Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants?

M Caliskan, H-C Tükel, M-E Benlidayi, A Deniz, M Caliskan, H-C Tükel, M-E Benlidayi, A Deniz

Abstract

Background: The number of patients using direct oral anticoagulants (DOACs) instead of vitamin K antagonists (VKA) is increasing and there is limited data on the safety of tooth extractions in patients taking DOACs. The aim of this study was to compare the amount of bleeding (AOB) and postoperative complications after tooth extractions between patients taking VKAs and patients taking DOACs without altering the anticoaguation therapy.

Material and methods: The study consisted of four groups: Direct thrombin inhibitor group, factor Xa inhibitor group, warfarin group and a control group. A single tooth was extracted in each patient and routine coagulation test values were recorded prior to extraction. AOB was measured for 20 minutes after tooth extraction. The patients were evaluated on 2nd and 7th days after extraction for bleeding. Status of bleeding was classified as no bleeding, mild bleeding controlled by gauze pads, moderate bleeding controlled by hemostatic agents and severe bleeding required hospitalization. Analysis of variance, chi square test and correlation analysis were used for statistical analysis of data.

Results: A total of 84 patients (48 male, 36 female) were included in this study. The mean age of patients was 57 (38-87) years. Mean AOB was 1388.6±913.0, 1909.29±1063.1, 3673±1415.4, 1593.33±672.5 mg for direct thrombin inhibitor, factor Xa inhibitor, warfarin and control groups respectively. Mean AOB was significantly higher for warfarin group, compared to other groups (p<0.05). The number of patients showing mild and moderate bleeding was significantly higher in warfarin group compared to other groups on the 2nd postextraction day (p=0.001). No bleeding was occurred in control group on 2nd and 7th postextraction days and no bleeding was occurred in direct thrombin inhibitor group on 7th postextraction day. The number of bleeding events among groups was not statistically significant on 7th postextraction day (p=0.251).

Conclusions: Patients taking warfarin had more bleeding compared to patients taking direct oral anticoagulants after tooth extractions. In patients taking direct oral anticoagulants simple tooth extractions can be safely carried out without altering the anticaogulant regimen with the use of local hemostatic agents.

Conflict of interest statement

Conflict of interest statement:All authors declare that they have no conflict of interest.

Figures

Figure 1
Figure 1
Graphic shows the AOB (mg) among groups.

References

    1. Bauer KA. Pros and cons of new oral anticoagulants. Hematology Am Soc Hematol Educ Program. 2013;2013:464–70.
    1. Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest. 2008;133(6 Suppl):160S–98S.
    1. Firriolo FJ, Hupp WS. Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113:431–41.
    1. Barnes GD, Ageno W, Ansell J, Kaatz S, Subcommittee on the Control of Anticoagulation of the International Society on T Haemostasis. Recommendation on the nomenclature for oral anticoagulants: communication from the SSC of the ISTH. J Thromb Haemost. 2015;13:1154–6.
    1. Perzborn E, Roehrig S, Straub A, Kubitza D, Misselwitz F. The discovery and development of rivaroxaban, an oral, direct factor Xa inhibitor. Nat Rev Drug Discov. 2011;10:61–75.
    1. Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013;368:699–708.
    1. Cheng JW, Vu H. Dabigatran etexilate: an oral direct thrombin inhibitor for the management of thromboembolic disorders. Clin Ther. 2012;34:766–87.
    1. Bacci C, Maglione M, Favero L, Perini A, Di Lenarda R, Berengo M. Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicentre, prospective, case-control study. Thromb Haemost. 2010;104:972–5.
    1. Wahl MJ, Pinto A, Kilham J, Lalla RV. Dental surgery in anticoagulated patients--stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:136–57.
    1. Karsli ED, Erdogan O, Esen E, Acarturk E. Comparison of the effects of warfarin and heparin on bleeding caused by dental extraction: a clinical study. J Oral Maxillofac Surg. 2011;69:2500–7.
    1. Salam S, Yusuf H, Milosevic A. Bleeding after dental extractions in patients taking warfarin. Br J Oral Maxillofac Surg. 2007;45:463–6.
    1. Sacco R, Sacco M, Carpenedo M, Mannucci PM. Oral surgery in patients on oral anticoagulant therapy: a randomized comparison of different intensity targets. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology. 2007;104:E18–E21.
    1. Evans IL, Sayers MS, Gibbons AJ, Price G, Snooks H, Sugar AW. Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg. 2002;40:248–52.
    1. Devani P, Lavery KM, Howell CJ. Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary? Br J Oral Maxillofac Surg. 1998;36:107–11.
    1. Mauprivez C, Khonsari RH, Razouk O, Goudot P, Lesclous P, Descroix V. Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;122:e146–e55.
    1. Johnston S. An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery. Int J Oral Maxillofac Surg. 2016;45:618–30.
    1. Morimoto Y, Yokoe C, Imai Y, Sugihara M, Futatsuki T. Tooth extraction in patients taking nonvitamin K antagonist oral anticoagulants. Journal of Dental Sciences. 2016;11:59–64.
    1. Hanken H, Grobe A, Heiland M, Smeets R, Kluwe L, Wikner J. Postoperative bleeding risk for oral surgery under continued rivaroxaban anticoagulant therapy. Clin Oral Invest. 2016;20:1279–82.
    1. Abdullah WA, Khalil H. Dental extraction in patients on warfarin treatment. Clin Cosmet Investig Dent. 2014;6:65–9.
    1. O'Connell JE, Stassen LF. New oral anticoagulants and their implications for dental patients. J Ir Dent Assoc. 2014;60:137–43.
    1. Munoz-Corcuera M, Ramirez-Martinez-Acitores L, Lopez-Pintor RM, Casanas-Gil E, Hernandez-Vallejo G. Dabigatran: A new oral anticoagulant. Guidelines to follow in oral surgery procedures. A systematic review of the literature. Med Oral Patol Oral Cir Bucal. 2016;21:e679–e88.
    1. Curto A, Albaladejo A, Alvarado A. Dental management of patients taking novel oral anticoagulants (NOAs): Dabigatran. J Clin Exp Dent. 2017;9:e289–e93.
    1. Curto A, Albaladejo A. Implications of apixaban for dental treatments. J Clin Exp Dent. 2016;8:e611–e4.
    1. Beyer-Westendorf J, Ebertz F, Forster K, Gelbricht V, Michalski F, Kohler C. Effectiveness and safety of dabigatran therapy in daily-care patients with atrial fibrillation. Results from the Dresden NOAC Registry. Thromb Haemost. 2015;113:1247–57.
    1. Breik O, Cheng A, Sambrook PJ, Goss AN. Protocol in managing oral surgical patients taking dabigatran. Aust Dent J. 2014;59:296–301.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe