Dental Clinical Effectiveness program has provided a series of guidelines for
dental patients on anticoagulants and antiplatelet drugs. This program is
initiated by the National Dental Advisory Committee (NDAC), operated by the NHS
for Education, Scotland.
provided by this program are aimed at highlighting the risks involved in
performing dental procedures on patients who are on anticoagulant
or antiplatelet drugs. As these drugs increase the clotting time of blood, such patients would bleed for an extended period of time after major dental procedures, resulting in excessive blood loss
. In extreme cases, the patient may require blood transfusions
as an emergency procedure.
‘Guidelines provided by the Scottish Dental Effectiveness Program in the management of dental patients on anticoagulants and antiplatelet drugs are described.’
Which Increase Risk of Bleeding during Dental Procedure:
certain medical conditions, which have been associated with an increase in
bleeding risk and they include:
- Liver disease
- Chronic renal failure
- Chemotherapy performed recently
- Idiopathic thrombocytic purpura
- Heart failure at an advanced stage
- Less severe forms of bleeding disorders
these medical conditions should be treated with greater care due to higher
risk of bleeding
. Moreover, dental
procedures should be started only after consultation with the physician who treated the patient for the medical condition.
these medical conditions should not be treated in a clinic but should be
treated in a hospital where emergency support is available.
Increase Bleeding Risk:
drugs increase the risk of bleeding:
- Anti-Coagulants and
Anti-Platelet Drugs - These drugs increase the
risk of bleeding and combined use of these drugs also pose an increased
risk of bleeding.
- Non- Steroidal Anti-Inflammatory Drugs - These drugs decrease the functions of the platelet to
- Cytotoxic Drugs - These drugs are
normally used in the suppression of the bone marrow. They result in
reduced activity of platelets as well as a decrease
in function of the liver, affecting coagulation.
- Drugs for the Nervous System - These drugs could increase coagulation time when combined with other antiplatelet drugs.
be asked about the drugs that they use. Often, some patients may be on
anticoagulant drugs without a prescription from a doctor.
The dentist should have the required
skill and expertise to arrest bleeding. Local hemostatic measures include:
- Open sockets should be plugged with hemostatic material
- Suturing open sockets
- Mouthwashes containing tranexamic acid should be used 4 times a
day for 2 days.
bleeding is extremely important and extra care should be extended to those
patients who are at an increased risk. While placing hemostatic material or
sutures for patients, their medical history and drug intake should be taken
into consideration. The time required for the patient to reach emergency should
also be factored in while placing the hemostatic material.
A must have
kit for a dental practitioner
- Collagen sponge, oxidized cellulose like as hemostatic material
- Suture kit
A patient who is
on a single or even dual anticoagulant drugs should be treated with care,
lowering the risk of bleeding. The anticoagulant drug
therapy should not be interfered without consultation with the patient's
physician as it could lead to thromboembolic event which may be hazardous.
Precautions for Dentists:
be extra cautious while treating patients who are on anticoagulant drugs
- The bleeding time of such patients will extend more than for
patients without anticoagulants. This should be considered while planning
the treatment time.
- The treatment procedure should be advanced slowly. For example,
a single tooth extraction should be performed, the bleeding time and effect on the patient should be observed, before resorting to further extractions.
- Ask for help from senior dentists or colleagues about treatment measures
- If a patient is on new anticoagulant drugs, then the patient's
physician should be consulted before beginning the dental procedure.
- Perform the dental procedure during the morning hours so that
the patient is monitored for a period of time before the patient is
allowed to go home.
- If the patient is at a high risk for bleeding, then anticoagulation drugs may be avoided on the day of the
- If the dental procedure is an emergency and the patient who is
at high risk for bleeding has already consumed the anti-coagulant for the
day, then the procedure should be delayed till the evening, if possible.
- If the patient takes injectable
anticoagulants, then the dental procedure should not be planned for the
same day but the next.
A dentist should
assess the drugs consumed by the patient before starting any procedure and
should be wary of prescribing any drugs to avoid cross-reaction. With careful planning and monitoring, patients on
anticoagulant and antiplatelet drugs may be treated with minimal risk of
Note - Certain anticoagulants like Clopidogrel
require 5 to 7 days of stoppage before undertaking any major surgical
procedure, whereas popular anticoagulants like aspirin requires 3 days. However
if you are on baby aspirin (75mg) stopping it on
the morning is adequate. Please consult your dentist and inform them if you are
on any long term medication. Be safe for the procedure.