Proposal for a tooth extraction protocol for patients taking direct oral anticoagulants: a clinical trial

To evaluate the feasibility of a protocol in which direct oral anticoagulants (DOACs) are not discontinued prior to tooth extractions, compared with warfarin.

A prospective blind study was conducted on anticoagulated patients with atrial fibrillation undergoing tooth extraction. Patients were divided into three groups according to the anticoagulant pharmacokinetics: 20 patients on rivaroxaban once daily; 18 on dabigatran or apixaban twice daily, and 20 on warfarin (control group). Extractions were scheduled during the lowest DOACs plasma concentration: 14 hours after the last rivaroxaban dose; 8 hours after the last dabigatran/apixaban dose; and with INR values between 2.0 and 3.0 in the warfarin group. Patients returned 24 hours after tooth extraction for evaluation of bleeding.

Fifty-eight patients were included in the study, in a total of 84 tooth extractions. No minor or major bleeding occurred in the rivaroxaban group. Two patients in the dabigatran/apixaban group (11.1%) and two in the control group (10%) presented minor bleeding. There was no statistically significant difference in bleeding rates among the groups (P = .324), and no major bleeding events were reported.

These preliminary results suggest that the protocol proposing non-discontinuing DOACs in extractions may be feasible in clinical practice.