Four newer direct-acting oral anticoagulants have been approved by regulatory agencies for use in patients to prevent or treat DVT and PE, or reduce the risk of stroke and systemic embolism in patients with NVAF. These are dabigatran (Pradaxa®), apixaban (Eliquis®), rivaroxaban (Xarelto®), and edoxaban (Savaysa® [Lixiana® in the European Union, Japan, and others]).1-4
These agents differ from traditional oral anticoagulant therapy (i.e., warfarin) in that they are targeted in action; are given as fixed doses; have more predictable pharmacokinetics and shorter half-lives; require little to no routine monitoring; and have fewer drug or food interactions.14
There is no direct evidence from prospective trials comparing different periprocedural management strategies for patients receiving the target-specific anticoagulants and evaluating effects on patient outcomes. A 2015 consensus guideline from the European Heart Rhythm Association15, 16
(updating a 2013 guideline17
) suggests that interventions not necessarily requiring discontinuation of the newer anticoagulants include extraction of 1 to 3 teeth; periodontal surgery; abscess incision; or implant positioning.
A 2018 systematic review18
looked at the question of how to safely manage direct-acting oral anticoagulants in patients requiring dental procedures with low-to-moderate risk of bleeding. Procedures that were defined as being low risk were administration of local anesthetic, simple restorations, supragingival scaling, and single tooth extraction; procedures considered moderate risk were extractions of 2 to 4 teeth and local gingival surgery of 5 or fewer teeth. Five papers were included in the review of evidence. Among patients receiving the direct-acting anticoagulants and undergoing dental procedures associated with low-to-moderate bleeding risk, bleeding rates were low whether the anticoagulant was continued or held periprocedurally. Bleeding that was documented was generally mild and controlled by local hemostatic measures.
A 2015 narrative review by Elad et al.19
specifically addressed the 4 currently marketed direct-acting oral anticoagulants, providing a general overview and potential management strategies for dental practitioners. The authors evaluated bleeding complication rates reported in 18 randomized, controlled trials comparing the new agents with conventional anticoagulants or placebo and also reviewed prior narrative reviews20
and case reports21, 22
of patients undergoing dental interventions while receiving the newer anticoagulant therapy. After consideration of factors such as patient comorbidity and the risk of bleeding from the procedure, and in addition to usual local measures to control bleeding (e.g., sutures, absorbable gelatin), the authors offered the following options for drug management:
- continue regular dose administration of the anticoagulant;
- postpone the timing of the daily dose of the anticoagulant (time the daily dose after the dental treatment or skip one daily dose); or time the dental intervention as late as possible after last dose of anticoagulant; or
- temporarily interrupt drug therapy for 24 to 48 hours.
According to the authors,19
“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.”
Another 2015 dental-specific narrative review by Thean and Alberghini11
offered similar advice regarding dental patient management, balancing the risks of perioperative bleeding against the risk of thrombosis. They also recommend that consideration be given to other supplements or drugs (e.g., fish oil, antiplatelet agents) patients may be taking or comorbid conditions patients may have that increase bleeding risk. The authors state that in conjunction with appropriate local measures to control bleeding, low-risk procedures such as scaling and/or root planing, restorative or endodontic treatment, simple extractions, or surgery lasting less than 45 minutes do not appear to require suspension of therapy with the new anticoagulants. For procedures associated with increased risk of bleeding, such as surgical extractions, multiple extractions, more complex oral surgery, or head and neck cancer surgery, the authors recommend a multidisciplinary preoperative approach that includes consultation with the patient’s physician regarding potentially stopping anticoagulant medications 2 to 5 days before surgery.
A 2013 systematic review23
by van Diermen et al. (updating a prior 2009 review24
) provided management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including the target-specific oral anticoagulants. The authors acknowledged that no clinical studies or guidelines had been published to directly address the periprocedural management of dental patients receiving the newer anticoagulants. It appears that the authors’ proposed recommendations regarding the target-specific anticoagulants were derived from published reports20, 25, 26
available at the time and extrapolation from evidence for other traditional anticoagulants (e.g., warfarin). This systematic review proposed that in patients undergoing “simple dental treatment” (e.g., single or multiple dental extractions [up to 3 teeth], up to 3 dental implants, scaling and root planing, probing, flap surgery, apex resection, alveoloplasty), therapy with the new anticoagulants should not be interrupted. They also recommended that patients be advised to not take their medication 1 to 3 hours immediately before dental treatment.