Sir, we write further to previous correspondence relating to the dental management of patients who are taking anticoagulant drugs and the lack of relevant guidance for dental practitioners.1,2,3 We offer the following observations based upon arrangements in our region.

In early 2012, it became clear that the drugs rivaroxaban (Xarelto) and dabigatran etexilate (Pradaxa) would be more widely prescribed in Tayside for patients living in the community than had previously been the case. It was also clear that dental practitioners, in both community and hospital settings, would have little prior knowledge of these drugs and their potential impact on the provision of dental care. A guideline for local use within the NHS Tayside Health Board Area was therefore drawn up4 to outline the principles of patient management to be adopted for any dental patient who is taking either of the drugs mentioned above. For ease of use by all dental practitioners, the guidance also incorporates information relating to the coumarins and to anti-platelet medications.

The guidance was compiled by a community based senior dental officer who is on the GDC specialist list for special care dentistry, with input from community and hospital-based colleagues on specialist lists in special care dentistry, oral surgery and oral and maxillofacial surgery. Medical expertise and input was provided by locally-based consultant colleagues in cardiology and haematology.

Our guidance suggests that an atraumatic extraction technique, with a limit of 3-4 teeth being extracted at any one visit, supplemented by local haemostatic measures (sutures, haemostat packs and locally applied pressure) at the time of extraction will allow safe treatment for these patients in a general or community dental practice environment. For coumarin drugs standard advice on pre-operative checking of the INR to ensure a level of <4 is advised. No pre-operative blood testing or dose adjustment is recommended for rivaroxaban or dabigatran.

Advice is also given with regard to the medical conditions which should prompt the dentist to seek advice from a senior dental or medical colleague before a dental procedure likely to cause a haemorrhage is undertaken. These conditions include patients with a recently placed stent, liver or renal impairment, alcohol problems and patients taking cytotoxic drugs or who have any underlying defect of their physiological clotting mechanisms.

In our locality we have been using these drugs (predominantly rivaroxaban) instead of warfarin for selected individuals with atrial fibrillation and for new patients presenting with deep vein thrombosis over the past year and no problems have been reported in relation to the implementation of the principles outlined in the guidance. From our experience, it would seem that those patients with uncomplicated medical histories can be safely treated in general dental practice.