6.4 Bleeding Disorders & Anticoagulation

Inherited Bleeding Disorders

Dental management

• Consult haematology before any invasive procedure. A written plan covering factor replacement, timing, and postoperative monitoring is essential.
• Avoid intramuscular injections and inferior alveolar nerve blocks where possible in severe disease (risk of compartment bleeding).
• Use local haemostatic measures (sutures, oxidised cellulose/Surgicel, tranexamic acid mouthwash).
• For children or severe cases, treatment may be in a specialist centre.

Acquired Bleeding Disorders

• Thrombocytopenia (platelet count < 150 x 10^9/L) may be immune (ITP), drug-related, or secondary to leukaemia or marrow failure. Bleeding risk rises sharply below 50 x 10^9/L; check with haematology before surgery and consider platelet transfusion for counts < 30–50 x 10^9/L before invasive dental work.
• Leukaemia and other haematological malignancies cause thrombocytopenia, neutropenia, and impaired clotting; liaise with the oncology/haematology team and time dental work around chemotherapy cycles.
• Liver disease impairs synthesis of vitamin K-dependent factors; check coagulation and platelets before surgery.

Anticoagulants

Warfarin (vitamin K antagonist)

Warfarin inhibits vitamin K-dependent clotting factors (II, VII, IX, X). It is monitored by the international normalised ratio (INR). Target INR varies by indication:

• AF, DVT/PE: typically 2.0–3.0.
• Mechanical mitral valve: typically 2.5–3.5 (higher for some valves).

SDCEP warfarin guidance (2nd edition, 2022)

• Treat without interrupting warfarin if INR < 4.0 (strong recommendation).
• Check INR ideally within 24 hours of surgery (up to 72 hours acceptable if the patient is stably anticoagulated).
• If INR >= 4.0, contact the anticoagulation service or GP and delay invasive treatment until INR is below 4.0; for urgent treatment, refer to secondary care.
• A 'stable' patient is one who does not require weekly monitoring and has had no INR > 4 in the last two months.

Direct oral anticoagulants (DOACs)

DOACs (also called NOACs) directly inhibit thrombin or factor Xa:

SDCEP DOAC guidance

Bleeding risk is categorised as low (e.g. 1–3 simple extractions, restorations with subgingival margins) or higher (e.g. >3 extractions, complex or surgical extractions, flap raising, implants, biopsies).

• Low-risk procedures: treat without interrupting the DOAC.
• Higher-risk procedures:
  • Apixaban or dabigatran (twice daily): omit the morning dose on the day of treatment; the evening dose can be taken as usual, but no earlier than 4 hours after haemostasis.
  • Rivaroxaban or edoxaban (once daily, morning): delay the morning dose; it may be taken 4 hours after haemostasis, with the next dose as usual the following morning.
  • Rivaroxaban or edoxaban (once daily, evening): no dose modification needed.

Antiplatelet Drugs

Aspirin (cyclooxygenase inhibitor) and clopidogrel (P2Y12 ADP-receptor antagonist) are commonly used alone or in combination (dual antiplatelet therapy, DAPT) after coronary stenting or acute coronary syndromes.

• Do not stop antiplatelet therapy for routine dental treatment, including simple extractions. Interruption of DAPT in a patient with a recent stent risks stent thrombosis and myocardial infarction.
• Local haemostatic measures are usually sufficient.
• For complex surgery or multiple extractions, plan with the cardiology or haematology team.

Local Haemostatic Measures

All patients at increased bleeding risk should have local measures planned in advance:

1. Sutures — close the socket to approximate wound edges.
2. Oxidised cellulose (Surgicel) — a resorbable haemostatic dressing packed into the socket.
3. Tranexamic acid 4.8% mouthwash — 10 mL rinsed for 5 minutes, four times daily for 2 days; do not eat or drink for 1 hour after each rinse.
4. Pack the socket with gelatin sponge (e.g. Gel foam) if needed.
5. Avoid NSAIDs for postoperative analgesia; use paracetamol.

Practical Treatment Plan

General measures

• Plan treatment early in the day and early in the week so bleeding can be reviewed and help is available.
• Limit the initial treatment area (e.g. single extraction, then assess bleeding before proceeding).
• Consider staging extensive procedures over separate visits.
• Only discharge the patient once haemostasis has been achieved.
• Give clear written postoperative advice and a contact number for bleeding problems.