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Oral Health & Diagnostic Sciences

Clinical Guidelines

Anticoagulation Patient Guidelines


Questions to Ask / Necessary Information
Reasons for agent (warfarin, Coumadin), dosage, how often monitored, stability
of dosage over time, most recent INR value/date, any complications, anticipated
time that will be on medication

Risk for Medical Emergency


Increased clinical bleeding, urgency of treatment, presence of local factors that
increase the potential for hemorrhage, block anesthesia requirement, number of
anticipated visits

Pertinent Laboratory Information


INR < 3.5 (Expected range for most indications 2.0 - 3.0, for prosthetic
heart valves 2.5 - 3.5) Laboratory results should be available within last 2
days for all surgical procedures
Coagulation monitoring is usually not required for rivaroxaban or
dabigatran (factor Xa inhibitors) and reliable tests are not available. There
are no evidence-based guidelines for the dental management of patients
receiving these agents.
Management For Dental Treatment

Preoperative Management

For Routine Dental Treatment


Dental care should be coordinated with normal monitoring of patients INR
by physician. This commonly is done every 4-6 weeks.
All care may be safely performed without altering anticoagulation levels up
to INR 3.5.
For patients on short term anticoagulation therapy, it might be
appropriate to defer dental treatment until after cessation of therapy.
Block anesthesia poses risk of excessive, difficult to control, hemorrhage
and needs to done carefully.
Infiltration and periodontal ligament injections are particularly well suited
for patients with deficiencies of coagulation.

For Surgical Procedures Including Initial Root Planing of Patients with


Extensive Disease
Confirm INR value < 3.5 within 48 hours of surgery
Most surgical procedures can be safely performed if INR < 3.5
For extensive surgical procedures individualize treatment and consider (in

January 2016
Oral Health & Diagnostic Sciences
Clinical Guidelines
consultation with physician) reduction of anticoagulation using partial
withdrawal protocol to INR 3.0 or less. There is rarely an indication for
complete elimination of anticoagulation.
Discontinuation of factor Xa inhibitor approximately two days before
elective surgery without the need for bridging anticoagulation and
resumption of the medication 6 to 10 hours after surgery with attainment of
adequate hemostasis have been suggested in the medical literature. A
consult with the treating physician is advised.

Management During Treatment


Consideration should be given to subdividing extensive procedures into
smaller surgeries to minimize risk of hemorrhage.

Postoperative Management

Avoid ASA, NSAIDs for analgesia. Use acetaminophen for postoperative


pain control.
Make sure hemorrhage is under control before dismissing the patient.
Many medications including common antibiotics affect the anticoagulation
produced by warfarin.
Give clear/ complete post-operative instructions including after hours
contact information.

Oral Manifestations
Spontaneous gingival bleeding, especially in those with thrombocytopenia
Petechiae, ecchymoses, jaundice, pallor and ulcers of the oral tissues
Hemarthrosis of TMJ (rare)
With the following co-morbidities,
o Chronic liver disease enlargement of parotid glands
o Leukemia gingival hyperplasia
o Neoplastic disease radiographic osseous lesions, oral ulcers and
tumors, drifting and loosening of teeth, paresthesias (e.g. burning
tongue, lip numbness)
References
1. Little, Falace. The dental management of the medically compromised patient. 8 edition.
Mosby, 2008.
2. Rhodus, Miller. Clinicians guide: the medically complex dental patients. Third edition B.C.
Decker, 2008
3. Schulman S, Crowther MA (2012) How I treat with anticoagulants in 2012: new and old
anticoagulants, and when and how to switch. Blood 119: 3016-3023.
4. Turpie AG, Kreutz R, Llau J, Norrving B, Haas S (2012) Management consensus
guidance for the use of rivaroxaban--an oral, direct factor Xa inhibitor. Thromb Haemost
108: 876-886.
5. Hong CH, Islam I(2013) Anti-Thrombotic Therapy: Implications for Invasive Outpatient
Procedures in Dentistry. Blood Disorders Transf 2013, 4:6

January 2016

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