Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery

Abstract

Objectives: A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. Materials and methods: A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. Results: 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. Conclusions: No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. Clinical relevance: direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.

Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis

“…A subsequent work performed on 12 patients receiving Rivaroxaban (discontinued 24 h before the procedure) who placed 57 implants showed no postoperative bleeding events [ 40 ]. A recent review did not demonstrate any differences in bleeding and thrombotic events in patients undergoing invasive dental procedures, while DOAC was either continued or discontinued for a short period [ 42 ]. No differences in terms of post-operative bleeding were found in a recent study comparing 31 patients on continued DOAC medication with 20 patients on continued vitamin K antagonization for tooth extraction.…”

Perioperative Management of Dental Surgery Patients Chronically Taking Antithrombotic Medications

“…Anticoagulants are divided into three pharmacological groups: vitamin K antagonists, anticoagulants that are not vitamin K antagonists and heparins and pentasaccharides [ 12 ].…”

“…The mechanism of action is based on the inhibition of vitamin K. As a result, deficient blood clotting factors (II, VII, IX, X) are synthetized by the liver. The onset of action occurs after 2–4 days, since these drugs do not act on already produced clotting factors [ 12 ].…”

“…The dosage of VKAs is individually adjusted for each patient, and the effectiveness of anticoagulant treatment is monitored by the international normalized ratio (INR), which should be between 2–3.5 in patients treated with VKAs. If the patients INR has significant fluctuations, a careful analysis of the prescribed medications and diet should be performed, as VKAs interact with various drugs and substances that reduce or increase their anticoagulant effect [ 1 , 12 , 13 ].…”

“…Oral anticoagulants, non-vitamin K antagonists (NOACs) are divided into two pharmacological groups [ 12 , 14 ].…”