Management of Patients Receiving Anticoagulant and Antiplatelet Therapy in Oral Surgery: Current Clinical Approaches

Abstract

Management of oral surgical procedures in patients receiving anticoagulant and antiplatelet therapy requires careful balancing between procedure-related bleeding risk and thromboembolic complications that may arise from interruption of antithrombotic treatment. Current practice is based more on individualized risk assessment than on routine discontinuation of therapy. Current evidence suggests that many simple and limited dental procedures can be performed safely without discontinuing antithrombotic therapy and that most bleeding events can be controlled with appropriate local hemostatic measures. Although there are some differences among vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs), and antiplatelet agents in terms of clinical management, the common principle is that routine interruption of therapy is usually unnecessary. Safe oral surgical management depends on individualized risk assessment, appropriate drug-specific decision-making, effective local hemostatic strategies, and planned postoperative follow-up. This review aims to evaluate preoperative risk assessment, drug-specific clinical management principles, local hemostatic approaches, and postoperative follow-up strategies in patients receiving anticoagulant and antiplatelet therapy in light of current literature.

Keywords

• Anticoagulants
• Platelet Aggregation Inhibitors
• Oral Surgical Procedures
• Hemostasis, Surgical
• Postoperative Hemorrhage

Oral Cerrahide Antikoagülan ve Antiagregan Tedavi Alan Hastaların Yönetimi: Güncel Klinik Yaklaşımlar

Abstract

Antikoagülan ve antiagregan ilaç kullanan hastalarda oral cerrahi girişimlerin yönetimi, cerrahiye bağlı kanama riski ile antitrombotik tedavinin kesilmesine bağlı gelişebilecek tromboembolik komplikasyonlar arasında dikkatli bir denge kurulmasını gerektirmektedir. Güncel yaklaşım, antitrombotik tedavinin rutin olarak kesilmesinden çok bireyselleştirilmiş risk değerlendirmesine dayanmaktadır. Mevcut veriler, basit ve sınırlı dental işlemlerin birçok olguda antitrombotik tedavi kesilmeden güvenli şekilde gerçekleştirilebildiğini ve gelişen kanamaların çoğu durumda lokal hemostatik önlemlerle kontrol altına alınabildiğini göstermektedir. Vitamin K antagonistleri (VKA), direkt oral antikoagülanlar (DOAC) ve antiagregan ilaçlar arasında klinik yönetim açısından bazı farklılıklar bulunmakla birlikte, ortak yaklaşım antitrombotik tedavinin rutin olarak kesilmemesi yönündedir. Güvenli oral cerrahi yönetimi; bireyselleştirilmiş risk değerlendirmesi, uygun ilaç yönetimi, etkili lokal hemostaz ve planlı postoperatif izlemin birlikte uygulanmasına dayanmaktadır. Bu derleme, antikoagülan ve antiagregan tedavi alan hastalarda oral cerrahi öncesi risk değerlendirmesini, ilaç grubuna göre klinik yönetim ilkelerini, lokal hemostaz yaklaşımlarını ve postoperatif izlem stratejilerini güncel literatür ışığında değerlendirmeyi hedeflemektedir.

Keywords

• Antikoagülanlar
• Trombosit Agregasyon İnhibitörleri
• Oral Cerrahi İşlemleri
• Kanamanın Durması, Cerrahi
• Postoperatif Kanama

References

1. 1. Dézsi CA, Dézsi BB, Dézsi AD. Management of dental patients receiving antiplatelet therapy or chronic oral anticoagulation: a review of the latest evidence. Eur J Gen Pract. 2017;23(1):197-202.
2. 2. Costa-Tort J, Schiavo-Di Flaviano V, González-Navarro B, Jané-Salas E, Estrugo-Devesa A, López-López J. Update on the management of anticoagulated and antiaggregated patients in dental practice: literature review. J Clin Exp Dent. 2021;13(9):e948-e956.
3. 3. Inchingolo F, Inchingolo AM, Piras F, Ferrante L, Mancini A, Palermo A, et al. Management of patients receiving anticoagulation therapy in dental practice: a systematic review. Healthcare (Basel). 2024;12(15):1537.
4. 4. Mingarro-de-León A, Chaveli-López B, Gavaldá-Esteve C. Dental management of patients receiving anticoagulant and/or antiplatelet treatment. J Clin Exp Dent. 2014;6(2):e155-e161.
5. 5. 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.
6. 6. M'Pembele R, Ahlbrecht S, Helten C, Mourikis P, Naguib D, Zako S, et al. High on-treatment platelet reactivity: aspirin versus clopidogrel. Pharmacology. 2023;108(1):83-89.
7. 7. Katz MS, Benidamou R, Ooms M, Heitzer M, Bock A, Elvers D, et al. Influence of antiplatelet medication and anticoagulation therapy after dental extractions on hospitalization: a retrospective 10-year study. BMC Oral Health. 2024;24(1):1485.
8. 8. Curtis J, Henderson DP, Zarghami M, Rashedi S, Bikdeli B. Management of antithrombotic therapy in patients undergoing dental procedures. J Thromb Haemost. 2025;23(1):47-72.

9. 9. Seo MH. Impact of continued antithrombotic use on bleeding risk in oral surgery: a retrospectively study in a population patients treated in a Korean university hospital. J Dent Sci. 2025;20(3):1506-1512
10. 10. Scottish Dental Clinical Effectiveness Programme. Management of dental patients taking anticoagulants or antiplatelet drugs [Internet]. 2nd ed. Dundee: Scottish Dental Clinical Effectiveness Programme; 2022 [cited 2026 Jun 16]. Available from: https://www.sdcep.org.uk/published-guidance/anticoagulants-and-antiplatelets/
11. 11. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093-1100.
12. 12. Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007 Feb 13;115(6):813-8.
13. 13. Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, et al. Perioperative management of antithrombotic therapy. Chest. 2022;162(5):e207-e243.
14. 14. Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;150(19):e351-e442.
15. 15. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-3826.
16. 16. Villa Zapata L, Hansten PD, Panic J, Horn JR, Boyce RD, Gephart S, et al. Risk of bleeding with exposure to warfarin and nonsteroidal anti-inflammatory drugs: a systematic review and meta-analysis. Thromb Haemost. 2020;120(7):1066-1074.
17. 17. Nochaiwong S, Ruengorn C, Awiphan R, Chai-Adisaksopha C, Tantraworasin A, Phosuya C, et al. Use of serotonin reuptake inhibitor antidepressants and the risk of bleeding complications in patients on anticoagulant or antiplatelet agents: a systematic review and meta-analysis. Ann Med. 2022;54(1):80-97.
18. 18. Narum S, Westergren T, Klemp M. Corticosteroids and risk of gastrointestinal bleeding: a systematic review and meta-analysis. BMJ Open. 2014;4(5):e004587.
19. 19. Lee JY, Park SH, Kim DM, Ko KA, Park JY, Lee JS, et al. Risk of post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants: a cohort study using the common data model. Sci Rep. 2024;14(1):7787.
20. 20. Dou K, Shi Y, Yang B, Zhao Z. Risk of bleeding with dentoalveolar surgery in patients taking direct oral anticoagulants or vitamin K antagonists: a systematic review and meta-analysis. Jpn Dent Sci Rev. 2025;61:188-199.
21. 21. Manor Y, Ben-Izhack G, Manor PA, Peleg O, Reiter S. Postoperative bleeding after dental implant surgery in patients on direct oral anticoagulants: a retrospective case-control study. Dent J (Basel). 2025;13(12):576.
22. 22. Krishnan NA, Kumar SV, Nair AH, Remya M, Thomas RB, Deepak KS, et al. Evaluation of bleeding time after dental extractions during uninterrupted single or dual antiplatelet treatment: a comparative study. Ann Maxillofac Surg. 2024;14(2):137-140.
23. 23. Darwish G. The effect of direct oral anticoagulant therapy (DOACs) on oral surgical procedures: a systematic review. BMC Oral Health. 2023;23(1):743.
24. 24. van Diermen DE, van der Waal I, Hoogstraten J. Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(6):709-716.
25. 25. Yang JH, Chen HM, Kuo YS, Chiang CP. Management of patients taking antithrombotic drugs before dental surgery. J Dent Sci. 2020;15(2):222-224.
26. 26. Weltman NJ, Al-Attar Y, Cheung J, Duncan DP, Katchky A, Azarpazhooh A, et al. Management of dental extractions in patients taking warfarin as anticoagulant treatment: a systematic review. J Can Dent Assoc. 2015;81:f20.
27. 27. Lu SY, Lin LH, Hsue SS. Management of dental extractions in patients on warfarin and antiplatelet therapy. J Formos Med Assoc. 2018;117(11):979-986.
28. 28. Izzetti R, Cinquini C, Nisi M, Mattiozzi M, Marotta M, Barone A. Direct oral anticoagulants and bleeding management following tooth extractions: a prospective cohort study. Dent J (Basel). 2024;12(9):279.
29. 29. Johansson K, Becktor JP, Naimi-Akbar A, Svensson PJ, Götrick B. Continuous use of direct oral anticoagulants during and after simple and surgical tooth extractions: a prospective clinical cohort study. BMC Oral Health. 2025;25(1):554.
30. 30. Hoda MM, Navaneetham R, Sham ME, Menon S, Kumar V, Archana S. Assessment of postoperative bleeding after dental extractions in patients who are on antiplatelet therapy: a prospective study. Ann Maxillofac Surg. 2021;11(1):75-79.
31. 31. Yong CW, Tan SHX, Teo GN, Tan TS, Ng WH. Should we stop dual anti-platelet therapy for dental extractions? An umbrella review for this dental dilemma. J Stomatol Oral Maxillofac Surg. 2022;123(6):e708-e716.
32. 32. Nisi M, Carli E, Gennai S, Gulia F, Izzetti R. Hemostatic agents for the management of bleeding risk associated with oral anticoagulant therapy following tooth extraction: a systematic review. Appl Sci. 2022;12(21):11017.
33. 33. Ockerman A, Miclotte I, Vanhaverbeke M, Vanassche T, Belmans A, Vanhove J, et al. Tranexamic acid and bleeding in patients treated with non-vitamin K oral anticoagulants undergoing dental extraction: the EXTRACT-NOAC randomized clinical trial. PLoS Med. 2021;18(5):e1003601.
34. 34. Iwabuchi H, Imai Y, Asanami S, Shirakawa M, Yamane GY, Ogiuchi H, et al. Evaluation of postextraction bleeding incidence to compare patients receiving and not receiving warfarin therapy: a cross-sectional, multicentre, observational study. BMJ Open. 2014;4(12):e005777.
35. 35. Mahé I, Bertrand N, Drouet L, Bal Dit Sollier C, Simoneau G, Mazoyer E, et al. Interaction between paracetamol and warfarin in patients: a double-blind, placebo-controlled, randomized study. Haematologica. 2006;91(12):1621-1627.
36. 36. Lane MA, Zeringue A, McDonald JR. Serious bleeding events due to warfarin and antibiotic co-prescription in a cohort of veterans. Am J Med. 2014;127(7):657-663.e2.