Treatment with Direct Oral Anticoagulants

10.4 Treatment with Direct Oral Anticoagulants

Section I: Clinical Scenario and Dental Considerations

Clinical Scenario

A 75‐year‐old female presents as an emergency to your dental clinic first thing in the morning, accompanied by her husband. She complains of pain from her upper left second molar tooth, which she reports is worse on clenching and chewing. This commenced 2 weeks ago when she was eating and part of the tooth fractured. The tooth is currently asymptomatic.

Medical History

  • Deep vein thrombosis (DVT) 2 years ago following hip replacement surgery
  • Osteoarthritis
  • Stage 2 chronic kidney disease (glomerular filtration rate of 60–89 mL/min)
  • Body mass index (BMI): 32 kg/m2


  • Rivaroxaban
  • Paracetamol
  • History of 2 corticosteroid injections in the involved joint 4 years ago

Dental History

  • Attends the dental practice yearly
  • Brushes her teeth twice a day but after her DVT became reliant on her husband to help her; uses a soft toothbrush only once a day as her gums bleed and she is worried that this will not stop because she is taking rivaroxaban
  • Clenches her teeth due to pain related to her osteoarthritis
  • Previous history of fractured lower molar teeth, including a lower left tooth which was stabilised 1  year ago with a large composite filling

Social History

  • South Asian origin
  • Lives with her husband
  • Attends appointments using their modified private car (husband drives)
  • Uses a walking stick
  • No tobacco or alcohol

Oral Examination

  • #27: probably fractured; likely to require a surgical extraction
  • Generalised soft deposits and plaque‐induced gingivitis

Radiological Examination

  • Long cone periapical radiograph: root canal treatment in tooth #27 (Figure 10.4.1)

Structured Learning

  1. How do you assess the bleeding risk of rivaroxaban in relation to dental procedures?
    • Rivaroxaban is the first orally active direct factor Xa inhibitor/anticoagulant (DOAC) developed
    • Unlike warfarin, routine laboratory monitoring of INR (international normalised ratio) is not necessary
    • Although the activated partial thromboplastin time (aPTT) and HepTest (a test developed to assay low molecular weight heparins) are prolonged in a dose‐dependent manner, neither test is recommended for the assessment of the pharmacodynamic effects of rivaroxaban
    • Anti‐Xa activity and inhibition of anti‐Xa activity monitoring is also not recommended despite being influenced by rivaroxaban
    • The patient’s previous bleeding history is often more helpful in determining the risk of bleeding
    • The invasiveness of the proposed procedure should also be assessed
      Photo depicts periapical radiograph showing root canal treatment in tooth number 26 and a small radiolucent periapical lesion suggestive of radicular fracture (S).

      Figure 10.4.1 Periapical radiograph showing root canal treatment in tooth #27 and a small radiolucent periapical lesion.

  2. The patient reports that she has taken her rivaroxaban earlier in the morning, before attending her dental appointment. What are the treatment options for managing the fractured tooth in this patient?
    • #27 is likely to require a surgical extraction
    • Plan for surgical dental extraction at a later date as:
      • The patient has already taken her rivaroxaban
      • The tooth is asymptomatic and does not require urgent removal
    • Smooth the rough tooth surface and/or place a temporary dressing to avoid further trauma to the tongue; particularly important as there is an increased bleeding risk; advise the patient to avoid eating on the tooth
  3. The patient is upset that you are not going to extract the tooth the same day as she finds travelling to the dental clinic tiring. Can you use reversal agents for rivaroxaban to facilitate invasive dental treatment the same day?
    • Andexanet alpha is a recombinant form of human factor Xa protein which binds specifically to apixaban or rivaroxaban, thereby reversing their anticoagulant effects
    • It is used in life‐threatening or uncontrolled bleeding (specialist supervision in hospital)
    • It is not used in relation to dental treatment
  4. How would you plan the exploratory surgery of the #27?
    • Exploratory surgery and eventual surgical extraction of the #27 should be considered as a high‐risk invasive dental procedure (Figure 10.4.2)
    • Consult with the physician regarding the proposed dental extraction, as the patient is elderly and has chronic kidney disease – both factors may have a negative impact on the clearance of the DOAC and hence increase its duration of action
    • Highlight that the procedure is at high risk of bleeding given that a surgical approach is likely
    • The patient’s previous bleeding history may also assist in determining the risk of bleeding
    • Confirm the plan regarding the timing of the extraction in relation to the DOAC medication
    • In most cases advice would be to withhold the morning dose of the rivaroxaban until haemostasis is achieved after the dental extraction
  5. What other factors do you need to consider in your risk assessment?
    • Social
      • Reduced mobility
      • Escort required – husband, who will also need to drive the patient to her appointments
    • Medical
      • Bleeding risk due to DOAC
      • Comorbidity related to chronic renal failure (including prescribing considerations), osteoarthritis, obesity and related complications (moving and handling, bariatric complications) (see Chapters 16.2 and 16.4)
        Photo depicts exploratory surgery showing radicular fracture.

        Figure 10.4.2 Exploratory surgery showing radicular fracture. Consequently, dental extraction was performed in the same treatment session.

    • Dental
      • Dental trauma due to clenching, with a history of fractured teeth
      • Reliance on husband to clean her teeth
      • Reduced brushing frequency
      • Use of a soft brush
  6. What advice would you give in relation to the patient’s bleeding gums?
    • Reassure the patient that it is important to continue to clean her teeth as usual even though she is taking an oral anticoagulant
    • Explain that poor oral hygiene can lead to gingivitis and periodontal disease, where the gums become swollen and bleed more easily – this will have a significantly greater impact than the anticoagulant
    • A soft brush may not be effective and she needs to brush at least twice daily
  7. How would you manage the tendency that this patient has to fracture her teeth?
    • Provide advice regarding clenching/bruxism and its relation to chronic pain/illness
    • Explain that it is likely to be the cause of the history of multiple tooth fractures
    • Consider provision of a mouthguard to protect remaining dentition; ensure the gingival health has improved first to avoid a deterioration in relation to higher plaque accumulation inside the guard; the design should avoid excessive contact with the soft tissues (minimise trauma due to anticoagulant medication)
    • Review the remaining dentition and consider the need for full‐coverage crowns on heavily restored teeth
    • Consider other underlying diseases (e.g. gastro‐oesophageal reflux)

General Dental Considerations

Oral Findings

  • Petechiae
  • Ecchymoses
  • Spontaneous gingival bleeding
  • Prolonged bleeding after invasive procedures (Figure 10.4.3)

General Dental Management

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Nov 6, 2022 | Posted by in Implantology | Comments Off on Treatment with Direct Oral Anticoagulants

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