The Physician-Dentist Dilemma: Modification of the Novel Anticoagulants in Implant Dentistry
by Randolph R. Resnik, DMD, MDS and Robert J. Resnik MD, MBA
Patients undergoing dental implant procedures often present with complex medical histories, including the use of novel anticoagulant medications. This newer class of anticoagulants, while essential for managing cardiovascular conditions, pose significant challenges in the context of surgical interventions due to their impact on bleeding and clotting mechanisms. This article will provide an overview of these medications as well as establishing a recommended modification protocol to minimize complications and ensure procedural success.
Novel Anticoagulants: An Overview
Novel anticoagulants, also known as direct oral anticoagulants (DOACs), have emerged as the preferred alternatives to warfarin (Coumadin) due to their targeted action, predictable pharmacokinetics, shorter half-lives, lack of dietary restrictions, and minimal monitoring requirements. The most common DOACs include; dabigatran (Pradaxa®), apixaban (Eliquis®), rivaroxaban (Xarelto®), and edoxaban (Savaysa®). These medications directly inhibit specific clotting factors: dabigatran targets thrombin, while rivaroxaban, apixaban, and edoxaban inhibit factor Xa.
Common Direct Oral Anticoagulants (DOAC)
COMMON DOAC MEDICATIONS:
Dabigatran (Pradaxa ®)
Apixaban (Eliquis ®)
Rivaroxaban (Xarelto ®)
Edoxaban ( Savaysa ®)
The indications for the use of DOAC therapy include prevention and treatment of venous thromboembolism, stroke prevention in atrial fibrillation, and management of acute coronary syndromes. Despite their advantages, the anticoagulant effects of DOACs pose significant challenges during surgical procedures, including dental implants, due to increased bleeding risks.
POTENTIAL COMPLICATIONS W/ DOAC ‘S:
Modification: Possible Thromoembolic Event
No Modification: Possible Bleeding Episodes
Inherent Problem in Oral Implantology
In the literature, the management of patients taking Direct Oral Anticoagulants is inconsistent for both dental surgeries and many common medical procedures. The lack of a generalized consensus may often lead to conflicting modification recommendations, thereby potentially leading to the unnecessary discontinuation of DOACs medications. Managing DOAC for dental surgical procedures requires careful consideration of both the potential consequences from discontinuation and the continuation of therapy into the pre- or peri-surgical period. If no modification of the DOAC medication is completed, then the dental implant procedure may be complicated by uncontrolled bleeding leading to hematoma formation, prolonged surgery, and compromised wound healing. If modification is utilized, then the patient may be subject to possible thromboembolism episodes, leading to severe cardiovascular events such as a stroke or myocardial infarction. Unlike Warfarin which can be reversed by Vitamin K, excessive bleeding from the DOAC’s require specific reversal agents which are very expensive and not available in most emergency rooms or healthcare facilities. Therefore, it should be anticipated that excessive bleeding from DOAC’s will need to be controlled by local hemostatic measures.
RECOMMENDATIONS:
Medical Clearance: A medical clearance should be initiated by the implant dentist with providing the patients physician all pertinent information concerning the surgical procedure such as the invasiveness of the procedure, estimated blood loss, surgery duration, and any prescribed medications. Dental implant clinicians should never alter any patient medications that were prescribed by their physician.
Patient Assessment: Effective modification of DOAC regimens requires comprehensive presurgical assessment and meticulous planning by the patient’s physician including;
Medical History Review: A detailed review of the patient’s medical history, including the indication for DOAC therapy, dosing regimen, renal function, and any previous bleeding or clotting events, is essential. With advancing age and medical illness , renal function can be expected to decrease, thereby leading to reduced drug clearance, which may result in higher plasma concentrations and increased risk of bleeding complications Laboratory Testing: While routine coagulation profiles (e.g., PT, INR, aPTT) are not always reliable for assessing DOAC activity, specialized tests like diluted thrombin time (dTT) for dabigatran and antiXa assays for factor Xa inhibitors can provide useful information. It has been shown that the effect of these medications on clotting is essentially the same regardless of age, sex, weight, race or dietary preferences. Most patients on these anticoagulants are undergoing routine monitoring of kidney, liver and anemia profiles by the prescribing physician. However, there is no established requirement for any bloodwork to be done prior to surgery.
Risk Stratification: Evaluating the risk of thromboembolic events versus the risk of surgical bleeding is crucial. Factors such as the invasiveness of the procedure, expected bleeding, medication dosage, and past bleeding history must be considered. When granting medical clearance, physicians are providing such clearance based on the information that is provided. Therefore, it is imperative the most accurate information is provided to the physician on the intended procedure (i.e., invasiveness, blood loss, etc.).
CLINICAL GUIDELINES AND EVIDENCE
Several clinical guidelines provide recommendations for managing patients on DOACs undergoing dental procedures. The American College of Cardiology (ACC) and the European Society of Cardiology (ESC) suggest individualized approaches based on bleeding risk and thromboembolic risk. Case studies and clinical trials have also shed light on the management of DOACs in dental implant surgery. For instance, a study by Wahl et al. (2015) demonstrated that temporary discontinuation of DOACs, combined with local hemostatic measures, effectively minimized bleeding complications without significantly increasing thromboembolic risk. In contrast, a 2019 systematic review and metaanalysis by Manfredi et al. on the management of direct oral anticoagulants (DOACs) for invasive oral procedures included 21 research papers. Among the studies included in the meta-analysis, the authors found no significant differences in postoperative bleeding events between patients who continued DOAC therapy and those who discontinued it.
PHYSICIAN MODIFICATION STRATEGIES
Modifying DOAC medications regimens involve several strategies. Each patient should be evaluated independently based on their specific medical issues and medications as well as risk factors for potential complications in discontinuing or continuing therapy, These strategies may include:
Temporary Discontinuation: For elective dental implant procedures, temporary discontinuation of DOAC medications is still a common approach. The timing of discontinuation depends on the specific drug’s pharmacokinetics. Currently, Eliquis (Apixiban) is the most prescribed DOAC. According to eliquis.com, for moderate to high risk procedures, Eliquis should be stopped at least 48 hours before surgery. For procedures with a low risk of bleeding, Eliquis may be stopped 24 hours prior to the procedure and continuation of the medication is usually initiated as soon as hemostasis is acquired. However, as more clinical data becomes available, it appears there is a trend for less medication modification for most dental surgeries. This is due to the premise of less associated morbidity with bleeding complications in comparison to embolic events.
Bridging Therapy: In patients at high risk of thromboembolic events, bridging therapy with short-acting anticoagulants such as low molecular weight heparin (LMWH) may be utilized. This involves cessation of the thrombin inhibitor and starting LMWH, which is then discontinued shortly before the procedure. Because of the shorter half-life of LMWH, better control of anticoagulation.Bridging requirements and dosing should be completed by the patient’s physician.
Dose Adjustment: For some patients, simply adjusting the dose of the DOAC medication rather than complete discontinuation may be sufficient. This approach aims to minimize bleeding risk while maintaining some level of anticoagulation. However, there is no definitive consensus in the literature that this approach has any additional benefit over the potential risk created by decreasing the dose of the medication
No Modification & Use of Local Hemostatic Measures: In some cases, the risk of a thromboembolic event is too great to warrant cessation or modification of DOAC’s. In these situations, it is imperative the clinician use local hemostatic measures to control bleeding. This may include hemostatic agents such as collagen sponges, fibrin sealants, topical thrombin, tranexamic acid as well as meticulous surgical techniques to minimize tissue trauma.
NOTE: Most commonly, resumption of anticoagulant therapy is started when hemostasis is achieved along with being based on the patient’s bleeding risk and the specific drug’s pharmacokinetics.
CONCLUSION
Modifying novel anticoagulants before dental implant procedures is a complex yet vital process to ensure patient safety and successful surgical outcomes. This requires a careful balance between the risks of bleeding and thromboembolic events through comprehensive assessments and tailored modification strategies developed by the patient’s physician, along with vigilant post-operative management. Therefore, discontinuation or continuation of DOAC’s is patient specific and should not be based on generalizations. Physicians should be asked to evaluate and determine the best course of action for each individual patient based on the patient’s specific medical history and risk for possible thromboembolic events. With the increasing use of novel anticoagulants in medicine, the dental implant community must be aware of the potential challenges these medications pose during surgical procedures. It is imperative the implant dentists work closely with the patient’s physician to ensure optimal care for those undergoing dental implants treatment.
REFERENCES
Manfredi, Maddalena, et al. “World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta‐analysis.” Oral diseases 25 (2019): 157-173.
Wahl, Michael J., et al. “Anticoagulants are dental friendly.” Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 125.2 (2018): 103-106. Lanau, Neus, et al. “Direct oral anticoagulants and its implications in dentistry. A review of literature.” Journal of clinical and experimental dentistry 9.11 (2017): e1346.
Zou, Lilin, and Li Hua. “Risk of bleeding with dental implant surgery in patients on anticoagulant or antiplatelet drugs: a systematic review and meta-analysis.” Acta Odontologica Scandinavica 81.2 (2023): 98-104.
Lusk, Kathleen A., et al. “Management of direct-acting oral anticoagulants surrounding dental procedures with low-to-moderate risk of bleeding.” Journal of Pharmacy Practice 31.2 (2018): 202-207.
Manor, Yifat, et al. “A retrospective analysis of dental implantation under anticoagulant treatment.” Clinical Oral Investigations 25 (2021): 1001-1009. Bajkin, Branislav V., Michael J. Wahl, and Craig S. Miller. “Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature.” Oral surgery, oral medicine, oral pathology and oral radiology 130.5 (2020): 522-532.