Bleeding Outcomes After Dental Extraction in Patients Under Direct-Acting Oral Anticoagulants vs. Vitamin K Antagonists: A Systematic Review and Meta-Analysis

Perioperative Factor Xa Inhibitor Discontinuation for Patients Undergoing Procedures With Minimal or Low Bleeding Risk

Importance

Discontinuation of oral anticoagulant treatment is common in clinical practice due to concerns about bleeding, even for procedures with minimal to low bleeding risk.

Objective

To explore whether perioperative discontinuation of factor Xa inhibitors is associated with major bleeding and thromboembolic events in patients with atrial fibrillation (AF) undergoing procedures with minimal to low bleeding risk.

Design, Setting, and Participants

This prospective, multicenter, single-arm cohort study conducted in Korea included patients with AF who planned to undergo a procedure with minimal to low bleeding risk between September 25, 2020, and April 5, 2024.

Exposure

The PERIXa (Perioperative Factor Xa Inhibitor Discontinuation in Patients With Atrial Fibrillation Undergoing Minimal to Low Bleed Risk Procedures) protocol recommending giving the last dose of factor Xa inhibitor (ie, apixaban, edoxaban, or rivaroxaban) 24 hours before the procedure (ie, endoscopy, dental procedure, or ocular surgery) and restarting treatment with the inhibitor the next day.

Main Outcomes and Measures

The primary outcome was major bleeding, and the secondary outcome included a composite of thromboembolic events 30 days after the index procedure with minimal to low bleeding risk.

Results

In total, 1902 patients were included in the modified intention-to-treat analysis set encompassing all patients who underwent the intended procedure (mean [SD] age, 70.4 [8.8] years; 1135 [59.7%] male; mean [SD] CHA2DS2-VASc [congestive heart failure, hypertension, age 75 years or older, diabetes, stroke, vascular disease, age 65-74 years, and female sex; range, 0-9, with higher scores indicating higher risk of stroke] score, 2.8 [1.3]; mean [SD] HAS-BLED [hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65 years, and drug or alcohol use; range, 0-9, with higher scores indicating higher risk of bleeding] score, 1.6 [0.7]). Among them, 921 (48.4%) were receiving apixaban, 616 (32.4%) were receiving edoxaban, and 365 (19.2%) were receiving rivaroxaban. Of the total procedures, 948 (49.8%) were endoscopy, 820 (43.1%) were dental procedures, and 120 (6.3%) were ocular surgery. The 30-day event rate of major bleeding was 0.1% (n = 2), and there were no composite thromboembolic events. The results were consistent in the per-protocol analysis, and no differences were observed by procedure category or factor Xa inhibitor type.

Conclusions and Relevance

In this cohort study, patients with AF receiving a factor Xa inhibitor and undergoing a procedure with minimal to low bleeding risk had low rates of major bleeding and thromboembolism when following the standardized PERIXa protocol for perioperative management of oral anticoagulant treatment, suggesting that this may be a safe and reasonable option for this patient population.

Influence of antiplatelet medication and anticoagulation therapy after dental extractions on hospitalization: a retrospective 10-year study

BACKGROUND

The aim of this retrospective study was to identify high-risk dental extraction patients and the timing of postoperative hemorrhage to evaluate whether preventive hospitalization should be considered in patients on antiplatelet medication (AP) or anticoagulants.

METHODS

Our study included 1595 procedures; 1319 were conducted under monotherapy (Group I: AP; Group II: indirect oral anticoagulant [IAC]; Group III: direct oral anticoagulant [DOAC]) and 276 under dual therapy (Group IV: double AP; Group V: AP and IAC; Group VI: AP and DOAC). We evaluated the incidence, frequency and timing of hemorrhage, hospitalization rate, and treatment of bleeding incidents.

RESULTS

The incidence of hemorrhagic events was significantly higher in the dual therapy groups compared to the monotherapy groups (p < 0.001). Comparing the procedures under monotherapy, those on DOAC (Group III) had a significantly higher risk of postoperative bleeding than Groups I and II (p < 0.001) and a higher rate of repeated bleeding episodes (p = 0.035). Regarding bleeding incidents, 44% (dual therapy) vs. 51.1% (monotherapy) occurred on the day of surgery.

CONCLUSIONS

The bleeding risk after dental extractions is overall low and patients were often hospitalized preventively due to their comorbidities rather than actual bleeding risk. Patients should be instructed about local compression, and surgeries should be completed in the morning to avoid emergency visits. However, patients with cardiovascular diseases and dual therapy had a higher risk of postoperative hemorrhage. Thus, hospitalization is to be considered in these cases.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the Medical Faculty of RWTH Aachen (Decision Number 24-136). This was a retrospective clinical study designed to analyze postoperative bleeding and hospitalization rates after dental extractions in patients on AP or anticoagulation therapy.

Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review

Importance

Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.

Observations

For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.

Conclusions and Relevance

When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

Post-extraction bleeding in patients on direct oral anticoagulants

Objectives

This study aimed to evaluate the association between use of direct oral anticoagulants (DOACs) and post-extraction bleeding and to quantify bleeding risk in patients receiving DOACs.

Materials and Methods

The study included 293 patients who were taking DOACs and underwent tooth extraction (414 teeth). The patients were divided into those who had the extraction while taking DOACs and those who discontinued DOACs before the extraction. Bleeding complications were recorded and compared between the patient groups and types of DOACs.

Results

Of the 293 patients, 12 patients (6.9%) had post-extraction bleeding. Post-extraction bleeding occurred in 12 of the 414 tooth extraction sites. Among the 246 patients who underwent dental extraction while continuing DOAC therapy, 12 patients (8.5%) had post-extraction bleeding. Among the 47 patients who underwent dental extraction after discontinuing the administration of DOACs, none reported post-extraction bleeding. There was no significant difference in the number of patients with post-extraction bleeding between the two groups (P=0.122).

Conclusion

Continuing DOAC therapy during dental extraction does not increase post-extraction bleeding tendency. These results are consistent with those of previous studies.

Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures

In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.

Controversies in Stoppage of Antiplatelet and Anticoagulant Medications Prior to Oral Surgery

Dental procedures can pose a risk of bleeding, and it is not uncommon for dentists to consult prescribing physicians regarding a mutual patient's antiplatelet and anticoagulant medication to prevent excessive bleeding during or after an upcoming procedure. However, there has been a growing controversy in the dental community surrounding the stoppage of these medications prior to dental procedures. Some believe that stopping these medications prior to dental procedures is necessary to reduce the risk of bleeding complications, while others argue that stopping them can increase the risk of stroke or other thromboembolic events. The debate has left many dentists and specialists unsure about the best course of action when it comes to managing bleeding risk during dental procedures.In this article, we will review the antithrombotic medications, indications, mechanism of action, and its effects on the coagulation pathway, laboratory testing and reversal agents. Also, we will explore the controversy surrounding the stoppage of novel anitplatelets (eg,: prasurgrel and ticagrelor), dual-antiplatelets, triple-antiplatelet, vitamin K antagonists (eg,: wafarin, coumadin), and direct oral anticoagulants (eg,: dabigatran, rivaroxaban, xarelto and endoxaban) in dentistry and examine the current evidence and guidelines for managing dental patients undergoing oral surgery.

Edoxaban use in the context of dental procedures: analysis from the EMIT-AF/VTE database

INTRODUCTION

Literature reviews support continuing anticoagulation during dental procedures. However, studies often present grouped anticoagulation data, and information on individual anticoagulant management would be helpful to dentists. The Edoxaban Management in Diagnostic and Therapeutic Procedures (EMIT-AF/VTE) programme (NCT02950168; NCT02951039) demonstrated low periprocedural bleeding and thrombotic event rates in patients with atrial fibrillation receiving edoxaban.

AIMS

To report periprocedural edoxaban interruption and clinical events in patients from EMIT-AF/VTE who underwent dental procedures.

METHODS

Dental procedures were categorised by type (cleaning/noncleaning). Edoxaban interruption, bleeding events, and thrombotic events were observed 5 days preprocedure through 29 days postprocedure.

RESULTS

Overall, 196 patients underwent 350 cleaning and/or noncleaning procedures; most patients (171/196 [87.2%]) underwent noncleaning procedures (282/350 [80.6%]), whereas 48/196 (24.5%) underwent 68/350 (19.4%) cleaning procedures. Edoxaban was uninterrupted for most cleanings (53/68 [77.9%]). Preprocedural interruption was common for single and multiple tooth extractions (single, 67/100 [67.0%]; multiple, 16/30 [53.3%]). The only major bleeding occurred after an unrelated cleaning. Minor bleeding occurred in 1/68 (1.5%) cleaning and 4/282 (1.4%) noncleaning procedures. There were no thrombotic events.

CONCLUSIONS

For most cleanings, edoxaban was not interrupted, whereas preprocedural interruption was more common for tooth extractions. Overall, bleeding rates were low, and no thrombotic events occurred.

Perioperative Management of Anticoagulant and Antiplatelet Therapy

Anticoagulant and Antiplatelet Drug ManagementManagement of patients on an anticoagulant or antiplatelet drug who require surgery or an invasive procedure is a common clinical problem. Douketis and Spyropoulos provide an evidence-based but practical approach to managing anticoagulants and antiplatelet drugs in the perioperative setting.

Local Tranexamic Acid for Preventing Hemorrhage in Anticoagulated Patients Undergoing Dental and Minor Oral Procedures: A Systematic Review and Meta-Analysis

Dental procedures have posed challenges in managing anticoagulated patients due to early reports of oral hemorrhage. This study aims to evaluate the risks of postoperative bleeding with the local application of tranexamic acid. A systematic search was conducted until 31 March 2022, with keywords including tranexamic acid, oral hemorrhage, dental, and/or coagulation. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane Library. Statistical analysis was conducted using Review Manager 5.4. In total, 430 patients were pooled in with the local application of tranexamic acid using mouthwash, irrigation, and compression with a gauze/gauze pad. The mean age was 61.8 years in the intervention group and 58.7 in the control group. Only 4 patients in the intervened group out of the 210 discontinued the trial due to non-drug-related adverse events. The risk difference was computed as -0.07 (p = 0.05), meaning that patients administered with local antifibrinolytic therapy for postoperative bleeding reduction for dental procedures were at a 7% less risk of oral bleeding. Current evidence on managing anticoagulated patients undergoing dental or oral procedures remains unclear. The present study presents favorable outcomes of postoperative bleeding with local tranexamic acid used in the postoperative period.