A good review of the medical history is the first step to provide excellent care for our dental patients. Many medications have an impact on our therapies or dictate a modification on the treatment plan. One example of such type medications is oral anticoagulants. Traditional oral anticoagulants includes heparin and vitamin K antagonist like Warfarin and risk assessment prior to dental treatment could be completed with a simple laboratory test (INR) prior to procedure. Within the last 5 years, there has been an increased use of newer oral anticoagulants.
The newest oral anticoagulants include the following non-vitamin K antagonist: Rivaroxaban (Xarelto), Dabigatran (Pradaxa), Apixaban. Dabigatran is an oral direct thrombin inhibitor. Rivaroxaban and Apixaban are Factor Xa inhibitors. The use of these medications for the management and prevention of venous thromboembolism and stroke prevention in patient with atrial fibrillations is increasing significantly. These medications provides the advantages of having a quicker onset and offset of action, fewer drug / food interactions, allow use of a fixed dose, doesn’t require constant monitoring and dose adjustments.
For regular dental procedures where minimal or no bleeding is expected, no modifications on the treatment plan is needed. For most of our surgical procedure (single or multiple extraction with or without bone graft, Scaling and Root planning, tissue graft, implants) routine bleeding control measurements will suffice to obtain hemostasis. These measurements include pressure, sutures, dressings and palatal stent.
In a study1 monitoring 564 patients undergoing implant surgery and bone grafting procedures, no post-operative bleeding was recorded for patient that were taking the newest oral anticoagulants. However, the challenge comes when significant bleeding is expected since no reversal agent is readily available. Available research suggest reversal with prothrombin complex , factor VIIa or concentrated of factors II, IX and X but additional research is needed to determine the protocol with some degree of predictability2. At this point, quantitative , calibrated factor IIa and Factor Xa assays are probably the optimal means of monitoring anticoagulant therapy2.
Also, it will be wise to consult with the patient primary physician for a short term modification on the drug regimen. Peak action of these anticoagulants occurs 4 hours after intake.
Scheduling a surgical procedure before intake may also aid in bleeding prevention.
1.Cheng, J. W., & Barillari, G. (2014). Non-vitamin K antagonist oral anticoagulants in cardiovascular disease management: evidence and unanswered questions. Journal of Clinical Pharmacy and Therapeutics, 118-135.
- Clemm R,Neukam FW, Rusche B, Musazada S, & Schmitt CM. (2015). Management of anticoagulated patients in implan therapy: a clinical comparative study. Clinical of Oral Implant Research, Epub ahead pf print.