Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study

Mauprivez, Cédric; Khonsari, R.H.; Razouk, Omar; Goudot, P.; Lesclous, Philippe; Descroix, Vianney

doi:10.1016/j.oooo.2016.06.003

Cited by 98 publications

(93 citation statements)

References 34 publications

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“…No instances of bleeding were recorded in this cohort, with 52.9% (9/17) of patient appointments being associated with temporary DOAC interruption. Our findings are consistent with the risk of bleeding issues being low when single‐tooth extractions are performed whether or not a DOAC is discontinued; however, our findings contrast with studies in which dabigatran, rivaroxaban, or apixaban were continued through dental extractions and minor or major bleeding was observed in 6.1%–20% of patients (Breik et al., ; Mauprivez et al., ; Zeevi et al., ). In the majority of these studies, including our study, use of atraumatic procedures along with local hemostatic measures including gelatin sponges and sutures appears to contribute to the low postoperative bleeding rate.…”

Section: Discussionsupporting

confidence: 88%

“…In case reports, DOACs have been temporarily discontinued prior to multiple tooth extractions, alveoloplasty, and tuberosity reduction and successful outcomes have been reported (Abayon, Kolokythas, Harrison, & Elad, ; Romond, Miller, & Henry, ). In contrast, in a recent study, where DOACs were not discontinued, minor bleeding was observed in 16.1% of patients (Mauprivez et al., ). Similarly, in a recent cross‐sectional study involving 305 oral procedures, one major (0.9%) and six minor (5.2%) bleeding events were documented (Zeevi et al., ).…”

Section: Introductionmentioning

confidence: 80%

“…Several of these publications suggest that DOACs can be discontinued 1–2 days before oral surgical procedures in patients with normal renal function (Albaladejo et al., ; Fakhri et al., ; Romond et al., ; van Ryn et al., ). In contrast, others advocate for not interrupting the DOAC prior to uncomplicated tooth extractions when renal function is not compromised, and local hemostatic measures are provided (Breik, Cheng, Sambrook, & Goss, ; van Diermen, van der Waal, & Hoogstraten, ; Elad et al., ; Firriolo & Hupp, ; Little, ; Mauprivez et al., ).…”

Section: Discussionmentioning

confidence: 99%

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Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation

Miller

2018

Oral Diseases

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Objective: To examine the effects of direct oral anticoagulants (DOACs) on bleeding complications following dental surgeries. Subjects and Methods:This 6-year retrospective study collected data from records of patients undergoing oral surgical procedures within a university setting. An electronic health record database was searched using current procedural terminology codes for oral surgical procedures. Information regarding patient, procedural factors, and postoperative complications were extracted. Data were analyzed by Fisher's exact test. Results:Of patients who had a procedural code associated with oral surgery, only 0.11% (12/11,320) took a DOAC. Twelve patients (10 males, age ranging from 44 to 90 years) underwent 17 surgeries by nine different practitioners involving 98 extractions, 14 alveoloplasties, two tuberosity reductions, and two tori removals. In nine cases, the DOAC was discontinued a mean of 52.5 hrs prior to surgery (range 12-120 hrs). Bleeding complications were not reported for patients whose drug was discontinued or continued. Documentation of drug continuation/discontinuation was poor. Conclusions:Bleeding was not observed with direct oral anticoagulation use in this oral surgery cohort. Drug discontinuation/continuation was not a factor in bleeding outcomes, and direct oral anticoagulation interruption was variable and poorly documented. K E Y W O R D Santicoagulants, bleeding, oral surgery, tooth extraction | INTRODUCTIONSince 2010, four direct oral anticoagulant (DOAC) drugs (ie, dabigatran, rivaroxaban, apixaban, and edoxaban) have been approved by the Food and Drug Administration. These drugs antagonize specific coagulation proteins (ie, Factor Xa and thrombin), which contribute to their pharmacological utility in preventing blood clots and strokes in patients who have atrial fibrillation. A main complication of DOAC use is bleeding. Current data indicate that DOACs demonstrate similar gastrointestinal bleeding rates (Spencer & Amerena, 2015) and lower major extra-cranial bleeding rates compared with warfarin (Connolly et al., 2009;Lee, 2016). The relationship of DOACs with dental procedure-related perioperative and postoperative bleeding is less well defined.At present, there are a limited number of clinical studies that have examined the use of DOACs and bleeding in association with invasive dental procedures. The two largest studies, the RE-LY and ARISTOTLE, reported on bleeding and dental procedures associated with dabigatran (n = 459) and apixaban (n = 1,435), respectively (Garcia et al., 2014;Healey et al., 2012). These studies while valuable do not specify the invasiveness and type of dental procedures performed, whether the DOAC was discontinued before the procedure and the relationship 244 | MILLER and MILLER of these factors to the frequency of major and minor bleeding. As a result, we depend on expert opinions (Albaladejo et al., 2017;Elad, Marshall, Meyerowitz, & Connolly, 2016;Firriolo & Hupp, 2012;Little, 2012;van Ryn et al., 2010) and smaller clinical studies to provide...

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 99%

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Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation

Miller

2018

Oral Diseases

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“…procedures with minimal risk), as for example superficial skin surgeries, parietal surgery, cataract surgery, and minor dental procedures [47]. It is suggested that the morning dose of anticoagulant should be omitted on the day of the procedure to avoid peak concentrations during the procedures [19].…”

Section: Perioperative Management Of Doacsmentioning

confidence: 99%

Perioperative management of patients on direct oral anticoagulants

et al. 2017

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Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10–15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure.As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians.This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.

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“…Evidence‐based data on the dental management of patients on DOACs are lacking. In the main, the available literature is derived from experts’ opinion, case reports, and small case series; unfortunately, data from systematic reviews, randomized clinical trials, cohort studies, or case–control studies are not currently available (Abayon, Kolokythas, Harrison, & Elad, ; Breik, Cheng, Sambrook, & Goss, ; Davis, Robertson, Shivakumar, & Lee, ; van Diermen, van der Waal, & Hoogstraten, ; Elad, Marshall, Meyerowitz, & Connolly, ; Firriolo & Hupp, ; Griffiths & Scully, ; Heidbuchel et al., ; Johnston, ; Kerr, Ogden, & Sime, ; Mauprivez et al., ; Nathwani and Wanis, ; NHS Tayside Integrated Dental Service, ; Patel et al., ; Romond, Miller, & Henry, ; Scottish Dental Clinical Effectiveness Pro‐gramme, ; Scully & Robinson, ; Sime, ; Zeevi et al., ).…”

Section: Introductionmentioning

confidence: 99%

Management of dental patients taking direct oral anticoagulants: Dabigatran

et al. 2018

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Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin because of the superior pharmacokinetic properties. Clinical guidelines on the influences of DOACs for dental procedures have emerged, but all of necessity based on low-quality available evidence. Herein, we share our experience with a case series, and propose a protocol regarding the management of dental patients taking DOACs.

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Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study

Cited by 98 publications

References 34 publications

Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation

Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation

Perioperative management of patients on direct oral anticoagulants

Management of dental patients taking direct oral anticoagulants: Dabigatran

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