Patient taking direct oral anticoagulants (DOACs) has to undergo oral surgery – considerations for practitioners

Marcin Pasternak, Justyna Kaczkowska


Haemostasis is an excellently orchestrated process; however, thrombosis or excessive bleeding can result in a breakdown of this subtly regulated mechanism. Anticoagulants prevent the formation of thrombi by blocking the coagulation cascade. Surgical interventions in anticoagulated patients carry a risk of periprocedural bleeding. Over the last decade, new agents – direct oral anticoagulants (DOACs) – were introduced into clinical practice to overcome the drawbacks of classic agents used for the prevention of thrombotic events. The most remarkable difference in comparison with traditional anticoagulants is the elimination of the need for monitoring. The article covers periprocedural management in DOAC-treated patients undergoing oral surgery procedures. Direct oral anticoagulants are characterized, paying attention to pharmacokinetic properties important for oral surgeons. Bleeding risk related to oral and dental implant surgery procedures are presented, followed by considerations crucial for the evaluation of patient-related bleeding factors. Aspects of surgical planning are discussed. Adequate measures and aids helpful in oral surgery interventions together with post-operative care are also summarized.


factor X inhibitors; direct thrombin inhibitor; oral surgery; bleeding

Full Text:



Zehnder JL. Drugs Used in Disorders of Coagulation. In: Katzung BG, editor. Basic & Clinical Pharmacology. 13th ed. New York: McGraw Hill Education; 2015. p. 584-601.

Lee JK. Dental management of patients on anti-thrombotic agents. J Korean Assoc Oral Maxillofac Surg 2018;44(4):143-50.

Jawień J. Leki wpływające na układ krwiotwórczy i układ krzepnięcia. In: Olszanecki R, Wołkow P, Jawień J, Korbut R, editors. Farmakologia. 2nd ed. Warszawa: PZWL Wydawnictwo Lekarskie; 2019. p. 454-77.

de Andrade NK, Motta RHL, Bergamaschi CC, Oliveira LB, Guimarães CC, Araújo JO, et al. Bleeding risk in patients using oral anticoagulants undergoing surgical procedures in dentistry: a systematic review and meta-analysis. Front Pharmacol 2019;10:866.

Khan N. Safe, effective and appropriate prescribing of anticoagulant therapies. Br J Cardiac Nurs 2019;14(4):1-11.

Lanau N, Mareque J, Giner L, Zabalza M. Direct oral anticoagulants and its implications in dentistry. A review of literature. J Clin Exp Dent 2017;9(11):e1346-54.

de Campos N, Furlaneto F, Buischi YDP. Bleeding in Dental Surgery. IntechOpen 2019. [22.03.2021].

Sivolella S, De Biagi M, Brunello G, Berengo M, Pengo V. Managing dentoalveolar surgical procedures in patients taking new oral anticoagulants. Odontology 2015;103(3):258-63.

Johnston S. An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery. Int J Oral Maxillofac Surg 2016;45(5):618-30.

Raszeja-Specht A , Michno A . Doustne antykoagulanty o działaniu bezpośrednim – nowe wyzwanie dla diagnostyki laboratoryjnej. Diagn Lab 2015;51(3):221-8.

Mauprivez C, Khonsari RH, Razouk O, Goudot P, Lesclous P, Descroix V. Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122(5):e146-55.

Gross PL, Weitz JI. New anticoagulants for treatment of venous thromboembolism. Arterioscler Thromb Vascul Biol 2008;28(3):380-6.

El Hussein MT, Cuncannon A. DARE to prescribe: Strategy to guide direct oral anticoagulant therapy. J Nurse Pract 2020;16(7):509-13.

Gómez‐Moreno G, Aguilar‐Salvatierra A, Fernández‐Cejas E, Delgado‐Ruiz RA, Markovic A, Calvo‐Guirado JL. Dental implant surgery in patients in treatment with the anticoagulant oral rivaroxaban. Clin Oral Implants Res 2016;27(6):730-3.

Lupi SM, Rodriguez Y Baena A. Patients taking direct oral anticoagulants (DOAC) undergoing oral surgery: a review of the literature and a proposal of a peri-operative management protocol. Healthcare (Basel) 2020;8(3):281.

Willmann S, Coboeken K, Kapsa S, Thelen K, Mundhenke M, Fischer K, et al. Applications of physiologically based pharmacokinetic modeling of rivaroxaban – renal and hepatic impairment and drug–drug interaction potential. J Clin Pharmacol 2021;61(5):656-65.

Byon W, Garonzik S, Boyd RA, Frost CE. Apixaban: a clinical pharmacokinetic and pharmacodynamic review. Clin Pharmacok 2019;58(10):1265-79.

De Caterina R, Kelly P, Monteiro P, Deharo JC, de Asmundis C, López-de-Sá E, et al. Design and rationale of the Edoxaban Treatment in routine clinical practice for patients with Atrial Fibrillation in Europe (ETNA-AF-Europe) study. J Cardiovasc Med 2019;20(2):97-104.

Lip GY, Agnelli G. Edoxaban: a focused review of its clinical pharmacology. Eur Heart J 2014;35(28):1844-55.

Martínez-Moreno E, Martínez-López F, Rodríguez-Lozano FJ, Oñate-Sánchez RE. Bleeding complications in anticoagulated and/or antiplatelettreated patients at the dental office: a retrospective study. Int J Environ Res Public Health 2021;18(4):1609.

Huisman MV, Klok FA. Pharmacological properties of betrixaban. Eur Heart J Suppl 2018;20(Suppl E):E12-5.

Patadiya N, Dumpala R. A high profile review on new oral clotting factor Xa inhibitor: betrixaban. Eur J Pharm Med Res 2021;8(1):239-47.

Ansell J, Laulicht BE, Bakhru SH, Burnett A, Jiang X, Chen L, et al. Ciraparantag, an anticoagulant reversal drug: mechanism of action, pharmacokinetics, and reversal of anticoagulants. Blood 2021;137(1):115-25. doi: 10.1182/blood.2020007116.

Muñoz-Corcuera M, Ramírez-Martínez-Acitores L, López-Pintor RM, Casañas-Gil E, Hernández-Vallejo G. Dabigatran: A new oral anticoagulant. Guidelines to follow in oral surgery procedures. A systematic review of the literature. Med Oral Patol Oral Cir Bucal 2016;21(6):e679-88.

Skripka A, Sychev D, Bochkov P, Shevchenko R, Krupenin P, Kogay V, et al. Factors affecting trough plasma dabigatran concentrations in patients with atrial fibrillation and chronic kidney disease. High Blood Press Cardiovasc Prev 2020;27(2):151-6.

Doherty JU, Gluckman TJ, Hucker WJ, Januzzi JL, Ortel TL, Saxonhouse SJ, et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 2017;69(7):871-98.

Pruszczyk P, Ciurzyński M, Opolski G, Stępińska J, Wożakowska-Kapłon B,Kalarus Z, et al. Wspólne stanowisko kardiologiczno-stomatologiczne dotyczące postępowania u pacjentów leczonych przeciwzakrzepowo poddawanych zabiegom stomatologicznym. Kardiol Pol 2016;74(1):87-98. doi: 10.5603/KP.2016.0014.

Gómez‐Moreno G, Fernández‐Cejas E, Aguilar‐Salvatierra A, de Carlos F, Delgado‐Ruiz RA, Calvo‐Guirado JL. Dental implant surgery in patients in treatment by dabigatran. Clin Oral Implants Res 2018;29(6):644-8.

Olek M, Blukacz M, Dawiec G. Wskazania i przeciwwskazania do stosowania leczenia odtwórczego z zastosowaniem implantów stomatologicznych. Twój Prz Stomatol 2020;3:62-8.

Dincq AS, Lessire S, Douxfils J, Dogné JM, Gourdin M, Mullier F. Management of non-vitamin K antagonist oral anticoagulants in the perioperative setting. Biomed Res Int 2014;2014:385014.

Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010;138(5):1093-100.

Padrini R. Clinical pharmacokinetics and pharmacodynamics of direct oral anticoagulants in patients with renal failure. Eur J Drug Metab Pharmacokinet 2019;44(1):1-12.

Chahine J, Khoudary MN, Nasr S. Anticoagulation use prior to common dental procedures: a systematic review. Cardiol Res Pract 2019;2019:9308631.

Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018;39(16):1330-93.

Vílchez JA, Gallego P, Lip GY. Safety of new oral anticoagulant drugs: a perspective. Ther Adv Drug Saf 2014;5(1):8-20.

Fenger‐Eriksen C, Münster AM, Grove EL. New oral anticoagulants: clinical indications, monitoring and treatment of acute bleeding complications. Acta Anaesthesiol Scand 2014;58(6):651-9.

Ciulla MM, Vivona P. Novel oral anticoagulants: a practical guide for dentists. Italian J Dental Med 2018;3(1):7-11.

de Almeida Barros Mourão CF, Miron RJ, de Mello Machado RC, Ghanaati S, Alves GG, Calasans-Maia MD. Usefulness of platelet-rich fibrin as a hemostatic agent after dental extractions in patients receiving anticoagulant therapy with factor Xa inhibitors: a case series. Oral Maxillofac Surg 2019;23(3):381-6.

O’Connell JE, Stassen LF. New oral anticoagulants and their implications for dental patients. J Ir Dent Assoc 2014;60(3):137-43.

Caliskan M, Tükel HC, Benlidayi E, Deniz A. Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants? Med Oral Patol Oral Cir Bucal 2017;22(6):e767-73.

Lakdawala YA, Masood S, Jawed S, Younus H. Common methods to arrest haemorrhage after tooth extraction in Dental out patient department. Pak J Surg 2020;36(3):260-3.

Foerster KI, Hermann S, Mikus G, Haefeli WE. Drug–drug interactions with direct oral anticoagulants. Clin Pharmacokinet 2020;59(8):967-80.

Pasternak M, Woroń J. Postępowanie w bólu poekstrakcyjnym. Ból 2020;21(1):47-52. doi: 10.5604/01.3001.0014.3422.


Copyright (c) 2021 Marcin Pasternak, Justyna Kaczkowska

License URL: