SDCEP Guidelines Overview

Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs

• This guidance offers a consistent strategy for dealing with dental care for individuals who are taking anticoagulants or antiplatelet medications.
• This is accomplished through research data and professional judgment, as well as recommendations and guidance related to dental treatment.

The SDCEP Initiative

• The Scottish Dental Clinical Effectiveness Programme (SDCEP) developed the recommendations.
• SDCEP operates within NHS Education for Scotland.
• SDCEP aims to support improvements in patient care.
• SDCEP develops user-friendly, evidence-based guidance on topics identified as priorities for oral health.

Guidance Scope

• This document mainly concerns dentists, therapists, and hygienists in primary dental care and the public dentistry system.
• It expands to secondary dental care, dental education, and undergraduate and postgraduate students.
• It does not cover the inpatient management of these cases.

Anticoagulants and Antiplatelet Drugs

• These drugs reduce the blood's ability to clot and are essential after injuries. Platelets activate, leading to adhesion and coagulation factor activation.
• Antiplatelet drugs hinder platelet aggregation required for haemostasis. Anticoagulants inhibit coagulation factors.
• These medications reduce the chance of thromboembolism in cardiac or vascular conditions, stroke history, and after procedures like joint replacements.
• The benefits of thromboembolic risk reduction should be considered when treating dental patients on these drugs.

Common Anticoagulants and Antiplatelet Drugs

• Warfarin, acenocoumarol, and phenindione (vitamin K antagonists) have been used to treat and prevent thromboembolism by inhibiting vitamin K modification of coagulation factors for over 50 years.
• Direct oral anticoagulants (DOACs) like dabigatran, apixaban, rivaroxaban, and edoxaban became available after 2008, overcoming warfarin's limitations and need for monitoring.
• Parenteral anticoagulants: unfractionated heparin and low molecular weight heparins (LMWHs) such as dalteparin, enoxaparin, and tinzaparin which are administered intravenously.
• Common antiplatelet drugs include aspirin, dipyridamole, and clopidogrel. Newer options are prasugrel and ticagrelor.

Availability of Reversal Agents

• Idarucizumab is approved for dabigatran reversal and andexanet alfa is approved for apixaban or rivaroxaban reversal.
• LMWHs include dalteparin, enoxaparin, and tinzaparin.

Assessing Bleeding Risk Before Dental Treatment

• Bleeding can occur due to anticoagulants or antiplatelet medications, so evaluation is important
• Serious bleeding events are rare, as post-operative bleeding events requiring additional hemostatic measures occur in ~4% of patients with uninterrupted anticoagulant therapy

Dental Procedures and Bleeding Risk

• Procedures unlikely to cause bleeding should be straightforward, whereas procedures likely to cause bleeding require consideration
• Bleeding risk is categorized as low or higher risk of complications (excessive bleeding)
• The term higher risk does not mean high risk, and is still likely to be considered minor

Managing Bleeding Risk

• Assess bleeding risk during dental treatment.
• If a patient is on a time-limited course of medication, delay non-urgent treatments.
• Inquiries about the patient's medications should be directed to the prescribing clinician.
• Ask about medical conditions and history.
• Plan treatment for early in the day and week.
• Give patients pre-treatment instructions.
• Provide post-treatment advice and emergency contact details.
• Ensure haemostasis before patient discharge. Suturing and packing may be needed.
• Paracetamol is advised in cases of pain relief unless contradicted.

Direct Oral Anticoagulants (DOACs)

• Assess coagulation with quantitative lab tests
• Don't interrupt anticoagulant medication
• Patients with prosthetic metal heart valves or coronary stents should not interrupt anticoagulant or antiplatelet therapy. Treat patients with a low bleeding complication risk while using their anticoagulant medication.

Procedures With a Higher Risk of Bleeding Complications With DOACs

• Advise that they skip or delay their morning dose.
• Plan treatment for early in the day.
• Where possible, stage the treatments.
• Advise patients on when to restart their medication.

Warfarin and Vitamin K Antagonists

• Manage therapeutic anticoagulation activity
• Those with INR level 4 or above should not interrupt their medication
• INR (International Normalized Ratio) measures clotting time and guides warfarin doses.
• Target INR differs from 2.5 to 3.5 ± 0.5, it is adjusted to achieve target level
• INR should have been checked ideally no more than 24 hours before procedure

Injectable Anticoagulants

• Prophylactic low dose should not be interrupted
• Treatment low doses of low molecular weight heparin are given with anti-coagulation medication, in these cases do not interrupt medication
• Assess whether the patient will use a higher or lower dose.

Antiplatelet Drugs

• Single or dual drugs do not interrupt medication, in cases of a low and higher risk of bleeding complication
• Treat according to general advice for managing bleeding risk
• Aspirin alone to consider initial limitation of treatment, high risk needs assessment
• Be aware that prolonged treatment may be up to an hour
• Combination of these drugs needs special consideration and assessment.