Extraction & antithrombotics

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Extraction & antithrombotics

Full reference · Version 0.2.0 · Updated

Planned extractions in patients taking antithrombotic medicines.

This reference does not calculate a patient-specific schedule for stopping, restarting or bridging antithrombotic therapy.

Medicines
18 entries

Medicine explorer

18 entries

Preparation

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Bleeding and thrombosis risk

Temporarily stopping treatment can increase the risk of thrombosis. The assessment depends on the procedure, the medicine and the patient.

TAR

Single antiplatelet agent (TAR in Dutch)

Single antiplatelet therapy

For an extraction assessed as having a low bleeding risk, KIMO recommends continuing a single antiplatelet agent. Patients taking more than one antithrombotic need a separately agreed plan.

TAR

Active ingredients and product names

Oral antiplatelet agents listed in the dental reference include the salicylates acetylsalicylic acid and carbasalate calcium, the P2Y12 inhibitors clopidogrel, prasugrel and ticagrelor, and dipyridamole.

Salicylates: acetylsalicylic acid and carbasalate calcium. P2Y12 inhibitors: clopidogrel, prasugrel and ticagrelor. Other oral antiplatelet agents: dipyridamole.

Brand names help identify medicines. Check the active ingredient on the current medication list. Check the full list for other antithrombotics as well.

Check all active ingredients and other antithrombotics on the current medication list.

  • Acetylsalicylic acid — Acetylsalicylzuur Cardio, Acetylsalicylzuur Neuro, Aspirine Protect.
  • Carbasalate calcium — Ascal '38', Ascal Cardio (Neuro), Carbasalaatcalcium Cardio.
  • Clopidogrel — Clopidogrel, Grepid, Iscover, Plavix.
  • Dipyridamole — Dipyridamol, Persantin.
  • Prasugrel — Efient, Prasugrel.
  • Ticagrelor — Brilique, Ticagrelor.

VKA

Acenocoumarol or phenprocoumon without another antithrombotic

A recent INR is required

For extraction while continuing a VKA, KIMO uses an INR of 3.5 or less, measured in the preceding 24 hours. The assessment must still take bleeding risk and local measures into account.

Consider factors beyond the INR

An INR within range does not rule out other factors that increase risk. Agree the plan beforehand if the risk is increased. Do not use this threshold on its own to make a treatment decision.

VKA

Active ingredients and product names

Acenocoumarol and phenprocoumon are the two VKA active ingredients listed in the Dutch medicines reference. Both are coumarins that counteract the action of vitamin K.

Acenocoumarol and phenprocoumon are coumarins that counteract the action of vitamin K.

The brand name helps identify the medicine. Check the active ingredient on the current medication list.

Check the active ingredient on the current medication list.

  • Acenocoumarol — Acenocoumarol.
  • Phenprocoumon — Fenprocoumon, Marcoumar.

DOAC

Single direct oral anticoagulant

Low bleeding risk

According to the Dutch national guideline, a DOAC need not be interrupted if the pre-procedure assessment identifies a low bleeding risk.

DOAC

Active ingredients and product names

The Dutch medicines reference lists four DOAC active ingredients. Apixaban, edoxaban and rivaroxaban inhibit factor Xa; dabigatran inhibits thrombin.

Factor Xa inhibitors: apixaban, edoxaban and rivaroxaban. Thrombin inhibitor: dabigatran.

Brand names help identify medicines. Check the active ingredient on the current medication list.

Check the active ingredient on the current medication list.

  • Apixaban — Apixaban, Eliquis.
  • Dabigatran — Dabigatran, Pradaxa.
  • Edoxaban — Lixiana.
  • Rivaroxaban — Rivaroxaban, Xarelto.

LMWH

Regular use of a single low-molecular-weight heparin

Regular use

For regular LMWH use and an extraction assessed as low risk for bleeding, KIMO's starting point is to continue the LMWH and use local measures.

LMWH

Active ingredients and product names

Low-molecular-weight heparins are injectable anticoagulants. These are the four active ingredients listed under LMWH in the Dutch medicines reference.

LMWHs are injectable low-molecular-weight heparins.

The brand names in the dental sources help identify medicines and may differ from current product names. Check the active ingredient on the medication list.

Check the active ingredient; names used for identification can differ from current product names.

  • Dalteparin — Fragmin.
  • Enoxaparin — Enoxaparine, Clexane, Enoxaparine Becat, Inhixa.
  • Nadroparin — Fraxiparine, Fraxiparine forte; KIMO also lists Fraxodi.
  • Tinzaparin — Innohep.

Combinations

Multiple antithrombotics, including two antiplatelet agents

Agree a plan in advance

Consult beforehand

For combinations that include a VKA or LMWH, the dental professional consults the anticoagulation service or specialist centre. For other combinations, agree the plan with the prescriber.

For combinations with a VKA or LMWH, consult the anticoagulation service or specialist centre. Otherwise, consult the prescriber.

Discuss the timing of the procedure as well

Timing and postponement

For combined anticoagulant and antiplatelet therapy, Dutch national guidance recommends considering postponement, where possible, until the combination is no longer indicated. If postponement is undesirable or not possible, agree on management for each medicine.

For combined anticoagulant and antiplatelet therapy, consider postponing the procedure if possible until the combination is no longer indicated. If that is undesirable or impossible, agree a plan for each medicine.

Combinations

Identifying multiple active ingredients

Identifying combinations

Check the number of antithrombotic active ingredients, not just the number of packs. A fixed combination can contain two antiplatelet agents.

Count antithrombotic active ingredients, not packs. One fixed combination can contain two antiplatelet agents.

Separately prescribed antithrombotics can also form a combination. The full medication list determines which groups are involved.

Check the full medication list for separately prescribed antithrombotics as well.

  • Clopidogrel + acetylsalicylic acid — fixed combination of two antiplatelet agents; brand name Duoplavin.
  • Dipyridamole + acetylsalicylic acid — fixed combination of two antiplatelet agents; names include Asasantin and Dipyridamol/acetylsalicylzuur.
  • Separate packs — also check for concurrent use of two antiplatelet agents or medicines from different antithrombotic groups.

Bleeding risk

Clinical assessment

Assess the risk of both the procedure and the patient. Relevant factors include:

  • A technically difficult procedure or a large wound area.
  • A wound that cannot be closed primarily or compressed adequately.
  • Infection at the operative site.
  • Patient vulnerability.

Do not assume low risk

The Dutch national table distinguishes extractions with and without additional risk factors. If risk is increased, agree the measures and medication plan beforehand. This app does not assign a risk score.

Measures around the procedure

KIMO lists measures such as reducing the wound area, staging treatment and using additional local measures if necessary. If these measures are expected to be insufficient, consult the relevant prescriber or anticoagulation service.

Local measures

Suturing and wound care

KIMO recommends suturing after a procedure that causes bleeding, regardless of the antithrombotic used or whether it was temporarily interrupted.

Local measures

Tranexamic acid

As an additional measure, KIMO lists 5% tranexamic acid. Gently rinse the wound with the solution, or bite on gauze soaked in it. Tranexamic acid can be omitted in patients taking a single antiplatelet agent.

Preparation and additional measures

Arrange the medicine in good time because it takes time to prepare. Absorbable wound dressings are not routinely recommended, but may be considered if additional risk factors are present.

KIMO describes rinsing with 10 mL for 2 minutes, four times daily for 2 to 5 days while the wound is bleeding. Biting on gauze soaked in the solution is the alternative.

Consultation & discussion

Agree the plan before the procedure

If consultation is needed, agree on the type and date of the procedure, the bleeding risk and how to manage the medication. Document the plan in your own patient record.

  • For VKA use, discuss checking the INR within 24 hours before the procedure.
  • For VKA use, inform the anticoagulation service of the procedure type and date at least one week in advance.
  • Report relevant complications after the procedure to the clinician involved.

Discuss with the patient

Discuss the bleeding risk if treatment continues and the thrombosis risk if it is temporarily stopped. If an interruption is agreed, give clear advice on restarting treatment. Check that the patient understands the explanation.

Pain relief & aftercare

Avoid NSAIDs for pain relief

KIMO advises against prescribing NSAIDs after a dental procedure that causes bleeding in patients taking antithrombotics, because NSAIDs increase bleeding risk. This also applies if the antithrombotic was temporarily interrupted.

Clear aftercare instructions

Explain wound care, the agreed pain relief and whom the patient can contact outside opening hours. If bleeding persists, the patient should contact the on-call dental professional.

  1. Bloedige ingrepen in de mondzorg, bij patiënten die antitrombotica gebruiken

    Kennisinstituut Mondzorg (KIMO) · Juni 2025

    Published: · Accessed:

    Open source: Bloedige ingrepen in de mondzorg, bij patiënten die antitrombotica gebruiken (new tab)

    https://www.hetkimo.nl/wp-content/uploads/2026/08/2025.06.13-KPR-Antitrombotica-Richtlijn.pdf

    • Doel en doelgroep, p. 11

      Preparation

    • Uitgangsvraag 1, p. 20

      TAR · LMWH

    • Uitgangsvraag 1, tabel en Kader 1; bijlage 7, p. 20, 68

      TAR

    • Bijlage 7, stof- en handelsnamen; herkenningsnamen uit het mondzorgoverzicht van 25 augustus 2019, p. 68–69

      TAR · LMWH

    • Uitgangsvraag 1 en 4, p. 20, 40

      VKA · Combinations

    • Uitgangsvraag 1, tabel, p. 20

      VKA · LMWH

    • Uitgangsvraag 1, tabel; Uitgangsvraag 4, stroomdiagram, p. 20, 40

      VKA · Combinations

    • Bijlage 7, stof- en handelsnamen, p. 68–69

      VKA · DOAC

    • Afkortingen en bijlage 7, p. 10, 68

      DOAC

    • Uitgangsvraag 1, tabel en Kader 1, p. 20

      LMWH

    • Uitgangsvraag 1, tabel; Bijlage 7, Combi-TAR en stof- en handelsnamen, p. 20, 68–69

      Combinations

  2. Antitrombotica: inschatten bloedingsrisico

    KIMO · Richtlijn 2025, uitgangsvraag 1

    Accessed:

    Open source: Antitrombotica: inschatten bloedingsrisico (new tab)

    https://www.hetkimo.nl/richtlijnen/antitrombotica/inschatten-bloedingsrisico/

    • Uitgangsvraag 1, tabel en Kader 1

      TAR

    • Kader 1

      Bleeding risk

    • Kader 1, factoren die het bloedingsrisico vergroten

      Bleeding risk

    • Aanbevelingen en Overwegingen

      Bleeding risk

  3. Antitrombotica: lokale maatregelen

    KIMO · Richtlijn 2025, uitgangsvraag 2

    Accessed:

    Open source: Antitrombotica: lokale maatregelen (new tab)

    https://www.hetkimo.nl/richtlijnen/antitrombotica/lokale-maatregelen/

    • Uitgangsvraag 2

      Local measures

    • Uitgangsvraag 2, Aanbevelingen

      Local measures

    • Uitgangsvraag 2, Aanbevelingen en Overwegingen

      Local measures

    • Aanbevelingen; Overwegingen

      Local measures

  4. Antitrombotica: patiënten informeren

    KIMO · Richtlijn 2025, uitgangsvraag 3 en patiënteninformatie

    Accessed:

    Open source: Antitrombotica: patiënten informeren (new tab)

    https://www.hetkimo.nl/richtlijnen/antitrombotica/patienten-informeren/

    • Uitgangsvraag 3, Overwegingen

      Preparation

    • Patiënteninformatie, Wat moet u niet doen?

      Local measures · Pain relief & aftercare

    • Uitgangsvraag 3

      Consultation & discussion

    • Uitgangsvraag 3, Aanbevelingen

      Consultation & discussion

    • Patiënteninformatie

      Pain relief & aftercare

    • Patiënteninformatie, Wanneer moet u contact opnemen?

      Pain relief & aftercare

  5. Antitrombotica: taakverdeling in de keten

    KIMO · Richtlijn 2025, uitgangsvraag 4

    Accessed:

    Open source: Antitrombotica: taakverdeling in de keten (new tab)

    https://www.hetkimo.nl/richtlijnen/antitrombotica/taakverdeling-in-de-keten/

    • Uitgangsvraag 4

      Consultation & discussion

    • Taken en verantwoordelijkheden; Bij patiënten die een VKA gebruiken

      Consultation & discussion

    • Communicatie met de patiënt

      Pain relief & aftercare

  6. Antitrombotica: NSAID-beleid

    KIMO · Richtlijn 2025, uitgangsvraag 5

    Accessed:

    Open source: Antitrombotica: NSAID-beleid (new tab)

    https://www.hetkimo.nl/richtlijnen/antitrombotica/nsaid-beleid/

    • Uitgangsvraag 5

      Pain relief & aftercare

    • Uitgangsvraag 5, Aanbevelingen

      Pain relief & aftercare

    • Aanbevelingen; Overwegingen

      Pain relief & aftercare

  7. Antitrombotisch beleid: periprocedureel beleid

    Cluster Antitrombotisch beleid / Richtlijnendatabase · Module 1 mei 2026

    Published: · Accessed:

    Open source: Antitrombotisch beleid: periprocedureel beleid (new tab)

    https://richtlijnendatabase.nl/richtlijn/antitrombotisch_beleid/periprocedureel_beleid_bij_antistolling.html

    • Tabel 1, MKA-chirurgie en tandheelkunde

      TAR

    • Tabel 1, MKA-chirurgie en tandheelkunde; Werkwijze rondom de operatie/ingreep

      TAR · VKA · Bleeding risk

    • Tabel 1

      VKA · DOAC · LMWH · Bleeding risk

    • Werkwijze rondom de operatie/ingreep

      DOAC

    • Tabel 1; Werkwijze rondom de operatie/ingreep

      LMWH

  8. Periprocedureel beleid bij DOACs, inclusief lage dosis DOAC's

    Cluster Antitrombotisch beleid / Richtlijnendatabase · Module 1 mei 2026

    Published: · Accessed:

    Open source: Periprocedureel beleid bij DOACs, inclusief lage dosis DOAC's (new tab)

    https://richtlijnendatabase.nl/richtlijn/antitrombotisch_beleid/periprocedureel_beleid_bij_antistolling/periprocedureel_beleid_bij_doacs_inclusief_lage_dosis_doac_s.html

    • Aanbeveling

      DOAC

    • Aanbeveling; Ingrepen met laag bloedingsrisico

      DOAC

    • Aanbeveling; Preprocedurele evaluatie patiënt op een DOAC

      DOAC

  9. Periprocedureel beleid bij combinatie van antitrombotica

    Cluster Antitrombotisch beleid / Richtlijnendatabase · Module 1 mei 2026

    Published: · Accessed:

    Open source: Periprocedureel beleid bij combinatie van antitrombotica (new tab)

    https://richtlijnendatabase.nl/richtlijn/antitrombotisch_beleid/periprocedureel_beleid_bij_antistolling/periprocedureel_beleid_bij_combinatie_van_antitrombotica.html

    • Aanbeveling

      Combinations

    • Aanbeveling, voetnoot

      Combinations

  10. Periprocedureel beleid TARs

    Nederlandse Internisten Vereniging / Richtlijnendatabase · Module 15 april 2021; beoordeeld 24 maart 2021

    Published: · Accessed:

    Open source: Periprocedureel beleid TARs (new tab)

    https://richtlijnendatabase.nl/richtlijn/antitrombotisch_beleid/periprocedureel_beleid_bij_antistolling/periprocedureel_beleid_tars.html

    • Aanbeveling

      Combinations

    • Aanbeveling, Wanneer staken dual antiplatelet therapy

      Combinations

  11. Salicylaten als trombocytenaggregatieremmer

    Zorginstituut Nederland / Farmacotherapeutisch Kompas · Geneesmiddelgroep, geraadpleegd 9 november 2026

    Accessed:

    Open source: Salicylaten als trombocytenaggregatieremmer (new tab)

    https://www.farmacotherapeutischkompas.nl/bladeren/groepsteksten/salicylaten_als_trombocytenaggregatieremmer

    • Geneesmiddelenoverzicht salicylaten als trombocytenaggregatieremmer

      TAR

  12. P2Y12-remmers

    Zorginstituut Nederland / Farmacotherapeutisch Kompas · Geneesmiddelgroep, geraadpleegd 9 november 2026

    Accessed:

    Open source: P2Y12-remmers (new tab)

    https://www.farmacotherapeutischkompas.nl/bladeren/groepsteksten/p2y12_remmers

    • Geneesmiddelenoverzicht P2Y12-remmers: orale clopidogrel, prasugrel en ticagrelor

      TAR

  13. Trombocytenaggregatieremmers, overige

    Zorginstituut Nederland / Farmacotherapeutisch Kompas · Geneesmiddelgroep, geraadpleegd 9 november 2026

    Accessed:

    Open source: Trombocytenaggregatieremmers, overige (new tab)

    https://www.farmacotherapeutischkompas.nl/bladeren/groepsteksten/trombocytenaggregatieremmers__overige

    • Geneesmiddelenoverzicht trombocytenaggregatieremmers, overige: dipyridamol

      TAR

    • Geneesmiddelenoverzicht trombocytenaggregatieremmers, overige: clopidogrel/acetylsalicylzuur

      Combinations

  14. Vitamine K-antagonisten

    Zorginstituut Nederland / Farmacotherapeutisch Kompas · Geneesmiddelgroep, geraadpleegd 9 november 2026

    Accessed:

    Open source: Vitamine K-antagonisten (new tab)

    https://www.farmacotherapeutischkompas.nl/bladeren/groepsteksten/vitamine_k_antagonisten

    • Geneesmiddelenoverzicht vitamine K-antagonisten; Werkingsmechanisme

      VKA

  15. Directwerkende orale anticoagulantia

    Zorginstituut Nederland / Farmacotherapeutisch Kompas · Geneesmiddelgroep, geraadpleegd 9 november 2026

    Accessed:

    Open source: Directwerkende orale anticoagulantia (new tab)

    https://www.farmacotherapeutischkompas.nl/bladeren/groepsteksten/directwerkende_orale_anticoagulantia

    • Geneesmiddelenoverzicht directwerkende orale anticoagulantia; Werkingsmechanisme

      DOAC

  16. Heparinen, LMWH's

    Zorginstituut Nederland / Farmacotherapeutisch Kompas · Geneesmiddelgroep, geraadpleegd 9 november 2026

    Accessed:

    Open source: Heparinen, LMWH's (new tab)

    https://www.farmacotherapeutischkompas.nl/bladeren/groepsteksten/heparinen__lmwh_s

    • Geneesmiddelenoverzicht heparinen, LMWH's

      LMWH

Planned extractions in patients taking antithrombotic medicines.

This reference does not calculate a patient-specific schedule for stopping, restarting or bridging antithrombotic therapy.