FACT SHEET: Direct Oral Anticoagulants (also known as “DOACs”, “direct-acting oral anticoagulants”, “novel oral anticoagulants” [“NOACs”], “new oral anticoagulants” [“NOAs”], “NOACs/DOACs”, “non-vitamin K antagonist oral anticoagulants”, and “target-specific oral anticoagulants”; include dabigatran, rivaroxaban, apixaban, and edoxaban1)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- No, assuming patient/client is medically stable.
Is medical consult advised?
- Yes, before dental hygiene care is initiated in order to clarify (with the family physician or cardiologist) why the patient/client is taking a DOAC, and to confirm medical history and concurrent drug therapy.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
Is medical consult advised?
- Yes, see above.
- Yes, if there are concerns with the patient/client’s kidney function, which is relevant to the excretion of DOACs2.
Is medical clearance required?
- Yes. Also, given the risk of serious thromboembolic complication (including stroke and even death) with DOAC discontinuation, it should be a physician, and not a dentist, who recommends interruption of a DOAC for a dental hygiene/dental procedure (which usually is not indicated for dental hygiene procedures). The risk of bleeding must be balanced with the risk of a thrombotic event if the anticoagulant is stopped.
Is antibiotic prophylaxis required?
Is postponing treatment advised?
- No, in most situations.
- In patients/clients with normal kidney and liver function taking DOACs (specifically, dabigatran, rivaroxaban, or apixaban), invasive dental hygiene and dental procedures with low bleeding risk3 can be carried out without interruption of the anticoagulant; ideally, the procedures should be performed as late as possible after the most recent dose (i.e., > 12 hours)4. These include procedures that involve manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa, including uncomplicated tooth extractions.
- For subgingival scaling, a small area should first be scaled to assess the bleeding tendency before instrumentation of larger areas is carried out.
Oral management implications
- Direct oral anticoagulants are increasingly being preferentially used instead of warfarin for prevention of ischemic (i.e., clot-induced) stroke in patients/clients with nonvalvular atrial fibrillation (NVAF)5 or venous thromboembolism (VTE). Other uses include prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE); postoperative thromboprophylaxis after hip or knee replacement surgery; reduction of risk of death, reinfarction, and thromboembolic events post-myocardial infarction; and management of peripheral artery disease (PAD).
- Compared with warfarin, DOACs have a broader therapeutic window, reduced bleeding risk, and shorter drug half-life. They have fewer potential food interactions6, have fewer interactions with medications7, and do not require routine coagulation monitoring for dose adjustments8. They are typically taken once or twice daily at a fixed dose and have a relatively rapid onset.
- Unlike warfarin, some DOACs lack a specific reversal agent in Canada9.
- Timing of the last dose of a DOAC prior to invasive dental hygiene procedures should be informed by physician consult. Ideally, this will be > 12 hours before the procedures.
- The patient/client taking a DOAC (or other anticoagulant or antiplatelet agent) should be informed that minor bleeding or oozing from gingival mucosa might be more common when not (appropriately) interrupting the drug regimen during dental hygiene/dental procedures.
- Tranexamic acid mouth rinse, in addition to application of local pressure, is useful to encourage clotting in patients/clients taking DOACs.
- Non-steroidal anti-inflammatory drugs (NSAIDs, including ibuprofen and naproxen) and aspirin (ASA) should not be used as analgesics in patients/clients taking DOACs. Acetaminophen is generally preferred.
- Anticoagulants (DOACs or warfarin) may result in increased and/or prolonged bleeding tendency in the oral cavity.
Related signs and symptoms
- Spontaneous bleeding, prolonged bleeding, and bruising are the main adverse effects.
- Intracranial bleeds (i.e., hemorrhagic stroke) and gastrointestinal bleeds are two of the more serious forms of spontaneous bleeding.
- Bleeding risk is increased in patients/clients > 75 years of age.
- Compared with warfarin, DOACs carry a 50% lower risk of intracranial hemorrhage.
- Dyspepsia (“upset stomach”) is a side effect of dabigatran.
References and sources of more detailed information
- The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2020;36(12):1847-1948.
- 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018;34(11):1371-1392.
- 2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2016;32(10):1170-1185.
- Felix J, Chaban P, Ouanounou A. Dental Management of Patients Undergoing Antithrombotic Therapy. J Can Dent Assoc 2020;86:k17
- Dr. Jose Lança in interview conducted by Dr. John O’Keefe. What is the Relevance of the Novel Anti-Coagulants (NOACs) to the Dental Practice? CDA Oasis Discussions.ca. Sept. 9, 2016.
- Tsolka P. Dental Procedures in Patients with Atrial Fibrillation and New Oral Anticoagulants. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):85-89.
- Siegal DM, Anand SS. Considerations for use of direct oral anticoagulants in arterial disease. Res Pract Thromb Haemost. 2021;5(4):10.1002/rth2.12502. Published 2021 May 28. doi:10.1002/rth2.12502
- Kaplovitch E, Dounaevskaia V. Treatment in the dental practice of the patient receiving anticoagulation therapy. J Am Dent Assoc. 2019 Jul;150(7):602-608. doi: 10.1016/j.adaj.2019.02.011. Epub 2019 May 17. PMID: 31109636.
- Wahl MJ. The mythology of anticoagulation therapy interruption for dental surgery. J Am Dent Assoc. 2018 Jan;149(1):e1-e10. doi: 10.1016/j.adaj.2017.09.054. PMID: 29304913.
- Curto A, Curto D, Sanchez J. Managing patients taking edoxaban in dentistry. J Clin Exp Dent. 2017;9(2):e308-e311. Published 2017 Feb 1. doi:10.4317/jced.53431
- 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-e1354. Published 2017 Nov 1. doi:10.4317/jced.54004
- Brady J and Morrison A. Managing the Minor Oral Surgery Patient on Novel Oral Anticoagulants. Oral Health. 2016 June 3.
- Constantinides F and Rizzo R. Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications. BMC Oral Health. 2016;16(5).
- Thrombosis Canada
- American Dental Association
- RDH Magazine (Anticoagulants and Antiplatelet Drugs in Dentistry: Stop the Interruption)
- American Heart Association
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
1 Dabigatran is a direct thrombin inhibitor, whereas rivaroxaban, apixaban, and edoxaban are factor Xa inhibitors. At the time of writing, limited data exists regarding dental management of patients/clients treated with edoxaban. Betrixaban (not licensed in Canada), another factor Xa inhibitor, was taken off the U.S. market in 2020.
2 Dabigatran is primarily excreted by the kidneys, whereas rivaroxaban, apixaban, and edoxaban are less renally dependent for elimination.
3 Supragingival scaling has a low presumed bleeding risk, whereas subgingival scaling and root surface instrumentation (such as root planing) are variably categorized as having either low or moderate bleeding risk (depending on the medical or dental reference). The 2016 AF Guidelines of the Canadian Cardiovascular Society classify subgingival scaling or other cleaning in the low risk category (along with dental extractions of 1 or 2 teeth, and endodontic [root canal] procedures).
4 Multiple extractions and minor oral/maxillofacial surgery, which are procedures with a higher risk of bleeding, can also be performed safely without interruption of DOACs, provided they are carried out 12 hours after the last dose of dabigatran and 10 hours after the last dose of apixaban or rivaroxaban. Patients/clients requiring complex oral/maxillofacial surgery may require discontinuation of DOACs for at least 24 hours preoperatively.
5 Warfarin is generally preferred for AF patients/clients with mechanical prosthetic heart valves, severe rheumatic mitral stenosis, or severe chronic kidney disease
6 Grapefruit juice may increase the levels of rivaroxaban and apixaban.
7 Dabigatran may interact with P-glycoprotein 1 inhibitors (e.g., ketoconazole and possibly itraconazole, clarithromycin, and erythromycin) — thereby increasing anticoagulation — or inducers (e.g., rifampicin, carbamazepine, and dexamethasone) — thereby decreasing anticoagulation. Rivaroxaban may interact with cytochrome P450 (CYP) 3A4 inhibitors (e.g., ketoconazole, itraconazole, voriconazole, and posaconazole) or inducers (clarithromycin and rifampin), as well as inhibitors and inducers of P-glycoprotein. With apixaban, similar to rivaroxaban, administration of potent CYP3A4 and P-glycoprotein inhibitors should be avoided.
8 Specifically, international normalized ratio [INR] titration is neither needed nor relevant for DOACs. (By contrast, when a patient/client is taking a vitamin K antagonist [VKA] such as warfarin, it is prudent to check the INR at least 24 to 72 hours before the invasive procedure.) Similarly, routine activated partial thromboplastin time [aPTT] coagulation test monitoring is not needed for DOACs.
9 Idarucizumab is a selective reversal agent for dabigatran, and it has been licensed for use in Canada. Andexanet is a reversal agent for rivaroxaban and apixaban, but it is not yet licensed for use in Canada. Vitamin K is the commonly used specific antidote for warfarin.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.