J Korean Assoc Oral Maxillofac Surg.  2024 Aug;50(4):189-196. 10.5125/jkaoms.2024.50.4.189.

Post-extraction bleeding in patients on direct oral anticoagulants

• Kim MJ
• Kim MK
• Kang SH

• KMID: 2559265
• DOI: http://doi.org/10.5125/jkaoms.2024.50.4.189

Abstract

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.

Keyword

Postoperative hemorrhage; Tooth extraction; Antithrombins; Factor Xa inhibitors; Anticoagulants

Reference

References

1. Miller SG, Miller CS. 2018; Direct oral anticoagulants: a retrospective study of bleeding, behavior, and documentation. Oral Dis. 24:243–8. https://doi.org/10.1111/odi.12698. DOI: 10.1111/odi.12698. PMID: 29480605.

2. Song J. 2021; Consideration of NOACs (novel or non-vitamin K-dependent oral anticoagulants) in dental procedure. J Korean Assoc Oral Maxillofac Surg. 47:409–10. https://doi.org/10.5125/jkaoms.2021.47.6.409. DOI: 10.5125/jkaoms.2021.47.6.409. PMID: 34969013. PMCID: PMC8721418.

3. Hiroshi I, Natsuko SY, Yutaka I, Masayori S, Hiroyuki N, Hirohisa I. 2022; Frequency of hemorrhage after tooth extraction in patients treated with a direct oral anticoagulant: a multicenter cross-sectional study. PLoS One. 17:e0266011. https://doi.org/10.1371/journal.pone.0266011. DOI: 10.1371/journal.pone.0266011. PMID: 35390010. PMCID: PMC8989216.

4. López-Galindo M, Grau-Benítez M. 2023; Systematic review on the effects of the discontinuation of the anticoagulant therapy and the postoperative bleeding, in patients under new oral anticoagulants after dental extraction. J Clin Exp Dent. 15:e338–45. https://doi.org/10.4317/jced.60122. DOI: 10.4317/jced.60122. PMID: 37152496. PMCID: PMC10155941.

5. Ono S, Ishimaru M, Yokota I, Konishi T, Okada A, Ono Y, et al. 2023; Risk of post-extraction bleeding with direct oral anticoagulant compared with warfarin: retrospective cohort study using large scale claims data in Japan. Thromb Res. 222:24–30. https://doi.org/10.1016/j.thromres.2022.12.007. DOI: 10.1016/j.thromres.2022.12.007. PMID: 36563522.

6. Ueda K, Inokoshi M, Kubota K, Yamaga E, Minakuchi S. 2023; Factors influencing postoperative bleeding after dental extraction in older adult patients receiving anticoagulation therapy. Clin Oral Investig. 28:22. https://doi.org/10.1007/s00784-023-05424-1. DOI: 10.1007/s00784-023-05424-1. PMID: 38147161.

7. Buchbender M, Schlee N, Kesting MR, Grimm J, Fehlhofer J, Rau A. 2021; A prospective comparative study to assess the risk of postoperative bleeding after dental surgery while on medication with direct oral anticoagulants, antiplatelet agents, or vitamin K antagonists. BMC Oral Health. 21:504. https://doi.org/10.1186/s12903-021-01868-7. DOI: 10.1186/s12903-021-01868-7. PMID: 34620135. PMCID: PMC8499467.

8. Müller M, Schlittler F, Schaller B, Nagler M, Exadaktylos AK, Sauter TC. 2019; Characteristics, treatment and outcome of bleeding after tooth extraction in patients on DOAC and phenprocoumon compared to non-anticoagulated patients-a retrospective study of emergency department consultations. Clin Oral Investig. 23:2273–8. https://doi.org/10.1007/s00784-018-2676-7. DOI: 10.1007/s00784-018-2676-7. PMID: 30291493.

9. Hua W, Huang Z, Huang Z. 2021; Bleeding outcomes after dental extraction in patients under direct-acting oral anticoagulants vs. vitamin K antagonists: a systematic review and meta-analysis. Front Pharmacol. 12:702057. https://doi.org/10.3389/fphar.2021.702057. DOI: 10.3389/fphar.2021.702057. PMID: 34776943. PMCID: PMC8585494.

10. Yoshikawa H, Yoshida M, Yasaka M, Yoshida H, Murasato Y, Fukunaga D, et al. 2019; Safety of tooth extraction in patients receiving direct oral anticoagulant treatment versus warfarin: a prospective observation study. Int J Oral Maxillofac Surg. 48:1102–8. https://doi.org/10.1016/j.ijom.2019.01.013. DOI: 10.1016/j.ijom.2019.01.013. PMID: 30745243.

11. Iwata E, Tachibana A, Kusumoto J, Hasegawa T, Kadoya R, Enomoto Y, et al. 2022; Risk factors associated with post-extraction bleeding in patients on warfarin or direct-acting oral anticoagulants: a retrospective cohort study. Oral Maxillofac Surg. 26:641–8. https://doi.org/10.1007/s10006-022-01039-0. DOI: 10.1007/s10006-022-01039-0. PMID: 35043275.

12. Yagyuu T, Kawakami M, Ueyama Y, Imada M, Kurihara M, Matsusue Y, et al. 2017; Risks of postextraction bleeding after receiving direct oral anticoagulants or warfarin: a retrospective cohort study. BMJ Open. 7:e015952. https://doi.org/10.1136/bmjopen-2017-015952. DOI: 10.1136/bmjopen-2017-015952. PMID: 28827248. PMCID: PMC5629650.

13. Rocha AL, Oliveira SR, Souza AF, Travassos DV, Abreu LG, Ribeiro DD, et al. 2019; Bleeding assessment in oral surgery: a cohort study comparing individuals on anticoagulant therapy and a non-anticoagulated group. J Craniomaxillofac Surg. 47:798–804. https://doi.org/10.1016/j.jcms.2019.01.049. DOI: 10.1016/j.jcms.2019.01.049. PMID: 30792032.

14. Svensson R, Hallmer F, Englesson CS, Svensson PJ, Becktor JP. 2013; Treatment with local hemostatic agents and primary closure after tooth extraction in warfarin treated patients. Swed Dent J. 37:71–7.

15. Al-Mubarak S, Al-Ali N, Abou-Rass M, Al-Sohail A, Robert A, Al-Zoman K, et al. 2007; Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy. Br Dent J. 203:E15discussion 410–1. https://doi.org/10.1038/bdj.2007.725. DOI: 10.1038/bdj.2007.725. PMID: 17694045.

16. Berton F, Costantinides F, Rizzo R, Franco A, Contarin J, Stacchi C, et al. 2019; Should we fear direct oral anticoagulants more than vitamin K antagonists in simple single tooth extraction? A prospective comparative study. Clin Oral Investig. 23:3183–92. https://doi.org/10.1007/s00784-018-2739-9. DOI: 10.1007/s00784-018-2739-9. PMID: 30392079.

17. Yang S, Shi Q, Liu J, Li J, Xu J. 2016; Should oral anticoagulant therapy be continued during dental extraction? A meta-analysis. BMC Oral Health. 16:81. https://doi.org/10.1186/s12903-016-0278-9. DOI: 10.1186/s12903-016-0278-9. PMID: 27566540. PMCID: PMC5002166.

18. Febbo A, Cheng A, Stein B, Goss A, Sambrook P. 2016; Postoperative bleeding following dental extractions in patients anticoagulated with warfarin. J Oral Maxillofac Surg. 74:1518–23. https://doi.org/10.1016/j.joms.2016.04.007. DOI: 10.1016/j.joms.2016.04.007. PMID: 27186873.

19. Ockerman A, Miclotte I, Vanhaverbeke M, Vanassche T, Belmans A, Vanhove J, et al. 2021; Tranexamic acid and bleeding in patients treated with non-vitamin K oral anticoagulants undergoing dental extraction: the EXTRACT-NOAC randomized clinical trial. PLoS Med. 18:e1003601. https://doi.org/10.1371/journal.pmed.1003601. DOI: 10.1371/journal.pmed.1003601. PMID: 33939696. PMCID: PMC8128271.

20. Conway SE, Hwang AY, Ponte CD, Gums JG. 2017; Laboratory and clinical monitoring of direct acting oral anticoagulants: what clinicians need to know. Pharmacotherapy. 37:236–48. https://doi.org/10.1002/phar.1884. DOI: 10.1002/phar.1884. PMID: 27983747.

21. Tripodi A, Ageno W, Ciaccio M, Legnani C, Lippi G, Manotti C, et al. 2018; Position paper on laboratory testing for patients on direct oral anticoagulants. A consensus document from the SISET, FCSA, SIBioC and SIPMeL. Blood Transfus. 16:462–70. https://doi.org/10.2450/2017.0124-17.

22. Gosselin RC, Dwyre DM, Dager WE. 2013; Measuring dabigatran concentrations using a chromogenic ecarin clotting time assay. Ann Pharmacother. 47:1635–40. https://doi.org/10.1177/1060028013509074. DOI: 10.1177/1060028013509074. PMID: 24259624.

23. Dunois C. 2021; Laboratory monitoring of direct oral anticoagulants (DOACs). Biomedicines. 9:445. https://doi.org/10.3390/biomedicines9050445. DOI: 10.3390/biomedicines9050445. PMID: 33919121. PMCID: PMC8143174.

24. Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, et al. 2021; 2021 Update of the International Council for Standardization in Haematology recommendations for laboratory measurement of direct oral anticoagulants. Thromb Haemost. 121:1008–20. https://doi.org/10.1055/a-1450-8178. DOI: 10.1055/a-1450-8178. PMID: 33742436.