Anticoagulants Warfarin (sold under several brand names including Coumadin) is an oral anticoagulant which works by preventing the formation of vitamin K-dependent clotting factors. Patients on warfarin are getting their blood tested routinely to ensure their International Normalized Ratio (INR) is within the therapeutic range. Dentists should ask patients about their most recent INR before providing any invasive dental care. A 2016 Clinical Practice Statement from the American Academy of Oral Medicine (AAOM) states “…moderately invasive surgery (e.g. uncomplicated tooth extractions) is safe with an INR up to 3.5, with some experts stating it is safe up to 4.0.” The AAOM recommends that the INR should be checked within 24 hours before highly invasive procedures. There are fewer prescriptions for warfarin since the introduction of direct acting oral anticoagulants (DOAC). These directly inhibit specific proteins in blood clotting. Compared to warfarin, DOAC’s are safer, more effective, cause less serious bleeding, do not require diet restrictions and do not require frequent lab tests to check INR. There are four common DOACs available in Canada: • apixaban (sold under the brand name Eliquis) • edoxaban (Liixiana) • rivaroxaban (Xarelto) • dabigatran (Pradaxa) Antiplatelets Antiplatelet and anticoagulant drugs work at different places in the coagulation system. Antiplatelets prevent platelets from sticking together and creating a blood clot. According to the Heart and Stroke Foundation, most people who have had a cardiac event take an antiplatelet drug. Antiplatelets are: • ASA, also called acetylsalicylic acid (sold under the brand name Aspirin, Asaphen, Entrophen, Novasen) • clopidrogel (Plavix) • prasugrel (Effient) • ticagrelor (Brilinta) What Treatment Modifications Should be Made with Patients on Blood Thinners Before Doing Invasive Dentistry? It is recommended to continue low-dose aspirin with invasive dental treatment. If a patient is on a blood thinner other than low-dose aspirin, the following are recommended: • Get a medical consult if you are concerned there will be unmanageable excessive bleeding. • Time the procedure so it is not performed soon after taking the medication. • Manage bleeding. Medical Consults A medical consult should be considered if you are concerned that you won’t be able to manage excessive bleeding. Procedures with a higher risk of excessive bleeding include extracting more than 3 teeth, surgical extractions, periodontal surgery and osteoplasty. Procedures considered to be low risk include scaling, doing 3 or less simple extractions, and a single implant. Discontinuing Blood Thinners A physician may advise a temporary discontinuation of a blood thinner if there is a risk of excessive bleeding, but this is not common. Stopping blood thinners is not often recommended to patients because: • The risk of having a heart attack or stroke is higher than the risk of uncontrolled bleeding. • It is easier to manage excessive bleeding than it is to manage a heart attack or stroke. Dentists should consult with the patient’s physician before altering drug regimens. A medical consult should be considered if you are concerned that you won’t be able to manage excessive bleeding. Procedures with a higher risk of excessive bleeding include extracting more than 3 teeth, surgical extractions, periodontal surgery and osteoplasty. 36 | 2024 | Issue 4 SupportingYour Practice
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