Dental surgery

Hi everyone, I've been taking Pradaxa for about two and half weeks and today was told I need surgery to remove a molar. I'm not concerned about the procedure because having AFib is far worse.

I spoke to nurse at EP office about when to stop the Pradaxa and she was vague. She said anywheres between 1 to 3 days. I'm sure that someone on this brilliant forum will give me a better answer. Please help as I'm frustrated with the whole system. She told me to ask the dentist  because he would know better how much bleeding is expected . He said best to ask EP! Craziness ! 

24 Replies

  • I take Apixaban and have had a large back tooth removed without problems.  I continued with my Apixaban as normal and the dentist followed his procedure for all anti-coagulated patients using observation after extraction and packing of the socket with dissolving gauze held in place with stitches.  

    I asked for non adrenaline injections as my AF is adrenaline based and the whole procedure was straightforward.  The vagueness of advice to stop a NOAC for 1 to 3 days would worry me, especially if it is an easy extraction.  Perhaps your dentist is new to NOACs but surely must have experience with warfarin patients. I was my dentist's first NOAC patient and he and I discussed the ins and outs of Apixaban - he also referred to what looked like a professional dictionary of some sort.

    Apixaban is taken twice daily and I had my extraction an hour before my morning dose was due.  I hope my experience is of some use.

  • Thanks Finvola - that's really helpful.  

  • Same with me but when taking Warfarin. I was also told that I need not stop it before laser prostate surgery. 

  • Good advice there. Your dentist should refer to his/her guidelines on anticoagulation but for warfarin patients the current one is NOT to stop the drug. Many minor operations can be carried out whilst on anticoagulants these days but as Finvola states do not have any local with adrenaline as it could affect your AF. Alternatives are available.

  • This not  to do with teeth but minor ops. My GP who prescribed my Apixaban stopped it for 36 hours before a minor op. to remove a facial 'blob' non cancerous. All was well.

  • I was told that even for many minor ops they do not need to stop anticoagulation.

  • That is excellent news PeterWh.I was just doing as I was told....op. was Nov. 2015.Maybe my GP is not  super up to date even though he is a 'youngish' man and seems 'with it'.He wouldn't mind me querying anything as he is always open to discussion.

  • Not doubting that you were told!!!  |even some of the younger ones do not know the guidelines re anticoagulation (on aspects other than dentistry, as well as).  I came across that last week when taken to A&E and seen by one of the young doctors!!! 

  • Hi Finvola.....what do you mean by adrenaline based?  Sort of heard of it before..... but how different is that from straightforward afib?

  • Lizty

    The numbing injection that the dentist normally gives has adrenaline in it because then it works faster and is also cheaper.  Anybody who has AF or ANY form of arrhythmia should always ask for the one without adrenaline since in many adrenaline is an arrhythmia stimulant.

  • Lizty

    Hi Finvola.....what do you mean by adrenaline based? Sort of heard of it before..... but how different is that from straightforward afib?

  • I meant that a surge of adrenaline, either internally caused by  fear, anger or anxiety or externally caused by certain drugs and anaesthetics starts off my arrhythmias.  It doesn't differ from vagal AF or AF which isn't influenced by adrenaline as far as I know - it's equally miserable.  I found out the hard way that adrenaline in local anaesthetics starts my AF.

  • Thanks...that's very clear. 

  • Finvola's advice is excellent and my comments are merely additional, based on personal experience. 

    I am surprised at the details of my medical health that now concerns my dentist who works for a large company called Oasis. A steroid injection into any part of the body is recorded as are details of all medication. They know that I have been on Pradaxa for over 18 months and it causes them no concern at all. The Hygienist isn't worried either and to say that he is thorough would be an understatement.

    I see the dentist every 3 months as my gums have receded ( hence the term " long in the tooth" ) This means that I have seen them 6 times whilst on Pradaxa.

    If it were me I would not miss a single dose and I would not expect any problems either.

  • Hello Gracey,

    My husband has AF and takes a similar drug to Pradaxa. (Equilis.)   His dentist said to ask the doctor about stopping it before a tooth extraction.  He stopped it for 3 days and had the extraction on Tuesday with no problems before or after the event.

  • I agree with Finvola's comments.  Additional information / experience given to support.

    My dentist is in her 30s and very clued up and told me these things over a year ago or so.  She said that a large number of dentists are NOT up to date, especially some of those who have been practicing for many years.

    She said NEVER stop ANY anticoagulation for dental treatment (to have work done or cleaning).  That includes warfarin and all of the NOACs.  She told me the current NICE guidelines are that the INR needs to be below 4.0 (four) for warfarin and that they can ask for a test to be done 24 to 72 hours prior to the treatment.  She also said that the biggest risk to people is in the few days after stopping anticoagulation (something that was only restated on this forum recently).  Hence not a good idea to stop 3 days beforehand.

    My AF is affected by adrenaline but she said if anyone has any form of AF or arrhythmia then only non adrenaline injections must be used.

    She also said to remind her EVERY time because although it is clearly on the records she said that this is a double check for her / the dental nurse (especially if the nurse gets a standard one out because of habit).

    She also said that if reconstruction work on a jaw was so extensive that stopping anticoagulation was deemed essential then that work should only be undertaken.  She also said wisdom tooth extraction did not necessitate stopping anticoagulation. 

  • I agree. Sometimes patients are more up to date than the clinician. We sometimes need to provide them with the relevant up to date documents. In this case, the NICE guidelines referred to by PeterWh are excellent.

    You can ask for non-adrenaline injections. Yes, the patient has a role in continually reminding the doctor, and continually checking on them. Done pleasantly, it is all part of the give and take.

    I was also able to ask that they avoid getting too near my throat -- I gag and choke easily.

    Mine was a colapsed molar, where each root canal had fused with the jaw therefore had to be cut out, root by root. It was done by a surgeon, in outpatients, with an INR test that morning, and INR less than 4.0. I had no bleeding at all after the Op.

    I have a high pain threshold, so the doctor used minimal anesthetic and told me to give a sign when it hurt. He also once stopped and said, I have almost finished with this root, one big push, can you bear it?

    You should plan in advance for pain control. One of the major disadvantages of the doctor being more careful about bleeding control, is that sometimes the natural big clot that fills the hole does not form as easily. As a result, bone etc can be exposed, and boy does that hurt for a few weeks. I think this is called 'dry socket' At least you know the pain will go down.

    NSAIDs are usually not recommended for anticoagulated people, so we have little left. Have the discussion before the treatment. Fortunately, I was able to sleep, and able to ignore the pain when concentrating hard. I found the prescribed pain killers ineffective. I should have been given the option of something to help me sleep at night.

  • Oh. Post extraction. I ate normally, but easy soft food. Avoid sugar, but happy with the good microbes such as cheese. I also brushed gently. I was told that a little bleeding is cleansing even for someone at high risk for endocarditis. I also got hold of some hydrogen peroxide (oral version) and found that helped me clean my mouth. It is out of fashion nowadays, but works a treat. Particularly good at attacking food particles and coping with bleeding. 

  • Great info and yes I forgot to mention that my dentist said that even for a lot of dentistry in hospital anticoagulation does not need to be stopped.  You certainly validated that statement - yours was more complex than a hospital extraction.

  • That is right. My dentist sent me to a surgeon because he knew it was too complicated for him. I can say though that even a difficult extraction was still done in outpatients, and without touching the anticoagulation. I was 40 minutes in the chair! Oh, and the cost including followup? 25 pounds + panoramic Xray of 10pounds. 

  • My cardiovascular said 24 hours before surgery was adequate. Check with your cardiologist.

  • Sorry I disagree. You should push the dentist or surgeon hard to leave you on Anticoagulation without a break. Only if they are refusing should you go to your EP or cardiologist. 

    By way of a background a few years ago EPs stopped Anticoagulation before ablations. Now very many, including some eminent ones, leave people on their anticoagulant throughout. When I had my ablation I was told that it was important that I had my warfarin the night before the ablation.  I was back on the ward about 6.30pm and able to sit up around 9.30pm. By say 10.00pm I was given that day's warfarin. 

  • Thank you for reassurance. I spoke to Dental Surgeon and I will be remaining on Pradaxa. So many caring and brilliant people on this forum. You all make me so confident about my decisions. Gracey 

  • Brilliant. Hope all goes well. 

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