Management of dental patients taking anticoagulants or antiplatelet drugs

For patients taking anticoagulant or antiplatelet drugs there is the concern that some dental procedures may lead to bleeding complications. So to encourage a consistent approach to the management of dental treatment for patients who are taking anticoagulants or antiplatelet drugs. The Scottish Dental Clinical effectiveness programme (SDCEP) has just launched its updated guidance on the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs.

Scope and purpose

The guidance is applicable to patients who are taking anticoagulant or antiplatelet drugs and present for outpatient dental treatment. Dental patients taking anticoagulants or antiplatelet drugs and are being treated as inpatients within a medical hospital setting are not discussed.

The guidance is primarily intended for dentists, hygienists in a primary care setting. It will also be of interest to secondary care dental teams and those in dental education. Elements of the guidance will also be of relevance to medical professionals, including those who prescribe or dispense anticoagulants and antiplatelet drugs.

Methodology

The guidance was developed by a multidisciplinary group that included patient representatives medical and dental practitioners and specialists along.

The methodology used to develop the guidance adheres as far as possible to international standards set out by the AGREE (Appraisal of Guidelines for Research and Evaluation) Collaboration. SDCEP uses a guideline methodology which has been approved by NICE (National Institute for Health and Care Excellence) and further details are available on the SDCEP website . A summary of the process used for this topic is included in Appendix 1 of the full guidance.

The core contents of the guidance document include sections on :-

Anticoagulants and Antiplatelet drugs
Assessing bleeding risk
Managing bleeding risk
Treating a patient taking
- Direct oral anticoagulants (DOAC)
- Warfarin or another vitamin K antagonist
- Injectable anticoagulants
- Antiplatelet drugs
- Anticoagulants and antiplatelet in combination
Drug interactions between anticoagulants or antiplatelet drugs and other medications

There are also appendices listing the main anticoagulant and antiplatelet drugs, indications for therapy and interactions with drugs prescribed by dentists.

Key recommendations are indicated in the text using a key symbol with the strength of recommendation rated using the GRADE approach . Other clinical advice points (based on consensus, expert opinion and existing best practice are indicated by a molar bullet point.

For the first time for SDCEP advice relating to environmental impact of the recommendations is provided and these are indicated by a leaf icon.

SDCEP leaf icon

Resources

The full guidance document is available to download from the SDCEP website together with a Quick Reference Guide which summarises the main recommendations and clinical practice advice using treatment planning flowcharts. In addition, a number of supporting tools including patient information are available.

Comment

This update to a highly accessed SDCEP guideline initially published in 2015 (Dental Elf – 18^th Sept 2015) has involved a full review of the 2015 edition in context of the latest evidence. The key changes highlighted are: –

inclusion of new information on the prevalence of anticoagulant use and the availability of reversal agent.
the DOAC key recommendations amended to apply to patients taking edoxaban, with further information and advice provided.
inclusion of a new key recommendation and expanded advice for the management of patients taking low molecular weight heparins;
updates to the evidence and basis for the key recommendations.
updates to the tables and appendices.

In addition to the content updates for the first time SDCEP have provided advice relating to the potential environmental impact of their recommendation. This is a welcome development one which will be built on in future guidelines and updates.

The Dental Elf