Perioperative Dental Management of Patients in The Background of Antithrombotic Use

Abstract

Objectives: Treatment and perioperative dental management in patients on antithrombotic medications poses a serious challenge to dental professionals due to perceived risk of bleeding complications. This article aims to study the anticoagulant / antiplatelet drugs currently available on the market, review contemporary oral anti-thrombotic treatment and offer management guidelines in such situations based on the review of pertinent literature. Material and Methods: Science Direct and Ovid databases, PubMed, Scopus and product literature were accessed to review relevant literature with respect to current anti-thrombotic drugs, indications for their use in medical conditions, complications related to their use and drug interactions. The search covered studies published in medical and dental journals in English with a relevant impact factor over a period of 10 years. Meta analyses, systematic reviews, randomized trials, cohort based and case-control studies and society-based guidelines were considered. Key words utilized in the search criteria included Warfarin, Coumarin, Aspirin, P2Y12 inhibitors, Prasugrel, Clopidogrel, Ticagrelor, Hemorrhage, Anti-thrombin, Platelet aggregation inhibitors and International Normalized Ratio (INR) and were validated by the MeSH dictionaries. Results: Dental practitioners today, are faced with the challenge of conducting surgical procedures on patients who are on anti-thrombotic medications for a variety of medical/ surgical co-morbid conditions. Although there is consensus amongst various studies regarding continuation of warfarin in therapeutic ranges for dento-alveolar surgery, there is insufficient evidence to reach a consensus in those groups who are at intermediate or high risk of bleeding. However, most studies and published literature do agree that there is no real increased risk of bleeding complications during conduct of these procedures if the patient’s INR is less than 3.5 along with adequate haemostatic measures. Conclusion: Regardless of the procedure to be performed, every case needs to be titrated on its individual merit based on both patient and surgical factors. Further, it is recommended that INR values should be established at least 72 hours prior to the surgery, which admits a margin of safety for dose modification if necessary. A meticulous case history with complementary hemostatic tests and adoption of adequate local hemostatic measures hold the key to not having the necessity to modify the antiplatelet or anticoagulation treatment in most cases. Additionally, the advent of newer anticoagulants and antiplatelets have raised the requirement of dedicated Randomized Clinical Trials to answer the specific clinical questions of bleeding risk versus thrombo-embolic complications in the perioperative management of such patients.