What’s recommended for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants?

This summary is based on the article published in the journal of Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology: Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants (December 2013)

Denise E. van Diermen, MD, PhD, Isaäc van der Waal, DDS, PhD, and Johan Hoogstraten, PhD

Context 

Oral antithrombotic medication (OAM) has long been used successfully to treat a variety of thrombotic diseases, such as myocardial infarction, stroke, and deep venous thrombosis, and to prevent cardiovascular diseases.(1-4) For decades, doctors and patients have worried about the adverse side effects of these medicines, mainly consisting of bleeding complications, either spontaneously or perioperatively.

In dentistry, this has been a major concern for years, resulting in the advice to temporarily discontinue OAM before invasive dental treatments, such as dental extractions. (5-7)

Purpose of the Review

• Search the scientific literature from 2007 to 2012 for guidelines and new studies on the dental management of patients using oral antithrombotic medication; Summarize the articles’ evidence and recommendations; and
• Propose an updated clinical practice guideline for general dentists.

Key Messages

• The evidence and subsequent recommendations from published guidelines all point in the same direction: do not interrupt oral antithrombotic medication, not even dual antiplatelet therapy, in simple dental procedures.
• Two systematic reviews (8-9) conclude in concordance with the earlier published guidelines, stating that “continuing the regular dose of warfarin therapy does not seem to confer an increased risk of bleeding when compared with discontinuing or modifying warfarin dose in patients undergoing minor dental procedures” (8) and “that there is no indication to alter or discontinue antiplatelet therapy before invasive dental procedures.” (9)
• General dentists can use the evidence-based recommendations derived from the available evidence described in this article for management of patients using oral antithrombotic medication, including the novel oral anticoagulants.

References

1. Seshasai SRK, Wijesuriya S, Sivakumaran R, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172:209- 216.
2. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42: 227-276.
3. Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative metaanalysis of individual participant data from randomised trials. Lancet. 2009;373:1849-1860.
4. Dentali F, Douketis JD, Lim W, Crowther M. Combined aspirinoral anticoagulant therapy compared with oral anticoagulant therapy alone among patients at risk for cardiovascular disease: a meta-analysis of randomized trials. Arch Intern Med. 2007;167: 117-124.
5. Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med. 1998;158:1610-1616.
6. Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. J Am Dent Assoc. 2000;131:77-81.
7. Piersma-Wichers G. [Coagulation disorders: risk factors for bleeding at dental procedures]. Ned Tijdschr Tandheelkd. 1998;105:136-138 [in Dutch].
8. Nematullah A, Alabousi A, Blanas N, Douketis JD, Sutherland SE. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis. J Can Dent Assoc. 2009;75:41.
9. Napenas JJ, Oost FCD, de Groot A, et al. Review of postoperative bleeding risk in dental patients on antiplatelet therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2013;115:491-499.