Introduction
Today, we delve into an important topic that intersects the worlds of cardiology and dentistry: anticoagulant therapy and dental treatment. In this article we will provide a comprehensive understanding of the current guidelines from the American Dental Association (ADA) regarding the management of anticoagulant therapy in the context of dental treatments.
What is Anticoagulant Therapy?
Anticoagulant therapy involves the use of medications to prevent blood clots in the body. These medications, often referred to as “blood thinners,” are typically prescribed to patients with conditions such as atrial fibrillation, deep vein thrombosis, or those who have undergone heart valve surgery (*remember*: patients with artificial heart valves require antibiotic prophylaxis!).
Note: many patients will also refer to aspirin and other anti-platelet medications such as clopidogrel and ticagrelor as “blood thinners” as well! When talking with your patients, be certain to take a comprehensive medication history, and differentiate between the two classes of medications!
There are three main classes of anticoagulants: Vitamin K Antagonists (VKAs), Direct Oral Anticoagulants (DOACs or sometimes NOACs) and Heparins. See the table below for an easy to read overview!
Anticoagulant Type |
Mechanism of Action |
Blood Testing Required |
Interactions with Food and Other Medications |
VKAs (Warfarin) |
Inhibits synthesis of vitamin K-dependent clotting factors in the liver |
Yes |
Yes |
DOACs (Apixaban, Rivaroxaban, Dabigatran) |
Directly inhibits Factor Xa or thrombin |
No |
Less |
Heparins (Unfractionated heparin, Enoxaparin, Dalteparin) |
Activates antithrombin, inhibiting thrombin and Factor Xa |
Yes |
Less |
The Intersection of Cardiology and Dentistry
Dental treatments, particularly those involving invasive surgical procedures, can pose a challenge for patients on anticoagulant therapy. The risk of bleeding during and after the procedure is generally much higher in these patients. However, discontinuing anticoagulant therapy also carries a risk: the potential for developing a blood clot. It’s a delicate balance that needs to be managed carefully.
It is best practice to engage in interprofessional communication when treating a patient under the care of a cardiologist. At DentalRx, we facilitate these communications on behalf of the attending dentist so that patients are always receiving the safest care possible.
If you are interested in how DentalRx can help facilitate interprofessional collaboration in your dental clinic, feel free to contact us!
Current American Dental Association Guidelines
The American Dental Association (ADA) has provided guidelines to help navigate this complex issue. According to the ADA, in most cases, it is safer to continue anticoagulant therapy than to stop it. The risk of developing a potentially life-threatening blood clot outweighs the risk of prolonged bleeding during or after dental treatment, which can be managed with local hemostatic measures.
However, the ADA guidelines also emphasize the importance of individualized patient assessment. The decision to continue or interrupt anticoagulant therapy should be made in consultation with the patient’s physician or cardiologist and should take into account the type of dental procedure, the patient’s overall health status, and the specific anticoagulant medication being used.
Anticoagulant Type |
Low/Medium Bleed Risk |
High Bleed Risk |
VKAs (Warfarin) |
Continue as normal |
Consult cardiologist (may temporarily target lower INR, but usually continued if INR stable) |
DOACs (Apixaban, Rivaroxaban, Dabigatran) |
Continue as normal |
Consult cardiologist (may hold for 24h pre and post dental procedure) |
Heparins (Unfractionated heparin, Enoxaparin, Dalteparin) |
Continue as normal |
Continue as normal (usually used as acute DVT/PT treatment); consider delaying elective dental procedures |
Oral Anticoagulant and Antiplatelet Medications and Dental Procedures
How to Assess Bleeding Risk
The HAS-BLED score is a commonly used tool to assess the risk of bleeding in patients with atrial fibrillation who are on anticoagulant therapy. The acronym HAS-BLED stands for the different factors that are considered in the assessment. Each factor contributes one point to the total score:
- Hypertension: Chronic or uncontrolled high blood pressure.
- Abnormal renal and liver function: This includes the presence of chronic kidney disease, liver disease, or biochemical evidence of significant hepatic or renal disease.
- Stroke: Previous history of stroke.
- Bleeding: History of bleeding, particularly if it required hospitalization or caused a decrease in hemoglobin level.
- Labile INR: Unstable or high international normalized ratio (INR) if the patient is on warfarin.
- Elderly: Age over 65 years.
- Drugs or alcohol: Concomitant use of drugs such as antiplatelet agents or nonsteroidal anti-inflammatory drugs (NSAIDs), or alcohol abuse.
The total score can range from 0 to 9. A score of 0 to 2 is generally considered low to moderate risk, while a score of 3 or more is considered high risk. However, the interpretation of the score is specifically in the context of atrial fibrillation, and should be used with discretion when being applied to invasive dental procedures.
Emergency Measures to Control Bleeding
In the event of excessive bleeding during or after dental procedures, there are several emergency measures that can be taken to control bleeding. These include both mechanical methods and the use of local hemostatic agents.
Mechanical methods include pressure dressings and sutures. Pressure dressings involve placing a gauze pad over the wound and applying pressure, often by having the patient bite down on the gauze. Sutures may be used to close the wound and help stop bleeding.
Local hemostatic agents include Gelatin Sponge (Gelfoam), Oxidized Regenerated Cellulose (Surgicel), and Topical Thrombin. These agents can be applied directly to the wound to help promote clotting and control bleeding.
In some cases, a prescription medication may be required to control bleeding such as tranexamic acid. Tranexamic acid (TXA) works by helping the blood to clot, thereby preventing prolonged bleeding.
The following is a standard prescription for tranexamic acid to stop post-operative bleeding:
- Tranexamic Acid 4.8% Mouthwash – Hold 5 to 10 mL in mouth and rinse for 2 minutes; drain gently, being careful not to forcibly spit and dislodge clots; do not eat or drink for 1 hour after using oral rinse. Repeat BID to QID for 1 to 2 days after the procedure*
*Systemically absorbed tranexamic acid promotes clotting throughout the entire body and therefore increases DVT, PE, Stroke, and MI risk. These prescription samples are for informational use only.
Conclusion
Navigating anticoagulant therapy during dental treatments can be complex, but with the guidance of the ADA and a team of informed healthcare professionals, patients can safely receive the dental care they need.
Remember, this blog post is intended to provide a general understanding of the topic. As a dental professional you must take into full consideration the patient’s disposition and consult with involved healthcare professionals for advice tailored to the specific circumstances.