FACT SHEET: Atrial Fibrillation (also known as “AF”, “Afib” and “a. fib.”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- No, assuming patient/client is medically stable.
Is medical consult advised?
- Yes, if atrial fibrillation is suspected in a previously undiagnosed patient/client.
- Yes, if atrial fibrillation is untreated.
- Yes, if previously asymptomatic AF is now symptomatic.
- Yes, if a patient/client with previously diagnosed AF that had reverted to normal sinus rhythm now presents with recurrent AF.
- Yes, if a patient/client taking warfarin is found to have international normalized ratio (INR) outside the therapeutic range for AF.1
- Yes, before dental hygiene care is initiated in order to confirm (with the family physician or cardiologist) the patient/client’s medical history, current drug therapy, and underlying cause of the AF.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Possibly (and likely).
Is medical consult advised?
- See above.
Is medical clearance required?
- Yes, if the patient/client has symptomatic AF.
- Yes, if the patient/client is taking an anticoagulant (e.g., warfarin2 or a direct oral anticoagulant3 [DOAC])4 or antiplatelet agent (e.g., clopidogrel, ticlopidine, dipyridamole, ticagrelor, or prasugrel), which increases risk of bleeding.
- Yes, if drug toxicity (e.g., digitalis toxicity) is suspected.
Is antibiotic prophylaxis required?
Is postponing treatment advised?
- Yes, if patient/client is taking warfarin and the up-to-date INR exceeds 4.05, which poses risk of excessive bleeding for procedures inherently at low bleeding risk (such as supragingival scaling).
- Yes, if patient/client is taking warfarin and the up-to-date INR exceeds 3.5, which poses risk of excessive bleeding for procedures carrying moderate bleeding risk (e.g., subgingival scaling and root surface instrumentation, according to some references), although continuation of therapeutic anticoagulation is generally recommended.6
- For invasive dental hygiene procedures and minor dental surgery, patients/clients usually do not have to alter warfarin dosage if up-to-date INR is between 2.0 and 3.5.
- If the dosage of warfarin is reduced by the patient/client’s physician, it will take 3 to 5 days for the desired reduction in INR to occur. The reduction should be confirmed by INR before the dental hygiene/dental/surgical procedure, which should be scheduled within 2 days of the reduction.7
- Patients/clients with AF usually do not have to cease their daily aspirin (acetylsalicylic acid, or ASA) medication before invasive dental hygiene procedures, simple extractions, or minor dental surgery.
- In patients/clients with normal kidney function taking a DOAC (specifically, dabigatran, rivaroxaban, or apixaban), invasive dental hygiene procedures (and many invasive dental procedures with low to moderate bleeding risk, such as simple extractions, subgingival crown and bridge preparations, and standard root canal treatment) can be carried out without disruption of the medication. However, the procedure should be performed as late as possible after the most recent dose — ideally, greater than 12 hours8.
- For subgingival scaling in patients/clients taking a DOAC, a small area should be scaled first to assess bleeding tendency before instrumentation of larger areas is attempted.
- Patients/clients with asymptomatic AF can generally undergo invasive dental hygiene procedures and minor dental surgery in a general practice setting.
Oral management implications
- An irregular pulse or heartbeat should alert the dental hygienist to the likelihood of atrial fibrillation. Patients/clients with AF are at elevated risk of ischemic events in the dental hygiene/dental office.
- A stress reduction protocol will minimize the risk of cardiac ischemia9 in the office setting. Short appointments in the late morning or early afternoon are generally better for patients/clients with AF, because the risk of an ischemic event is highest during the first few hours of daily activity.
- Oral sedation (in consultation with physician or dentist) may be appropriate in certain circumstances. If used, an escort should be available to take the patient/client home.
- Restriction of epinephrine (or other vasoconstrictor) is generally recommended for patients/clients with cardiac dysrhythmia or otherwise at risk of cardiac ischemia.
- Some patients/clients with AF may have memory, language, communication, or attention deficits. In such circumstances, a family member or other caregiver should be included in treatment discussions.
- Digitalis (e.g., digoxin) is sometimes used in the management of AF. The dental hygienist should be alert to the signs of digitalis toxicity (e.g., anorexia, nausea, vomiting, altered vision, neurologic abnormalities, and facial pain), which should prompt medical referral.
- Transexamic acid mouth rinse, in addition to application of local pressure, may be used to achieve clotting in patients/clients taking anticoagulants or antiplatelet agents. Treatment should be stopped if excessive bleeding occurs, and the patient/client should not be discharged until bleeding has been controlled.
- For affected patients/clients in the dental/dental hygiene setting, all drugs that may cause bleeding or potentiate the anticoagulation action of warfarin or other anticoagulants should be avoided. For warfarin, these include aspirin or other non-steroidal anti-inflammatory agents (NSAIDs), some antibiotics (including erythromycin and metronidazole), and some herbal medications. Also, drugs that may antagonize the action of warfarin (such as barbiturates, steroids, and nafcillin), should be avoided in order that desirable therapeutic anticoagulation not be disrupted.
- Because inflammation may be an independent risk factor for the initiation and maintenance of AF, it has been hypothesized that regular dental scaling may lower risk of AF by improving periodontal health. While some studies have shown an association between annual dental scaling and reduced occurrence of new-onset AF, causality has not been proven. Nonetheless, optimal oral hygiene, both in and out of the dental hygiene office, should be promoted.
- There are no oral manifestations caused directly by atrial fibrillation. However, medications used to treat AF may have oral side effects.
- Anticoagulants (whether warfarin or DOACs) and antiplatelet agents may result in increased and/or prolonged bleeding tendency in the oral cavity.
- Quinidine’s oral side effects include bitter taste, xerostomia, petechiae, and gingival bleeding.
- Procainamide can cause bitter taste and oral ulcerations.
- Flecanide can cause metallic taste.
- Propafenone can cause xerostomia and alteration of taste.
- Sotalol can cause lichenoid reactions and alteration of taste.
- Amiodarone can cause alteration of taste.
- Beta-blockers can cause taste changes.
- Calcium channel blockers can cause gingival hyperplasia
- Digoxin can cause excessive salivation.
Related signs and symptoms
- Atrial fibrillation is the most common sustained cardiac dysrhythmia. It is characterized by rapid uncoordinated contraction of the atria10, usually between 350 and 600 times per minute (versus normal range of 60 to 100). The disorganized electrical impulses in the atria11 lead to incomplete atrial emptying, and the ventricles cannot regularly contract in response to the inconsistent impulses. The net effect is increased risk of clot formation, stroke12, and heart failure. Angina may also occur.
- AF affects between 500,000 and 1,000,000 Canadians.13 Prevalence of sustained AF increases with age (< 1% up to age 50 years, reaching 4% at age 65 years and 12% of persons 80 years and older). Lifetime risk is about 25%.
- Risk factors include coronary artery disease, angina, myocardial infarction, hypertension, heart failure, mitral valve stenosis, hyperthyroidism, hypoxia, obstructive sleep apnea, diabetes, and alcohol abuse. Surgery may predispose certain patients/clients to AF. Management consists of either rhythm or rate control14 — with emphasis on treatment of the underlying cause — as well as drugs specifically directed at reduction of clot formation.
- The cardinal sign of AF is an irregularly irregular, typically rapid, heartbeat15. AF may be continuous or intermittent.16
- Symptoms of AF include palpitations, light-headedness, shortness of breath, chest pain, and fatigue. However, some persons with AF have no overt symptoms (“silent” AF).
References and sources of more detailed information
- CDHO Knowledge Network
- The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2020;36(12):1847-1948.
- 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018;34(11):1371-1392.
- 2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2016;32(10):1170-1185.
- Tsolka P. Dental Procedures in Patients with Atrial Fibrillation and New Oral Anticoagulants. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):85-89.
- Humber C. Point of Care — A patient new to my practice has atrial fibrillation. How should I modify the patient’s regular dental care in light of this condition? JCDA. 2005 Nov;71(10):735-736.
- Camm AJ, Savelieva I and Lip GYH. Rate control in the medical management of atrial fibrillation. Heart. 2007 Jan;93(1):35-38.
- Hassan A, Lip GYH, Fauchier L, Harris RV. Atrial Fibrillation and Oral Health. Arrhythmia & Electrophysiology Review. 2021;10(1):7–9.
- Thrombosis Canada
- Heart & Stroke
- Dentistry IQ
- RDH Magazine (same article as Dentistry IQ article above but different graphics)
- Mayo Clinic
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3rd edition). Baltimore: Wolters Kluwer Health, 2015.
1 The optimal INR range in patients/clients with AF is between 2.0 and 3.0.
2 Warfarin is a vitamin K antagonist (VKA). Its effect on clotting is monitored by the international normalized ratio (INR).
3 DOACs include dabigatran, rivaroxaban, apixaban, and edoxaban.
4 Direct anticoagulants are generally now preferred over warfarin in the management of nonvalvular atrial fibrillation (NVAF).
5 An INR cut-off of 3.5, rather than 4.0, is cited in some references.
6 In patients/clients undergoing dental procedures carrying a high risk of bleeding (such as multiple extractions, periodontal surgery, and extensive maxillofacial surgery), an INR between 2.0 and 3.0 (or < 1.5, according to some references) is desirable.
7 After the dental hygiene procedure, the patient/client will generally resume the normal dose of warfarin. However, if there are significant complications (e.g., excessive bleeding), the patient/client’s physician should be contacted before resumption of the patient/client’s usual warfarin dosage.
8 Patients/clients who require complex oral/maxillofacial surgery may need to discontinue their DOAC for at least 24 hours preoperatively.
9 cardiac ischemia = inadequate blood supply to the heart muscles.
10 The atria are the upper chambers of the heart.
11 In a patient/client with AF, an electrocardiogram (ECG) shows no discrete P waves, but rather fine undulations between QRS complexes.
12 1 in 6 strokes occurs in person with AF.
13 Historical estimates of overall AF prevalence of 1% to 2% of the general population are likely underestimates, because these estimates were derived from populations with AF diagnosed using electrocardiograms (ECG), and did not routinely account for patients/clients with paroxysmal AF (which is estimated to be approximately two-thirds of the AF population) or patients/clients with silent AF.
14 Medical heart rhythm management aims to re-establish normal sinus rhythm (NSR) via one of a variety of anti-arrhythmic agents (e.g., quinidine, procainamide, flecainide, ibutilide, propafenone, sotalol, and amiodarone). Cardioversion (i.e., elective transthoracic delivery of an electric shock) is also used to achieve NSR. Occasionally, cardiac ablation (i.e., a procedure to destroy aberrant conductive heart tissue) may be attempted to restore normal rhythm. Medical heart rate management aims to minimize symptoms and heart damage associated with excessive heart rate via medications such as beta-blockers, calcium channel blockers, and cardiac glycosides (e.g., digitalis/digoxin). Electrophysiological/surgical interventions are also sometimes used to reduce the rapid ventricular rate found in patients/clients with AF.
15 While auscultation of the chest typically reveals a rapid heartbeat (say, 110 beats per minute), not all of these beats may get transmitted to periphery. Thus, the peripheral pulse rate may be slower (say, 90 beats per minute). The difference between the rapid heartbeats and the peripheral pulse (in this example, 20) is known as the pulse deficit of atrial fibrillation
16 In paroxysmal AF, temporary episodes start suddenly and usually resolve within 24 hours without medical assistance. In persistent AF, episodes last longer than 7 days and usually require treatment for restoration of normal rhythm. In permanent AF, the irregular heart rhythm lasts for more than a year despite treatment.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.