Novel anticoagulants: general overview and practical considerations for dental practitioners

Abstract

Currently, 4 novel Direct Oral Anticoagulants (DOACs) were approved by the FDA. This review focuses on these agents and proposes a matrix for the general dentists to assess bleeding risk in dental management of patient on DOACs. The outline covers the pharmacology of DOACs (rivaroxaban, apixaban, edoxaban and dabigatran), bleeding complications, risk associated with discontinuation, monitoring/reversal, and implications for the dental practitioners. A total of 18 randomized controlled trials were identified with mixed results in regards to the risk for bleeding. Considering the pharmacology of DOACs and challenges in monitoring and reversing their effect, the dentist should consider carefully the management of patients on DOACs as it may differ from patients on conventional anticoagulants. Based on the type of dental procedure and the medical risk assessment, several general treatment approaches can be considered: continue DOACs, time dental treatment as late as possible after the last DOACs dose, discontinue DOACs for 24hrs, or discontinue DOACs for 48hrs. Based on the current reported dental literature, limited dental surgery may benefit from the first 2 conservative options. However, this needs to be proven in comparative clinical trials.

Dental note: Treating patients on new anticoagulant drugs

“…Recent reviews [2][3][4] have not identified any randomised controlled trials, case-control studies or systematic reviews of the new drugs in patients having dental procedures. There is no firm clinical evidence on which to base a decision to either continue or discontinue the drugs before invasive dental treatment.…”

“…There is no firm clinical evidence on which to base a decision to either continue or discontinue the drugs before invasive dental treatment. To date, all published guidelines have been based purely on expert opinion and the consensus of multidisciplinary writing groups [4][5][6][7] or on clinical experience. 8 All guidelines recommend that dentists should take a cautious approach when performing invasive dental treatments for patients taking the new anticoagulants.…”

Novel anticoagulants – an update on the latest developments and management for clinicians treating patients on these drugs

“…Procedures associated with an increased risk of bleeding such as multiple dental extractions, more invasive oral surgery (such as the use of local flaps or wide local excision of a tumour) and more invasive head and neck or salivary gland surgery requires a multidisciplinary team approach pre‐operatively, and discussion with haematology colleagues in complex cases . In these situations, the NOAC drug may need to be stopped for a period prior to surgery and in patients with a high thrombotic risk, continued anticoagulation with another agent (such as a low molecular weight heparin derivative) may need to be considered (Fig. ).…”

Short review of dental care for patients with cardiovascular diseases

“…Većinu stomatoloških krvarenja moguće je sanirati sa kompresijom ili hirurškom suturom. Ukoliko je potrebno, moguće je odložiti dozu NOAK-a, izostaviti jednu dozu leka ili prekinuti lek na 24-48h 17 .…”

“…Individual assessment of each patient is required depending on comorbidity and planned dental intervention.The majority of dental bleeding can be stopped with local measures such as mechanical compression or suturing. If necessary, it is possible to postpone a dose of NOAC, skip one dose or discontinue the drug for 24-48h 17 .…”