SDCEP - Anti-coagulants

Question 1

What should you do if a patient is taking an anticoagulant/anti-platelet drug which is NOT likely to cause bleeding?

Answer 1

Treat with caution using SOPs
Take care to avoid treatment that could result in bleeding.

Question 2

What should you do if a patient is taking an anticoagulant/anti-platelet drug which is likely to cause bleeding, but the medication is time limited?

Answer 2

Delay non-urgent treatment until the medication course is finished.

If urgent contact specialist

Question 3

What should you do if a patient is taking an anticoagulant/anti-platelet drug which is likely to cause bleeding, and has other medical complications?

Answer 3

Consult with prescribing clinician, specialist, or GP.

Question 4

What is a direct oral anticoagulant? Give three examples.

Answer 4

Drugs used to directly inhibit specific proteins within the coagulation cascade.

Used for stroke and MI prevention

Lowers risk of thromboembolic events

Apixaban (2 daily)
Dabigatran (2 daily)
Rivaoxaban (1 daily)

Question 5

What should you do for a low bleeding risk procedure on a patient taking apixaban?

Answer 5

Treat without interrupting the medication

Question 6

What should you do for a high bleeding risk procedure on a patient taking dabigatran?

Answer 6

Advise patient to miss morning dose.

Question 7

What should you do for a high bleeding risk procedure on a patient taking rivaroxiban?

Answer 7

Miss daily dose, could consider taking 4 hours after treatment if haemostasis is okay.

Question 8

What is the general advise for treating a patient on a direct oral anti-coagulant?

Answer 8

Treat early in the day
Limit treatment area and assess bleeding
Consider staging treatment
Strongly consider suture/pack for XLA

Question 9

What is a vitamin K antagonist? Give three examples.

Answer 9

Drugs which directly impact the vitamin K dependant clotting factors (2, 7, 9, 10).

Used to lower risk of thromboembolic events.

Warfarin, acenocoumarol, phenindione

Question 10

What should you do if you need to perform a routine extraction on a patient taking warfarin with no other medical complications?

Answer 10

Check INR ideally 24 hours before procedure:

If <4 treat without interrupting medication
If >4 delay invasive treatment or refer if urgent

Note: can be done 72 hours before if stably coagulated.

Question 11

What are injectable anticoagulants? Give two examples.

Answer 11

Low molecular weight heparin, which binds to antithrombin, interrupting two steps of the clotting cascade.

Reduce the risk of thromboembolic events.

Enoxaparin, and dalteparin.

Question 12

What should you do if you need to perform an extraction on a patient taking a prophylactic dose of dalteparin?

Answer 12

Treat without interrupting medication.
Consider limiting treatment area
Consider staging treatment
Strongly consider suturing and packing

Question 13

What should you do if you need to perform an extraction on a patient taking a high dose of enoxaparin?

Answer 13

Consult with prescribing clinician for more information.

Question 14

What is aspirin?

Answer 14

A drug used for reduction of inflammation, analgesia, and prevention of clotting.

Decreased prostaglandin and TXA2 production.

Question 15

What should you do if a patient is taking regular aspirin, and you need to perform an extraction?

Answer 15

Treat without interrupting medication
Consider limiting initial treatment area
Consider staging treatment
Use local haemostatic measures

Question 16

What are clopidogrel, dipyridamole, and prasugrel?

Answer 16

Anti-platelet drugs

Prevent adhesion of platelets to each other and lower the risk of clot formation in abnormal places.

Can be used in combination therapy.

Question 17

What should you do if you need to perform an extraction on a patient taking clopidogrel?

Answer 17

Treat without interrupting medication
Expect prolonged bleeding
Limit treatment area
Consider staging treatment
Strongly consider suturing and packing

Question 18

What should you do if you need to perform an extraction on a patient who is on a combination of anticoagulants and anti-platelets?

Answer 18

Consult with the prescribing medical practitioner to help assess the bleeding risk.

Question 19

Which dental procedures are unlikely to cause bleeding?

Answer 19

Local anaesthesia
BPE
Supra-gingival PMPR
Direct or indirect restorations
Orthograde endodontics
Impressions and pros
Fitting/adjusting orthodontic appliances

Question 20

Which dental procedures are likely to cause bleeding, but are low risk of post op bleeding complications?

Answer 20

Simple extractions of 1-3 teeth
Incision and drainage of swellings
Detailed 6PPC
Root surface PMPR
Subgingival restorations

Question 21

Which dental procedures are likely to cause bleeding, but are high risk of post op bleeding complications?

Answer 21

Complex extractions with a large wound
Flap raising surgical procedure
Gingival recontouring
Biopsies