Anticoagulants and post-operative bleeding following oral surgery

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In recent years a new group of direct oral anticoagulants (DOACs) has been introduced to replace warfarin and other coumarin derivatives. The new DOACs (dabigatran, rivaroxaban, apixaban and edoxaban) can be administered in fixed doses once or twice daily, are not affected by food and have fewer drug–drug interactions.  A universally accepted consensus on the management of patients taking  DOACs is not yet available.

The aim of this review and meta-analysis was to assess the postoperative bleeding risk of DOACs during oral surgery procedures.

Methods

Searches were carried out in the PubMed, Scopus, Web of Science and Cochrane Library databases. Observational studies investigating the risk of postoperative bleeding in patients under DOAC therapy after any kinds of oral surgery procedures were considered. Two reviewers independently selected studies, extracted data and assessed risk of bias using the Newcastle Ottawa Scale.  Meta-analysis of postoperative bleeding risk was calculated where possible.

Results

  • 13 studies (5 prospective case-control, 2 prospective case-control, 3 cross-sectional, 2 case series and a case report) were included.
  • The patient population consisted of 428 females (43.6%) and 553 males (56.4%), with an average age of 68 years (range 19 – 97).
  • The most frequently used anticoagulant was rivaroxaban (62.6%, n = 250) followed by dabigatran (26.1%, n = 104) and apixaban (11.3%, n = 45).
  • 7 studies modified the usual anticoagulant regime 6 did not.
  • Tooth extraction was the most commonly performed procedure (71.4%, n = 568).
  • 796 surgical procedures were performed, 69 postoperative bleeding events were reported, occurring from 2h28 to 9days32 from surgery.
  • Meta-analysis indicated a 3-fold increase in bleeding risk for DOACs patients.
Bleeding risk No. of studies Risk Ratio (95%CI)
Patients on DOACs 5 3.04 (1.31–7.04)
Patients on Rivaroxaban 3 4.13 (1.25–13.69)
Patients on Dabigatran 2 1.00 (0.21–4.82)

Conclusions

The authors concluded: –

patients taking DOACs have a three-fold increased risk of postoperative bleeding after oral surgery procedures. Rivaroxaban has a major risk of bleeding when compared with the other DOACs, while dabigatran may determine fewer postoperative bleeding events. More clinical studies are required to confirm this trend and to define the relative risk of postoperative bleeding for apixaban.

Comments

The authors have undertaken a good search for evidence identifying only a small number of observational studies. While this does provide the clinician with some information the findings need to be interpreted with caution. There is a potential for selection bias and loss to follow up in these studies and the authors also highlight that the definition for post-operative bleeding was not adequately described in all the studies. As overall risk of bleeding for patients on DOACs was calculated although as changes to patients DOACs regimen prior to surgery are recommended by some being able to compare bleeding risk between those were changes are made or not would be helpful. With the anticipated of DOACs prescribing in the future having a better understanding of whether or not to amend treatment regiments and potential risks would be helpful so further well conducted high quality studies are needed.

In the meantime some guidance is available from the Scottish Dental Clinical Effectiveness Programme.

Links

Primary Paper

Bensi C, Belli S, Paradiso D, Lomurno G. Postoperative bleeding risk of direct oral anticoagulants after oral surgery procedures: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2018 Jul;47(7):923-932. doi:10.1016/j.ijom.2018.03.016. Epub 2018 Apr 5. Review. PubMed PMID: 29627150.

Other references

Dental Elf – 29th Aug 2016

Anticoagulant therapy and dental extractions

 

SDCEP Guidance 2015 –  Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs

 

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