In DOAC era, dentists are still stopping anticoagulants before tooth extractions

One in three dentists say they would stop anticoagulants in patients undergoing tooth extraction, despite guidelines saying this is unnecessary and may put patients at risk of serious thrombotic events such as stroke.

A survey of 89 dental practitioners in WA found that 57 (36%) would advise stopping anticoagulants and antiplatelets for between 24-72 hours preceding an extraction as a precaution against risk of bleeding.

While most of the dentists said they would not change anticoagulant therapy, 32.6% said they would stop DOACs and 29.2% would advise stopping warfarin prior to an extraction.

Dentists who were younger (less than five years in practice) were less likely to recommend stopping anticoagulants than those who had been in practice for longer, perhaps reflecting therapeutic inertia over changes in guidelines on anticoagulation and the ‘warfarin wars’ controversies over the risk and benefits of thrombosis vs bleeding risk.

Dentists who did a higher volume of tooth extractions (10-30 teeth per month) were more likely to stop anticoagulants before an extraction.

The authors of the study noted that guidelines on anticoagulant use have been revised in recent years to advise that cessation is unnecessary for minor procedures that are only at low risk of causing bleeding such as dentistry (extraction of up to three teeth) as well as joint injections, cataract surgery and pacemaker insertion.

“Regardless of the dental procedure, the risk of thromboembolism, stroke and myocardial infarction far outweighs the consequences of prolonged bleeding which can usually be controlled with local measures including placement of a haemostatic agent, closure with sutures and use of tranexamic acid,” they wrote.

“Hence, for most dental procedures, VKAs and DOACs must be maintained,” they said.

They also noted that may dentists would advise stopping anticoagulants for only 24 hours, which had little scientific rationale particularly if the average life of the DOAC or warfarin was long.

They said the INR would usually dictate practice for patients on warfarin, but that in general, dental practitioners should consider the greater risk of a thromboembolic event if the patient were to cease their anticoagulants and/or antiplatelets.

“The recommendations should be for local measures to control bleeding and to limit the number of extractions to three or less teeth rather than ceasing DOACs and/or antiplatelets,” they said.

“If there are any concerns regarding a patient’s risk of bleeding following an extraction, a pre-operative discussion with the medical practitioner who prescribed the anticoagulant, whether this is a general practitioner or specialist, would be valuable.”

They concluded that the knowledge gap in understandig of anticoagulant risk and benefits “may be something that requires action through the dental curriculums i.e. through the Australian Dental Council”.

“It is possible that there needs to be detailed guidelines in Australia to aid dentists managing the patients on anticoagulant and/or antiplatelet therapy,” they added.

The survey results are published in the Australian Dental Journal.

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