Management of dental patients receiving antiplatelet therapy or chronic oral anticoagulation: A review of the latest evidence

Figures & data

Table 1. A comprehensive classification of dental interventions based on the associated bleeding risks as recommended by the Scottish Dental Clinical Effectiveness Programme (SDCEP) [2].

	Dental procedures that are likely to cause bleeding
Dental procedures that are unlikely to cause bleeding	Low bleeding risk procedures	High bleeding risk procedures
•Local anaesthesia by infiltration, intraligamentary or mental nerve block •Local anaesthesia by inferior dental block or other regional nerve blocks •Basic periodontal examination (BPE) •Supragingival removal of plaque, calculus, and stain •Direct or indirect restorations with supragingival margins •Endodontics (orthograde) •Impressions and other prosthetic procedures •Fitting and adjustment oforthodontic appliances	•Simple extractions (1–3, with restricted wound size) •Incision and drainage of intraoral swellings •Detailed six-point full periodontal examination •Root surface instrumentation (RSI) •Direct or indirect restorations with subgingival margins	•Complex extractions, adjacent extractions that will cause a large wound, or more than three extractions at once •Flap raising procedures  ^ Elective surgical extractions  ^ Periodontal surgery  ^ Preprosthetic surgery  ^ Periradicular surgery  ^ Crown lengthening  ^ Dental implant surgery •Gingival recontouring •Biopsies

Table 2. Periprocedural recommendations in case of dental procedure.

	Periprocedural recommendations
Presumed bleeding risk of procedure	SAPT/DAPT with ASA ± clopidogrel	VKA	DOACs
Unlikely to cause bleeding	Perform dental procedure without interruption	Perform dental procedure without interruption. if INR is ≤3.5 24 hours before the intervention.	Continue therapeutic anticoagulation, perform dental procedure at trough concentrations
Low bleeding risk dental procedures	Perform dental procedure without interruption	Perform dental procedure without interruption if INR is ≤3.5 24 h before the intervention. Delay if INR >3.5 and adjust VKA dose until INR ≤3.5	Continue therapeutic anticoagulation, perform dental procedure at trough concentrations
High bleeding risk dental procedures*	Perform dental procedure without interruption	Perform dental procedure without interruption if INR is ≤3.5 24 h before the intervention. Delay if INR >3.5 and adjust VKA dose until INR ≤3.5	Delay (rivaroxaban, edoxaban) or skip (apixaban, dabigatran) one dose on the morning of the dental intervention

*Application of local haemostatic measures and other preventive strategies recommended, e.g. limiting the surgical site or performing the dental intervention in the morning.

SAPT: single antiplatelet therapy; DAPT: dual antiplatelet therapy; ASA: acetylsalicylic acid; VKA: vitamin K antagonist; DOAC: direct oral anticoagulant; INR: international normalized ratio.

Scottish Dental Clinical Effectiveness Programme (SDCEP). 2015. Management of dental patients taking anticoagulants or antiplatelet drugs. Dental Clinical Guidance. Available from: http://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf

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