Sir, I work in the oral surgery department of a London Hospital and regularly treat patients with significant co-morbidities many of which take an anticoagulant medication, primarily warfarin. Within the last year I have come across an increasing number of patients taking the newer range of novel oral anti-coagulants (NOACs), which do not require routine blood test monitoring.1 I am, however, concerned at the lack of research (no clinical trials) and experience using these medicines along with dental extractions.

A recent case of a 78-year old-lady who had started taking dabigatran for atrial fibrillation approximately three months earlier, having previously taken warfarin for a number of years, highlighted this for me. She suffered considerable post-operative bleeding and bruising over a two-week period following extraction of the upper left wisdom tooth, which was completed under local anaesthetic via an atraumatic forceps technique with Surgicel and 3-0 Vicryl absorbable sutures placed as precautionary local haemostatic measures.

Despite being introduced in 2008 the NOACs are only just starting to be used more frequently for conditions such as atrial fibrillation and prevention of stroke as an alternative to aspirin. Recommendation from the Scottish Dental Clinical Effectiveness Programme states that if patients are undergoing a low bleeding risk procedure no interruption in their medication should occur; an atraumatic extraction is considered to be low risk. For higher risk procedures, the medication should be missed on the day of their procedure; however, the evidence supporting these suggestions is of low quality.2

The case above was very distressing for the patient and her family; as a result I have concerns as to how dental procedures can be safely carried out on this new population. The decision to stop a medication can be of concern to both the dentist and patient if not fully considered with their physician.