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Antithrombotic Medications – What Every Dentist
Should Know: A Review

By Marci H. Levine, DMD, MD and Analia Veitz-Keenan, DDS

Introduction have many available resources to consult efficacy to Coumadin, these drugs have a
As academic dentists at a dental school, we for guidance and up-to-date information, significant advantage in that they do not
surveyed our colleagues in order to assess such as the internet, textbooks, dental col- require INR testing. They also have the
dentists’ understanding, acceptance and leagues, and other medical/healthcare pro- benefit of fewer cross-reactions with foods,
implementation of the published ADA rec- fessionals. However, the various recom- making them more tolerable for patients.
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ommendations as they pertain to patients mendations on the management of patients
on antithrombotic medications. Based on on antithrombotic medications, especially Injectable heparin is an anticoagulant in-
the results of our study, continuing educa- those in need of surgical procedures, can dicated for both the prevention and treat-
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tion modules are needed to help support be controversial or confusing. ment of thrombotic events, such as deep
dentists’ decision-making and to keep up- vein thrombosis (DVT) and pulmonary
to-date information available for easy in- The American Dental Association (ADA) embolism (PE) as well as atrial fibrillation.
corporation into clinical practice. routinely revises their website with evi- Heparin is also used to prevent excess co-
dence-based recommendations on several agulation during procedures such as cardi-
Antithrombotic medications are common- topics for dentists. “Oral Anticoagulant ac surgery and hemodialysis. It can be used

ly used by the patients we routinely treat. and Antiplatelet Medications and Dental for many different off-label indications.
They are often prescribed by patients’ phy- Procedures,” is one of them and several For example, patients who present with
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sicians and cardiologists to prevent clot related articles are available for clinicians, acute coronary syndromes (ACS) and who
formation or treat clots that have already but awareness of these resources, accep- undergo percutaneous coronary interven-
formed. tance of the guidelines, and current im- tion (PCI), may be prescribed heparin.
plementation in clinical practice is largely
Excessive thrombosis is highly relevant to unknown. Heparin blocks several different factors
a variety of disease states. These include of the clotting cascade, and, if needed,
atrial fibrillation, many forms of stroke, its effects on bleeding can be assessed by
acute and chronic coronary artery disease, Antithrombotic Medications- Important the partial prothrombin time test (PTT) .
prosthetic heart valves, and venous throm- Information Thrombocytopenia, a known side effect,
boembolism are all large areas of cardio- Antithrombotic medications include anti- typically occurs in up to 30% of patients
vascular medicine in which thrombosis is a coagulants and antiplatelet agents. Anti- who receive heparin. 9,10
major part of the pathology and for which coagulants decrease the formation of fi-
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the use of antithrombotic medications are brin and reduce the rate of clot formation. Antiplatelet medications often include:
widely used. Antiplatelet agents inhibit platelet aggre- aspirin, clopidogrel (Plavix®), ticagrelor
gation. Commonly prescribed anticoagu- (Brilinta®), prasugrel (Effient®), dipyrida-
Various classes of antithrombotic medica- lants include: warfarin (Coumadin®), hep- mole, dipyridamole/aspirin (Aggrenox®),
tions target different aspects of the clotting arin, rivaroxaban (Xarelto®), dabigatran ticlopidine (Ticlid®) and injectable eptifi-
process; they may act at the platelet level (Pradaxa®), apixaban (Eliquis®), edoxaban batide (Integrilin®).
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or in the coagulation cascade, and their (Savaysa®), enoxaparin (Lovenox®) and
mechanisms of action can vary widely. In fondaparinux (Arixtra®). Indications for Physicians may choose to prescribe anti-
everyday clinical practice, it is not unusual warfarin include atrial fibrillation, venous platelet agents for patients with a history
to see patients who take different regimens thromboembolism and prosthetic heart of coronary artery disease, cerebrovascular
of “blood thinners.” valves. 5 accidents (such as stroke), and peripheral
artery disease. Up until recently, most pa-
Although each class of drug has differ- Since the 1960s, warfarin has been the only tients were treated with dual-antiplatelet
ent implications for patients in terms of oral anticoagulant drug in regular use for therapy with a combination of aspirin and
preoperative testing and daily monitoring treating patients with thromboembolic dis- clopidogrel. Some patients were found to
regimens, they all have an increased risk ease. Since the approval of the direct-act- be non-responders to clopidogrel and neg-
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for bleeding. Bleeding can be especially ing oral anticoagulants (DOACS), the use ative reactions associated with cigarette
problematic for dentists in terms of visibil- of warfarin has been declining. The man- smoking and other types of drugs such as
ity during procedures and in managing safe ufacturing of all strengths of Coumadin® protein pump inhibitors commonly pre-

hemostasis for patients after procedures. was recently discontinued in October 2020 scribed for acid reflux, were found.
Therefore, dentists need to be very familiar and patients are now being prescribed new-
with these medications in reference to pos- er alternative drugs that have significant With advances in drug therapy design,
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sible complications during and after dental advantages. drugs such as prasugrel, ticagrelor and
treatment. the glycoprotein IIb/ IIIa antagonists are
Suitable options include: dabigatran changing the ways patients are being man-
The Problem - Antithrombotic Medica- (Pradaxa®), a direct thrombin inhibitor; aged. Dual therapy may no longer be nec-
tions rivaroxaban (Xarelto®), a factor Xa inhib- essary as newer drugs are now replacing
When treating a patient who is taking anti- itor; and apixaban (Eliquis®), also a factor the older regimens. Ticagrelor has a dif-
thrombotic medications, dentists typically Xa inhibitor. With a similar or superior ferent chemical structure from clopidogrel

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