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Patients Taking Direct Oral Anticoagulants (DOAC) Undergoing Oral Surgery: A Review of the Literature and a Proposal of a Peri-Operative Management Protocol

1
Department of Clinical Surgical, Pediatric and Diagnostic Sciences, University of Pavia, 27100 Pavia, Italy
2
Department of Dentistry, IRCCS San Raffaele Hospital, 20123 Milan, Italy
3
Dental School, Vita Salute University, 20132 Milan, Italy
*
Author to whom correspondence should be addressed.
Healthcare 2020, 8(3), 281; https://doi.org/10.3390/healthcare8030281
Received: 2 July 2020 / Revised: 17 August 2020 / Accepted: 18 August 2020 / Published: 20 August 2020
(This article belongs to the Special Issue Innovative Solutions for Oral Healthcare)
Patients on anticoagulant therapy for the prevention of cardiovascular accidents present an increased risk of bleeding following dental and oral surgery. Four recently introduced non-vitamin K antagonist oral anticoagulants, namely dabigatran etexilate (direct thrombin inhibitor), rivaroxaban, apixaban, and edoxaban (Xa factor direct inhibitor), are widely spreading for convenience of use compared to the older drug class. Dental management of patients taking these drugs has substantial differences compared to patients on vitamin K antagonist therapy. Anticoagulation is not assessed directly through a hematological test, but indirectly by renal function. The interventions must be scheduled at the time of minimum blood concentration of the drug. Bleeding can occur even after several days following the surgery. The interaction with drugs administered for dental care must be carefully evaluated. The peri-operative diet can influence the risk of bleeding. Local measures favoring coagulation must be adopted. The interventions with higher risk must be divided into multiple less invasive interventions. Although antidotes exist for these drugs, their use does not seem necessary for dental interventions that have been planned optimally. Furthermore, in this review of the literature a decision protocol is proposed for the evaluation of the suspension of the anticoagulant drug before oral surgery. Cessation of any anticoagulant should only be made in consultation with the patient’s general practitioner/cardiologist, who will weigh up the risk of bleeding from the proposed procedure with the risk of thrombosis/stroke in each individual patient. View Full-Text
Keywords: DOACs; coagulation; surgery; peri-operative planning DOACs; coagulation; surgery; peri-operative planning
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Lupi, S.M.; Rodriguez y Baena, A. Patients Taking Direct Oral Anticoagulants (DOAC) Undergoing Oral Surgery: A Review of the Literature and a Proposal of a Peri-Operative Management Protocol. Healthcare 2020, 8, 281.

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