dentist_anticoag.pdf

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More. . .Copyright 2011 by Therapeutic Research Center

P.O. Box 8190, Stockton, CA 95208 ~Phone: 209-472-2240 ~Fax: 209-472-2249www.pharmacistsletter.com ~www.prescribersletter.com ~www.pharmacytechniciansletter.com

PL Detail-Document #270503This PL Detail-Document gives subscribers

additional insight related to the Recommendations published in

PHARMACISTS LETTER / PRESCRIBERS LETTERMay 2011

Managing Anticoagulant and Antiplatelet Drugs Before Dental ProceduresBackground

Patients taking warfarin or antiplatelet agents

face an increased risk of bleeding due to dental

procedures. But stopping these medications may

put the patient at risk of a thrombotic event (e.g.,

DVT, stroke). Therefore, the risk of bleeding

must be weighed against the risk and

consequences of thrombosis. This article reviews

recommendations for managing these medications

in patients requiring a dental procedure.

Recommendations and RationaleWarfarin or aspirin can be continued with local

hemostatic measures (see below) provided the

INR is less than 4 during most dental

procedures.1,2 These include crowns, bridges, root

canals, simple extraction of a limited number of

teeth, implants, surgical tooth removal,

supragingival scaling, and gingival surgery.3,4

These recommendations are based on studies of

patients taking warfarin or low-dose aspirin

undergoing simple extractions as well as oral

surgery.3 There is less data pertaining to bleeding

risk with clopidogrel, prasugrel (Effient), ordipyridamole, either alone or with aspirin.1,3,5 The

risk of bleeding with dipyridamole/aspirin is

similar to that of aspirin alone.5 Clopidogrel and

prasugrel should be handled like aspirin

monotherapy (i.e., they should not be stopped).3,5

However, patients taking clopidogrel or prasugrel

(and by extension ticlopidine) plus aspirin are at

higher risk of bleeding.5 Patients taking such

combinations could be considered for inpatient

management by a dentist or oral surgeon familiar

with these patients. Alteration of antiplatelet

therapy is not recommended.3,5 At this time, thereis no data about the bleeding risk with dabigatran.

Life-threatening bleeding after dental surgery

is rare.1 The risk of thromboembolism off

warfarin for as little as two days may be as high as

0.02% to 1%. The risk of death or disability due

to holding warfarin is higher than the risk of death

or disability due to continuing it during most

dental procedures.2

Managing BleedingIt is recommended that patients taking warfarin

or antiplatelet agents be scheduled early in the

day, and early in the week, to facilitate optimal

management of both early and late re-bleeding.3

For patients taking warfarin, the INR should be

checked within 24 hours before the procedure.

But within 72 hours prior is acceptable if the

patients INR is generally stable.2 For help if theINR is out of range, get ourPL Chart, How to

Manage High INRs in Warfarin Patients.

Hemostatic measures include use of a gelatin

sponge sutured within the socket,

vasoconstrictor/anesthetic combinations, and

atraumatic surgical techniques.1,3 Having the

patient bite down on gauze sponge/pad for 15 to

30 minutes after closure is suggested too.3

Observe for hemostasis before the patient leaves.

A thrombin solution-soaked gel sponge can be

used for persistent bleeding.6 Instruct patients

to:3,7Rest for two or three hours.Not disturb the clot with the tongue or any

object, or by sucking on straws, cigarettes, etc.

Avoid hot foods/liquids and hard foods for thefirst day.

Do not rinse for 24 hours.Avoid chewing on the affected side for at least a

day or two.

If bleeding starts, hold pressure with gauze or aslightly moistened tea bag (black tea) for

20 minutes, and call the dentist if it does not

stop.

Avoid NSAIDs for at least 24 hours postprocedure.

In addition to these general measures,

aminocaproic acid solutions have been

recommended for use in warfarin-treated patients.

Aminocaproic acid solution is easier to make and


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(PLDetail-Document#270503: Page 2 of 3)

More. . .Copyright 2011 by Therapeutic Research Center

P.O. Box 8190, Stockton, CA 95208 ~Phone: 209-472-2240 ~Fax: 209-472-2249www.pharmacistsletter.com ~www.prescribersletter.com ~www.pharmacytechniciansletter.com

is less expensive than tranexamic acid solution.8

In general, tranexamic acid mouthwash is not

recommended. It is expensive, difficult to obtain,

and has unproven additive benefit when used with

other local hemostatic measures including

suturing.2

In one protocol, patients are instructed to hold

10 mL of an aminocaproic acid solution for twominutes in the affected area just before the

procedure. After the procedure, they are

instructed to repeat this every one to two hours

until the solution is gone. Make sure that patients

hold the solution in the area rather than swish it

around like mouthwash, which can disturb the

clot. An aminocaproic acid solution can be made

by diluting a 5 gram vial with sterile water for

injection to a total volume of 100 mL.8

(Aminocaproic acid is not available in Canada.)

Stopping NSAIDsNSAIDs, including COX-2 inhibitors, havereversible antiplatelet effects. If the risk of

stopping the NSAID isnt significant, then

stopping them before the procedure can lower

bleeding risk. To ensure absence of antiplatelet

effect, NSAIDs should be discontinued five half-

lives before the procedure. The following chart

shows how long before the procedure each

NSAID should be discontinued.9

NSAID Time to hold before

procedure

Diclofenac (e.g.,Voltaren),

Ibuprofen (e.g.,

Motrin),

Indomethacin (e.g.,

Indocin),

Ketoprofen

One day beforeprocedure

Celecoxib (Celebrex),

Diflunisal,

Naproxen (e.g.,

Naprosyn),

Sulindac (e.g., Clinoril)

Two to three days

before procedure

Meloxicam (e.g.,Mobic

[U.S.],Mobicox

[Canada]),

Nabumetone,

Piroxicam (e.g.,

Feldene)

Ten days before

procedure

ConclusionCurrent literature does not address stopping

cilostazol (Pletal [U.S. only]), heparins, or

dabigatran (Pradaxa; Pradax [Canada]) before

dental procedures. But based on what is known

about similar agents, consider continuing them,

assuming they are necessary. Patients taking

antiplatelet combinations could be considered forinpatient management.

Before a patient taking warfarin has a dental

procedure, check their INR to ensure it is within

the therapeutic range. Discontinue any unneeded

antiplatelet agents (e.g., NSAIDs). And avoid

prescribing antibiotics that can increase warfarin

effect (e.g., erythromycin, clarithromycin,

metronidazole).3 Patients at high risk of

thromboembolism requiring major oral surgery

should be considered for inpatient management

[Evidence level C; expert opinion].4

Users of this PL Detail-Document are cautioned to use

their own professional judgment and consult any othernecessary or appropriate sources prior to making

clinical judgments based on the content of this

document. Our editors have researched theinformation with input from experts, government

agencies, and national organizations. Information and

internet links in this article were current as of the dateof publication.

Levels of Evidence

In accordance with the trend towards Evidence-BasedMedicine, we are citing the LEVEL OF EVIDENCE

for the statements we publish.

Level Definition

A High-quality randomized controlled trial (RCT)

High-quality meta-analysis (quantitativesystematic review)

B Nonrandomized clinical trialNonquantitative systematic reviewLower quality RCT

Clinical cohort studyCase-control studyHistorical controlEpidemiologic study

C ConsensusExpert opinion

D Anecdotal evidenceIn vitro or animal study

Adapted from Siwek J, et al. How to write an evidence-based

clinical review article. Am Fam Physician 2002;65:251-8.

Project Leader in preparation of this PL Detail-

Document: Melanie Cupp, Pharm.D., BCPS


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(PLDetail-Document#270503: Page 3 of 3)References1. J eske AH, Suchko GD. Lack of a scientific basis

for routine discontinuation of oral anticoagulationtherapy before dental treatment. J Am Dental

Assoc 2003;134:1492-7.2. U.K. National Health Service. Surgical

management of the primary care dental patient onwarfarin. March 2007.

http://www.dundee.ac.uk/tuith/Static/info/warfarin.pdf. (Accessed April 11, 2011).3. Pototski M, Amenabar J M. Dental management of

patients receiving anticoagulation or antiplatelettreatment. J Oral Sci 2007;49:253-8.

4. Madrid C, Sanz M. What influence doanticoagulants have on oral implant therapy? Asystematic review. Clin Oral Implants Res2009;20(Suppl 4):96-106.

5. U.K. National Health Service. Surgicalmanagement of the primary care dental patient onantiplatelet medication. J anuary 2010.http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Surgical-management-of-the-primary-care-dental-patient-

on-antiplatelet-medication/. (Accessed April 22,2011).

6. Holtzclaw D, Toscano N. Management of theactively bleeding and hypovolemic dental patient. JImplant Adv Clin Dent 2009;1:19-27.

7. University of Washington Medical CenterAnticoagulation Clinics. Suggestions foranticoagulation management before and afterdental procedures.http://www.uwmcacc.org/pdf/dental.pdf. (AccessedApril 13, 2011).

8. Bussey HI. Should I stop my patients warfarinprior to a dental procedure?http://www.clotcare.com/faq_amicarsolution.aspx.(Accessed April 11, 2011).

9. Douketis J D, Berger PB, Dunn AS, et al. Theperioperative management of antithrombotictherapy: American College of Chest Physiciansevidence-based clinical practice guidelines (8thedition). Chest 2008;133(Suppl 6):299S-339S.

Cite this document as follows: PL Detail-Document, Managing Anticoagulant and Antiplatelet Drugs Before

Dental Procedures. Pharmacists Letter/Prescribers Letter. May 2011.

Evidence and Recommendations You Can Trust

3120 West March Lane, P.O. Box 8190, Stockton, CA 95208 ~TEL (209) 472-2240 ~FAX (209) 472-2249Copyright 2011 by Therapeutic Research Center

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