1. Challenges in treating anticoagulated patients
The situation is certainly familiar to you: During the anamnesis before a planned extraction, the patient casually mentions taking blood thinners. At this moment, there are immediately important questions about treatment safety:
- Is it necessary to pause medication?
- What specific precautionary measures should be taken?
- Is the INR value within the safe range for the planned procedure?
Over 1 million people in Germany take blood-thinning medications. The most famous representatives: ASS and Marcumar. But then there are the new, direct oral anticoagulants, or DOAK for short. Since their invention in the early 2000s, the prescription rate of anticoagulants has more than doubled. Why It is significantly easier for patients to take. Plus, there's no need to measure INR anymore.
The challenge in treating these patients lies not only in the risk of bleeding during the procedure, but also in the occurrence of secondary bleeding. Especially when they take place outside practice opening hours. However, with a structured approach and good patient education, these risks can be minimized.
2. The main antithrombotic agents and their indications
Vitamin K antagonists:
- Marcumar®, Falithrom® (phenprocoumon)
- Coumadin® (warfarin) - rare in Germany
Direct oral anticoagulants (DOAC):
- Pradaxa® (dabigatran) — thrombin inhibitor
- Xarelto® (rivaroxaban) — factor Xa inhibitor
- Eliquis® (apixaban) — factor Xa inhibitor
- Lixiana® (edoxaban) — factor Xa inhibitor
antiplatelet agents:
- ASS® (acetylsalicylic acid)
- Plavix® (clopidogrel)
- Brilique® (ticagrelor)
- Efient® (prasugrel)
Parenteral anticoagulants:
- Clexane® (enoxaparin)
- Fragmin® (dalteparin)
- Heparin (unfractionated)
Choosing the right blood thinner depends on the patient's underlying disease. While classic drugs such as Marcumar® require regular INR checks, the newer DOAK do without these controls. This makes therapy much easier. Anticoagulants and anticoagulants are particularly often used for the following diseases:
The most common indications for antithrombotic drugs:
- Deep Vein Thrombosis (DVT)
- atrial fibrillation (VHF)
- pulmonary embolism (LE)
- Condition after surgery to prevent thrombosis (e.g. hip or knee TEP)
- Condition following a heart attack or stroke (secondary prophylaxis)
- Mechanical heart valves
- Coronary heart disease (CHD)
- Peripheral arterial disease (PAD)
Both the indication and the corresponding medication determine whether or not to discontinue treatment. In high-risk patients (e.g. with mechanical heart valves), discontinuation can have life-threatening consequences.
3. INR areas and their significance
The INR (International Normalized Ratio) value is a standardized laboratory value for monitoring vitamin K antagonist therapy. It provides information about the coagulability of blood. In healthy people without anticoagulation, the INR value is around 1.0. The higher the value, the more blood coagulation is inhibited. The “therapeutic area” (Table 1) describes the respective target value for different indications. Outpatient dental surgical procedures should only be performed up to INR 3.5.
4. Five rules that give you peace of mind
- Always consult your family doctor or cardiologist, especially if you have complex medications or additional risks.
- Only carry out procedures whose complication management you are proficient in. If uncertain: Bank transfer.
- Plan a wound care strategy before surgery: Prepare sutures, hemostatic agents, tranexamic acid.
- Patients are not discharged until local anesthesia has completely worn off. (Attention: risk of rebleeding!)
- No risky procedures on Fridays to avoid complications over the weekend.
Always carefully document your medication history and the decision process regarding maintaining or pausing anticoagulation. Good documentation is not only legally important, but also helps with follow-up and treatment planning.
5. What works in practice — and what is better not?
According to the 2017 guideline, the following medications (in monotherapy!) may be used for “simple dental and surgical procedures in the compressible area” be passed on.
Outpatient procedures in practice:
- Easy extractions (few teeth)
- periodontal treatments
- Easy implantations
- Minor osteotomies
Better in a specialist clinic:
- More extensive dental restorations
- More complex osteotomies
- wisdom tooth removals
- Comprehensive implantological measures including bone augmentationsBone augmentations
6. Emergency Management: Preparation and Checklist
You should have this ready:
- suture material
- electrocautery (if available)
- hemostatic agents (collagen cones, fleece, sponges)
- tranexamic acid 5% (local tamponade)
- Desmopressin nasal spray for vWF or FVIII deficiency
- Bandage plate (made in advance)
- alginate and impression spoon (In case a bandage plate was not produced → let it set in the patient's mouth)
For aftercare, you should give the patient clear written instructions on how to act in the event of post-bleeding. This includes emergency numbers and specific instructions for action. A follow-up check the following day is recommended for high-risk patients.
In case of rebleeding:
- Compression (min. 20 min.)
- Tranexamic acid-soaked swab or mouthwash
- Re-stitching if necessary
- Referral to specialist clinic if bleeding persists
7. Red Flags: When it is better not to be treated on an outpatient basis
In this case, “red flags” refer to clinical warnings that pose an increased risk of complications — in particular those that make outpatient treatment questionable or even contraindicated.
Note that patients with multiple risk factors (old age, polymedication, liver or kidney disease) may have an additional increase in the risk of bleeding, even if the individual parameters are within the acceptable range.
8. Conclusion and FAQ: Common questions and safe procedure
Conclusion: Keep a cool head — even with antithrombotic agents
Antithrombotic patients are part of everyday life. With these rules, you can maintain control and avoid unnecessary risks:
- Consultation with the doctor
- Good planning and aftercare
- Don't go it alone in problematic constellations
The treatment of patients undergoing anticoagulation requires a structured approach, but not excessive anxiety. With good preparation, careful hemostasis and adequate aftercare, most dental procedures can be performed safely. The individual risk assessment is decisive: The risk of bleeding must always be weighed against the thromboembolic risk (by the prescribing specialist).
Do I have to pause DOAK?
No, good timing is sufficient for simple procedures.
How high does the INR have to be with Marcumar®?
If indicated in the therapeutic range of 2.0—3.5 (consultation with a general practitioner!)
Can I just stop using ASS?
No, ASS 100 is not paused - the risk of heart attack/stroke prevails.
How long before an implantation should DOAK be paused?
The decision must be made individually with the attending physician. Usually 24 hours in advance, depending on the preparation.
What to do for patients with dual platelet inhibition/anticoagulation?
These patients have a particularly high risk of bleeding. Elective procedures should be postponed until only monotherapy is necessary. In emergencies, a clinic referral is required.
sources:
S3 guideline “Dental surgery under oral anticoagulation/antiplatelet aggregation”, 2017. https://register.awmf.org/de/leitlinien/detail/083-018
