27 December 2021

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DOACs: risk of bleeding during oral surgery

Alessandra Abbà

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The number of patients under treatment with oral anticoagulant and antiplatelet drugs - used for primary and secondary prevention of venous thromboembolic diseases - has grown. There are two types of oral anticoagulant treatment: vitamin K antagonists (e.g. warfarin and coumarin) and DOACs-direct oral anticoagulant (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). In particular the latter, which have been object of research and study in recent years, have a wide therapeutic window and no need for regular and systematic monitoring of INR. The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. 

Patients being treated with oral anticoagulant are at higher risk for bleeding when undergoing oral surgery or dental extractions. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. However, there is not enough scientific data about the protocol to apply in these patients on DOACs undergoing dental treatment. Thus is necessary to evaluate the potential bleeding risk of these drugs, the possibility of thromboembolic events occurring if they are withdrawn or the need to change to heparin previously. 

Material and methods:
in this review a comprehensive search of the PubMed, Scopus and ISI Web of Science databases was conducted in order to identify studies evaluating the relationship between DOACs and dental procedures. All kind of articles (rando-mized clinical trials, cohort studies, case-control studies, case series and case reports), performed in adult patients under treatment with any kind of DOACs drug who underwent a dental procedure that implied any kind of bleeding, were considered. 

Results: 

11 studies were judged to be of interest on the basis of the criteria selected and included in the review. Between these, 2 are randomized clinical trials, 3 are prospective studies, 3 are retrospective studies, 2 are case series and 1 is a case report.

Conclusions:
There is no consensus about the protocol to follow in patients in treatment with DOACswho need a dental procedure or bleeding. However, all the authors agree that it is necessary to individualize each case evaluating the difficulty of the procedure and the related risk of bleeding with the consensus between the dentist and the patient´s responsible physician. However DOACs are safe drugs in terms of bleeding. The possible postoperative bleeding complications are manageable with conventional haemostasis measurements. The bridging approach with heparin does not seem to be recommended.

For additional information: Direct oral anticoagulants and its implications in dentistry. A review of literature