Sir, NICE recently recommended dabigatran etexilate as a possible treatment to prevent stroke and systemic embolism in people with atrial fibrillation. The US Food and Drug Administration have also approved rivaroxaban. It is possible that these two anticoagulants will eventually replace warfarin.

Dabigatran and rivaroxaban are quickly absorbed and have short half-lives compared to warfarin so, in the event of excessive anticoagulant activity, discontinuing the drug is usually sufficient. They have no antidotes. There is no need for routine coagulation monitoring in the same way as warfarin using the prothrombin time INR. Most dental situations such as removal of a small number of teeth would be comparable to treating a patient with an INR ≤4, relying on local measures to obtain haemostasis – pressure with sterile pads (moistened with water, normal saline or 5% tranexamic acid solution), absorbable oxidised cellulose sponges, and sutures.

The known drug interaction profiles of both dabigatran and rivaroxaban as regards antimicrobials and analgesics are less restrictive than with warfarin. It may be better to confine analgesic use to paracetamol since NSAIDs have antiplatelet effects. Table 1 shows data relevant to dental health care.

Table 1 Data comparing warfarin with new anticoagulant drugs
Full size table