J Korean Assoc Oral Maxillofac Surg 2021; 47(6): 409~410
Consideration of NOACs (novel or non-vitamin K-dependent oral anticoagulants) in dental procedure
Jiyoung Song, PhD
Section Editor of JKAOMS
Department of Oral and Maxillofacial Surgery, School of Medicine, Jeju National University, Jeju, Korea
Jiyoung Song
Department of Oral and Maxillofacial Surgery, School of Medicine, Jeju
National University, 15 Aran 13-gil, Jeju 63241, Korea
TEL: +82-64-717-1844
E-mail: 2460song@naver.com
ORCID: https://orcid.org/0000-0002-9500-6557
; Published online December 31, 2021.
© Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Body

Over many decades, systemic oral intake of anticoagulants such as vitamin K antagonists was used for preventing thromboembolism or reducing its risk. Nowadays, three NOACs (novel or non-vitamin K-dependent oral anticoagulants) have been approved for use: dabigatran (Pradaxa), which is a direct thrombin inhibitor, and rivaroxaban (Xarelto) and apixaban (Eliquis), which are factor Xa inhibitors. They have several advantages such as a rapid onset time, concentration peaking immediately, and low drug-to-drug and food interactions in comparison with vitamin K antagonists such as warfarin and acenocumarol1-4.(Table 1)

According to the literature reviews, there is no evidence of that NOACs increase bleeding in simple dental procedures such as scaling, root planning, root canal treatment, restorative treatment, or simple extraction in comparison with vitamin K antagonists. Therefore, there is no need to discontinue the routine dosage of NOACs in patients with normal renal function and without other risk of bleeding tendency1. Local hemostatic measures such as local surgical sutures, antifibrinolytic treatment, and fibrin glue are used to prevent bleeding3,4.

In case of surgical or multiple tooth extraction, complex oral surgery, or head and neck surgery, NOACs are discontinued ≥24 hours before dental surgery in patients with normal renal function. Patients with renal failure discontinue NOACs earlier depending on the degree of renal impairment or switching to another anticoagulant before surgery. NOACs are restarted at least 24 hours postoperatively1,3.

In conclusion,

1. NOACs do not need to be interrupted in routine dental procedures.

2. Interruption of NOACs ≥24 hours before dental surgery is needed in cases of high risk of maxillofacial bleeding such as during head and neck surgery, surgical or multiple tooth extraction, and according to patient’s renal function.

Although the number of patients treated with NOACs is increasing, the available evidence-based guidelines are still weak. Further studies and cooperation of dental and medical doctors are needed.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Tables

Characters of NOACs (novel or non-vitamin K-dependent oral anticoagulants) and warfarin

Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) Warfarin (Coumadin)
Action Thrombin inhibitor Factor Xa inhibitor Factor Xa inhibitor Vitamin K antagonist
Half-life in plasma (hr) 12-17 7-13 8-13 36-42

References
  1. Costantinides F, Rizzo R, Pascazio L, Maglione M. Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications. BMC Oral Health 2016;16:5. https://doi.org/10.1186/s12903-016-0170-7.
    Pubmed KoreaMed CrossRef
  2. 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:e1346-54. https://doi.org/10.4317/jced.54004.
    Pubmed KoreaMed CrossRef
  3. Martinez M, Tsakiris DA. Management of antithrombotic agents in oral surgery. Dent J (Basel) 2015;3:93-101. https://doi.org/10.3390/dj3040093.
    Pubmed KoreaMed CrossRef
  4. Brennan Y, Gu Y, Schifter M, Crowther H, Favaloro EJ, Curnow J. Dental extractions on direct oral anticoagulants vs. warfarin: the DENTST study. Res Pract Thromb Haemost 2020;4:278-84. https://doi.org/10.1002/rth2.12307.
    Pubmed KoreaMed CrossRef


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