Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs
Patients taking anticoagulants or antiplatelet drugs can have a higher risk of bleeding complications following invasive dental procedures. Newer oral anticoagulants and antiplatelet drugs available in the UK are being increasingly prescribed and so more patients taking them are presenting for dental treatment.
Guidance from the Scottish Dental Clinical Effectiveness Programme (SDCEP), Management of Dental Patients Taking Anticoagulants and Antiplatelet Drugs, was published in 2015, and addresses the management of dental treatment for these patients. In line with SDCEP’s standard five-year guidance review period, the scheduled review of the guidance topic commenced in 2020. An updated version of this guidance was published in 2022.
The need for national guidance on this topic arose from concerns about the lack of clarity around dental specific recommendations for the new drugs, and uncertainty about referral for these patients. The guidance aimed to clarify recommendations and expert advice for the newer oral anticoagulants and antiplatelet drugs and present these, along with up-to-date recommendations for the more established medications, within a single information resource. To inform the development of the guidance, the following work was carried out by TRiaDS:
Informing the Scope of the Guidance
The scope of the guidance was informed by conducting telephone interviews with sixteen general dental practitioners (GDPs) from both rural and city practices from across Scotland. The aim was to identify current practice and factors which may influence the management of patients taking these drugs. The interviews also helped establish what dentists wanted from this guidance.
A patient questionnaire (PDF) was developed to ensure that patients’ views were represented in the guidance. The questionnaire was distributed using two routes: (i) It was posted on three charity websites: Anticoagulation Europe; the Atrial Fibrillation Association; The Stroke Association, and (ii) It was also distributed (face-to-face) through anticoagulation clinics in NHS Tayside with the help of colleagues from the Scottish Health Council. A summary report (PDF) [accessible version (Word)] is available.
Diagnostic analyses comprised of four stages: consultation feedback questionnaire; semi-structured telephone interviews; pre-guidance publication questionnaire; post-guidance publication questionnaire.
1.Consultation feedback questionnaire
As part of SDCEP’s consultation process the draft guidance was circulated to organisational and individual stakeholders including GDPs for feedback. A number of questions focusing on the barriers and facilitators to implementation were included in the consultation feedback form.
2.Semi-structured telephone interviews
Dentists (GDPs) and dental hygienists (DHs) took part in interviews during the consultation period. Feedback gathered at consultation informed the interview questions which aimed to identify salient beliefs regarding the barriers and facilitators related to the implementation of the recommendations in the draft guidance.
3.Pre-guidance publication questionnaire
A questionnaire underpinned by the Theoretical Domains Framework was sent to a random sample of GDPs across Scotland six weeks prior to the publication and dissemination of the guidance. The content of the questionnaire was informed by the findings of the consultation feedback and the interviews.
4.Post-guidance publication questionnaire
A post-guidance questionnaire was distributed six months after publication to identify any changes in practice following publication and dissemination of this SDCEP guidance.
2022 Guidance Update
Informing the Scope of the Guidance
To inform the scope of the guidance update, online interviews were conducted with dental practitioners from across Scotland.
Recruitment emails were sent to the SDPBRN Rapid Evaluation Practitioners, NHS Tayside’s Public Involvement Team and the Patient and Public Involvement and Engagement Co-ordinator for the Health Service Research Unit in the University of Aberdeen, for distribution to their network members.
Four interviews were conducted with dental practitioners: two GDPs, one Oral Medicine specialist working in a hospital service, and one special care dentist working in the Public Dental Service. Practitioners were asked about their experiences of using the 2015 guidance, if there had been anything particularly challenging to implement, and if there were any topics that they felt should be included in the update.
Feedback on the guidance was overall positive, and suggestions were made for the updated version, including taking into consideration new available anticoagulant and antiplatelet medications, and updating the statistics regarding medication use. Suggestions were also made regarding activities to support implementation following the publication and dissemination of the updated guidance.
A pre-guidance publication questionnaire based on the COM-B model of behaviour was sent to dental practitioners before the publication of the updated guidance. The purpose of this questionnaire was to inform the development of appropriate training and support to help practitioners implement this guidance by exploring aspects of current management of patients taking anticoagulants or antiplatelet drugs in primary care dental practice. This questionnaire asked about current practice and beliefs regarding the recommendations within the guidance. The results of this questionnaire are currently being analysed and will be published in a peer-reviewed journal in due course.
A post-guidance publication questionnaire will be sent to dental practitioners six months following the publication of the updated guidance.
The SDCEP guidance is accompanied by several patient-facing resources, including patient information leaflets and post-treatment advice sheets. To inform the update of these resources, TRiaDS conducted interviews with patients and patient advocates, and developed a short online questionnaire, to collect feedback on the existing resources and suggestions for improvements.
For more information, please contact: TRiaDS@nes.scot.nhs.uk