Pragmatic approach to manage new oral anticoagulants
in patients undergoing dental extractions: a prospective
Jimoh Olubanwo Agbaje
Received: 27 May 2016 /Accepted: 15 November 2016 / Published online: 28 November 2016
Springer-Verlag Berlin Heidelberg 2016
Objectives The aim of this study was to validate a standard-
ized pragmatic approach to manage new oral anticoagulants
(NOACs) in patients who undergo dental extractions.
Materials and methods This prospective case-control study in
patients undergoing dental extraction included 26 patients
(mean age 76 years, 57% male) treated with dabigatran,
rivaroxaban, or apixaban and 26 matched controls.
Regardless of timing of extraction, drug regimen, or renal
function, patients were instructed to skip only the dose on
the morning of the procedure. A procedural bleeding score
was recorded and early and delayed bleeding was assessed
at day 1 and day 7. Bleeding events were compared with a
prospectively matched control group not taking any anti-
Results There was no difference in the procedural bleeding
score or in early bleeding events (5 in both groups).
However, delayed bleeding occurred more frequently in
anticoagulated compared to non-anticoagulated patients
(7 versus none, p = 0.01).
Conclusions Skipping the morning dose of NOACs avoids
excess bleeding during and early after the procedure.
However, anticoagulated patients had an increased risk of de-
layed bleedings. Further study is needed to determine the op-
timal post-procedural management.
Clinical relevance This is the first prospective study for the
management of patients on NOACs undergoing dental extrac-
tion. Our pragmatic approach, omitting only a single morning
dose, can guide clinical practice. Both patients and physicians
should be aware of the increased delayed bleeding risk.
Keywords Tooth extraction
Since the introduction of new oral anticoagulant drugs
(NOACs), the number of patients treated with this class of
antithrombotics is steadily increasing. NOACs are indicated
in the prevention and treatment of deep vein thrombosis and
pulmonary embolism and in the prevention of stroke in pa-
tients with atrial fibrillation . Four NOACs are available:
one thrombin inhibitor (dabigatran) and three factor Xa inhib-
itors (rivaroxaban, apixaban and edoxaban). They differ in
dosing regimen (once or twice daily) and degree of renal elim-
ination. In contrast to vitamin K antagonists (VKAs), NOACs
have a short onset of action (peak plasma levels after 1 to 4 h)
and a short half-life (5–17 h). The optimal periprocedural
management of NOACs in dental extractions remains unclear.
For major surgical procedures, VKAs are discontinued pri-
or to the procedure and resumed thereafter. Because of the
slow onset and offset of these drugs, the perioperative man-
agement of VKAs is complex. Bridging with low-molecular
weight heparins (LMWH) was often used, but this results in
increased bleeding complications . Since there is no in-
creased risk of major bleeding when performing minor proce-
dures such as dental extractions on stable VKA treatment, it is
current practice not to discontinue VKAs for dental extrac-
tions . However, the rate of minor and moderate bleeding
* Isabel Miclotte
Department of Oral and Maxillofacial Surgery, University Hospitals
Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
Department of Cardiovascular Medicine, University Hospitals
Leuven, Herestraat 49, 3000 Leuven, Belgium
Clin Oral Invest (2017) 21:2183–2188