Do you need to hold Eliquis before a dental extraction?

Results

Due to the lack of quality scientific evidence in the literature on this issue, an expert opinion is proposed. In anticoagulated patients with a direct anticoagulant drug and undergoing extractions, it is recommended to precisely know the half-life of the drug used, the dental extraction having to be carried out at the time of maximum decrease of the plasma concentrations of the specific anticoagulant, delaying its administration at least 4 hours after the extraction, simultaneously applying local haemostatic measures such as sutures, different haemostatic sponges or dressings, or compression with dry gauze or preferably soaked in tranexamic acid (Grade D Recommendation). Taking into account the current limited evidence and its methodology, future lines of research should focus on being able to answer this PICO question through well designed clinical trials evaluating the effectiveness of the different local haemostatic measures in patients treated with direct anticoagulants undergoing extractions compared with healthy controls and with an adequate sample size.

Clinical practice guideline of the spanish society of oral surgery for oral surgery in patients with coagulation disorders. Copyright: © 2024 Medicina Oral S.L. Creative Commons Attribution 2.5 International (https://creativecommons.org/licenses/by/2.5/).

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/).

Discussion

Recent studies are in favor of DOAC continuation for oral invasive procedures, but conclusions are limited by methodological considerations [[40], [41], [42], [43]]. A recent meta-analysis comparing the bleeding outcomes after dental extraction in patients under uninterrupted DOACs vs VKAs has included 8 studies comparing 539 patients on DOAC therapy and 574 patients on VKAs. It concluded, based on studies of very low quality that patients on DOACs may have a reduced risk of hemorrhage, and incited to interpret this result with caution [23]. Another meta-analysis showed that there was no significant difference in the bleeding risk between patients continuing or discontinuing VKAs while undergoing dental extractions, and also no significant difference in postoperative bleeding risk at 1 day and 7 days [25]. A systematic review of the effects of the discontinuation of anticoagulant therapy and postoperative bleeding after simple dental extraction in patients under DOACs and VKAs has shown that the most common complication was the immediate postoperative bleeding, mostly minor, in both groups, with no significant difference in the bleeding rates between the DOACs and VKAs [24], but this conclusion was not based on any quantitative analysis. However, the 7 included studies had bias, and the management of treatments and the hemostatic measures were different from one study to another, which may have influenced the bleeding rates. Moreover, published articles are majorly based on tooth extractions, which are not representative of the wide range of invasive procedures practiced in oral surgery, which entail different hemorrhagic risks.

Oral anticoagulant periprocedural management in patients undergoing an oral, dental implant or periodontal surgery: a prospective national observational survey. © 2025 The Authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Review

Direct oral anticoagulants (DOACs): For procedures with minimal bleeding risk (e.g., minor dental procedures), DOACs may be continued; if there is concern about excessive bleeding, they may be discontinued on the day of the procedure [44]. Heparin bridging is not required for perioperative DOAC management [44]. Antiplatelet agents: Aspirin and clopidogrel should generally be continued for simple dental procedures. Elective dental care should be deferred for six weeks after bare-metal stent (BMS) placement and six months after drug-eluting stent (DES) placement to avoid premature discontinuation of dual antiplatelet therapy [34]. Cardiac conditions requiring infective endocarditis prophylaxis and considerations for anticoagulation during dental procedures are summarized in Table 6.

The Oral Cavity as a Window to Systemic Disease: Diagnostic Clues and Pre-treatment Dental Management for Interdisciplinary Trainees. Copyright © 2026, Sarbeland et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Background

Some anticoagulants may be associated with a higher bleeding risk than others, but the specific incidence of heavy and light postoperative hemorrhage and its temporary occurrence after the operation often remains unclear [8, 9]. While AP therapy with ASA does not seem to be associated with a higher risk of hemorrhage compared to healthy patients, dual AP therapy increases the risk for postoperative bleeding after tooth extraction [10]. A multicenter study by Hiroshi et al. addressing extractions in patients taking direct oral anticoagulants (DOACs) and warfarin showed no significant difference in postoperative bleeding events between these medications [11]. However, Miranda et al. found a significantly higher risk of hemorrhage after teeth extraction in patients who had undergone replacement of warfarin with LWMH compared to patients taking DOACs [12]. Growing evidence exists that the interruption of anticoagulants and bridging is neither necessary nor worth the risk of thromboembolic incidents since bleeding after minor oral surgery is usually not life-threatening [13–16].

Influence of antiplatelet medication and anticoagulation therapy after dental extractions on hospitalization: a retrospective 10-year study. © The Author(s) 2024. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).