleeding risk procedures

Treat without interrupting medication. (Conditional recommendation; very low certainty evidence)

• 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 root surface debridement to three teeth, then assess bleeding before continuing).
• Use local haemostatic measures to achieve haemostasis. Strongly consider suturing and packing.

Higher bleeding risk procedures

Apixaban or dabigatran (twice daily): advise the patient to miss their morning dose. Rivaroxaban or edoxaban (once daily): advise the patient to delay their morning dose — taken 4 hours after haemostasis has been achieved. (Conditional recommendation; very low certainty evidence)

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

• Having missed the morning dose, the patient should take their evening dose at the usual time, as long as no earlier than 4 hours after haemostasis has been achieved.
• The delayed morning dose may be taken 4 hours after haemostasis has been achieved; the next dose is taken as usual the following morning. If the patient normally takes their dose in the evening, they take it at the usual time on the day of treatment, as long as no earlier than 4 hours after haemostasis has been achieved.
• Advise the patient to contact the practice for advice if bleeding occurs prior to, or after, restarting their DOAC.
• The patient should avoid missing subsequent doses of their DOAC, unless absolutely required in an emergency situation to control bleeding.

If a higher-risk procedure is required urgently and the patient has already taken their morning dose of DOAC, it is advisable to delay the procedure until later in the day, where possible, to allow levels of anticoagulation to decrease.

Warfarin and other vitamin K antagonists

Ensure the patient’s INR has been checked, ideally no more than 24 hours before the procedure. If the patient has a stable INR, checking no more than 72 hours before is acceptable. A stable patient is one who does not require weekly monitoring and who has not had any INR measurements above 4 in the last two months (BNF definition).

If INR is below 4: treat without interrupting medication. (Strong recommendation; low certainty evidence)

• Consider limiting the initial treatment area (e.g. perform a single extraction or limit root surface debridement to three teeth, then assess bleeding before continuing).
• For procedures with a higher risk of bleeding complications, consider carrying out the treatments in a staged manner, where possible, over separate visits.
• Use local haemostatic measures to achieve haemostasis. Strongly consider suturing and packing.

If INR is 4 or above: delay invasive treatment, or refer if urgent. Inform the patient’s anticoagulation service or general medical practitioner and delay invasive dental treatment until the INR has been reduced to less than 4. For urgent treatment, refer the patient to secondary dental care.

Injectable anticoagulants (LMWH)

Establish whether the patient is taking a prophylactic (low) dose or a treatment (higher) dose. For patients with renal impairment, or body weight below 50kg or above 100kg, the dose is likely to have been adjusted and consultation with the prescribing clinician may be required to confirm which they are taking.

Prophylactic (low) dose: treat without interrupting medication. (Conditional recommendation; very low certainty evidence)

Treatment (higher) dose, or uncertainty about the dose: consult the prescribing clinician.

Antiplatelets

Aspirin alone: treat without interrupting medication. (Strong recommendation; low certainty evidence) Patients taking aspirin alone are unlikely to have a higher risk of post-operative bleeding complications than non-anticoagulated patients and may not require suturing.

Clopidogrel, dipyridamole, prasugrel or ticagrelor — single or dual therapy: treat without interrupting medication. (Strong recommendation; low certainty evidence)

• Be aware that bleeding may be prolonged (up to an hour). Take this into account when planning treatment time.
• Limit the initial treatment area (e.g. perform a single extraction or limit root surface debridement to three teeth, then assess bleeding before continuing).
• For procedures with a higher risk of bleeding complications, consider carrying out the treatments in a staged manner, where possible, over separate visits.
• Use local haemostatic measures to achieve haemostasis. Strongly consider suturing and packing.

Patients with a coronary artery stent will be prescribed dual antiplatelet therapy for up to 12 months. It is extremely important that this treatment is not stopped prematurely or interrupted without prior discussion and written advice from the patient’s cardiologist.

Anticoagulant + antiplatelet combinations

Consult with the patient’s prescribing clinician. Consult with the patient’s prescribing clinician in order to assess the likely impact of the particular drug combination and the patient’s medical condition on their bleeding risk.

• Patients on combination therapies are likely to have a higher bleeding risk and may have additional medical complications.
• Some patients might only be on these drug combinations for 3–4 weeks, so it may be possible to delay dental treatment.
• The medication should not be stopped prematurely or interrupted without prior discussion and written advice from the patient’s cardiologist.

Never interrupt

Do not interrupt anticoagulant or antiplatelet therapy, except under direct written instruction from the patient’s cardiologist, for:

• patients with prosthetic metal heart valves or coronary stents
• patients who have had a pulmonary embolism or deep vein thrombosis in the last three months
• patients on anticoagulant therapy for cardioversion

For every patient on these drugs

• Plan treatment for early in the day and week, to allow time for the management of prolonged bleeding or rebleeding, should it occur.
• Provide the patient with pre-treatment instructions (e.g. timing of INR testing or any modification of their medication schedule).
• Perform the procedure as atraumatically as possible, use appropriate local haemostatic measures and only discharge the patient once haemostasis has been achieved.
• If travel time to emergency care is a concern, place particular emphasis on measures to avoid complications (limiting the initial treatment area, staging treatment, haemostatic measures, 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 post-treatment advice and emergency contact details.