Perioperative Dental Management of Patients in The Background of Antithrombotic Use

Author(s): Gulnar Sethna*, Rajeev Sivasankar, Pallavi Gaitonde, Priyadarshan Gaitonde

Journal Name: Current Dentistry

Volume 1 , Issue 1 , 2019

Become EABM
Become Reviewer
Call for Editor

Graphical Abstract:


Objectives: Treatment and perioperative dental management in patients on antithrombotic medications poses a serious challenge to dental professionals due to perceived risk of bleeding complications. This article aims to study the anticoagulant / antiplatelet drugs currently available on the market, review contemporary oral anti-thrombotic treatment and offer management guidelines in such situations based on the review of pertinent literature.

Material and Methods: Science Direct and Ovid databases, PubMed, Scopus and product literature were accessed to review relevant literature with respect to current anti-thrombotic drugs, indications for their use in medical conditions, complications related to their use and drug interactions. The search covered studies published in medical and dental journals in English with a relevant impact factor over a period of 10 years. Meta analyses, systematic reviews, randomized trials, cohort based and case-control studies and society-based guidelines were considered. Key words utilized in the search criteria included Warfarin, Coumarin, Aspirin, P2Y12 inhibitors, Prasugrel, Clopidogrel, Ticagrelor, Hemorrhage, Anti-thrombin, Platelet aggregation inhibitors and International Normalized Ratio (INR) and were validated by the MeSH dictionaries.

Results: Dental practitioners today, are faced with the challenge of conducting surgical procedures on patients who are on anti-thrombotic medications for a variety of medical/ surgical co-morbid conditions. Although there is consensus amongst various studies regarding continuation of warfarin in therapeutic ranges for dento-alveolar surgery, there is insufficient evidence to reach a consensus in those groups who are at intermediate or high risk of bleeding. However, most studies and published literature do agree that there is no real increased risk of bleeding complications during conduct of these procedures if the patient’s INR is less than 3.5 along with adequate haemostatic measures.

Conclusion: Regardless of the procedure to be performed, every case needs to be titrated on its individual merit based on both patient and surgical factors. Further, it is recommended that INR values should be established at least 72 hours prior to the surgery, which admits a margin of safety for dose modification if necessary. A meticulous case history with complementary hemostatic tests and adoption of adequate local hemostatic measures hold the key to not having the necessity to modify the antiplatelet or anticoagulation treatment in most cases. Additionally, the advent of newer anticoagulants and antiplatelets have raised the requirement of dedicated Randomized Clinical Trials to answer the specific clinical questions of bleeding risk versus thrombo-embolic complications in the perioperative management of such patients.

Keywords: Anticoagulants, Warfarin, Oral surgical procedures, Hemorrhage, Anti-thrombin, Platelet aggregation inhibitors, International Normalized Ratio (INR).

Toscano NJ, Holtzclaw DJ, Moss HD, Shumaker N. Implant considerations in the anticoagulated patient-A Review. J Osseointeg 2010; 3(2): 84-91.
Corcuera M, Acitores M, Pintor R. Dabigatran: A new oral anticoagulant. Guidelines to follow in oral surgery procedures. A systematic review of the literature. Med Oral Patol Oral Cir Bucal 2016; 21(6): e679-88.
O’Connell J, Staseen L. New oral anticoagulants and their implications for dental patients. J Ir Dent Assoc 2014; 60(3): 137.
Lusk K, Rebekah M, Benitez R, et al. Management of direct-acting oral anticoagulants surrounding dental procedures with a low-to-moderate risk of bleeding. J Pharm Pract 2018; 31(2): 202-7.
Fuster V, Pumphrey C, Mc Goon M, et al. Systemic thrombo-embolism in mitral and aortic Starr-Edwards prostheses: a 10-19 year follow-up. Circulation 1982; 66: 157-61.
Campbell C, Smyth S, Montalescot G, et al. Aspirin dose for the prevention of cardio-vascular disease: A systematic review. JAMA 2007; 297(18): 2018-24.
Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood 2012; 120: 2954-62.
Armstrong MJ, Schneck MJ, Biller J. Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients. Neurol Clin 2006; 24: 607-30.
Aframian DJ, Lalla RV, Peterson DE. Management of dental patients taking common hemostasis-altering medications Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(Suppl 1): S45 e1-11
Napeñas JJ, Oost FC, Degroot A, et al. Review of postoperative bleeding risk in dental patients on antiplatelet therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115(4): 491-9.
Jeske AH, Suchko GD. Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment. J Am Dent Assoc 2003; 134(11): 1492-7.
Blinder D, Manor Y, Martinowitz U, Taicher S. Dental extractions in patients maintained on oral anticoagulant therapy: Comparison of INR value with the occurrence of postoperative bleeding. Int J Oral Maxillofac Surg 2001; 30: 518-21.
Van Diermen DE, van der Waal I, Hoogvliets MW, Ong FN, Hoogstraten J. Survey response of oral and maxillo -facial surgeons on invasive procedures in patients using anti-thrombotic medication. Int J Oral Maxillofac Surg 2013; 42(4): 502-7.
Ward BB, Smith MH. Dentoalveolar procedures for the anticoagulated patient: Literature recommendations versus current practice. J Oral Maxillofac Surg 2007; 65: 1454-60.
Constantinides F, Rizzo R, Pascazio L, et al. Managing patients taking novel oral anti-coagulants (NOAs) in dentistry: A discussion paper on clinical implications. BMC Oral Health 2016; 16: 5.
Patel N, Patel V, Sarkar D, et al. Dual anti-platelet therapy and dentoalveolar surgery. How do we manage patients on anti-platelet medication? Br Dent J 2014; 217: E24.
Van Ryn J, Stangier J, Haertter S, et al. Dabigatran etexilate-A novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 2010; 103: 1116-27.
Lanau N, Mareque J, Giner L, et al. Direct oral anticoagulants and its implications in dentistry. A review of the literature. Clin Exp Dent 2017; 9(11): e1346-54.
Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med 1998; 158(15): 1610-6.
Harbour R, Miller J. Scottish intercollegiate guidelines network grading review group. a new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334-6.
Scottish Dental Clinical Effectiveness Programme (SDCEP). 2015. Management of dental patients taking anticoagulants or antiplatelet drugs. Dental Clinical Guidance. Available from:. http://www. content/uploads/2015/09/SDCEP-Anticoagulants- Guidance
Todd DW. Anticoagulated patients and oral surgery. Arch Intern Med 2003; 163(10): 1242.
Campbell JH, Alvarado F, Murray RA. Anticoagulation and minor oral surgery: should the anticoagulation regimen be altered? J Oral Maxillofac Surg 2000; 58: 131-5.
Al-Mubarak S, Al-Ali N, Abou Rass M, et al. Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy. Br Dent J 2007; 203: E15.
Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003; 139(11): 893-900.
Nematullah A, Alabousi A, Blanas N. Dental surgery for patients on anticoagulant therapy with warfarin: A systematic review and meta-analysis. J Can Dent Assoc 2009; 75(1): 41.
Shi Q, Xu J, Zhang T, et al. Post-operative Bleeding Risk in Dental Surgery for Patients on oral anticoagulant therapy: a meta-analysis of observational studies. Front Pharmacol 2017; 8(8): 58.
Muthukrishnan A, Bishop K. An assessment of the management of patients on warfarin by general dental practitioners in South-west Wales. Br Dent J 2003; 195(10): 22.
Dodson TB. Strategies for managing anti coagulated patients requiring dental extractions: An exercise in evidence-based clinical practice. J Mass Dent Soc 2002; 50: 44-50.
Scully C, Wolff A. Oral surgery in patients in patients on anticoagulant therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94(1): 57-64.
Bakathir A. Minor oral surgery procedures in patients taking Warfarin. A 5-year retrospective study at Sultan Qaboos University Hospital, Sultanate of Oman. Squ Med J 2009; 9(3): 279-86.
Douketis JD. Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood 2011; 117(19): 5044-9.
Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of anti-thrombotic therapy: antithrombotic therapy and prevention of thrombosis 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines Chest 2012; 141(2): e326S-e350S.
Abdullah WA, Khalil H. Dental extraction in patients on warfarin treatment. Clin Cosmet Investig Dent 2014; 6: 65-9.
Weltman NJ, Al-Attar Y, Cheung J. Management of dental extractions in patients taking warfarin as anti- coagulant treatment: a systematic review. J Can Dent Assoc 2015; 81: f 20.
Shaer F, Raslan I, Osaimi N, et al. Documentation of various approaches and out-comes in patients on warfarin undergoing dental procedures: a Review article. Am J Cardiovasc Dis 2016; 6(3): 109-17.
Akwaa F, Spyropoulos AC. Novel oral anticoagulants: a review literature and considerations in the special clinical situations. Hosp Pract 2013; 41(1): 8-18.
Hawkins D. Limitations of traditional anticoagulants. Pharmacotherapy 2004; 24(7 Pt 2): 62S-5S.
Firriolo FJ, Hupp WS. Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113(4): 431-41.
Lim H, Ho P. Direct oral anticoagulants in dental patients including the frail elderly population. Dent J 2016; 4: 7.
Mingarro-de-León A, Chaveli-López B. Alternative to oral dicoumarin anticoagulants: Considerations in dental care. J Clin Exp Dent 2013; 5: e 273-8.
Healey JS, Eikelboom J, Douketis J, et al. Periprocedural bleeding and thrombo-embolic events with Dabigatran compared with warfarin: results from the Randomized Evaluation of long-term anticoagulation therapy (RE-LY) randomized trial. Circulation 2012; 126: 343-8.
Douketis JD, Healey JS, Brueckmann M, et al. Perioperative bridging anticoagulation during dabigatran or warfarin interruption among patients who had an elective surgery or procedure. Sub study of the RE-LY trial. Thromb Haemost 2015; 113: 625-32.
Moreno G, Fernández-Cejas E, Aguilar-Salvatierra A, et al. Dental implant surgery in patients in treatment by dabigatran. Clin Oral Implants Res 2016; 27(6): 730-3.
Borea G, Montebugnoli L, Capuzzi P, et al. Tranexamic acid as a mouthwash in anti-coagulant-treated patients undergoing oral surgery. An alternative method to discontinuing anticoagulant therapy. Oral Surg Oral Med Oral Pathol 1993; 75: 29-31.
Bacci C, Maglione M, Favero L, et al. Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicenter, prospective, case-control study. Thromb Haemost 2010; 104: 972-5.
Dinkova A, Kirova D. Management of patients on anti- coagulant therapy undergoing dental surgical procedures. Review article of IMAB 2013; 19(4).
Paraschiv C, Esanu I, Ghiuru R, et al. Dental implications of the new oral anticoagulants. Romanian Journal of Oral Rehabilitation 2015; 7: 30-6.
Caliskan M, Tukel H, Benlidaya M, et al. Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants? Med Oral Patol Oral Cir Bucal 2017; 22(6): e767-73.
Flanagan D. Tranexamic acid tamponade to control postoperative surgical hemorrhage. J Oral Implantol 2015; 61(3): e1044-50.
Turpie AG, Kreutz R, Llau J, et al. Management consensus guidance for the use of Rivaroxaban–an oral, direct factor Xa inhibitor. Thromb Haemost 2012; 108: 876-86.
Raval A, Joaquin E, Chung MK, et al. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting -A Scientific statement from the American Heart Association Circulation 2017; 135: 00-00.
Breik O, Cheng A, Sambrook P, et al. Protocol in managing oral surgical patients taking dabigatran. Aust Dent J 2014; 59: 296-301.
Curto A, Curto D, Sanchez J. Managing patients taking Edoxaban in dentistry. A Systematic review. J Clin Exp Dent 2017; 9(2): e308-11.
Rognoni C, Marchetti M, Quaglini S, et al. Edoxaban versus warfarin for stroke prevention in non-valvular atrial fibrillation: a cost- effectiveness analysis. J Thromb Thrombolysis 2015; 39: 149-54.
Richards D. Guidelines for the management of patients who are taking oral anticoagulants and who require dental surgery. Evid Based Dent 2008; 9: 5-6.
Scott A, Gibson J, Crighton A. The management of dental patients taking new generation oral anticoagulants. Prim Dent J 2014; 3: 54-8.
Tsolka P. Dental procedures in patients with atrial fibrillation and new oral anti-coagulants. Arrhythm Electrophysiol Rev 2014; 3: 85-9.
Elad S, Marshall J, Meyerowitz C, et al. Novel anticoagulants: general overview and practical considerations for dental practitioners. Oral Dis 2016; 22: 23-32.
Johnston S. An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery. Int J Oral Maxillofac Surg 2016; 45: 618-30.
Green B, Mendes RA, Van der Valk R, et al. Novel anti- coagulants - An update on the latest developments and management for clinicians treating patients on these drugs. J Oral Pathol Med 2016; 45: 551-6.
Yang S, Shi Q, Liu J, et al. Should oral anti-coagulant therapy be continued during dental extraction? A meta-analysis. BMC Oral Health 2016; 16: 81.
Bathala MS, Masumoto H. Oguma, et al Pharmacokinetics, biotransformation, and mass balance of Edoxaban, a selective, direct factor Xa inhibitor, in humans. Drug Metab Dispos 2012; 40: 2250-5.
Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569-619.
Hong CH, Intekhab I. Anti-thrombotic therapy: Implications for invasive outpatient procedures in dentistry. J Blood Disord Transfus 2013; 4: 6.
Dattatraya A, Darawade D, Kumar S, et al. Influence of aspirin on post-extraction bleeding - A clinical study. J Int Soc Prev Community Dent 2014; 4(Suppl. 1): S63-7.
Grobe A, Fraederich M, Smeets R. Post operative bleeding risk for oral surgery under continued Clopidogrel anti-platelet therapy. BioMed Res Int 2015; 823651.
Nathwani S, Martin K. Exodontia in dual antiplatelet therapy: the evidence. Br Dent J 2016; 220: 235-8.
Kudse Dalati M. Sibai L, et al Management of bleeding disorders in the dental practice: Managing patients on anticoagulants. Dent Update 2012; 39: 358-63.
Davis C, Robertson C, Shivakumar S, et al. Implications of Dabigatran, a direct thrombin inhibitor, for oral surgery practice. J Can Dent Assoc 2013; 79: 74-81.
Olmos-Carrasco O, Pastor-Ramos V, Espinilla-Blanco R, et al. Hemorrhagic complications of dental extractions in 181 patients undergoing double antiplatelet therapy. J Oral Maxillofac Surg 2015; 73: 203-10.
Zhao B, Wang P, Dong Y, et al. Should aspirin be stopped before tooth extraction? A meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119: 522-30.
Lu SY, Tsai CY, Lin LH, et al. Dental extraction without stopping single or dual anti-platelet therapy: results of a retrospective cohort study. Int J Oral Maxillofac Surg 2016; 45: 1293-8.
Johnston SA. New generation of antiplatelet, and anticoagulant medication and the implications for the dental surgeon. Dent Update 2015; 42: 840-2.
Johnston S. An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery. Int J Oral Maxillofac Surg 2016; 45: 618-30.
Alcaide L, Martin C, Mourelle P. Dental management in patients with antiplatelet therapy: A systematic review. J Clin Exp Dent 2017; 9(8): e1044-50.

open access plus

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2019
Published on: 28 June, 2018
Page: [30 - 39]
Pages: 10
DOI: 10.2174/2542579X01666180629094559

Article Metrics

PDF: 49