When considering whether to continue or stop anticoagulant therapy prior to surgical procedures, two things should be taken into account: Surgical factors, primarily the degree to which the procedure is likely to lead to clinically relevant bleeding; and patient factors, specifically, the bleeding risk factors present for an individual.
Traditionally, dentists have been advised to undertake dental procedures of low and higher risk patients on warfarin, if the INR checked at the time of the procedure is less than four. However, there is less experience in undertaking such procedures on patients taking Direct Oral Anticoagulants (DOACs).
Guidance from the European Heart Rhythm Association (EHRA) includes ensuring any dental procedure is undertaken at trough levels of DOAC.
They highlight that a practical approach may be to schedule the intervention 18 to 24 hours after the last dose, and then restart the DOAC six hours post-procedure. This would mean no interruption in dosing for drugs taken once daily, but skipping a single dose for those taking a twice daily drug.
The patient should remain at the dental practice until bleeding has stopped and be given clear advice on when they should restart their DOAC
The patient should remain at the dental practice until bleeding has stopped and be given clear advice on when they should restart their DOAC, usually six hours after the procedure.
The patient should be advised to seek medical advice should significant bleeding occur once DOAC therapy is reinitiated. A tranexamic acid mouthwash may be used to minimise bleeding post-procedure.
The Scottish Dental Clinical Effectiveness Programme (SDCEP) published specific guidance on the management of dental patients taking anticoagulants or antiplatelet drugs in 2015. They recommend that if there is a low risk of bleeding, the procedure should be performed without interruption to the DOAC therapy. However, if there is a higher risk of bleeding, patients should be advised to miss or delay the morning dose of DOAC before treatment.
They also recommend that for all procedures consideration should be given to:
- treating early in the day
- limiting the initial treatment area and assessing bleeding before continuing
- staging extensive or complex procedures
- actively considering suturing and packing.
Their advice on restarting DOAC is similar to that of the EHRA.
Heidbuchel H et al 2015. Europace 17, 1467–1507.
Patel J et al 2017. British Dental Journal 222, 245-249.
Scottish Dental Clinical Effectiveness Programme. 2015.