Clinical practice advice

For a patient who is taking an anticoagulant or antiplatelet drug(s) and requires dental treatment that is unlikely to cause bleeding (see Bleeding risks for dental procedures):

• Treat the patient following standard procedures, taking care to avoid causing bleeding.

For a patient who is taking an anticoagulant or antiplatelet drug(s), and requires dental treatment that is likely to cause bleeding, with either a low or higher risk of bleeding complications (see Bleeding risks for dental procedures):

• If the patient is on a time-limited course of anticoagulant or antiplatelet medication, delay non-urgent, invasive dental procedures where possible until the medication has been discontinued.

• • If the medication is being taken in preparation for an elective surgical procedure it may be possible, in a dental emergency, to interrupt the drug treatment in liaison with the surgical consultant
  • Patients with acute deep vein thrombosis or pulmonary embolism may be taking high dose apixaban or rivaroxaban for the first 1 to 3 weeks of treatment. It would be advisable to delay any dental procedures likely to cause bleeding until the patient is taking the standard dose (see also final point below)

• If the patient has another relevant medical condition(s) or is taking other medications that may increase bleeding risk (see Patient bleeding risk factors – Other medical conditions and Patient bleeding risk factors – Other medication), consult with the patient’s prescribing clinician, specialist or general medical practitioner if more information is required in order to assess the likely impact on bleeding risk.

• • Consulting in advance of the appointment, could reduce wasted appointments and travel

• If advice is required on aspects of the procedure, liaise with a more experienced colleague, ideally in your own setting (see Contacts and Referrals).

• • Clinical experience indicates that most patients can be safely treated in primary care and only in exceptional circumstances should referral be required
  • Enquiries about the patient’s medication should be directed to the prescribing clinician

• Plan treatment for early in the day and week, where possible, to allow time for the management of prolonged bleeding or rebleeding episodes, should they occur.

• Provide the patient with pre-treatment instructions^a (e.g. for timing of INR testing or any modification of their medication schedule).

• • Provision of pre-treatment instructions (e.g. electronically or written) could reduce wasted appointments and travel

• Perform the procedure as atraumatically as possible, use appropriate local measures (see Haemostatic measures) and only discharge the patient once haemostasis has been achieved.

• • Suturing and packing at the time of treatment may reduce the likelihood of the patient having to reattend or travel to emergency care for the management of post-operative bleeding

• If travel time to emergency care is a concern, place particular emphasis at the time of the initial treatment on the use of measures to avoid complications (e.g. limiting the initial treatment area, staging treatment, haemostatic measures and post-treatment monitoring).

• Advise the patient to take paracetamol, unless contraindicated, for pain relief rather than NSAIDs such as aspirin, ibuprofen, diclofenac or naproxen.

• Provide the patient with post-treatment advice and emergency contact details.^a

• Follow the specific recommendations and advice given in the Treatment Recommendations section for the management of patients taking the different anticoagulants or antiplatelet drugs.

• Do not interrupt anticoagulant or antiplatelet therapy, except under direct written instruction from the patient’s cardiologist, for:

• • patients with prosthetic metal heart valves or coronary stents
  • patients who have had a pulmonary embolism or deep vein thrombosis in the last three months
  • patients on anticoagulant therapy for cardioversion

^a Pre- and post-treatment advice sheets are available at www.sdcep.org.uk