SDCEP Management of Dental Patients Taking Anticoagulant or Antiplatelet Drugs

Question 1

Give examples of dental procedures are unlikely to cause bleeding?

Answer 1

• LA infiltration/block
• BPE
• supragingival PMPR
• restorations with supragingival margins
• impressions
• fitting/adjusting orthodontic appliances

Question 2

What are examples of dental procedures that are likely to cause bleeding on a low risk scale?

Answer 2

• simple extractions (1-3 teeth, with restricted wound size)
• incision & drainage of intra-oral swellings
• detailed 6PPC
• root surface debridement
• restorations with subgingival margins

Question 3

What are examples of dental procedures that are likely to cause bleeding on a high risk scale?

Answer 3

• complex extractions (>3 extractions, or adjacent extractions that will cause large wound)
• flap raising procedures
• gingival recontouring
• biopsies

Question 4

In a patient taking warfarin, what do you require to have before giving an IDB?

Answer 4

INR level
- ensure <4

Question 5

Why do patients with chronic renal failure have an increased bleeding risk?

Answer 5

associated platelet dysfunction

Question 6

Why do patients with liver disease have an increased bleeding risk?

Answer 6

• reduced production of coagulation factors
• reduction in platelet number & function due to splenomegaly
• alcohol excess can result in direct bone marrow toxicity & reduced platelet numbers

Question 7

Give examples of medical conditions which have an increased risk of bleeding?

Answer 7

• chronic renal failure
• liver disease [caused by alcohol, hepatitis etc.]
• haematological malignancy
• recent or current chemotherapy or radiotherapy [within 3 months for chemo, 6 months for radiotherapy]
• haemophilia / von Willebrand’s
• advanced heart failure
• connective tissue disorders
• platelet disorders

Question 8

Why do patients with recent or current chemotherapy/radiotherapy have an increased bleeding risk?

Answer 8

Pancytopenia including reduced platelet numbers

Question 9

Why do patients with advanced heart failure have an increased bleeding risk?

Answer 9

resulting liver failure

Question 10

What drug groups can be associated with increased bleeding risks?

Answer 10

• anticoagulants
• antiplatelets
• cytotoxic drugs
• biologic immunosuppression therapies
• NSAIDs
• SSRIs & anti-epileptics

Question 11

When assessing a patients bleeding risk, what things should you consider?

Answer 11

• current use of anticoag/antiplatelet drugs [is it lifelong or limited time]
• ask about any medical conditions
• ask about bleeding history

Question 12

What local measures should be used to assist with haemostasis after treatment of high risk bleeding patients?

Answer 12

• absorbant gauze
• haemostatic packing material (oxidised cellulose, collagen sponge)
• suture kit

Question 13

How do DOACs and Warfarin primarily differ? Why is this relavant?

Answer 13

DOACs = rapid onset (1-4 hrs) & short half lives (max 18hrs)

• Possible to modify an individuals anticoagulation status rapidly

Question 14

How many times a day is Apixaban taken?

Answer 14

twice (morning & evening)

Question 15

How many times a day is Dabigatran taken?

Answer 15

twice (morning and evening)

Question 16

How many times a day is Rivaroxaban taken?

Answer 16

once

Question 17

How many times a day is Edoxaban taken?

Answer 17

once

Question 18

A patient enters your practise and they are taking a DOAC, the procedure is low-risk, how do you manage them?

Answer 18

Treat without interrupting medication

Question 19

A patient enters your practise and they are taking a DOAC, the procedure is high-risk, how do you manage them?

Answer 19

Apixaban/Dabigatran = miss morning dose

Edoxaban/Rivaroxaban = delay morning dose

Question 20

In addition to altering anticoagulant medications, what other measures should be undertaking to lower risk of bleeding complications?

Answer 20

• plan treatment early in day/week
• limit initial treatment area & assess bleeding before continuing
• use local haemostatic measures [suturing etc]

Question 21

When should patients restart their anticoagulant medication after a procedure with a higher risk of bleeding?

Answer 21

4 hours after treatment

Question 22

What INR level should a patient taking warfarin have so that you are able to treat them without interrupting their medication?

Answer 22

INR below 4 [within 72 hours is acceptable but prefer 24 hrs]

Question 23

Your patients INR level is >4, but they require emergency treatment, what should you do?

Answer 23

Refer to secondary care

Question 24

A patient is taking single/dual antiplatelet drugs, how should they be managed before treatment?

Answer 24

treat without interrupting their medication