Direct oral anticoagulant agents (DOACs) are increasingly being used for the treatment of non-valvular atrial fibrillation, thromboembolism, and acute coronary syndrome as an alternative to traditional agents such as warfarin. DOACs are considered to have a number of advantages, rapid onset, short-half lives, fewer drug-drug interactions and routine monitoring is not required.  However, there is a lack of clarity on discontinuing DOACs before invasive dental procedures.

The aim of this review was to assess the evidence regarding bleeding events following invasive oral procedures in patients using DOACs.

Methods

Searches were conducted in the PubMed, Embase, Scopus, Web of Science, and the Cochrane Library database for studies reporting on bleeding in adult patients treated with DOACs undergoing invasive oral procedures.  Two reviewers independently selected studies, extracted data and assessed study quality and risk of bias using the National Heart Lung Blood Institute (NHLBI) study quality assessment tools and the Newcastle Ottawa Scale.  Odds ratio (OR) and 95% confidence interval (CI) were pooled to estimate the risk of post-operative bleeding.

Results

• 21 studies (9 prospective case-controls,4 retrospective case controls, 5 retrospective and 1 prospective observational and 3 case series) were included.
• Rivaroxaban was the most frequently used DOAC (49.8%), followed by dabigatran (24.7%), apixaban (20.8%) and edoxaban (2.9%).
• Procedure performed included, extractions (single/multiple), implants (single/multiple), scaling and root planing, mucosal biopsies, cyst enucleation, abscess incision and drainage, gingivectomy, and ridge augmentation
• Intra-operative bleeding
  • 14 studies did not report data, 4 studies reported no bleeding with 3 studies reporting bleeding.
• Post-operative bleeding
  • Only 8 studies reported on direct comparisons between patients continuing or discontinuing DOACs.
  •  Meta-analysis (6 studies) indicated an OR = 0.92 (95%CI; 0.37-2.27) for postoperative bleeding events for patients taking DOACs.
  • From the 21 studies post-operative bleeding events (POBE) were recorded in 740 patients
  • 59/497 (11.8%) POBE occurred in patients who continued DOACs, while 27/200 (13.5%) events occurred in patients discontinuing DOACs.
• A majority of studies reported use of sutures and other local haemostatic measures (gelatin sponges or foam, cellulose, tranexamic acid or a combination) were used in 13 studies

Conclusions

The authors concluded: –

This review found no important differences in bleeding events in patients who continued versus patients who discontinued DOAC therapy, and no thromboembolic events in any patient group. Within the limits of this review, it seems clear that the discontinuation of DOAC therapy is not indicated before invasive oral procedures to mitigate POBE. Because postoperative bleeding is a risk associated with any invasive oral procedure, regardless of DOAC use or its discontinuation, intra- and postoperative protocols to achieve haemostasis with local measures in patients using these drugs should be developed and validated.

Comments

The reviewers have searched a good range of databases and followed a standard approach to this review. However, as they highlight none of the included studies were randomised controlled trials and only a small number of the studies involved direct comparisons.  So, while the findings suggest that there was no difference between post-operative bleeding episodes in those continuing or discontinuing DOACs the findings should be viewed cautiously as suggested by the authors.  Ideally, well designed, conducted and reported randomised controlled trials of appropriate size involving a range of invasive oral procedures and continuing and discontinuation of DOACs should be conducted to improve the quality of the available evidence.

Links

Primary Paper

 Manfredi M, Dave B, Percudani D, Christoforou J, Karasneh J, Diz Dios P, Glick M, Kumar N, Lockhart PB, Patton LL. World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta-analysis. Oral Dis. 2019 Jun;25 Suppl 1:157-173. doi: 10.1111/odi.13086.PubMed PMID: 31140701.

Other references

Dental Elf – 7^th Sep 2018

Oral anticoagulant therapy: Preventing bleeding in patients having dental extractions

Dental Elf – 29^th  Aug 2016

Anticoagulant therapy and dental extractions