Anticoagulation Myth Busters
“All patients must stop anticoagulant agents prior to dental procedures”
“Dental procedures are generally considered to be interventions associated with minor bleeding risk.”1
In order to minimise the risk of bleeding complications, guidelines advise that all dental procedures are risk stratified, taking into account the risk of bleeding associated with the dental procedure itself, alongside the patient’s individual stroke risk (based on CHA2DS2-VASc) and their bleeding risk (based on HAS-BLED).2 Where possible, modifiable bleeding risk factors should be addressed and the use of non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided.3 The risk of significant bleeding during dental procedures in patients on warfarin with an INR >4 or a NOAC is small and thus oral anticoagulants do not routinely need to be withheld in the majority of stable patients undergoing a routine dental procedure.4, 5
The timing of NOAC dosing in relation to when the procedure is planned should be taken into consideration to minimise post-procedural bleeding. Dental surgeons should aim to undertake procedures when peak NOAC concentrations have reduced (i.e., at least 5-6 hours post dose).5 Current guidance suggests achieving this by delaying the morning dose of a NOAC for procedures with a high risk of bleeding.2, 4, 5 In addition, guidelines suggest waiting a minimum of four to six hours after the procedure, and ensuring haemostasis has been achieved, prior to re-starting NOAC therapy.5
Patients at high risk of bleeding undergoing more invasive procedures, should be considered for referral to specialist units for their procedures.
- Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. Europace. 2018.
- Programme SDCE. Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs Dental Clinical Guidance. In: Programme SDCE, editor. 2015.
- Sivolella S, De Biagi M, Brunello G, Berengo M, Pengo V. Managing dentoalveolar surgical procedures in patients taking new oral anticoagulants. Odontology. 2015;103(3):258-63.
- Perry DJ, Noakes TJ, Helliwell PS, British Dental S. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Dent J. 2007;203(7):389-93.
- Patel JP, Woolcombe SA, Patel RK, Obisesan O, Roberts LN, Bryant C, et al. Managing direct oral anticoagulants in patients undergoing dentoalveolar surgery. Br Dent J. 2017;222(4):245-9.