anticoagulants and antiplatelets

Question 1

general advice for tx likely to cause bleeding

Answer 1

plan tx early in day and week
atraumatic tx
local haemostatic measures
only discharge once haemostasis achieved
written post-tx advice
emergency contact
if travel time concern, emphasise measures to avoid complications

Question 2

if meds aren’t lifelong/long-term

Answer 2

delay dental tx where possible

consult GP

Question 3

give 3 vit K antagonists

Answer 3

warfarin
acenoconmarol
phenindione

Question 4

treating pts on vit K antagonists

Answer 4

check INR within 24hrs (up to 72hrs if stably anti coagulated)
if INR below 4
- tx without interrupting meds
- consider staging extensive/complex tx
- actively consider suturing and packing
INR 4 or above
- delay tx, refer if urgent

Question 5

taking anti platelets - just aspirin

Answer 5

tx without interrupting meds
consider staging extensive/complex procedures
local haemostatic measures
consider limiting initial tx area

Question 6

taking clopidogrel/dipyridamole/prasugrel/ticagrelor single or dual (with aspirin)

Answer 6

tx without interrupting meds
expect prolonged bleeding
consider staging extensive/complex procedures
actively consider suturing and packing
limit initial tx area

Question 7

name 4 DOACs

Answer 7

dabigatran
apixaban
rivaroxaban
edoxaban

Question 8

NOACs general advice

Answer 8

advise pt to miss/delay morning dose before tx
tx early in day
limit initial tx area and assess bleeding before continuing
stage extensive/complex procedures
actively consider suturing and packing
advise pt when to restart meds

Question 9

pt taking injectable AC/other drug combinations

Answer 9

dalteparin, enoxaparin, tinzaparin
prophylactic (low dose) - tx without interrupting meds
tx (higher dose) or uncertainty about the dose: consult w the prescribing clinician for more info
consider limiting initial tx area and staging extensive or complex procedures, strongly consider suturing and packing

Question 10

procedures unlikely to cause bleeding

Answer 10

LA (inc blocks)
BPE
supra gingival scaling
restorations with supra gingival margins
orthograde endo
pros
ortho appliances

Question 11

procedures likely to cause bleeding - low risk

Answer 11

simple extractions (1-3 teeth, restricted wound size)
I+D of IO swellings
6PPC
RSI and sub gingival scaling
restorations with sub gingival margins

Question 12

procedures likely to cause bleeding - higher risk

Answer 12

complex extractions, adjacent extractions that will cause a large wound, >3
flap raising procedures
 - elective surgical extractions
 - PD surgery
 - pre-prosthetic surgery
 - periradicular surgery
 - crown lengthening
 - implant surgery
 - gingival recontouring
 - biopsies

Question 13

apixaban action

Answer 13

inhibitor of factor Xa

Question 14

rivaroxaban action

Answer 14

inhibitor of factor Xa

Question 15

dabigatran action

Answer 15

direct thrombin inhibitor

Question 16

NOAC dose schedules for high risk procedures - apixaban

Answer 16

normal x2 per day
miss morning pre-tx dose
take normal evening dose
 - as long as >4hrs since haemostasis achieved
continue normal drug schedule after

Question 17

NOAC dose schedules for high risk procedures - dabigatran

Answer 17

normal x2 per day
miss morning pre-tx dose
take normal evening dose
 - as long as >4hrs since haemostasis achieved
continue normal drug schedule after

Question 18

NOAC dose schedules for high risk procedures - rivaroxaban if usual dose x1 in morn

Answer 18

delay morning dose
take 4 hours post-haemostasis
continue normal drug schedule after

Question 19

NOAC dose schedules for high risk procedures - rivaroxaban if usual dose x1 in evening

Answer 19

take at usual time in evening as long as >4hrs since haemostasis achieved
continue normal drug schedule after

Question 20

do not interrupt anticoagulant/antiplatelet therapy for

Answer 20

pts with prosthetic metal heart valves or coronary stents
pts who have had a PE or DVT in the last 3m
pts on anticoagulant therapy for cardioversion

Question 21

are LAs likely to cause bleeding?

Answer 21

no

Question 22

which DOACs are taken twice a day?

Answer 22

apixaban and dabigatran

Question 23

which DOACs are taken once a day/

Answer 23

rivaroxaban and edoxaban

Question 24

NOAC dose schedules for high risk procedures - edoxaban if usual dose x1 in morn

Answer 24

delay morning dose
take 4 hours post-haemostasis
continue normal drug schedule after

Question 25

NOAC dose schedules for high risk procedures - edoxaban if usual dose x1 in evening

Answer 25

take at usual time in evening as long as >4hrs since haemostasis achieved
continue normal drug schedule after

Question 26

anticoagulant/antiplatelet combinations

Answer 26

consult with pts prescribing clinician in order to assess the likely impact of the particular drug combination and the pts medical condition on their bleeding risk

Question 27

env considerations

Answer 27

pt travel - minimise wasted appts and unnecessary travel

• confirm MH in advance e.g. by phone to check for any changes that could impact tx and require postponement
• consult with doctor in advance of appt if more info required
• provide pre and post tx instructions (electronically, written if required)
• suture and pack at time of tx - this may reduce likelihood of pt having to reattend for management of post-op bleeding