Management of Direct-Acting Oral Anticoagulants Surrounding Dental Procedures With Low-to-Moderate Risk of Bleeding

Abstract

The purpose of this article is to review the available evidence regarding how to safely manage direct-acting oral anticoagulant (DOAC) therapy in patients requiring dental procedures with low-to-moderate risk of bleeding. A literature search was performed using MEDLINE and PubMed. Each author performed an independent search to ensure all pertinent articles were identified. The reference sections of each article were also reviewed. Pertinent articles were evaluated by each author for inclusion. Articles were eligible for inclusion if the participants were taking DOAC therapy surrounding a dental procedure known to have low-to-moderate risk of bleeding. Studies could be prospective or retrospective and included case reports, case series, and clinical trials. Articles were excluded if they assessed dental procedures known to carry a high risk of bleeding or were review articles. Twenty-five articles were identified, 5 of which met inclusion criteria including 2 case series, 1 retrospective study, and 2 prospective trials. Variation in the management of DOAC therapy surrounding these procedures was found. Among patients undergoing low-to-moderate risk dental procedures while receiving DOAC therapy, bleeding rates were low regardless of whether the DOAC was held or continued surrounding the procedure. Documented bleeding was mild and easily controlled by local hemostatic measures. Patients can safely continue DOAC therapy surrounding these dental procedures.

Bleeding in Dental Surgery

“…After decades of controversial data, there is currently a nearly unanimous consensus that anticoagulation therapy, for most dental surgeries, should not be discontinued. The higher risk of bleeding complications is compensated by the elevated risk of developing thromboembolic complications [1,[81][82][83][84].…”

Dental management of patients taking antiplatelet, oral anticoagulant and novel anticoagulant medications

“…There is also the opinion that the patients taking dabigatran should be treated similarly to those receiving low-molecular-weight heparins 48 . Up to now, there has been a lack of well-designed clinical trials that would include a number of patients taking dabigatran and require a dental surgery 49,55,56 .…”

“…There is insufficient data in the literature about the safety of dental surgical procedures in patients taking FXa inhibitors 49,54,56,59,64 . However, similar recommendations given for dental treatment of the patients taking dabigatran are applicable to the patients taking FXa inhibitors 47,48,50,52,58 .…”

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

“…There are many indications for the prescription of anticoagulation drugs, such as the prevention and treatment of deep vein thrombosis, atrial fibrillation, stroke, and embolism after heart valve replacement. 370 In recent years, the novel oral anticoagulants (NOACs)/ direct oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban (Table 1) 371,372 joined the vitamin K antagonists (warfarin, phenprocoumon) and heparin in the group of widely prescribed anticoagulants. 370,372,373 Not only the nomenclature but also the drug administration pattern and the absence of monitoring tools for drug efficacy of the NOACs may be confusing for dentists.…”

“…370 In recent years, the novel oral anticoagulants (NOACs)/ direct oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban (Table 1) 371,372 joined the vitamin K antagonists (warfarin, phenprocoumon) and heparin in the group of widely prescribed anticoagulants. 370,372,373 Not only the nomenclature but also the drug administration pattern and the absence of monitoring tools for drug efficacy of the NOACs may be confusing for dentists. 373 The perioperative management of the patients taking any of those drugs remains a challenge.…”