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Anticoagulant medications Antiplatelet medications ly and enabling early detection of hyperten-
sion, ultimately promoting patient-centered
Along with the most commonly prescribed Along with anticoagulant medications, anti- care.
anticoagulant, warfarin (vitamin K antago- platelet medications are used to prevent the
nist), there are also other medications such events of thromboembolism. According to References
as a direct thrombin inhibitor (i.e dabiga- the American Dental Association (ADA), 1. GBD 2015 Risk Factors Collaborators. Global,
tran), and a factor Xa inhibitor (i.e rivaroxi- commonly used antiplatelet regimens in- regional, and national comparative risk assessment
ban) that are also often prescribed to manage clude the following: aspirin, clopidogrel, of 79 behavioural, environmental and occupation-
thromboembolism. These regimens have ticlopidine, prasugrel, and ticagrelor. Sim- al, and metabolic risks or clusters of risks, 1990-
28
the potential to impact dental procedures, ilar to anticoagulant regimens, it is strongly 2015: a systematic analysis for the Global Burden
particularly invasive dental procedures, so recommended not to alter or discontinue of Disease Study 2015 [published correction ap-
it is critical that oral healthcare providers antiplatelet regimens prior to dental pro- pears in Lancet. 2017 Jan 7;389(10064):e1]. Lan-
familiarize themselves with the appropriate cedures as the risk of thromboembolism is cet. 2016;388(10053):1659-1724. doi:10.1016/
management strategies when encountering much higher than that of bleeding. 29 S0140-6736(16)31679-8.
patients taking anticoagulant medications. 27 2. Ostchega Y, Fryar CD, Nwankwo T, Nguyen
Use of local anesthesia with epinephrine DT. Hypertension Prevalence Among Adults
Warfarin has a narrow therapeutic index Aged 18 and Over: United States, 2017-2018.
and its onset of action ranges from 48 to The addition of epinephrine to local an- NCHS Data Brief. 2020;(364):1-8.
72 hours while its effect lasts about two to esthetics reduces toxicity, increases anes- 3. Mills KT, Stefanescu A, He J. The global ep-
five days. Despite the fear of bleeding risk, thetic effect, and improves the hemostatic idemiology of hypertension. Nat Rev Nephrol.
it is incumbent on all dental providers to be effect. Despite its advantages, the use of 2020;16(4):223-237. doi:10.1038/s41581-019-
cognizant of the fact that warfarin therapy local anesthetic in conjunction with epi- 0244-2.
should not be discontinued before dental nephrine is still controversial in patients 4. Wang G, Fang J, Ayala C. Hypertension-as-
procedures due to the potentially life-threat- with hypertension or complications from sociated hospitalizations and costs in the United
ening risk of thromboembolism. In lieu of hypertensive heart diseases. In particular, States, 1979-2006. Blood Press. 2014;23(2):126-
30
warfarin therapy cessation, INR taken 24 to the use of epinephrine can increase the risk 133. doi:10.3109/08037051.2013.814751.
48 hours prior to dental procedure should be of hypertensive or hypotensive episodes 5. Cleveland Clinic. Hypertensive Heart Dis-
obtained to assess the degree of anticoagu- and arrhythmias, and the hemostatic effect ease. Cleveland Clinic. Updated September 21,
lation. If the INR is equal to or less than 3.5, of epinephrine can lead to delayed wound 2021. Accessed June 4, 2022. https://my.cleve-
it is considered safe to proceed with dental healing and increased risk of infection. 26,30 landclinic.org/health/diseases/21840-hyperten-
treatment. 27 However, it is found that using one to two sive-heart-disease.
cartridges of local anesthetic with 1:80,000, 6. Huguet N, Larson A, Angier H, et al. Rates
Due to warfarin’s narrow therapeutic index 1:100,000, or 1:200,000 of epinephrine in of Undiagnosed Hypertension and Diagnosed
and pharmacodynamics, the use of direct patients with hypertension or complications Hypertension Without Anti-hypertensive Med-
thrombin inhibitors, dabigatran (Pradaxa ), with hypertensive heart diseases is safe with ication Following the Affordable Care Act. Am
®
and factor Xa inhibitors, rivaroxiban (Xarel- the exception of patients with uncontrolled J Hypertens. 2021;34(9):989-998. doi:10.1093/
to ), edoxaban (Savaysa ), betrixaban hypertension. There were no differences ajh/hpab069.
®
®
(Bevyxxa ) and apixaban (Eliquis ) are in- in systolic blood pressure, diastolic blood 7. Flack JM, Adekola B. Blood pressure and
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creasing these days. Unlike warfarin, they pressure, and heart rate between the group the new ACC/AHA hypertension guidelines.
have less interactions with other drugs and that received local anesthetic with epineph- Trends Cardiovasc Med. 2020;30(3):160-164.
food, faster onset of action, shorter half- rine and the group that received local an- doi:10.1016/j.tcm.2019.05.003.
lives, and more predictable pharmacody- esthetic without epinephrine. 30,31 Since one 8. Goetsch MR, Tumarkin E, Blumenthal RS,
namics. In addition, they don’t require reg- to two cartridges of local anesthetic with Whelton SP. New Guidance on Blood Pressure
ular screening of their anticoagulant effect epinephrine are sufficient for most of dental Management in Low-Risk Adults with Stage
meaning that they don’t require lab values procedures, the use of local anesthetic with 1 Hypertension. Expert Analysis. June 2021.
such as INR before dental procedures with epinephrine is considered safe. https://www.acc.org/latest-in-cardiology/arti-
the exception of emergency surgery, brain cles/2021/06/21/13/05/new-guidance-on-bp-
hemorrhage, and overdose. They are consid- Conclusion management-in-low-risk-adults-with-stage-1-
ered safe to use due to their short half-lives. htn. Accessed June 4, 2022.
Discontinuation of the use or alteration of Given the high prevalence of hypertension 9. Bhatt HV, Fischer GW. Atrial Fibrillation:
the dose before invasive dental procedures and hypertension-related systemic and car- Pathophysiology and Therapeutic Options. J Car-
with the exception of major oral and max- diac complications, it is essential that dental diothorac Vasc Anesth. 2015;29(5):1333-1340.
illofacial surgery and extensive extractions professionals understand the current burden doi:10.1053/j.jvca.2015.05.058
is strongly not recommended. The risk of of hypertension and hypertension-related 10. Vizzardi E, Curnis A, Latini MG, et al.
thromboembolism is much higher than that systemic complications. In addition, since Risk factors for atrial fibrillation recurrence:
of bleeding. 27 hypertension is a modifiable risk factor, be- a literature review. J Cardiovasc Med (Hag-
ing cognizant of appropriate management erstown). 2014;15(3):235-253. doi:10.2459/
In conclusion, it is critical for dental provid- strategies for patients with such conditions JCM.0b013e328358554b.
ers to understand that anticoagulant thera- is also incumbent on all dentists. In partic- 11. Zimetbaum P. Atrial Fibrillation [pub-
pies should not be discontinued or altered ular, there is no need to alter or discontinue lished correction appears in Ann Intern Med.
before most dental procedures that do not anticoagulant or antiplatelet regimens since 2017 Jun 20;166(12 ):920]. Ann Intern Med.
involve major oral and maxillofacial sur- the risk of thromboembolism is much higher 2017;166(5):ITC33-ITC48. doi:10.7326/
gery and extensive extractions, and the use than that of bleeding. Oral healthcare pro- AITC201703070.
of local hemostasis measures when needed viders can serve as the frontline to reduce 12. Malakar AK, Choudhury D, Halder B, Paul
is sufficient to successfully control bleed- the socioeconomic burden of hypertension P, Uddin A, Chakraborty S. A review on coro-
ing. 28 through monitoring blood pressure regular- nary artery disease, its risk factors, and therapeu-

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