Guidelines for the management of patients on oral anticoagulants requiring dental surgery

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Perry DJ, Noakes TJC, Helliwell PS.  Guidelines for the management of patients on oral anticoagulants requiring dental surgery. British Dental Journal 203, 389 – 393 (2007).

Blockquote text:  The objective of these guidelines is to provide healthcare professionals, including primary care dental practitioners, with clear guidance on the management of patients on oral anticoagulants requiring dental surgery. The guidance may not be appropriate in all cases and individual patient circumstances may dictate an alternative approach.

Formats

Summary of key recommendations

  1. The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4 (ie <4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extraction (grade A level Ib)
  2. For patients stably anticoagulated on warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their anticoagulant regimen (grade C, level IV)
  3. The risk of bleeding in patients on oral anticoagulants undergoing dental surgery may be minimised by:
    • The use of oxidised cellulose (Surgicel) or collagen sponges and sutures (grade B, level IIb)
    • 5% tranexamic acid mouthwashes used four times a day for two days (grade A, level Ib). Tranexamic acid is not readily available in most primary care dental practices.
  4. For patients who are stably anti-coagulated on warfarin, a check INR is recommended 72 hours prior to dental surgery (grade A, level Ib)
  5. Patients taking warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesia following dental surgery (grade B, level III).
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