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allowing for faster absorption with faster holding the drug. 13,14 An INR of greater MI) far outweigh the consequences of pro-
onset. It is also more potent than clopido- than 3.5 warrants medical consultation longed bleeding, which can most often be
grel and lacks cross-reactivity with other with the treating physician for guidance as controlled with local measures. 19,20
drugs in its class. to holding the drug and/or replacing it with
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a shorter acting one (such as Lovenox). 15 Considerations should be made as to the
Dental implications amount of dental treatment that can be
When seeing a patient in the dental office As for all of the other medications dis- safely performed on any given day, espe-
who is on an antithrombotic medication, it cussed, antiplatelets (eg: Aspirin, clopido- cially when a patient is on these medica-
is important to ask relevant questions about grel) and the DOACS, there is no hemato- tions. Most practitioners would agree to
the patient’s medical history and indica- logical test to assist in the evaluation of the limit the extent of an invasive procedure
tions for its use (why is the patient on the patient’s bleeding risk before undergoing when a patient is most at risk for bleeding.
medication; how long has the patient been invasive procedures. A standardized and Low-risk bleeding procedures include sim-
taking it; and if the patient has seen his/her widely accepted platelet function assay that ple extractions (fewer than three teeth), in-
physician for an evaluation recently). Most fulfils all the criteria for an ideal near-pa- cision and drainage of intra-oral swellings,
patients are prescribed these medications tient test (and can be used in the clinical restorations involving subgingival margins,
for cardiovascular comorbidities (such as a care setting) is still lacking. 16 biopsies and simple implant placements.
myocardial infarction or stroke) and/or his- If multiple extractions or multiple quad-
tory of a clot (deep venous thrombosis or New oral anticoagulants do not require rants of subgingival scaling are required,
pulmonary embolism). The specific type routine monitoring of coagulation. Point procedures should ideally be spaced out
of medication, dosage and frequency used of care testing should not be used to assess over multiple appointments. High-risk
should also be recorded. Patients should the INR in patients on DOACS. 17 bleeding procedures include multiple ex-
be appropriately counseled to consult their tractions (more than 3), complex or sur-
treating physicians if alterations are sug- It is important to remember that most cases gical extractions, procedures requiring a
gested (Fig. 1). of intraoral bleeding can be well controlled flap to be raised, generalized periodontal
surgery, and crown lengthening. For such
Pa&ent evalua&on dental procedures, they should be spaced
Medical history- Review of out over multiple appointments whenev-
er possible. This is done in an effort to
Systems and Medica&ons control postoperative bleeding that could
range from none to severe. Patients who
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are medically complex and/or require still
Pa&ent is currently taking prescribed more advanced procedures or more major
an&thrombo&c medica&ons operations, should consider having them
performed in a monitored setting such as a
surgical center or hospital. These facilities
A dental procedure where offer more available resources in the event
bleeding control is expected/ of a bleeding catharsis.
needed
Dental therapeutics to control bleeding
during procedures are the same
No Yes
(local anesthesia with epinephrine,
resorbable collagen, suturing, gauze for
Type of an&thrombo&c medica&on pressure hemostasis, for severe cases

topical thrombin, aminocaproic acid
VKA’s /Coumadin DOACs An&platelets
rinses or tranexamic acid
INR 24/48 hours Check for pain medication control –
< 3.5 proceed with No current laboratory No current laboratory NSAIDs use should be recommended
treatment
>3.5 consider delayed test to assess risk test to assess risk with caution 21
procedure or a referral
Figure 1. Instruct patient to bite gauze applying
pressure for 15-30 minutes
Hematological Testing: Assessing The with local anesthesia with epinephrine, ab-
Patient’s Risk For Excessive Bleeding sorbable products (such as collagen plugs Table 1.
Preoperative testing is rarely needed with and other dissolvable materials), gauze for
today’s newer medications. Only patients pressure hemostasis, and sutures. (Tables Written instructions including how to
on warfarin still require INR (Internation- 1,2) It is considered to be unusual in to- manage bleeding/pain when it occurs
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al Normalized Ratio) testing within 24- day’s routine clinical practice for patients (rinsing with water to remove clots,
48 hours of an invasive dental procedure to need to hold or alter the dosages of their packing gauze and biting for 20 minutes
where bleeding control may be needed. An antithrombotic medications. The risks x3 cycles, tea bags 22
INR of less than 3.5 is generally considered of reducing or holding these medication
to be safe to proceed without changing or regimens (i.e., thromboembolism, stroke, Table 2.
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