Many current dentistry guidelines do not recommend discontinuing oral anticoagulants before a minor dental procedure. Instead, local haemostatic measures are taken to reduce bleeding and ensure a patient can continue their treatment. These measures may include mechanical pressure, suturing, or local haemostats like tranexamic acid. Tranexamic acid is administered in the form of a topical solution applied with gauze or used as an oral rinse. Studies have shown that post-procedural bleeding can be reduced in patients taking oral anticoagulants with the use of tranexamic 4.8% mouthwash.

Anticoagulants and Dentistry

In recent years, the number of patients using anticoagulant medications has increased significantly. Most dentists will regularly treat patients who are on these medications. A tranexamic acid solution may be useful for procedures on patients taking these medications so they may continue their treatment without interruption. It may also be used in other situations where control of bleeding is necessary whether the patient is on OAs or not.

A specific plan should be developed balancing the risk of bleeding with the risk of thrombosis. This plan should often involve consultation with the patient’s physician. There are various anticoagulant therapies available that dentists should be aware of including both vitamin k antagonists and newer direct-acting agents. Warfarin is a vitamin K antagonist that is often prescribed as an oral anticoagulant. Newer oral anticoagulants include dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis).

What is Tranexamic Acid?

Tranexamic acid is a synthetic derivative of the amino acid lysine. It exerts its antifibrinolytic effect through the reversible blockade of lysine binding sites on plasminogen molecules. It has a variety of applications for controlling blood loss including postpartum bleeding, menstruation, nosebleeds, tooth extraction, and various surgical procedures. It may be used in emergency rooms to stop bleeding after traumatic injuries. Tranexamic acid is about 10 times more potent in vitro than aminocaproic acid.

How Can You Get Tranexamic Acid?

TA is commercially available in the form of an oral tablets and an intravenous injection. For dentistry, these forms are not ideal. Systemic administration is not necessary for most oral procedures and can increase adverse effects, especially in patients on anticoagulants. A topical application is preferable and can be made by a compounding pharmacy from bulk ingredients.

For patients on anticoagulation therapy, tranexamic acid should not be taken orally or given intravenously. Topical application is the administration method of choice for all oral procedures. The locally applied solution can provide safe hemostasis during the surgery and after the patient leaves the office. Compounding pharmacies thus provide an essential service to dentists in making topically applied formulations of tranexamic acid.

Discontinuing Oral Anticoagulants

For major procedures, dentists will often require the discontinuation of oral anticoagulants. This is where it becomes important for dentists to coordinate with a patient’s medical doctor regarding timing of discontinuing medication. Tranexamic acid may not be able to reduce bleeding to the same extent as discontinuing oral anticoagulants would. Some studies have shown that patients on OAs still bleed more even when using tranexamic acid compared to when patients discontinue their OA. However these studies are not entirely conclusive and more research needs to be done in this area.

Since discontinuing an OA can be detrimental to a patient’s health and lead to thromboembolic events, making surgery more dangerous, tranexamic acid is used by many practitioners to reduce bleeding. This helps ensure the patient can continue taking their medication and also have a safe procedure with a good clinical outcome. The most evidence exists for its use in surgical tooth extraction but it may be used for other procedures as well.

How is Tranexamic Acid 4.8% Used

Tranexamic acid 4.8% is used in a variety of ways to improve hemostasis. It is dispensed in a solution that may be used as a pre- or post-operative oral rinse. The patient usually will be prescribed to use the rinse 2-4 times per day for at least 48 hours after their procedure. The solution is sometimes used to soak compressive gauze which is pressed against the wound or for the patient to bite on. If using gauze, it must be pressed against the wound for about an hour. Gelfoam or Surgifoam may be soaked in tranexamic acid and placed in the socket or held on the area. TA solution can be used as a post-operative irrigant applied by the dentist before continuing with gauze, Gelfoam, or rinsing.

Articles

• Efficacy of local tranexamic acid treatment for prevention of bleeding after dental procedures: A systematic review and meta-analysis – Journal of Dental Sciences
• Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications – BMC Oral Health
• Anticoagulation Use prior to Common Dental Procedures: A Systematic Review – Cardiology Research and Practice
• Tranexamic Acid as a Hemostatic Adjunct in Dentistry – Aegis Dental Network