Dental Management of Patients on Chronic Oral Anticoagulants: A Review
Anticoagulants are prescribed to prevent and manage arterial and venous thrombi. These drugs have are associated with risk of increased bleeding time and also post-operative hemorrhage. Dental surgeons are always in dilemma on continuing the antiplatelet drugs on patients taking them while performing minimal procedures involving surgery orally. We present a review of frequently used anticoagulants focusing on the management of these patients while carrying minor oral surgical procedures.
Anticoagulants, Bleeding, Cardiovascular risk, Dental extraction, Oral Surgery, Thromboembolism
In spite of the advantages with anticoagulants, they are associated with the risks of bleeding during oral surgical procedures. Therefore, dental surgeons advise such patients on antiplatelet therapy while treating for minor dental procedures to stop using drugs especially before extractions which might affect them to thromboembolic complications. Till now even after few studies on these drugs and dental procedures, dentists are in a dilemma whether to continue or stop anticoagulants during extractions .
Amusingly, studies have failed to reveal excessive or prolonged post-operative hemorrhage aspects of anti-platelet drugs following simple dental extractions in comparison to those controls who are not taking anticoagulants [2,3]. Studies have shown the inherent risks after unduly stopping anti-coagulant therapy [4,5].
WHO introduced International Normalized Ration (INR) in 1983 to draft a standard calibration of the prothrombin time and consequently optimal range related to therapeutic anticoagulants therapy was established. This approach led to the diminution in patient’s anticoagulation points and a simultaneous decline in the morbidity caused from iatrogenic haemorraghe .
Till now there is a lack of clear guidelines to oral maxillofacial surgeons and general practitioners related to the management of the individual’s undergoing anticoagulant therapy and who are need of dento alveolar . Recently a survey carried out revealed that dentists have knowledge about managing patients who are subjected to the schematic anticoagulants treatment and were significantly lacking the noesis regarding the latest anticoagulants medicines. Furthermore, most dentists overestimate the haemorraghe risk, thus there is a need of programmes pertaining to educating the doctors and dental fraternity through continuing dental education programmes and orient them in this setting .
Hence we present this review with an aim to establish a holistic approach based on the latest evidence obtained from the patients undergoing dental treatments and who are on anti-thrombotic management so that it provides a platform for the dental professionals and dental specialist in accurate judgement of the case and taking correct decision without patient getting subjected to risk. for this aim to achieve we carried out a systematic search of literature through Pub med using Anticoagulants, Bleeding, Cardiovascular risk, Dental extraction, Oral Surgery, Thromboembolism, as search terms.
Dental Patients Receiving Oral Anticoagulant Therapy
Vitamin K Antagonists (VKA)
Vitamin K antagonists (VKA) are agents that reduce the action of vitamin K, thereby reduce blood clotting. VKA are shown to be effective preventive or therapeutic agents for arterial and venous Thromboembolism. Sometimes these drugs cause haemorrhage, which may be life threatening. The most commonly used VKA is warfarin .
American College of Chest Physicians (ACCP) current guidelines on the management of the anti-thrombotic therapy patient prior to the operation recommends the dental doctors that surgery without VKA pause and with co delivery of proheamostatic medicines . The British protocols also suggest that the VKA must not be pause in most of the cases that are in need of dental surgery . Predominantly the studies revealed that most of cases show same rates of post-operative haemorrhage after dental surgical procedure in both patients who are asked to stop the anticoagulants and patients continuing this medicines [12,13].
Hence on basis of the useable proof stopping usage of VKA before dental procedures is not suggested for treatments that are rarely causes bleeding and for the cases whose INR levels are ≤ 3.5 24 hours prior to the planned intervention. However if INR is ≥ 3.5, there is a need for adjusting dosage of anticoagulants and at the same time it is advised to postpone the procedure till the patient’s INR becomes less than 3.5 [14,15].
Direct Oral Anticoagulants (DOAC)
Recently four direct oral anticoagulants (DOACs), dabigatran, rivaroxaban, apixaban and edoxaban, are been in usage, also termed as new/novel oral anticoagulants or non-vitamin K oral anticoagulants (NVKA). These drugs directly blocks a certain protein which is important part of coagulation procedure; while VKAs hinder clotting factors synthesis which are vitamin K dependent [16,17]. Currently, there are no precise evidence-based guidelines available for managing patients receiving DOACs. Heidbuchel et al. suggested that mininmal surgical procedures with a minimum bleeding risk like dental extractions doesn’t warrant the stoppage of DOACs in patients with kidney functioning under normal parameters [18,19].
However in patients taking DOACs and for whom dental procedures pose higher risk of bleeding complications, for them it is suggested to postpone the morning dose of once-daily agents (rivaroxaban, edoxaban) on the day when the dental procedure is to be carried out, and pass over single dose of twice daily medications (apixaban, dabigatran). If haemostasis is obtained, DOACs is suggested to be restarted sixto- eight hours after the procedure is completed. As these drugs have a shorter time to achieve peak plasma concentration, restarting the drugs after achieving haemostasis presents an immediate regaining of anticoagulation after the intervention .
Studies recommending discontinuation of antiplatelet therapy
Daniel et al found that continuing aspirin caused post-operative bleeding and advised discontinuation for 7-10 days before surgical procedures . Few authors suggested to stop anticoagulants only for 3 days will be sufficient. Scully and Wolf, Little et al. and Burger et al. recommended to stop using antiplatelets to avoid the risks of post-operative bleeding [22-24].
Elad et al. noticed severe bleeding and life threatening hemorrhagic shock in patients who are on double antiplatelet therapy (100 mg aspirin and 75 mg clopidogrel /day) subsequently following the non-surgical periodontal therapy . Several studies have documented bleeding risk in patients taking antiplatelet drugs undergoing cardiac surgeries [26,27].
Studies recommending continuation of antiplatelet therapy
Bajkin et al. summarised that individual undergoing single or dual antiplatelet medicines therapy can take up the procedures of extractions safely without stopping drugs and recommended to take local haemostatic measures to control post-operative bleeding . Verma et al. stated that stopping aspirin before simple tooth extraction is not needed as they did not notice any post-operative bleeding in their patients .
Olmos-Carrasco et al. also did not observed any hemorrhagic complications, after dental extractions without withdrawal of double antiplatelet therapy . The American College of Chest Physicians recommended continuation of antiplatelet drugs perioperatively in patients who need operation within 6 weeks of placement of a metal stent or 6 months of placement of a drug-eluting stent. They observed the occurrence of acute myocardial infarction in such patients after withdrawal of antiplatelet therapy .
Girotra et al. concluded that there was no necessity to stop antiplatelet therapy, but suggested a need for measures to control haemoraghe in individual with dual antiplatelet therapy . Hanken et al., stated that aspirin prolongation in patients who undergo dental osteotomies has no effect on the occurrence of post-operative bleeding and must not be interrupted . Nooh, et al. reported that patients on 81 mg ASA daily may perhaps undergo dental extraction without any bleeding risks .
Van Diermen et al. suggested not stopping oral antithrombotic agents even in patients who are taking dual antiplatelet therapy, in simple dental procedures . Broekema et al. from their prospective study summarised that dentoalveolar surgery is secure in individuals being regaled with anticoagulants drugs . Many other studies have recommended that teeth extraction may be proceed with safety without discontinuation of antiplatelet therapy [37,38].
Oral surgery considerations
Minor oral surgical procedures such as simple extractions (<3 teeth), supragingival scaling, gingival surgeries, crown and bridge placement, may be safely carried out without altering the antiplatelet medication dose. In cases where there is a need to remove more than three teeth, it is advisable to carry out multivisit procedure with 2-3 teeth removal at a time. Scaling and gingival surgeries should mainly be restricted to a limited area to assess if bleeding is problematic [39,40].
Management of post-operative bleeding
Dental surgery is a non-compartment procedure, and bleeding in the oral cavity is immediately visible and can therefore be treated without delay . All patients who are on anticoagulants should be deemed to have drug-induced altered platelet function. Studies showed the occurrence of an increased bleeding if two antiplatelet drugs used combined than with monotherapy. It is advisable to remove granulation tissue in extraction sockets before placing hemostatic agents as it is a frequent source of post-extraction bleeding .
Local haemostatic measures
Commonly used haemostatic measures include application of pressure (biting firmly on gauze for 30 minutes), hemostatic matrix like oxidized regenerated cellulose, absorbable gelatin sponge, or collagen with figure of eight sutures applied to the extraction socket. They have no intrinsic coagulation factors or activities but are designed to stimulate clot formation by providing a 3-dimensional scaffold used for clot organization. Other agents include topical thrombin, bone wax (ostene), 4.8% tranexamic acid mouthwash, HemCon Dental Dressing (chitosan-based agent), hemostatic solutions (aluminum solution), tannic acid, and fibrin glue. Recently newer local hemostatic agents are in usage such as zeolite (QuikClot), chitosanbased agents (N-acetyl glucosamine polymer), and poly-N-acetyl glucosamine agents. Patients are strictly advised to follow the post-operative instructions for the maintenance of the blood clot [43,44].
Patients on anticoagulation therapy should be treated the same as healthy patients, and the dentist should have sufficient knowledge about various local measures for hemostasis.
- Santhosh Kumar MP. Dental Management of Patients on antiplatelet therapy: Literature update. Asian J Pharm Clin Res 2016; 9:26-31.
- Brennan MT, Valerin MA, Noll JL, et al. Aspirin use and post-operative bleeding from dental extractions. J Dent Res 2008; 87:740-744.
- Krishnan B, Shenoy NA, Alexander M. Exodontia and antiplatelet therapy. J Oral Maxillofac Surg 2008; 66:2063-2066.
- Spertus JA, Kettelkamp R, Vance C, et al. Prevalence, predictors and outcomes of premature discontinuation of thienopyridine therapy after drug eluting stent placements: Results from the premier registry. Circulation 2006; 113:2803-2809.
- Kovich O, Otley CC. Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation. Jam Acad Dermatol 2003; 48:233-237.
- Lockhart PB, Gibson J, Pond SH, et al. Dental management consideration for the patients for the patients with an acquired coagulopathy. Part 2: Coagulopathies from drugs. Br Dent J 2003; 195:495-501.
- Patel N, Patel V, Sarker D, et al. Dual Antiplatelet therapy and dento alveolar surgery. How do we manage patients on anti-platelet medication? Br Dent J 2014; 217:24.
- Chinnaswami R, Bagadia RK, Mohan A et al. Dentist knowledge, attitude and practice in treating patients taking oral antithrombotic medications: A survey. J Clin Diagn Res 2017; 11:88-91.
- El-Helou N, Al-Hajje A, Ajrouche R, et al. Adverse drug events associated with vitamin K antagonists: Factors of therapeutic imbalance. Vasc Health Risk Manag 2013; 9:81–88.
- Douketis JD, Spropoulos AC, Spencer FA et al. Perioperatively management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th Edn: American college of chest physician’s evidence based clinical practice guidelines. Chest 2012; 141: 326-350.
- Perry DJ, Noakes TJC, Helliwell PS. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Dent J 2007; 203:389–393.
- Evans IL, Sayers MS, Gibbons AJ, et al. Can warfarin be continued during dental extraction? Results of a randomised controlled trila. Br J Oral Maxillofac Surg 2002; 40:248–252.
- Bajkin BV, Popovic SL, Selakovic SD. Randomized, prospective trial comparing bridging therapy using low molecular weight heparin with maintenance of oral anticoagulation during extraction of teeth. J Oral Maxillofac Surg 2009; 67:990–995.
- Abdullah WA, Khalil H. Dental extraction in patients on warfarin treatment. Clin Cosmet Investig Dent 2014; 6:65–69.
- Weltman NJ, Al-attar Y, Cheung J. Management of dental extractions in patients taking warfarin as anticoagulant treatment: A systematic review. J Can Dent Assoc 2015; 81:20.
- Julia S, James U. Direct oral anticoagulants: A quick guide. Eur Cardiol 2017; 12:40–45.
- Barnes GD, Ageno W, Ansell J, et al. Recommendation on the nomenclature for oral anticoagulants: communication from the SSC of the ISTH: Reply. J Thromb Haemost 2015; 13:2132–2133.
- Johnston S. An evidence summary of the management of patients taking direct oral anticoagulants (DOCAS) undergoing dental surgery. Int J Oral Maxillofacial Surg 2016; 45:618-630.
- Heiduchel H, Verhamme P, Alings M, et al. Updated European heart rhythm association practical guide on the use of non-vitamin K antagonist anticoagulant in patients with non valvular atrial fibrillation. Europace 2015; 17:1467–1507.
- Gomez-Moreno G, Aguilar-Salvatierra A, Mart m-Piedra MA, et al. Dabigatran and rivaroxaban, new oral anticoagulants. New approach in dentistry. J Clin Exp Dent 2010; 2:1–5.
- Daniel NG, Goulet J, Bergeron M, et al. Antiplatelet drugs: Is there a surgical risk. Can Dent Assoc 2002; 68:683-687.
- Scully C, Wolff A. Oral surgery in patients on anticoagulant therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94:57-64.
- Little JW, Miller CS, Henry RG, et al. Antithrombotic agents: Implications in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 93:544-551.
- Burger W, Chemniyius JM, Knesissl GD, et al. Low dose aspirin for secondary cardiovascular prevention-cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation-review and meta-analysis. J Intern med 2005; 257:399-414.
- Elad S, Chackartchi T, Shapira L, et al. A critically severe gingival bleeding following non-surgical periodontal treatment in patients medicated with anti-platelet. J Clin Periodontol 2008; 35:342-345.
- Ferraris VA, Ferraris SP, Lough FC, et al. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Ann Thorac Surg 1988; 45:71-4.
- Toyota K, Yasaka M, Iwade K, et al. Dual antithrombotic therapy increases severe bleeding events in patients with stroke and cardiovascular diseases: A prospective, multicenter observations study. Stroke 2008; 39:1740-1745.
- Bajkin BV, Urosevic IM, Stankov KM, et al. Dental extractions and risk of bleeding in patients taking single and dual antiplatelet treatment. Br J Oral Maxillofac Surg 2015; 53:39-43.
- Verma G, Tiwari AK, Chopra S. Aspirin and exodontia: A comparative study of bleeding complications with aspirin therapy. Int J Dent Sci Res 2013; 1:50-53.
- Olmos-Carrasco O, pastor-Ramos V, Espinilla Blanco R, et al. Haemorraghic complications of dental extractions in 181 patients undergoing double antiplatelet therapy. J Oral Maxillofac Surg 2015; 73:203-210.
- Grines CL, Bonow RO, Casey DE, et al. 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 intervention, American college of surgeons and American dental associations with representation from the American college of physicians. Circulation 2007; 115:813-818.
- Girotra C, Padhye M, Mandlik G, et al. Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: A prospective study. Int J Oral Maxillofac Surg 2014; 43:99-106.
- Hanken H, Tieck F, Kluwe L, et al. Lack of evidence for increased postoperative bleeding risk for dental osteotomy with continued aspirin therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119:17-9.
- Nooh N. The effect of aspirin on bleeding after extraction of teeth. Saudi Dent J 2009; 21:57-61.
- van Diermen DE, Van der Waal I, Hoogstraten J. Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116:709-716.
- Broekema FI, Van Minnen B, Jansma J, et al. Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants. Br J Oral Maxillofac Surg 2014; 52:15-19.
- Bajkin BV, Bajkin IA, Petrovic BB. The effects of combined oral anticoagulant-aspirin therapy in patients undergoing tooth extractions: A prospective study. J Am Dent Assoc 2012; 143:771-776.
- Morimoto Y, Niwa H, Minematsu K. Risk factors affecting postoperative hemorrhage after tooth extraction in patients receiving oral antithrombotic therapy. J Oral Maxillofac Surg 2011; 69:1550-1556.
- Napenas JJ, Oost FC, DeGroot A, et al. Review of postoperative bleeding risk in dental patients on antiplatelet therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:491-499.
- Brennan MT, Valerin MA, Noll JL, et al. Aspirin use and post-operative bleeding from dental extractions. J Dent Res 2008; 87:740-744.
- Wahl MJ. Dental surgery and antiplatelet agents: Bleed or die. Am J Med 2014; 127:260-2697.
- Medeiros FB, de Andrade AC, Angelis GA, et al. Bleeding evaluation during single tooth extraction in patients with coronary artery disease and acetylsalicylic acid therapy suspension: A prospective, double-blinded, and randomized study. J Oral Maxillofac Surg 2011; 69:2949-2955.
- Borea G, Montebugnoli L, Capuzzi P, et al. Tranexamic acid as a mouthwash in anticoagulant-treated patients undergoing oral surgery. An alternative method to discontinuing anticoagulant therapy. Oral Surg Oral Med Oral Pathol 1993; 75:29-31.
- Sindet-Pedersen S, Ramström G, Bernvil S, et al. Hemostatic effect of tranexamic acid mouthwash in anticoagulant-treated patients undergoing oral surgery. N Engl J Med 1989; 320:840-843.
Citation: Adel Alenazi, Dental Management of Patients on Chronic Oral Anticoagulants: A Review, J Res Med Dent Sci, 2020 8(1): 120-124.
Received: 19-Dec-2019 Accepted: 23-Jan-2020