Editing Anticoagulant (section)

==Dental considerations for long-term users==
Dental practitioners play an important role in the early detection of anticoagulant overdose through oral manifestations, as the patient does not show any symptoms. Dental treatment of patients taking anticoagulant or antiplatelet medication raises safety concerns in terms of the potential risk of bleeding complications following invasive dental procedures. Therefore, certain guidelines for the dental care of patients taking these drugs are needed.

<big>'''Detecting overdose'''</big>

An overdose of anticoagulants usually occurs in people who have heart problems and need to take anticoagulants in the long term to reduce the risk of stroke from their high blood pressure.

An [[Prothrombin time|International Normalised Ratio (INR)]] test would be recommended to confirm the overdose so that the dosage can be adjusted to an acceptable standard. The INR test measures the time it takes for a clot to form in a blood sample relative to a standard.

An INR value of 1 indicates a level of coagulation equivalent to that of an average patient not taking warfarin, and values greater than 1 indicate a longer clotting time and, thus, a longer bleeding time.

<big>'''Assessing bleeding risk'''</big>

There are two main parts to the assessment of bleeding risk:
* Assessment of the likely risk of bleeding associated with the required dental procedure
* Assessment of the patient's individual-level bleeding risk

<big>'''Managing bleeding risk'''</big>

A patient who is on anticoagulants or [[Antiplatelet drug|antiplatelet]] medications may undergo dental treatments which are unlikely to cause bleeding, such as local anesthesia injection, basic gum charting, removal of plaque, calculus and stain above the gum level, direct or indirect fillings which are above the gingiva, [[root canal treatment]], taking impression for denture or crown and fitting or adjustment of [[Orthodontics|orthodontic appliances]].&nbsp; For all these procedures, it is recommended that the dentist treat the patient following the normal standard procedure and taking care to avoid any bleeding.

For a patient who needs to undergo dental treatments which are more likely to cause bleeding, such as simple tooth extractions (1-3 teeth with small wound size), drainage of swelling inside the mouth, periodontal charting, [[Scaling and root planing|root planing]], &nbsp;direct or indirect filling which extends below the gingiva, complex filling, flap raising procedure, gingival recontouring and biopsies, the dentist needs to take extra precautions apart from the standard procedure. The recommendations<ref>{{cite web|url=https://www.scottishdental.org/management-of-dental-patients-taking-anticoagulants-or-antiplatelet-drugs-new-guidance-from-sdcep/|title=Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs – New guidance from SDCEP {{!}} Scottish Dental|date=15 September 2015 |language=en-GB|access-date=2020-02-20}}</ref> are as follows:
* if the patient has another medical condition or is taking other medication that may increase bleeding risk, consult the patient's general medical practitioner or specialist
* if the patient is on a short course of anticoagulant or antiplatelet therapy, delay the non-urgent, invasive procedure until the medication has been discontinued
* plan treatment for early in the day and week, where possible, to allow time for the management of prolonged bleeding or re-bleeding if it occurs
* perform the procedure as traumatically as possible, use appropriate local measures and only discharge the patient once [[hemostasis]] has been confirmed
* if travel time to emergency care is a concern, place particular emphasis at the time of the initial treatment on the use of measures to avoid complications
* advise  the patient to take [[paracetamol]], unless contraindicated, for pain relief rather than [[Nonsteroidal anti-inflammatory drug|NSAIDs]] such as [[aspirin]], [[ibuprofen]], [[diclofenac]] or [[naproxen]]
* provide the patient with written post-treatment advice and emergency contact details
* follow the specific recommendations and advice given for the management of patients taking different anticoagulants or antiplatelet drugs

There is general agreement that in most cases, treatment regimens with older anticoagulants (e.g., warfarin) and antiplatelet agents (e.g., [[clopidogrel]], [[ticlopidine]], [[prasugrel]], [[ticagrelor]], and/or aspirin) should not be altered before dental procedures. The risks of stopping or reducing these medication regimens (i.e., [[Venous thrombosis|thromboembolism]], [[stroke]], [[myocardial infarction]]) far outweigh the consequences of prolonged bleeding, which can be controlled with local measures. In patients with other existing medical conditions that can increase the risk of prolonged bleeding after dental treatment or receiving other therapy that can increase bleeding risk, dental practitioners may wish to consult the patient's physician to determine whether care can safely be delivered in a primary care office. Any suggested modification to the medication regimen before dental surgery should be done in consultation and on the advice of the patient's physician.

Based on limited evidence, the consensus appears to be that in most patients who are receiving the newer direct-acting oral anticoagulants (i.e., dabigatran, rivaroxaban, apixaban, or edoxaban) and undergoing dental treatment (in conjunction with usual local measures to control bleeding), no change to the anticoagulant regimen is required. In patients deemed to be at higher risk of bleeding (e.g., patients with other medical conditions or undergoing more extensive procedures associated with higher bleeding risk), consideration may be given, in consultation with and on advice of the patient's physician, to postponing the timing of the daily dose of the anticoagulant until after the procedure; timing the dental intervention as late as possible after last dose of anticoagulant; or temporarily interrupting drug therapy for 24 to 48 hours.