Currently, the number of patients on oral anticoagulation is increasing. There is a paucity of data regarding maintaining oral anticoagulation especially novel oral anticoagulants around the time of specific dental procedures. A dentist has three options: either to stop anticoagulation, to continue it, or to bridge with heparin. A systematic review of 10 clinical trials was conducted to address this issue.
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There is both a growing number of individuals prescribed anticoagulation or antiplatelet therapy, as well as medications for this purpose. There is strong evidence for the older medications i. A base font size A medium font size A larger font size. Oral Health Topics. Anticoagulant and antiplatelet agents are prescribed for individuals who are at high risk for or who have had thromboembolic events e. These include patients who have experienced deep-vein thrombosis DVT or pulmonary embolism PE or who have nonvalvular atrial fibrillation NVAF , a cardiac arrhythmia that predisposes patients to clot formation.
Adverse effects associated with these drugs can include prolonged bleeding or bruising. The serious risks of stopping or reducing these medication regimens need to be balanced against the potential consequences of prolonged bleeding, which can be controlled with local measures such as mechanical pressure, hemostatic agents e. Four newer direct-acting oral anticoagulants have been approved by regulatory agencies for use in patients to prevent or treat DVT and PE, or reduce the risk of stroke and systemic embolism in patients with NVAF.
A consensus guideline from the European Heart Rhythm Association 15, 16 updating a guideline 17 suggests that interventions not necessarily requiring discontinuation of the newer anticoagulants include extraction of 1 to 3 teeth; periodontal surgery; abscess incision; or implant positioning. Procedures that were defined as being low risk were administration of local anesthetic, simple restorations, supragingival scaling, and single tooth extraction; procedures considered moderate risk were extractions of 2 to 4 teeth and local gingival surgery of 5 or fewer teeth.
Five papers were included in the review of evidence. Among patients receiving the direct-acting anticoagulants and undergoing dental procedures associated with low-to-moderate bleeding risk, bleeding rates were low whether the anticoagulant was continued or held periprocedurally. Bleeding that was documented was generally mild and controlled by local hemostatic measures. A narrative review by Elad et al. The authors evaluated bleeding complication rates reported in 18 randomized, controlled trials comparing the new agents with conventional anticoagulants or placebo and also reviewed prior narrative reviews 20 and case reports 21, 22 of patients undergoing dental interventions while receiving the newer anticoagulant therapy.
After consideration of factors such as patient comorbidity and the risk of bleeding from the procedure, and in addition to usual local measures to control bleeding e. However, this needs to be proven in comparative clinical trials.
They also recommend that consideration be given to other supplements or drugs e. A systematic review 23 by van Diermen et al. The authors acknowledged that no clinical studies or guidelines had been published to directly address the periprocedural management of dental patients receiving the newer anticoagulants.
They also recommended that patients be advised to not take their medication 1 to 3 hours immediately before dental treatment. Given the importance of antiplatelet medications post-stent implantation in minimizing the risk of stent thrombosis, the medications should not be discontinued prematurely.
There is general agreement that in most cases, treatment regimens with older anticoagulants e. The risks of stopping or reducing these medication regimens i. On the basis of limited evidence, general consensus appears to be that in most patients who are receiving the newer direct-acting oral anticoagulants i.
In patients deemed to be at higher risk of bleeding e. Further research is needed to definitively establish periprocedural management strategies for these patients, especially those considered to be at high risk of bleeding. Boehringer Ingelheim Pharmaceuticals Inc. Accessed January 22, Bristol-Myers Squibb. Daiichi Sankyo Inc. Savaysa edoxaban tablets for oral use rev. Janssen Pharmaceuticals Inc. Which oral anticoagulant for atrial fibrillation.
Med Lett Drugs Ther ;58 Which oral anticoagulant for atrial fibrillation? JAMA ; 19 State of the art: Oral antiplatelet therapy. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. J Am Dent Assoc ; 6 Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians.
J Am Dent Assoc ; 5 Circulation ; 6 Thean D, Alberghini M. Anticoagulant therapy and its impact on dental patients: a review. Aust Dent J ;61 2 Review of postoperative bleeding risk in dental patients on antiplatelet therapy. Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment.
J Am Dent Assoc ; 11 Daniels PR. Peri-procedural management of patients taking oral anticoagulants. BMJ ;h Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace ;17 10 Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary. Eur Heart J ;38 27 European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation.
Europace ;15 5 J Pharm Pract ;31 2 Novel anticoagulants: general overview and practical considerations for dental practitioners. Oral Dis ;22 1 Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients. Protocol in managing oral surgical patients taking dabigatran. Aust Dent J ;59 3 ; quiz Dental management considerations for a patient taking dabigatran etexilate: a case report.
Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants. Dental management of patients using antithrombotic drugs: critical appraisal of existing guidelines. Little JW. New oral anticoagulants: will they replace warfarin? Management consensus guidance for the use of rivaroxaban--an oral, direct factor Xa inhibitor. Thromb Haemost ; 5 Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis.
J Can Dent Assoc ;75 1 Chest ; 6 Suppl SS. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: report of the Guideline Development Subcommittee of the American Academy of Neurology.
Neurology ;80 22 Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Dent J ; 7 United Kingdom National Health Service.
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Suggestions for anticoagulation management before and after dental procedures
Faculty of Dentistry. Universitat Internacional de Catalunya, Spain. Vice-dean for Research. Dean of the Faculty of Dentistry.
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