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FACT SHEET: Direct Oral Anticoagulants and Oral Antithrombotic Therapy Oral antithrombotic agents1 comprise direct oral anticoagulants, vitamin K antagonist anticoagulants, and antiplatelet agents. Direct oral anticoagulants are 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”; these include dabigatran, rivaroxaban, apixaban, and edoxaban2. The main vitamin K antagonist (VKA) in Canada is warfarin.3 Antiplatelet (AP) agents include aspirin, ticagrelor, ticlopidine, prasugrel, and clopidogrel.

Date of Publication: August 4, 2017.
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Note: This fact sheet focuses on direct oral anticoagulants unless otherwise indicated. More information on warfarin (in particular, international normalized ration [INR] monitoring implications for dental/dental hygiene procedures) can be found in the Atrial Fibrillation and Stroke fact sheets. More information on antiplatelet agents can be found in the Stroke and Post-Myocardial Infarction fact sheets.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No, assuming patient/client is medically stable.

Is medical consult advised?

  • No, if the dental hygienist can ascertain:
    • why the patient/client is taking a DOAC; and
    • other relevant medical history and concurrent drug therapy; and
    • the patient/client’s medical status is stable and suitable for procedures (both from the underlying medical indication for DOAC use and from the DOAC itself).
  • Yes, if the dental hygienist cannot ascertain:
    • why the patient/client is taking a DOAC; or
    • other relevant medical history and concurrent drug therapy.
  • Yes, if the patient/client’s medical status is, or is suspected to be, unstable and/or unsuitable for procedures (either from the underlying medical indication for DOAC use or from the DOAC itself).

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes (in accordance with the “any blood disorders” contraindication specified in Ontario Regulation 501/07 pursuant to the Dental Hygiene Act). DOACs (and warfarin and antiplatelet agents) elevate risk of bleeding.

Is medical consult advised?

  • See above.
  • Yes, if there are concerns with the patient/client’s kidney function, which is relevant to the excretion of DOACs4.

Is medical clearance required?

  • Yes (as per Ontario Regulation 501/07). Clearance can be given from a physician or dentist, or both. See caveat immediately below.
  • 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? 

  • No.

Is postponing treatment advised?

  • No, in most situations (assuming clearance has been obtained from a physician or dentist, or both):
    • In patients/clients with normal kidney and liver function taking DOACs, invasive dental hygiene and dental procedures with low bleeding risk5 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)6. 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.
    • Routine dental cleanings can usually be safely performed without interrupting anticoagulation therapy.

Oral management implications

  • In most cases, medical treatment regimens with older anticoagulants (e.g., warfarin), newer DOACs (e.g., dabigatran, rivaroxaban, apixaban and edoxaban), and antiplatelet agents7 (e.g., ticagrelor, ticlopidine, prasugrel, clopidogrel and/or aspirin) should not be altered before routine dental/dental hygiene procedures with a low bleeding risk. The risks of ceasing or reducing these medication regimens (e.g., myocardial infarction, stroke, and thromboembolism) considerably outweigh the consequences of prolonged bleeding, which can be controlled with local hemostatic measures.
  • 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)8 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 interactions9, have fewer interactions with medications10, and do not require routine coagulation monitoring for dose adjustments11. They are typically taken once or twice daily at a fixed dose and have a relatively rapid onset. 
  • Reversal agents are licensed for most DOACs in Canada12, although timely availability may be an issue.
  • 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.
  • In addition to application of local pressure, tranexamic acid13 mouth rinse can be considered to promote clotting in patients/clients taking DOACs (or warfarin or antiplatelet agents), before and after bleeding-prone procedures.
  • Due to increased risk of bleeding, non-steroidal anti-inflammatory drugs (NSAIDs, including ibuprofen and naproxen) and aspirin (ASA) should generally not be used as analgesics in patients/clients taking anticoagulants. Acetaminophen is generally preferred for patients/clients on anticoagulants or antiplatelet agents.

Oral manifestations

  • Anticoagulants (DOACs or warfarin) and antiplatelet agents can cause 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 of DOACs. These are also adverse effects of warfarin14 and antiplatelet agents.
  • 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 taking DOACs.
  • 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


Date: June 11, 2017
Revised: January 17, 2022; June 12, 2024; January 15, 2025 (Initiation sections only); March 1, 2026


FOOTNOTES

1 This fact sheet does not address outpatient injectable (subcutaneous) anticoagulant therapy, including low molecular weight heparin (LMWH, such as enoxaparin and dalteparin), fondaparinux (a selective factor Xa inhibitor alternative to LMWH), or unfractionated heparin (UFH). It also does not address intravenous thrombolytic therapy for management of acute ischemic stroke or myocardial infarction, which is of little direct relevance to dental hygienists.
2 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.
3 Other, less commonly encountered (in North America) oral vitamin K antagonists are phenprocoumon, acenocoumarol, and fluindone. These VKAs are variously used in Europe, Africa, and India.
4 Dabigatran is primarily excreted by the kidneys, whereas rivaroxaban, apixaban, and edoxaban are less renally dependent for elimination.
5 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).
6 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.
7 Antiplatelet agents are used for some of the same indications as anticoagulants. They may be preferentially used over anticoagulants to prevent blood clots in the arterial system, which are typically platelet-rich. Amongst their various uses, they are used to prevent ischemic strokes, transient ischemic attacks (TIAs), and myocardial infarctions. They are also used for prevention of stent thrombosis following coronary stenting.
8 Warfarin is generally preferred for AF patients/clients with mechanical prosthetic (as distinct from bioprosthetic, or tissue) heart valves, or moderate to severe mitral stenosis. DOACs are contraindicated during pregnancy, and patients/clients with severe chronic kidney disease or liver disease may also need specialty consultation.
9 Grapefruit juice may increase the levels of rivaroxaban and apixaban.
10 Dabigatran may interact with P-glycoprotein 1 inhibitors (e.g., antifungals such as ketoconazole and possibly itraconazole, and antibiotics such as clarithromycin and erythromycin) — thereby increasing anticoagulation — or inducers (e.g., anti-tuberculosis antibiotic rifampicin, anticonvulsant carbamazepine, and corticosteroid dexamethasone) — thereby decreasing anticoagulation. Rivaroxaban may interact with cytochrome P450 (CYP) 3A4 inhibitors (e.g., antifungals such as 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.
11 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.
12 Specific DOAC reversal agents licensed in Canada are idarucizumab (for dabigatran) and andexanet (for rivaroxaban and apixaban). If specific DOAC antidotes are unavailable, then non-specific coagulation factor concentrates (such as 4-factor prothrombin complex concentrate [4F-PCC] or activated PCC [aPCC]) may be considerations to reduce bleeding. Vitamin K is the commonly used specific antidote for warfarin.
13 Tranexamic acid is a pro-hemostatic, antifibrinolytic agent. Another drug that may be used as an oral topical antifibrinolytic agent is e-aminocaproic acid (EACA).
14 Warfarin can also rarely cause skin necrosis (due to an acquired protein C deficiency following warfarin treatment) and purple toe syndrome (typically occurring 3 to 8 weeks following initiation of warfarin therapy, and for which the underlying cause is cholesterol microembolization).


* 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.