Patients Taking Direct Oral Anticoagulants (DOAC) Undergoing Oral Surgery: A Review of the Literature and a Proposal of a Peri-Operative Management Protocol

Abstract

Patients on anticoagulant therapy for the prevention of cardiovascular accidents present an increased risk of bleeding following dental and oral surgery. Four recently introduced non-vitamin K antagonist oral anticoagulants, namely dabigatran etexilate (direct thrombin inhibitor), rivaroxaban, apixaban, and edoxaban (Xa factor direct inhibitor), are widely spreading for convenience of use compared to the older drug class. Dental management of patients taking these drugs has substantial differences compared to patients on vitamin K antagonist therapy. Anticoagulation is not assessed directly through a hematological test, but indirectly by renal function. The interventions must be scheduled at the time of minimum blood concentration of the drug. Bleeding can occur even after several days following the surgery. The interaction with drugs administered for dental care must be carefully evaluated. The peri-operative diet can influence the risk of bleeding. Local measures favoring coagulation must be adopted. The interventions with higher risk must be divided into multiple less invasive interventions. Although antidotes exist for these drugs, their use does not seem necessary for dental interventions that have been planned optimally. Furthermore, in this review of the literature a decision protocol is proposed for the evaluation of the suspension of the anticoagulant drug before oral surgery. Cessation of any anticoagulant should only be made in consultation with the patient’s general practitioner/cardiologist, who will weigh up the risk of bleeding from the proposed procedure with the risk of thrombosis/stroke in each individual patient.

A prospective comparative study to assess the risk of postoperative bleeding after dental surgery while on medication with direct oral anticoagulants, antiplatelet agents, or vitamin K antagonists

“…In the case of a highrisk intervention, surgery should be performed at least 24h after the last intake of DOAC. High risk intervention is defined as multirooted teeth, whereas low-risk intervention is defined as the extraction of 1-3 teeth per quadrant or 2 implant placements [11]. In several studies, no significant postoperative bleeding was seen in DOAC groups compared to other AT groups, whereas the postoperative bleeding was significantly greater in DOAC groups than in healthy controls [11,15].…”

“…High risk intervention is defined as multirooted teeth, whereas low-risk intervention is defined as the extraction of 1-3 teeth per quadrant or 2 implant placements [11]. In several studies, no significant postoperative bleeding was seen in DOAC groups compared to other AT groups, whereas the postoperative bleeding was significantly greater in DOAC groups than in healthy controls [11,15]. This is not in accordance with our results within the DOAC group, where the 8 postoperative bleeding events occurred within 27 surgical interventions and were correlated to type A and C procedures.…”

“…If high-risk surgical intervention is to be performed, the authors recommended that the intervention should be performed, at the earliest, 24 hours after the last intake of medication. The authors have classified a low-risk situation as one to three tooth extractions or one to two implant placements, and a high-risk situation as 4 or more tooth extractions or more than two implant placements, and the studies were grouped according to that [11]. Nevertheless, when regarding the current state of evidence-based literature, and when including all anticoagulation medications regardless of their effect, one fact becomes apparent: postoperative bleeding does occur; however, it seems to be mostly minor so it is always concluded that the medication should be continued in so called low-risk procedures under local haemostatic measures.…”

Systematic review on the effects of the discontinuation of the anticoagulant therapy and the postoperative bleeding, in patients under new oral anticoagulants after dental extraction

“…The patients under a NOACs have to be under daily medication. ( 2 ) The first new oral anticoagulant was developed in 2010: Dabigatran. Followed by Rivaroxaban (2011), Apixaban (2012), Edoxaban (2014).…”

Anticoagulantes Orales de Acción Directa y sus Implicancias en la Exodoncia: Una Revisión Sistemática

“…Un rango de INR terapéutico para la mayoría de los pacientes es de 2.0 a 3.0 (Kaplovitch & Dounaevskaia, 2019). Por otra parte, los ACOD no requieren monitoreo de rutina, aunque influyen en las pruebas de coagulación más comunes como el Tiempo de Tromboplastina Parcial activada (TTPa), Tiempo de Protrombina (TP) e INR, estas son menos relevantes debido a la elevada respuesta variable vinculada tanto a condiciones instrumentales como fisiológicas (Nathwani & Wanis, 2017;Lupi & Rodriguez Y Baena, 2020) Para prevenir las hemorragias, los AO pueden interrumpirse antes de los procedimientos dentales. La hemorragia también puede provocar una interrupción no programada de los anticoagulantes y la interrupción temporal pone a los pacientes en riesgo de eventos tromboembólicos.…”