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Anticoagulant, Antiplatelet Medications and Dental Procedures

Do you take medications like aspirin, warfarin (Coumadin, Jantoven, Marfarin), clopidogril (Plavix), or ticlopidine (Ticlid) to prevent heart attack or stroke, resulting from a blood clot?

These medications make it more difficult for your blood to clot and because of this, you may have trouble with bleeding after certain dental procedures.  It may take longer than you would expect for any bleeding to stop.  In light of this, you might consider reducing your dosage or stop taking the medications entirely before receiving dental care.  However, it is generally agreed that anticoagulant drug regimens should not be altered prior to dental treatment.1-5  If you stop taking, or take less of, the anticoagulant medication, you increase your chance for blood clot development, which could result in thromboembolism, stroke or heart attack.  The risks of stopping or reducing this medication routine outweigh the consequences of prolonged bleeding, which can be controlled with local measures.  For example, you may be asked to bite down on sponges treated with a liquid that helps control bleeding.

Some patients who are taking these anticoagulant medications have additional medical problems that increase the risk of prolonged bleeding after dental treatment.1  If you have one of these conditions, your dentist may want to refer you to a hospital dental clinic.  These medical conditions include:

  • liver impairment or alcoholism
  • kidney failure
  • certain blood disorders.

Talk to your doctor or dentist if you are curious about these medications and how they may affect your dental treatment.

References

1. United Kingdom National Health Service. Surgical management of the primary care dental patient on antiplatelet medication. National Electronic Library of Medicines.  Accessed April 27, 2011.

2. Douketis JD, Berger PB, Dunn AS. The perioperative management of antithrombotic therapy American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition).  Accessed April 27, 2011.

3. Grines CL, et al. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents. Circulation 2007;115:813-8.  Accessed April 27, 2011.

4. 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. Journal of the Canadian Dental Association 2009;75(1):41-41i. Accessed May 2, 2011.

5. Armstrong MJ, Gronseth G, Anderson DC, Biller J, Cucchiara B, Dafer R. Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2065-9. Accessed May 29, 2013.

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Please note: The ADA does not provide specific answers to individual questions about fees, dental problems, conditions, diagnoses, treatments or proposed treatments, or requests for research. Information about dental referrals, complaints and a variety of dental procedures may be found on ADA.org.

Patients with a history of heart attack or stroke may take anticoagulant medications like warfarin (Coumadin), clopidogril (Plavix), ticlopidine (Ticlid) or aspirin.  These medications are used to prevent formation of blood clots that could lead to another thromboembolic event, heart attack or stroke.

Because these are anticoagulant medications, bleeding time after dental treatments, for example, may be prolonged.  In light of this, some dentists might consider recommending that the patient reduce his or her dosage or stop taking the medications entirely before receiving dental care.  However, it is generally agreed that anticoagulant drug regimens should not be altered prior to dental treatment.1-3  A systematic review and meta analysis found no increased risk of bleeding associated with continuing regular doses of an anticoagulant in comparison with discontinuing or modifying the dose for patients undergoing single and multiple tooth extraction.4 The American Academy of Neurology recommends that patients undergoing dental procedures continue taking aspirin or warfarin for stroke prevention.5

Without the anticoagulant medications, these patients are at high risk for blood clot development, which could result in thromboembolism, stroke or heart attack.  The risks of stopping or reducing this medication regimen outweigh the consequences of prolonged bleeding, which can be controlled with local measures.

Some patients who are taking these anticoagulant medications have additional medical problems that increase the risk of prolonged bleeding after dental treatment.1  Before treating these patients, you may wish to consult his or her physician to determine whether care can safely be delivered in a primary care office.  These medical conditions include:

  • liver impairment or alcoholism
  • kidney failure
  • thrombocytopenia, hemophilia, or other haemostatic disorders.

Anticoagulant Medications Available in the United States

 

Brand Name

  Manufacturer
 Aggrenox (aspirin plus dipyridamole)   Boehringer Ingelheim Pharmaceuticals, Inc.
(800) 243-0127
 Aspirin  Multiple manufacturers
 Coumadin, Jantoven, Marfarin (warfarin)  Multiple manufacturers
 Effient (prasugrel)  Eli Lilly and Co.
(866) 333-4368
 Persantine (dipyridamole)  Teva Pharmaceuticals USA
 (215) 591-3000
 Plavix (clopidogrel)  Bristol-Myers Squibb/Sanofi  Pharmaceuticals Partnership
(800) 981-2491
 Pletal (cilostazol)  Teva Pharmaceuticals USA
(215) 591-3000
 Pradaxa (dabigatran etexilate)  Boehringer Ingelheim Pharmaceuticals, Inc.
(866) 398-8973
 Ticlid (ticlopidine)  Teva Pharmaceuticals USA
(215) 591-3000

 

For Patients with Coronary Artery Stents

Your patient may be taking antiplatelet medications following a coronary artery stent procedure. A coronary stent is a wire mesh tube that is implanted permanently into a blocked artery to restore blood flow to the heart. Patients can receive either a drug-coated stent or a plain metal stent. As with any medical procedure, both uncoated and drug-coated stents are associated with risks. One rare but serious risk for both types of stents is the formation of a blood clot inside the stent, also known as stent thrombosis. Stent thrombosis can potentially lead to a heart attack or even death in some cases. Fortunately, the rates of stent thrombosis are low.

To reduce the risk of stent thrombosis post-stent implantation, patients are prescribed dual antiplatelet therapy. Most commonly, patients are prescribed aspirin and a second drug- clopidogrel (also known as Plavix) or ticlopidine (also known as Ticlid). Patients usually take aspirin for life, and clopidogrel or ticlopidine for several months or even years.

In February 2007, the American Heart Association, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the American College of Surgeons, and the American Dental Association published their consensus opinion about drug-eluting stents and antiplatelet therapy.3 The advisory document states that healthcare providers who perform invasive or surgical procedures (i.e. dentists) and are concerned about periprocedural and postprocedural bleeding should contact the patient’s cardiologist regarding the patient’s antiplatelet regimen and discuss optimal patient management, before discontinuing the antiplatelet medications. Given the importance of antiplatelet medications post-stent implantation in minimizing the risk of stent thrombosis, the medications should not be discontinued prematurely.

References

1. United Kingdom National Health Service. Surgical management of the primary care dental patient on antiplatelet medication. National Electronic Library of Medicines.  Accessed April 27, 2011.

2. Douketis JD, Berger PB, Dunn AS. The perioperative management of antithrombotic therapy American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition).  Accessed April 27, 2011.

3. Grines CL, et al. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents. Circulation 2007;115:813-8.  Accessed April 27, 2011.

4. 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. Journal of the Canadian Dental Association 2009;75(1):41-41i. Accessed May 2, 2011.

5. Armstrong MJ, Gronseth G, Anderson DC, Biller J, Cucchiara B, Dafer R. Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2065-9. Accessed May 29, 2013.

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