Anticoagulants and antiplatelets

Question 1

What dental procedures is unlikely to cause bleeding

Answer 1

Local anaesthesia by
infiltration, intraligamentary
or mental nerve blocka

Local anaesthesia by inferior dental block or other regional
nerve blocks

Basic periodontal
examination (BPE)

Supragingival removal of
plaque, calculus and stain

Direct or indirect restorations with supragingival margins

Endodontics - orthograde

Impressions and other
prosthetics procedures

Fitting and adjustment of
orthodontic appliances

Question 2

What dental procedures have a low risk of post op bleeding complications

Answer 2

Simple extractionsd
(1-3 teeth, with restricted wound size)

Incision and drainage of intraoral swellings

Detailed six-point full
periodontal examination

Root surface debridement

Direct or indirect restorations with subgingival margins

Question 3

What dental procedues have a higher risk of post op bleeding complications

Answer 3

Complex extractions, adjacent extractions that will cause a large wound or more than 3 extractions at once

Flap raising proceduresf
including:
-Elective surgical extractions
-Periodontal surgery
-Preprosthetic surgery
-Periradicular surgery
-Crown lengthening
-Dental implant surgery

Gingival recontouring

Biopsies

Question 4

What medical conditions are associated with an increased bleeding risk

Answer 4

Liver disese

Chronic renal failure

Haematological malignancy

Recent chemo

Advanced heart failure

Inherited coag. disorders

Accquired/inherited platelet disorders

Connective tissue disorders

Question 5

What main drug groups are associated with increase bleeding risk

Answer 5

Anticoags

Antiplatelets

Cytotoxic drugs or drugs associated with bone marrow suppression

Biologic immunosuppression therapies

NSAIDS

Drugs affecting the nervous system

Question 6

What would you do if the pt is taking anticoags or antiplatelets and requires Tx that is unlikely to cause bleeding

Answer 6

Treat the patient following standard procedures, taking care to avoid causing bleeding

Question 7

What would you do for a pt that is on a time-limited course of anticoagulant or antiplatelet medication and requires Tx that is likely to cause bleeding

Answer 7

delay non-urgent, invasive dental procedures where possible until the medication has been
discontinued

If emergency Tx required interrupt the drug treatment in liaison with the surgical consultant

Question 8

What would you do for a pt that is taking anticoags or antiplatelets and requires Tx that is likely to cause bleeding

Answer 8

Plan treatment for early in the day and week

Provide the patient with pre-treatment instructions e.g. INR

Perfrom Tx as atraumatically as possible with appropriate local measures and only discharge when haemostasis achieved

Advise the patient to take paracetamol, unless contraindicated, for pain relief rather than
NSAIDs such as aspirin, ibuprofen, diclofenac or naproxen

Provide the patient with post-treatment advice and emergency contact details

Question 9

What conditions would you not, unless told you can, interrupt anticoagulant or antiplatelet therapy

Answer 9

Pt with prosthetic metal heart valves or coronary stents

Pt with pulmonary ebolsim or DVT in past 3 months

Pt on anticoag therapy for cardioversion

Question 10

If a Pt is taking a DOAC and requires a dental procedure with a low risk of bleeding complications what do you do

Answer 10

treat without interrupting

Question 11

If a pt is taking a DOAC and requres a dental procedure with a higher risk of bleeding what do you do

Answer 11

Advise them to miss or delay their morning dose on day of dental Tx

Question 12

What DOAC’s can the pt not take there dose for on the day of dental procedure with a higher risk of bleeding complications

Answer 12

Apixaban

Dabigatran

Question 13

What DOAC’s can the pt delay there morning dose for on the day of a dental procedure with a higher risk of bleeding complications

Answer 13

Rivaroxaban

Edoxaban

Question 14

If a pt is taking a DOAC and requires Tx that is likely to cause bleeding with a low risk of bleeding complications what do you do

Answer 14

Treat the patient according to the general advice for managing bleeding risk without advising the patient to miss or delay a dose of their medication

Plan Tx early in day

Limit Tx area e.g. single XLA

Use local haemostatic measures and consider sutures

Question 15

What DOAC’s can be taken in the evening that the pt doesn’t need to modify

Answer 15

rivaroxaban or edoxaban in the evening

Question 16

If a pt is taking a DOAC and requires Tx that is likely to cause bleeding with a higher risk of bleeding complications what do you do

Answer 16

Advise pt to miss or delay (if evening dose its fine)

Plan TX early in day

Consider the Tx’s in a staged manner over multiple visits

Use local haemostatic measures and consider sutures

Advise pt when to restart medication

Question 17

When advising pt to restart medication of DOAC what do you tell them for each drug

Answer 17

For rivaroxaban or edoxaban that is taken once a day:
-take 4 hours after haemostasis has been achieved with the next dose should be taken as
usual the following morning

For apixaban or dabigatran:
-having missed the morning dose, the
patient should take their evening dose of DOAC at the usual time as long as no earlier than 4 hours after haemostasis has been achieved

Question 18

What must the INr be below to carry on Tx

Answer 18

4

Question 19

If a pt is taking antiplatelet drugs and requires Tx that is likely to cause bleeding, with either a low or higher risk of bleeding complications what do you do

Answer 19

Treat the patient according to the general advice for managing bleeding risk without interrupting their antiplatelet medication

Question 20

If pt is taking aspirin and requires Tx that is likely to cause bleeding, with either a low or higher risk of bleeding complications what do you do

Answer 20

Consider limiting the initial treatment area

Consider Tx in a staged manner

Question 21

If pt is taking another single antiplatelet drug or dual antiplatelet drugs and requires Tx that is likely to cause bleeding, with either a low or higher risk of bleeding complications what do you do

Answer 21

Be aware that bleeding may be prolonged

Limit the initial treatment area

Consider Tx in a staged manner

Use local haemostatic measures to achieve haemostasis. Strongly consider suturing and
packing