How long should Xarelto be held before a dental extraction?

Discussion

It is now well-established that uncomplicated dental extractions can be safely carried out without interruption of VKAs therapy provided INR is maintained <3.5 and local hemostatic measures are performed to control bleeding (Nematullah et al., 2009). However, no clear guidelines exist on the perioperative management of patients receiving DOAC (Brennan et al., 2019). Recommendations range from the continuation of DOAC during dental extractions to omitting one or two doses of the drug before the procedure (Brennan et al., 2019). A recent survey by Precht et al. (2019) has demonstrated 94% of dental practitioners continue with VKAs during single tooth extractions but 62% of them interrupt DOAC therapy. Given such ambiguity, the results of our review present some clarity on the risk of hemorrhage with uninterrupted DOAC as compared to uninterrupted VKAs after dental extractions. We found a statistically significant reduced risk of hemorrhage with DOAC as compared to VKAs. Individually, none of the included studies noted a significant difference and all of them concluded that patients on DOACs have a similar bleeding tendency as compared to VKAs.

Bleeding Outcomes After Dental Extraction in Patients Under Direct-Acting Oral Anticoagulants vs. Vitamin K Antagonists: A Systematic Review and Meta-Analysis. Copyright © 2021 Hua, Huang and Huang. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

5.2 Direct Oral Anticoagulants (DOACS)

The risk of bleeding and adjustment of anticoagulant therapy with newer drugs depend on the type of dental procedure. Low-risk procedures have lesser chances of bleeding and include simple restorations, local anesthetic administration, supragingival scaling, and single-tooth extraction. Moderate risk procedures include extraction of 2 to 4 teeth and gingival surgery of up to 5 teeth. High-risk procedures are associated with a higher risk of bleeding and comprise extracting ≥6 teeth, generalized gingival surgery of ≥6 teeth, and multiple dental implant placement [126]. According to the available evidence, DOAC therapy can be continued safely for low-to-medium risk dental procedures as the involved risk of bleeding is low. In case bleeding occurs, local hemostatic measures can be used to manage it [125]. It is recommended not to perform these dental procedures during the peak concentrations of DOAC therapy but close to the end of the dosing cycle. Another alternative is to administer the DOAC after the procedure instead of before or perform the procedure 12–24 hours after the DOAC administration. In case of invasive or surgical dental procedure involving moderate to high risk of bleeding, it is recommended by manufacturers to discontinue edoxaban and rivaroxaban 24 hours prior and apixaban 48 hours before the procedure [127, 128, 129]. If discontinuation of DOAC is necessary, it should be reinitiated on the same day of the dental procedure. Overall, there is limited evidence at hand on the dental management of patients taking NAOCs and further studies are strongly recommended.

Dental Management Considerations for Patients with Cardiovascular Disease—A Narrative Review. Copyright: © 2022 The Author(s). Published by IMR Press. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Discussion

According to current Scottish Dental Clinical Effectiveness Programme (SDCEP) guidelines, patients undergoing invasive dental procedures such as extraction of 1–3 teeth or incision and drainage with a low risk of bleeding should continue their DOAC regime, which NHS recommends and most guidelines [38–40]. Conversely, patients undergoing dental procedures associated with a high risk of bleeding, such as multiple tooth extractions, flap-raising procedures, biopsies, and gingival re-contouring, should miss or delay their morning DOAC dose on the day of treatment to reduce the high risk of bleeding [41]. Besides, dentists prefer to undertake the procedure when peak DOAC concentrations have subsided, i.e., 4–6 h after the last dose. Among the studies that reported postoperative bleeding, a study by Hanken et al. reported 52 oral procedures performed under anticoagulant therapy with Rivaroxaban. The postoperative bleeding complications of these procedures were compared with those of 285 oral procedures in healthy patients without anticoagulant or antiplatelet therapy.

The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review. © The Author(s) 2023. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).