Treating patients on new anticoagulant drugs

The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review

BACKGROUND

Direct oral anticoagulants (DOACs) were developed to overcome the drawbacks of oral anticoagulants. However, not much has been discussed about the perioperative management of patients on DOACs during oral surgical procedures. Thus, we aim to determine the risk of perioperative and postoperative bleeding during oral surgical procedures in patients on DOACs.

METHODS

A detailed literature search was performed to find potentially relevant studies using the Cochrane Library, Clinical Key, ClinicalTrials.gov, Google Scholar, Ovid, ScienceDirect, and Scopus. Every article available for free in English literature for the past 10 years, between 2012 and 2022, was searched.

RESULTS

A total of 2792 abstracts were selected through a search strategy across various search engines. Based on inclusion and exclusion criteria, eleven clinical studies using DOACs as anticoagulants or studies comparing patients with and without DOACs under oral surgery procedures were found. The results were inconsistent and varied, with a few studies recommending DOAC administration with the bare minimum reported complications and others finding no statistically significant difference between discontinuation or continuation of drugs, especially across basic dental procedures.

CONCLUSION

Within the limitations of the study, it can be concluded that minor oral surgical procedures are safe for patients on DOAC therapy. However, the continuation or discontinuation of DOACs in patients undergoing oral surgical procedures remains controversial and requires further studies to extrapolate the results.

Dental interventions in oral antithrombotic therapy

Dentists commonly encounter patients taking oral antithrombotic agents who require invasive dental procedures. Although antithrombotics can cause an increase in bleeding, there is consensus that treatment regimens with antiplatelet agents, older anticoagulants (warfarin) and direct oral anticoagulants should not be altered before routine dental procedures when the risk of bleeding is low. Thromboembolic risk of their discontinuing likely outweighs potential bleeding complications associated with surgery. Therefore, the risks of stopping or reducing these medications must be weighed against the potential consequences of prolonged bleeding, which can be controlled with local measures such as mechanical pressure, suturing, haemostatic agents or antifibrinolytics. Some patients who are taking antithrombotic medications may have additional comorbid conditions or receive other therapy that can increase the risk of prolonged bleeding after dental treatment. Where a patient is believed to be at high bleeding risk, the dentist should consider a consultation with the patient's physician to discuss temporarily discontinuing the antithrombotic therapy.

Assessment of Postoperative Bleeding after Dental Extractions in Patients Who Are On Antiplatelet Therapy: A Prospective Study

Introduction:

Patients with ischemic heart disease are placed on antiplatelet therapy (APT). This study allows a definite protocol to be set which will allow us the make the right judgment when it comes to extractions in patients on APT.

Materials and Methods:

For this study, 100 patients were taken up for dental extraction after obtaining a thorough case history. Bleeding time was assessed preoperatively for all the patients and patients with normal bleeding time were taken up for surgery under local anesthesia. Local haemostatic measures were employed after the extraction. Patients were monitored for first 30 minutes at the clinic and a telephonic review of all the patients was done at 24 h–48 h interval after the procedure. If there was an active ooze from the surgical site at any point, haemostatic measures with local haemostatic agents were carried out.

Results:

In patients with mono antiplatelet therapy, bleeding was noted in 16 patients after the 1 h time interval and was absent after 24h–48 h time intervals. The q = 32 and the P < 0.001, making it statistically significant. Regarding patients on dual APT, bleeding was noted in ten patients after 1 h, and in one patient after 24 h with no patients presenting with bleeding at the 48 h time interval. The q = 16.545 and P < 0.001, making it statistically significant.

Discussion:

The benefits of continuing APT for patients who require dental extraction outweighs the risks of postoperative bleeding.

Conclusion:

Antiplatelets are used for the prevention of myocardial infarction, ischemic stroke, and vascular death among patients who are at high risk of these events. Antiplatelets have minimal impact on the amount and duration of bleeding following routine dental extractions.

Current practices of Western Australian general dentists regarding management of patients on anticoagulant/antiplatelet therapy

PURPOSE

Currently, there are little to no published studies outlining general dentists' knowledge in the management of patients on anticoagulant/antiplatelet therapies in Australia. The aim of this study was to investigate the current practices of Western Australian (WA) general dentists with regards to dental management of patients taking anticoagulants/antiplatelets.

MATERIALS AND METHODS

WA dentists were invited to undertake a survey to investigate their knowledge on the management of patients taking anticoagulant/antiplatelet. The questionnaire provided to WA general dentists consisted of pre-extraction advice on patients (direct oral anticoagulants [DOACs], antiplatelets, warfarin, dual antiplatelets and antiplatelet/anticoagulant). Results were analysed using descriptive statistics as well as chi-square tests.

RESULTS

Of the 89 participants, 40.5% had <5 years of general dental experience. Most WA general dentists (64%-71%) responded with 'no change' when performing extractions on patients on DOACs, antiplatelet therapy, warfarin, dual antiplatelets and antiplatelets/anticoagulants (P = 0.00). Furthermore, dentists with 6-10 years of experience were more likely to cease antiplatelet for 24 h before extractions (P < 0.05). Dentists who extracted 10-30 teeth per month were likely to stop antiplatelets and DOACs for more than 48 h compared to other groups (P < 0.05).

CONCLUSION

Most WA dentists would not cease anticoagulant/antiplatelet therapy when undergoing dental extractions.

Direct oral anticoagulants and its implications in dentistry. A review of literature

BACKGROUND

Four novel direct oral anticoagulants (DOACs) named dabigatran, rivaroxaban, edoxaban and apixaban have been recently introduced to overcome some of the drawbacks of existing anticoagulants. They have less interactions and do not require routine monitoring. 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

A comprehensive search of the PubMed, Scopus and ISI Web of Science databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The quality of the reported information was assessed following the PRISMA statement.

RESULTS

Eleven studies that met the inclusion criteria were included in the review: 2 randomized clinical trials, 3 prospective studies, 3 retrospective studies, 2 case series and 1 case report.

CONCLUSIONS

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. Consensus among the professionals involved in the management of the patient is fundamental in invasive dental treatments and in complex patients. Key words:Oral anticoagulants, DOAC, NOAC, dabigatran, rivaroxaban, apixaban, edoxaban, bleeding, oral surgery.