(7) Retrospective Cohort Study of the Effects of NOACs on Postoperative Bleeding Following Dental Extraction

Abstract: Novel oral anticoagulants (NOACs) are a revolutionary tool to decrease morbidity among patients with a high risk of thromboembolic events. Perioperative management of anticoagulants such as Warfarin have been well studied, but guidelines for perioperative management of patients on NOACs remains controversial. In part, this issue stems from a lack of a standardized and affordable monitoring test, such as an INR (Berton et al., 2019). Studies show that NOACs lead to a bleeding risk synonymous with an INR of 2-4, a moderately safe value for most basic dentoalveolar extractions (Brennan et al., 2020). While others have shown that there is the same post-operative bleeding risk across the board with Warfarin or NOAC therapy post extractions (Berton et al., 2019). Nevertheless, it is the provider's goal to minimize as many risks as possible for a patient, whether for thromboembolic events or post-operative bleeding. This study will retrospectively review post-operative complications (bleeding) after dentoalveolar extractions for patients on and off NOACs in the periprocedural period to establish patient care guidelines.

Chart review was retrospectively performed from May 2012 through December 2018 in the Department of Oral & Maxillofacial Surgery at the Virginia Commonwealth University School of Dentistry (Richmond, VA). Patients included in this review were at least 18 years old and had undergone dental extraction(s) while on NOACs. NOACs included were rivaroxaban (Xarelto), apixaban (Eliquis), dabigatran (Pradaxa), and edoxaban (Savaysa). Fisher’s Exact test and Wilcoxon rank-sum test were used to describe associations between demographics, surgical factors and complications (diagnosis, procedure, NOAC, number of extractions) and preoperative NOAC discontinuation. Median and range or interquartile range (IQR; range from 25th to 27th percentile) were assessed for continuous variables due to the skewness in data. All analyses were performed in SAS EG v.6.1 (SAS Institute, Cary, NC) with a 0.05 significance level.

The search identified 58 individuals who underwent dental extractions while on NOACs. Patients were predominantly male (71%) between 23-95 years old (median = 73). Patients were on rivaroxaban (57%), apixaban (29%), dabigatran (12%) and edoxaban (2%) (Table 1). Perioperatively, 45% of these patients had discontinued NOAC use. Indication for extraction was diagnosis of non-restorable tooth (88%). The number of extractions ranged from 1-10 (median = 2). Only 3 of the 58 patients (5%) had documented postoperative bleeding complications. All three patients were male and discontinued NOACs preoperatively.
There was a significant association between discontinuation of NOAC therapy and postoperative bleeding complications (12% of those who discontinued compared to 0% of those with continued use; p-value - 0.0843).

The question of continued NOAC therapy remains a significant debate in the world of exodontia. Our study indicates a marginally significant association between continuing NOACs and decreased bleeding outcomes post dentoalveolar extractions. However, these results should be interpreted with caution due to the little postoperative complications across both populations. This data is preliminary as we plan to expand on it with additional years of inclusion from May 2012 through January 2023 prior to this abstract presentation. Pending our results, further prospective studies may be warranted to propose credible, safe, and actionable guidelines on patient NOAC therapy.

References:
1. 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(2):278-284. Published 2020 Feb 11. doi:10.1002/rth2.1230

2. Berton, F., Costantinides, F., Rizzo, R., Franco, A., Contarin, J., Stacchi, C., Maglione, M., Visintini, E., Di Lenarda, A., & Di Lenarda, R. (2019). Should we fear direct oral anticoagulants more than vitamin K antagonists in simple single tooth extraction? A prospective comparative study. Clinical oral investigations, 23(8), 3183–3192. https://doi-org.proxy.library.vcu.edu/10.1007/s00784-018-2739-9

Table 1: Patient Demographics and Surgical Factors