Managing Anticoagulation

Thromboembolism is three times more likely to occur in patients whose anticoagulation is discontinued than in patients whose anticoagulation was continued through routine dental surgery. Primary care communication with dentists prior to procedures in medically complicated individuals on anticoagulants is vital!

Procedural Recommendations

  • Cleanings, fillings, and simple extractions can be performed without interrupting anticoagulation (traditional vitamin K antagonists, newer direct oral anticoagulants (DOACs), and antiplatelet agents)
  • If receiving single antiplatelet therapy, dual antiplatelet therapy, or acetylsalicylic acid, dental procedures can be performed without interruption.
  • If patients must remain anticoagulated (such as those who have mechanical heart valves) for major oral surgery that carries a high risk of bleeding, a transition to peri-operative heparin should be considered.

Bleeding can be controlled in the following ways:

  • Medication: tranexamic acid, epsilon caproic acid mouthwash, topical thrombin
  • Pressure: absorbable collagen, Surgicel, Gelfoam, tea bags
  • Surgically, if necessary

References

Ansell, J et al Managing Oral Anticoagulant Therapy. Chest. 2001 Jan;119 (1supplement):22S-38S.

Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review.[comment]. Archives of Internal Medicine. 2003;163(8):901-8.

Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. Journal of the American Dental Association. 2000;131(1):77-81.

Beirne OR, Evidence to continue oral anticoagulant therapy for ambulatory oral surgery, Journal of Oral and Maxillofacial Surgery, 63:540-545, 2005.

Grines CL et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents. Circulation. 2007;115:1-6.

Dézsi CA, Dézsi BB, Dézsi AD. Management of dental patients receiving antiplatelet therapy or chronic oral anticoagulation: A review of the latest evidence. Eur J Gen Pract. 2017; 23(1): 196-201.

Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S.

Patel JP, Woolcombe SA, Patel RK, et al. Managing direct oral anticoagulants in patients undergoing dentoalveolar surgery. Br Dent J. 2017; 222(4):245-249.

Mauprivez C, Khonsari RH, Razouk O, et al. Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016; 122(5):e146-e155.