Direct Oral Anticoagulants and Medical Comorbidities in Patients Needing Dental Extractions: Management of the Risk of Bleeding.


Senior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy. Electronic address: [Email]


OBJECTIVE : The purpose of this study was to measure the frequency of bleeding during and after tooth extraction in patients exposed to direct oral anticoagulants (DOACs) and identify risk factors for prolonged or excessive bleeding.
METHODS : This retrospective cohort study involved 100 patients who underwent tooth extractions according to the European Heart Rhythm Association protocol: continuation of DOAC therapy for extractions of up to 3 teeth in the same session performed at the (presumed) time of DOAC trough concentration. We respected an interval of at least 4 hours between extraction and last DOAC intake. The outcome of interest was incidence of mild, moderate, and severe bleeding during the intervention and in the 7-day follow-up period. Data analysis considered the presence of comorbidities as the primary predictor for bleeding; additional predictors were age, gender, type of comorbidity, indication for DOAC therapy, DOAC agent, and extraction of contiguous teeth.
RESULTS : Of the patients, 64 had comorbidities (diabetes in 50%). The distributions of demographic, clinical, and dental variables were similar for patients with and without comorbidities. We observed 4 bleeding episodes (1 moderate episode 1 hour after the extraction and 3 mild episodes the day after the extraction) in the comorbidity group and none in the non-comorbidity group (4 of 64 vs 0 of 36, P = .29; overall bleeding rate, 4 of 100). The factor significantly triggering bleeding in patients with comorbidity was extractions of couples and triplets of multirooted teeth (P = .004).
CONCLUSIONS : Tooth extractions in patients with comorbidities taking DOACs may be safely managed as long as they are performed at least 4 hours after the last DOAC intake and do not involve 2 or 3 contiguous premolars and molars.