Clinical Guideline 2 - Version 5

Valid to: March 2017

Medication that may Influence Haemostasis

Purpose
This Clinical Guideline provides advice to public oral health clinicians regarding the
management of patients taking medication that may influence Haemostasis.
Evidence-based clinical guidelines are intended to provide guidance, and are not a standard
of care, requirement, or regulation. However, the application of clinical guidelines in
publicly-provided oral health services allows for consistency to occur across large patients
cohorts with a variety of oral health clinicians.
Medications which are associated with prolonged bleeding times and greater operative risk
include Heparin, which is used primarily for in-patient short-term therapy, e.g. renal
dialysis, (Accordingly renal dialysis patients that are on heparin should not have teeth
removed on the day of dialysis) Warfarin and antiplatelet medications.
Patients on Warfarin and antiplatelet medications like Aspirin, Clopidogrel and dabigatran
etexilate are encountered frequently in dental practice.
The risk of increased hemorrhage is also associated in patients with qualitative or
quantitative platelet anomalies, congenital and acquired coagulopathies, including those
with chronic kidney conditions, liver failure, or alcoholics (Daniel et al 2002). In these
situations, it is best to proceed with treatment only after a medical consultation.
The main issue for evaluation of patients who are identified as taking anticoagulant or
antiplatelet medication is a risk benefit assessment of ceasing/reducing the medication and
risking thromboembolism, versus maintaining/reducing the medication and risking local
wound bleeding (Goss, 2002). The risks of ceasing/reducing the medication may include
deep-vein thrombosis, cerebro-vascular event, or myocardial infarction, all of which are lifethreatening events. A philosophy of NO change to anticoagulant or antiplatelet
medication doses is recommended.

Guideline
Clinical Considerations
While taking the medical and drug history of the patients before any dental treatment it is
essential to ascertain if the patient is taking any anticoagulation or antiplatelet medication.
The name, dosage and indication of such medications should be recorded along with any
other medications being taken by the patient. For patients on warfarin the patients
international normalized ratio (of prothrombin time) (INR) should be monitored (Rice
2003).
Platelet coagulation time is only useful in patients with known platelet disorders, and is not
a routine test for patients on antiplatelet medication.
There are a number of other medications that may interfere with the coagulation process
and potentiate the effect of anticoagulants. Reference should be made to a listing of
pharmaceutical products, e.g. MIMS.
Dabigatran and Rivaroxaban are increasingly used in Australia as oral anticoagulants and
unlike warfarin, there is no laboratory tests available to guide treatment or any reversal
agent.
Drugs commonly used in dentistry that interact with warfarin include carbamazepine,
metronidazole, sulphonamides, erythromycin, miconazole (oral gel) and tetracycline (ADJ,
2003). Concurrent use of Aspirin and non-steroid anti-inflammatory drugs (NSAIDS) with

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Clinical Guideline 2 - Version 5

Valid to: March 2017
warfarin should also be avoided because of increased risk of bleeding due to antiplatelet
effect.
Prolonged/unreasonable use of any oral antibiotic for treating tooth infection is not
recommended in warfarinised patients due to potential for gut flora suppression and risk of
elevated INR due to vitamin K deficiency.
Local anesthetic agents, paracetamol and codeine do not interact with warfarin.
If the patient is on anticoagulant or antiplatelet medication, the patients medical
practioners should be consulted before undertaking dentoalveolar surgery including
extractions. In all cases local measures help to achieve hemostasis. Do not cease the
antiplatelet/anticoagulation medication.
In cases where spontaneous/uncontrolled bleeding is experienced then urgent medical
attention is required.

Treatment Considerations
Warfarin
Common medical conditions for which patients are warfarinised, and the usual therapeutic
INR ranges, are:
Deep vein thrombosis
1.5 2.5
Prosthetic heart valve
2.5 3.5
Stroke
1.5 2.5
Pulmonary embolism
1.5 2.5
Atrial fibrillation
1.5 2.5
The following management protocol is proposed for patients who are on warfarin and
require extraction or dentoalveolar surgery (ADJ, 2003).

Detailed medical history should be taken which includes warfarin dosage, INR
stability and underlying medical condition.

Assessment of the need for antibiotic prophylaxis depending upon patients

underlying predisposing medical condition.

Warfarin is not ceased and preoperative assessment of INR for Warfarin is needed
within 24 hours of the dental procedure to ensure it is within the therapeutic range
acceptable for the patient. Consultation with the patients physician may be
necessary to interpret test results.

Most patients on Warfarin are usually held in the INR range of 2 3.5.

If the INR is less than 2.2:

Proceed with surgery if no other contraindications

Tranexamic acid mouthwash is not required.

In Special Needs situations, where there is concern about the patients

ability to follow good local measures more care needs to be taken with
INR.

In both Special Needs Department at the Royal Dental Hospital of

Melbourne, and the Royal Childrens Hospital of Melbourne, extractions
are not provided at higher INR levels.

Do not advise patients to cease Warfarin, but consult with the patients
medical practitioner. Use local measures to control bleeding (see below
under the heading, local measures to control bleeding)

If INR is 2.2 to 4:
o

Proceed with surgery if no other contraindications

Use local measures to control bleeding (see below under the heading,
local measures to control bleeding)

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Use tranexamic acid mouthwash (see protocol below)

If the preoperative INR result is more than 4, the patients physician should be
consulted and dental surgery delayed until INR is within the patients therapeutic
range. If the INR returns to acceptable level, surgery should occur the afternoon of
the INR test.

Tranexamic acid mouthwash protocol:

Used for patients whose INR is 2.2 to 4.0

On day of surgery get a bottle of 4.8% tranexamic acid mouthwash. This

is available in Australia through the pharmacy department of major
hospitals. Dentists are able to contact the hospital departments by phone
and obtain the prepared mouthwash at a cost of approximately $15 to
the patient.

For dentists with no access to major public hospital, a 5% solution of

tranexamic acid mouthwash can be made by crushing a 500mg tablet
and dispersing it in 10 ml of water immediately before administration.
Pharmaceutical benefits scheme (PBS) does not subsidize tranexamic
acid 500 mg tablets when prescribed by a dental practioner but are
available as a private dental prescription at a cost of around $31 for a 20
tablets pack.

Newer formulations mouthwash/gel of Tranexamic acid are available

which have an expiry of up to 6 months from compounding pharmacies.

Following extraction of teeth irrigate sockets with tranexamic acid

mouthwash using a disposable syringe

Ask patient to bite on a gauze pack soaked in tranexamic acid

mouthwash.

Give patient tranexamic acid mouthwash and advice to rinse with 10 ml

for 2 minutes, 4 times a day for 2 to 5 days.

Review patient after 2 days of extraction and check for bleeding,

infection or pain and treat as necessary.

Review patient again in 1-2 weeks to confirm wound healing.

Administration of 10 ml of a 4.8% tranexamic acid mouthwash results in an

average concentration of 7 micrograms of tranexamic acid per ml of saliva after
two hours and the drug remains at detectable levels in the saliva for eight hours.
There is insignificant inhibition of systemic fibrinolysis and no side effects following
this treatment provided the patients follow the directions (i.e., do not swallow the
mouthwash)
Tranexamic acid has also been shown to accelerate normal wound healing (Bjoerlin
1988; Vinkier 1984)

Local measures to control bleeding in warfarinised patients undergoing dental

extractions

Local anaesthetic should be administered cautiously avoiding

venepuncture; infiltrating a small amount of local anaesthetic solution
with 1:100000 or 1:200000 adrenaline close to the surgery site to
encourage local vasoconstriction.

Controlled, minimally traumatic surgical technique

Local pressure with gauze packs

Sutures

Absorbable packs (Surgicel, Gelfoam)

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Tranexamic acid mouthwash (INR 2.2-4)

Antiplatelet medications
Antiplatelet drugs include acetylsalicylic acid (e.g. aspirin), non steroidal anti-inflammatory
medication (e.g. ibuprofen or naproxen), ticlopidine (e.g. Tilodene), clopidogrel (e.g.
Plavix), and dipyridamole (e.g. Persantin), amongst others. It is important to assess the
reason for which the patient is taking the medication. The bleeding time can be used as an
indicator as to the extent of the effect of any antiplatelet drugs. Bleeding time is normally 4
8 minutes.
In patients taking antiplatelet medication for treatment and prevention of thromboembolic
diseases, best practice advocates that:

Patients do not stop taking the medication prior to dental surgery provided that
there is no high risk of severe bleeding.

Intraoperative recommendations are;

o

Use of a minimally traumatic surgical technique plus a local anaesthetic combined

with a vasoconstrictor

Use of local haemostatic methods suturing of sockets and mucoperiosteal flaps,

placement of oxidized cellulose gauze or Gelfoam in the sockets, and mechanical
pressure.

Special Needs Patients

It is important to assess the ability of the patient and their carers to follow through
with 'good local measures' after extractions and invasive procedures.

Where it is anticipated that local measures won't be adequately followed through,

additional precautions are necessary.

Sockets are routinely sutured, and sometimes packed also, after dental extractions,
depending on the assessment of the patients situation.

Assess exactly what the carer and patient can do and what they are unlikely to do.
Things to consider include: Physical disability, intellectual disability, cognitive
impairment, movement disorder, dysphagia, seating/posture of patient with
aspiration/choking risk, lack of support/confidence from carers, and safety of carers
in managing bleeding.

For patients taking Warfarin, the 'rule of thumb' within the Special Needs
Department at RDHM is that extractions are not performed when INR is >2.5 and
scaling is not performed when INR is >2.8.

At the Royal Childrens Hospital of Melbourne, extractions are not done when a
patient has an INR >2.0

If in any doubt, it is prudent to obtain advice from a medical practitioner,

hematologist, or oral surgeon.

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Definitions
Nil

Revision date

Policy owner

March 2017

Clinical Leadership Council

Approved by

Date approved

Director of Clinical Leadership, Education

and Research

March 2014

References and related documents

G Carter, AN Goss,J Lloyd,R Tocchetti.current concepts of the management of

dental extractions for patients taking warfarin. Australian Dental Journal
2003,48(2);89-96

Australian prescriber vol.26 No.4 2003 and vol.33 No.2 April 2010

R.G.Woods,N Savage; Australian prescriber 2002;25:69

Therapeutic guidelines,oral and dental:2012,version 2

Daniel N et al. Antiplatelet drugs: Is there a surgical risk? Journal of the Canadian
Dental Association December 2002, 68(11):683-687b

Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other
indications. Drugs 1999;57(6):1005-10032.

Goss AN, Carter G. Dental patients receiving warfarin therapy. Australian Prescriber
2002; 25(5):105-106.

Purcell CAH. Dental management of the anticoagulated patient. New Zealand Dental
Journal 1997; 93:87-92.

Rice PJ, Perry RJ, Afzal Z, Stockley IH. Antibacterial prescribing and warfarin: a
review. BDJ 2003; 194(8):411-415.

Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart

valves undergoing oral and maxillofacial operations. B J Oral Maxillofac Surg 2000;
38(2):124-126.

Bjoerlin G,Nilsson IM.The effect of antifibrinolytic agents on wound healing.Int J

Oral Maxillofac Surg 1988;17:273-276

Vinkier F,Vermylen J. Wound healing following dental extractions in rabbits: Effects

of tranexamic acid, warfarin anticoagulation and socket packing.J Dent Res
1984;63:646-649

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