Updated SDCEP guidance on dental management of patients taking anticoagulants and antiplatelets

Jun 15, 2022

In March 2022, the Scottish Dental Clinical Effectiveness Programme (SDCEP) published the second edition of its guidance on the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs.

This guidance is principally aimed at dentists, hygienists and therapists in primary care dental practice. It provides recommendations about the assessment of bleeding risk, treatment planning and management of patients who have been prescribed anticoagulants and antiplatelet drugs.

Endorsed by the Royal Colleges, and the College of General Dentistry, the guidance aims to promote the safe and effective provision of oral health care for this group of patients.

Updated recommendations from SDCEP

Dental practitioners will be aware of the risk of bleeding complications when they perform invasive dental procedures in patients taking anticoagulants or antiplatelet drugs. This updated guidance from SDCEP provides clear and practical advice to enable dental teams to manage this group of patients within primary care.

First published in 2015, the guidance aims to encourage a consistent and evidence-based approach to the dental management of patients taking these medications. The 2022 update incorporates current evidence to support the clinical practice recommendations. It was developed by a multidisciplinary group using SDCEP’s NICE-accredited methodology.

The Full Guidance is available from the SDCEP website.

Topics covered

The guidance includes recommendations about:

• Assessment of bleeding risk from dental treatment: Dental practitioners can refer to the guidance, which includes a table categorising dental procedures according to low or high risk of post-operative bleeding complications.
• Medical history: This should include questions about the patient’s use of medications, including anticoagulants or antiplatelet drugs, as well as medical conditions and bleeding history. The guidance advises delaying non-urgent, invasive procedures where possible for patients receiving time-limited anticoagulant or antiplatelet drugs. The full guidance also provides advice about the management of patients with other relevant medical complications, including when to consult with the patient’s prescribing clinician, specialist or GP.
• Treatment planning: For all patients taking anticoagulants or antiplatelet drugs who require dental treatment likely to cause bleeding, general advice is given regarding treatment planning to avoid complications, and provision of pre-treatment and post-treatment instructions to the patient.
• Management according to the type of anticoagulant or antiplatelet drug: Further advice is provided, specific for patients taking direct oral anticoagulants (DOACs), vitamin K antagonists such as warfarin, injectable anticoagulants (low molecular weight heparins), antiplatelet drugs, or a combination of anticoagulants/antiplatelet drugs.

Following a full review of the original 2015 guidance, many of the recommendations remain unchanged in this update. However, Steven Johnston, Senior Dental Officer, NHS Orkney, and Chair of the group that developed the updated guidance, commented:

“Prescribing of anticoagulants and antiplatelet drugs has increased since publication of the first edition of the guidance and dental practitioners are increasingly likely to encounter patients taking them, particularly the Direct Oral Anticoagulants or DOACs.”

“The second edition of the guidance provides up-to-date recommendations to continue to help clinicians manage dental care for these patients and includes the newer DOAC edoxaban and expanded advice about the low molecular weight heparins.”

Environmental considerations

This edition of the guidance is also the first SDCEP document to consider the potential environmental impact of its recommendations. The advice offered to support implementation of environmentally sustainable oral health is intended to minimise patient travel, a significant contributor to a dental practice’s carbon footprint:

• Confirm medical history in advance in case of changes that lead to postponement.
• Consult with the patient’s prescribing clinician, specialist or medical practitioner in advance, if required.
• Provide pre- and post-treatment patient instructions.
• Suture and pack at the time of treatment to avoid reattendance for postoperative bleeding.

Implementation and supporting resources

Reassuringly, a recent study by Woolcombe et al, looking at the implementation of the 2015 guidance, concluded that the recommendations were safe to follow – among a cohort of 98 patients who underwent 119 dentoalveolar procedures, none experienced major haemorrhage.

Yet, absolute compliance with the recommendations was achieved in less than half of cases. This suggests that dental staff need additional education and support to fully implement the guidance.

Helpfully, SDCEP provides supporting tools to assist with the implementation of the 2022 guidance:

• Quick Reference Guide, summarising the key recommendations in flowchart form.
• Patient information leaflet explaining the importance of providing medication details to the dental practitioner.
• Post-treatment advice for patients.
• Pre-dental treatment instructions: templates for patients receiving DOACs or warfarin.
• Local contacts for advice and referral: template form.

Dental practitioners have a responsibility to make decisions appropriate for the individual patient, with the consent of the patient. Where significant departures from this guidance are deemed necessary, the SDCEP guidance advises that “the reasons for this, are documented in the patient’s clinical record”.

If you require dento-legal advice about the management of patients taking anticoagulants or antiplatelet drugs, please contact Dental Defence Society for expert support.