Here’s a tip. If you don’t like blood, don’t go into dentistry. Dentists see a lot of blood, and often get their (gloved) hands full of it. Bleeding is common and of little concern during many dental procedures as is the occasional bit during routine brushing and flossing. While rare, uncontrolled bleeding, during or following dental treatment, is one of the most distressing situations for both dentists and their patients.
Though in previous articles I've challenged some assertions made by self-titled “holistic” dentists, they do correctly state the obvious; that practitioners must consider a patient's overall health and medical profile, and not just of their mouth, before initiating treatment. When filling out a medical questionnaire, people are asked to list any medications they are on. Of particular note are anticoagulants, commonly referred to as “blood thinners.”
Anticoagulants are medicines that help prevent blood clots. They're given to people at a high risk of getting clots, to reduce their chances of developing serious conditions such as strokes, heart attacks and pulmonary embolisms. Dentists must consider the use of any of these agents by patients prior to initiating treatment, particularly those that elicit significant bleeding such as extractions and periodontal surgery. In past decades blood thinners were routinely halted for several days prior to many dental procedures.
Current Guidelines
Both the American and Canadian Dental Associations, in consultation with various medical groups, have developed guidelines regarding interruption of anticoagulant therapy prior to dental treatment. When making these decisions, dentists must weigh the potential serious risks of interrupting these medications against the likelihood of inability to control prolonged bleeding using local measures such as mechanical pressure, hemostatic agents and suturing. So let's examine current recommendations for the three most common situations dentists encounter.
Baby Aspirin
Though less commonly prescribed than in the past, many people routinely take this antiplatelet drug to prevent blood clots leading to heart attacks and strokes. Current recommendations do not suggest discontinuing the use of daily aspirin before minor dental treatment, including routine extractions of one to three teeth, as the risk of discontinuation outweighs potential bleeding complications.* **
WARFARIN
During past decades this anticoagulant, also known as Coumadin, was the most common in its class encountered in dental practices. Having gained notoriety for its use as rat poison, warfarin acts by reducing the active form of vitamin K that is essential for normal clotting, thus increasing prothrombin time. The international normalized ratio (INR) blood test measures clotting time, with a level below 1.1 considered normal. People taking Coumadin generally have an IRN between 2-3 for effective therapeutic effect. There is general agreement that in most cases, interruption of this older anticoagulant is not required before most routine dental procedures.* ** Practically speaking, most people prescribed this drug do not have their current INR readily available. According to the North American Thrombosis Forum (Aug. 2022), dentists need not routinely consult a patient's doctor about stopping warfarin before simple dental procedures including routine extractions.
DOACs (Direct Oral Anticoagulants)
More recently, physicians are prescribing newer direct-acting oral anticoagulants, with Apixaban (Eliquis) being common. These targeted agents have several advantages over traditional vitamin K antagonists while requiring little to no routine monitoring. Based on limited evidence, general consensus appears to be that most patients receiving a DOAC need not alter their regimen when having routine dental treatment.* That being said, dentists should always consult with the prescribing physician prior to adjusting treatment.
Considerations
Despite general consensus among national medical and dental associations not to interrupt anticoagulation therapy prior to most dental treatments, dentists must consider various factors before making this decision. Some people have comorbid conditions or are on other medications that can prolong clotting time. In these instances dentists should consult their patient’s physician in order to make an informed decision. Additionally, for more complex procedures with increased risk of bleeding, consultation with medical professionals pre-op is highly recommended.
So What’s a Dentist to do?
While interrupting therapeutic levels of continuous anticoagulation for dental surgery is not based on scientific fact, some doctors and dentists still adhere to these older regimens. I’ve seen patients show up having already stopped their anticoagulant by themselves in anticipation of an extraction. Others are instructed by their physician to interrupt therapy prior to dental surgery contrary to what the literature says. In these instances, I encourage people to consult their doctor regarding current guidelines. Ultimately, the dentist is responsible for guiding their patients in this matter and must carefully assess the risk of interrupting medications against rare bleeding complications. Nonetheless, it would be ill-advised to disregard a physician's instructions, despite current recommendations. While the patient’s health always comes first, no dentist wants to find themselves on the receiving end of an investigation. And that seems right, quite right. Bloody well right!
Sources
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**J Can Dent Assoc 2020;86:K17
Dr. Mark Grossman is a practicing dentist and likes to take a bite out of nonsense when it comes to dental issues.
