Dr. Jose Lança, from the Faculty of Dentistry and the Faculty of Medicine at the University of Toronto, speaks with Dr. John O’Keefe about the important decisions dentists need to make when treating patients who are on anticoagulants and who need dental surgery: should they, or not, ask the patient to stop taking their anticoagulant medication?
- The monitoring of warfarin anticoagulation is aimed at conventional anticoagulation INR of 2.0-3.0 (normal INR:0.9-1.1). Intensive anticoagulation is defined as an INR of 2.5-3.5, and critical values of >4.5-5.0.
- Do not be quick in discontinuing oral anticoagulants just because the patient might experience a bit more bleeding during or after dental surgery.
- What outweighs in terms of benefits for the dentist may result in serious risk or damage for the patient.
- The dentists should inform the patient about the risk of more bleeding prior to the surgery and should explain that this risk is mainly due to the fact that they are on anticoagulation therapy.
The drug names mentioned, in addition to warfarin (a vit. K antagonist) and low dose acetylsalicylic acid (Aspirin®) (platelet aggregation inhibitor) are as follows:
Inhibitors of platelet aggregation
- Clopidogrel (Plavix®) – platelet aggregation inhibitor
- Dipyridamole (Persantine®) – Inhibitor of Platelet Adhesion and Aggregation and coronary vasodilator
- Tranexamic acid (Cyclokapron®) – antifibrinolytic
New/Novel Oral Anticoagulants (NOACs) (shorter half-life than warfarin)
- Dabigatran (Pradaxa®) – anticoagulant, direct thrombin inhibitor
- Rivarobaxan (Xarelto®) – anticoagulant, Factor Xa inhibitor
Selective inhibitor for NOAC Dabigatran (Pradaxa®)
- Idarucizumab (Praxbind®) – monoclonal antibody, selective antidote for Dabigatran (Pradaxa®). Approved by the FDA since October 2015. Approved by Health Canada in April 2016
Note: a selective inhibitor for Rivarobaxan (Xarelto®) is currently in phase 3 clinical trials.
Dr. Lanca’s Presentation
Dr. Lanca’s COncluding Remarks
- A. J. Lança: Anticoagulants in Dental Practice, To Stop or Not-to-Stop? (PDF)
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- Sanchez-Palomino P et al. Dental extraction in patients receiving dual antiplatelet therapy. Med Oral Patol Oral Circ Bucal. 2015; 20(5):e616-620.
- Warfarin Anticoagulation and Dental Procedures. Lexicomp, Online, March 9, 2016
- Lu SY et al. Dental extraction without stopping single or dual antiplatelet therapy: results of a retrospective cohort study. Int J Oral Maxillofacial Surg. 2016; S0901-5027 (16)00069-2. [Epub ahead of print].
- Wahl MJ, Pinto A, Kilham J, Lalla RV. Dental surgery in anticoagulated patients – stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 Feb;119(2):136-57.
- Weltman NJ et al. Management of dental extractions in patients taking warfarin as anticoagulant treatment: a systematic review. J Can Dent Assoc. 2015;81:f20.
- Armstrong MJ et al. Summary of evidence-based guidelines: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease. Neurology 2013; 80:2065-2069.
- Karslı ED et al., Comparison of the effects of warfarin and heparin on bleeding caused by dental extraction: a clinical study. J Oral Maxillofac Surg. 2011; Oct; 69(10):2500-2507.