The young and the anticoagulated: A guide to blood thinners for today’s dental hygienist

The use of blood thinners is no longer limited to elderly patients. Dental teams today are more likely to see younger patients on anticoagulation therapy¹: a 25-year-old with factor V Leiden after a DVT during air travel, a 32-year-old athlete newly diagnosed with atrial fibrillation, or a 28-year-old postpartum patient recovering from a pulmonary embolism. These scenarios introduce unique challenges, including temporary anticoagulation protocols and pregnancy considerations, and often require coordination with both the dentist and the patient’s physician if bleeding is a concern for upcoming dental care.

As dental professionals, staying current on blood thinners—regardless of patient age—is critical for preventing complications. Effective care means being aware of side effects, drug interactions, and black box warnings, all of which can be quickly accessed in the MedAssent DDS Digital Drug Handbook.

Understanding the anticoagulant landscape

Warfarin: The established standard

Warfarin² (Coumadin) remains a cornerstone treatment for atrial fibrillation, mechanical heart valves, and thrombotic disorders. Its pharmacokinetic effects, however, are notoriously variable—impacted by diet, other medications, and individual patient factors—requiring routine monitoring and dosage adjustments by a physician.

If a patient reports taking warfarin, hygienists should ensure this is documented and brought to the dentist’s attention prior to any procedures. Many commonly prescribed dental medications, such as amoxicillin and ampicillin, can significantly increase the risk of bleeding (even life-
threatening in some cases) when used with warfarin.

Direct oral anticoagulants (DOACs)

The introduction of DOACs—apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), and edoxaban (Savaysa)—has revolutionized anticoagulation therapy. These medications directly inhibit Factor Xa or thrombin, offering more predictable pharmacokinetics and eliminating routine monitoring requirements.³ It’s essential for hygienists to recognize these medications by name and understand their relevance during medical history reviews.

Parenteral anticoagulants

Low molecular weight heparins like enoxaparin⁴ (Lovenox) are used for bridging therapy, acute treatment, and during pregnancy. Patients on Lovenox typically have complex medical conditions requiring careful monitoring. If a patient reports using Lovenox, hygienists should notify the dentist to determine if physician consultation is needed before dental treatment.

Drug interactions every hygienist should know

NSAIDs, aspirin, and antiplatelet agents

Combining blood thinners with NSAIDs or aspirin significantly increases bleeding risk.⁵ This includes both prescription and over-the-counter medications. Patients may not think to mention OTC drugs, so it’s important to ask specifically about products like Advil, Motrin, or aspirin-containing medications. Alert the dentist if any concerning combinations are identified.

Antibiotics, antifungals, and other medications

Many antibiotics prescribed in dentistry can increase bleeding risk depending on the type of anticoagulant.⁶ This also applies to antifungals,⁷ antivirals, and other common medications. Always check for interactions using a reliable clinical resource such as MedAssent DDS. As a hygienist, you should be aware of the following drug interactions to recognize when extra caution or a referral to the dentist is warranted:

• Penicillin antibiotics (e.g., amoxicillin, ampicillin): can raise bleeding risk with warfarin
• Metronidazole: may cause serious, even life-threatening bleeding with warfarin
• Fluoroquinolone antibiotics (e.g., ciprofloxacin, levofloxacin): can increase bleeding risk with warfarin and DOACs such as apixaban (Eliquis) and rivaroxaban (Xarelto)
• Macrolide antibiotics (e.g., azithromycin): May increase bleeding with both warfarin and DOACs such as apixaban (Eliquis) and rivaroxaban (Xarelto)
• Trimethoprim-sulfamethoxazole: can elevate bleeding risk with warfarin
• Doxycycline: increases risk of severe bleeding⁸ with warfarin and some DOACs such as apixaban (Eliquis) and rivaroxaban (Xarelto)
• Azole antifungals (e.g., fluconazole, ketoconazole)⁷: may amplify bleeding risk with warfarin and DOACs such as apixaban (Eliquis)
• Antivirals (e.g., acyclovir, valacyclovir)⁷: can increase the anticoagulant effect of warfarin
• Alprazolam (Xanax)⁹: may enhance warfarin’s effect
• Antiseizure medications (e.g., phenytoin, carbamazepine)⁹: can interfere with anticoagulant levels or efficacy

This is not an exhaustive list, but these examples illustrate why hygienists must be vigilant in reviewing medications and alerting the dentist if a potential interaction is present.

Practical safety strategies for hygienists

Medical history review

At every visit, ask patients about all medications—including over-the-counter products and supplements. Record all relevant medications and update the dentist if anything new appears, if there’s been a change in medications, or if you suspect a potential interaction.

Recognizing bleeding risks

Routine hygiene procedures are typically low risk, but prolonged or excessive bleeding can occur. The American Dental Association (ADA) generally advises against stopping anticoagulants for most dental procedures, as the risk of thromboembolic events may outweigh the risk of bleeding.¹ If you observe excessive bleeding during treatment, pause the procedure and alert the dentist immediately.

Conclusion

The landscape of anticoagulation is evolving, as are the responsibilities of the dental team. Today’s patients on blood thinners may be young and otherwise healthy but still face serious risks during dental care.

Understanding the different types of anticoagulants, being aware of high-risk medication interactions, and recognizing bleeding risks are all critical to patient safety. While treatment decisions ultimately lie with the dentist, hygienists play a pivotal role in identifying risks, flagging concerns, and supporting informed, safe, and effective care.

By staying informed and attentive, you help ensure the best possible outcomes for every patient—regardless of age or complexity. 

Editor's note: This article appeared in the August/September 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subsciption. Sign up here.

References

1. Oral anticoagulant and antiplatelet medications and dental procedures. American Dental Association. Updated September 28, 2022. https://www.ada.org/resources/ada-library/oral-health-topics/oral-anticoagulant-and-antiplatelet-medications-and-dental-procedures
2. Patel S, Singh R, Preuss CV, Patel N. Warfarin. StatPearls [Internet]. StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK470313/
3. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the Efficacy and Safety of New Oral Anticoagulants with Warfarin in Patients with Atrial Fibrillation: A Meta-analysis of Randomised Trials. Database of Abstracts of Reviews of Effects (DARE): Quality-Assessed Reviews [Internet]. Centre for Reviews and Dissemination (UK); 1995. https://www.ncbi.nlm.nih.gov/books/NBK174292/
4. Jupalli A, Iqbal AM. Enoxaparin. StatPearls [Internet]. StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK539865/
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6. Rifadin (rifampin capsules USP) and Rifadin IV (rifampin for injection USP). Food & Drug Administration. Revised November 2010. Accessed June 10, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/050420s073,050627s012lbl.pdf
7. Mar PL, Gopinathannair R, Gengler BE, et al. Drug interactions affecting oral anticoagulant use. Circ Arrhythm Electrophysiol. 2022;15(6):e007956. doi:1161/CIRCEP.121.007956
8. Ansong S, Doad J, Igweonu-Nwakile EO, Okafor C. Drug-drug interaction of warfarin and doxycycline leading to a large rectus sheath hematoma. Cureus. 2025;17(3):e81312. doi:10.7759/cureus81312
9. Gronich N, Stein N, Muszkat M. Association between use of pharmacokinetic-interacting drugs and effectiveness and safety of direct acting oral anticoagulants: nested case-control study. Clin Pharmacol Ther. 2021;110(6):1526-1536. doi:1002/cpt.2369