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Curtis J, Henderson DP, Zarghami M, Rashedi S, Bikdeli B. Management of antithrombotic therapy in patients undergoing dental procedures. J Thromb Haemost 2024:S1538-7836(24)00570-1. [PMID: 39395540 DOI: 10.1016/j.jtha.2024.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/10/2024] [Accepted: 09/12/2024] [Indexed: 10/14/2024]
Abstract
A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.
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Affiliation(s)
- James Curtis
- Department of Dentistry, Prisma Health Medical Group-Midlands, Columbia, South Carolina, USA
| | - Daniel P Henderson
- Department of Pharmacy, Anticoagulation Management Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pharmacy, Atrial Fibrillation Medication Management Clinic, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mehrdad Zarghami
- Jamaica Hospital Medical Center, Queens, NY 11418, USA; Department of Medicine, Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sina Rashedi
- Department of Medicine, Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Behnood Bikdeli
- Department of Medicine, Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Yale-New Haven Hospital/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA.
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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; 12:279. [PMID: 39329845 PMCID: PMC11430983 DOI: 10.3390/dj12090279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/26/2024] [Accepted: 08/27/2024] [Indexed: 09/28/2024] Open
Abstract
The aim of the present study was to assess the occurrence of intra-, peri-, and post-operative bleeding following tooth extractions in patients treated with direct oral anticoagulants (DOACs). Consecutive patients requiring at least one dental extraction were enrolled. The DOAC regimen was either maintained or suspended. Patients were classified in subgroups depending on the number of teeth extracted per procedure (≤3 or >3), the need for flap elevation, and the performance of osteotomy. Bleeding was recorded intra-operatively; peri-operatively at 20, 40, 60, and 80 min after the procedure; and daily in the first seven days following tooth extractions. Forty-nine patients treated with DOACs (17 with rivaroxaban, 16 with apixaban, 8 with edoxaban, and 8 with dabigatran) were enrolled. Of them, 33 refrained from DOAC administration pre-operatively. The performances of >3 teeth extractions, flap elevation, and osteotomy were significantly associated with higher bleeding rates (p < 0.05). In patients treated with rivaroxaban and apixaban, bleeding episodes were more frequent. Although DOAC treatment may increase the rates of intra-operative, peri-operative, and post-operative bleeding, the recorded episodes were mild and manageable. DOAC suspension may reduce peri-operative bleeding, while no effect could be observed for post-operative bleeding.
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Bajkin BV, Tadic AJ, Komsic JJ, Vuckovic BA. Risk of dentoalveolar surgery postoperative bleeding in patients taking direct oral anticoagulants and vitamin K antagonists: A prospective observational study. J Craniomaxillofac Surg 2024; 52:772-777. [PMID: 38580558 DOI: 10.1016/j.jcms.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/21/2024] [Accepted: 03/30/2024] [Indexed: 04/07/2024] Open
Abstract
The aim of this study was to evaluate whether direct oral anticoagulants (DOAC) and vitamin K antagonists (VKA) increase the risk of postoperative bleeding after dentoalveolar surgery. Patients were classified into two groups: one taking DOAC and the other taking VKA with a therapeutic INR range. The control group comprised non-anticoagulated subjects. Participants were matched regarding dentoalveolar procedure. The primary predictor was anticoagulant status. The primary outcome was postoperative bleeding. The DOAC group comprised 77 patients, while the VKA group and control group each consisted of 103 participants. In each group, 103 dentoalveolar surgical procedures were conducted. Postoperative bleeding was recorded in 3/103 (2.9%), 5/103 (4.8%), and 1/103 (0.97%) occasions in the DOAC, VKA, and control groups, respectively, without significant difference (χ2; p = 0.54). The fully adjusted odds ratio for postoperative bleeding was 0.14 (CI 0.01-1.61; p = 0.05) for patients taking DOAC and 0.19 (CI 0.02-1.65; p = 0.285) for those taking VKA compared with non-anticoagulated controls. In conclusion, there was no increase in risk for clinically significant postoperative bleeding after dentoalveolar surgery in patients taking DOAC or VKA compared with non-anticoagulated subjects. Dentoalveolar surgery in patients taking DOAC and VKA can be performed safely without therapy cessation. The study was registered at Clinicaltrials.gov (NCT04505475).
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Affiliation(s)
- Branislav V Bajkin
- Dental Clinic of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia.
| | - Ana J Tadic
- Dental Clinic of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
| | - Jelena J Komsic
- Dental Clinic of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
| | - Biljana A Vuckovic
- Clinic of Hematology, Clinical Centre of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia
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Valenzuela-Mencia J, Serrera-Figallo MÁ, Torres-Lagares D, Machuca-Portillo G, Sánchez-Fernández E, Valmaseda-Castellón E, Peñarrocha-Diago M, Fernández-Mosteirín N, Somoza-Martin JM, Pérez-Jardón A, Chamorro-Petronacci CM, García-García A. Clinical practice guideline of the spanish society of oral surgery for oral surgery in patients with coagulation disorders. Med Oral Patol Oral Cir Bucal 2024; 29:e58-e66. [PMID: 37330959 PMCID: PMC10765342 DOI: 10.4317/medoral.26063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND The number of patients treated with coagulation disorders, and more specifically with anticoagulant therapy, has increased worldwide in recent years due to increased life expectancy in developed countries. The protocols for managing this type of patient in oral surgery has varied over recent years, especially after the appearance of new direct-acting oral anticoagulants (DOACs). The assessment of risk of bleeding in this type of patient when undergoing a surgical procedure continues to be a controversial issue for patients, dentists and general practitioners. The objective of this document is to offer recommendations, based on evidence, for decision making for patients with coagulopathies who require dental surgical intervention. MATERIAL AND METHODS Based on the indications of the "Preparation of Clinical Practice guidelines in the National Health System. Methodological manual", we gathered a group of experts who agreed on 15 PICO questions based on managing patients with coagulation disorders in dental surgical procedures, such as fitting of implants or dental extractions. RESULTS The 15 PICO questions were answered based on the available evidence, being limited in most cases due to the lack of a control group. Two of the PICO questions were answered by the experts with a grade C recommendation, while the rest were answered with grade D. CONCLUSIONS The results of this review highlight the need to undertake well designed clinical trials with control groups and with a representative sample size.
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Chan MH, Sun F, Malakan J. Controversies in Stoppage of Antiplatelet and Anticoagulant Medications Prior to Oral Surgery. Dent Clin North Am 2024; 68:21-45. [PMID: 37951634 DOI: 10.1016/j.cden.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Dental procedures can pose a risk of bleeding, and it is not uncommon for dentists to consult prescribing physicians regarding a mutual patient's antiplatelet and anticoagulant medication to prevent excessive bleeding during or after an upcoming procedure. However, there has been a growing controversy in the dental community surrounding the stoppage of these medications prior to dental procedures. Some believe that stopping these medications prior to dental procedures is necessary to reduce the risk of bleeding complications, while others argue that stopping them can increase the risk of stroke or other thromboembolic events. The debate has left many dentists and specialists unsure about the best course of action when it comes to managing bleeding risk during dental procedures.In this article, we will review the antithrombotic medications, indications, mechanism of action, and its effects on the coagulation pathway, laboratory testing and reversal agents. Also, we will explore the controversy surrounding the stoppage of novel anitplatelets (eg,: prasurgrel and ticagrelor), dual-antiplatelets, triple-antiplatelet, vitamin K antagonists (eg,: wafarin, coumadin), and direct oral anticoagulants (eg,: dabigatran, rivaroxaban, xarelto and endoxaban) in dentistry and examine the current evidence and guidelines for managing dental patients undergoing oral surgery.
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Affiliation(s)
- Michael H Chan
- Oral & Maxillofacial Surgery, Department of Veterans Affairs, New York Harbor Healthcare System (Brooklyn Campus), 800 Poly Place (Bk-160), Brooklyn, NY 11209, USA; Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue (Box-187), Brooklyn, NY 11201, USA.
| | - Feiyi Sun
- Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
| | - Jonathan Malakan
- Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
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Ueda K, Inokoshi M, Kubota K, Yamaga E, Minakuchi S. Factors influencing postoperative bleeding after dental extraction in older adult patients receiving anticoagulation therapy. Clin Oral Investig 2023; 28:22. [PMID: 38147161 DOI: 10.1007/s00784-023-05424-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVES To investigate factors influencing postoperative bleeding occurrence after dental extraction in older patients receiving anticoagulation therapy. MATERIALS AND METHODS This retrospective study included patients aged ≥ 65 years receiving one of the following anticoagulants: apixaban, edoxaban, rivaroxaban, and warfarin. Patients who underwent one to multiple tooth extractions in the geriatric dentistry clinic at Tokyo Medical and Dental University Hospital between August 1, 2016, and November 30, 2020, were included. The outcome variable was postoperative bleeding occurrence. Logistic regression analysis was performed with the following ten factors as explanatory variables: age, sex, maximum systolic blood pressure during the extraction, type of local anesthesia, vertical incision, osteotomy, usage of surgical splints, the mesiodistal width of the extracted tooth on a radiograph, use of antiplatelet agents, and history of diabetes requiring medication. RESULTS Among 395 participants (mean age, 82.3 ± 6.5 years) included in this study, 75 patients experienced postoperative bleeding after tooth extraction. Logistic regression analysis revealed that the odds ratios for the vertical incision (18.400, p < 0.001), osteotomy (3.630, p = 0.00558), usage of surgical splints (1.860, p = 0.0395), and the mesiodistal width of the extracted tooth on a radiograph (1.060, p = 0.0261) were statistically significant. CONCLUSIONS For dental extraction in older patients receiving anticoagulants, postoperative bleeding is more likely to occur in patients with vertical incision, osteotomy, and posterior or multiple tooth extractions. CLINICAL RELEVANCE Dentists should consider suturing and adjunctive hemostatic procedures for patients undergoing vertical incision, osteotomy, and multiple tooth extractions while receiving anticoagulation therapy to minimize the risk of postoperative bleeding.
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Affiliation(s)
- Kaori Ueda
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Masanao Inokoshi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan.
| | - Kazumasa Kubota
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
- Kubota Dental Clinic, 1-16-2 Iguchi, Mitaka, Tokyo, 181-0011, Japan
| | - Eijiro Yamaga
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Shunsuke Minakuchi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
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Chen C, Saxena M, von Heymann C, Vanassche T, Jin J, Lersch R, Köhler S, Santamaria A, Unverdorben M, Colonna P. Edoxaban use in the context of dental procedures: analysis from the EMIT-AF/VTE database. BDJ Open 2023; 9:38. [PMID: 37580338 PMCID: PMC10425372 DOI: 10.1038/s41405-023-00164-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023] Open
Abstract
INTRODUCTION Literature reviews support continuing anticoagulation during dental procedures. However, studies often present grouped anticoagulation data, and information on individual anticoagulant management would be helpful to dentists. The Edoxaban Management in Diagnostic and Therapeutic Procedures (EMIT-AF/VTE) programme (NCT02950168; NCT02951039) demonstrated low periprocedural bleeding and thrombotic event rates in patients with atrial fibrillation receiving edoxaban. AIMS To report periprocedural edoxaban interruption and clinical events in patients from EMIT-AF/VTE who underwent dental procedures. METHODS Dental procedures were categorised by type (cleaning/noncleaning). Edoxaban interruption, bleeding events, and thrombotic events were observed 5 days preprocedure through 29 days postprocedure. RESULTS Overall, 196 patients underwent 350 cleaning and/or noncleaning procedures; most patients (171/196 [87.2%]) underwent noncleaning procedures (282/350 [80.6%]), whereas 48/196 (24.5%) underwent 68/350 (19.4%) cleaning procedures. Edoxaban was uninterrupted for most cleanings (53/68 [77.9%]). Preprocedural interruption was common for single and multiple tooth extractions (single, 67/100 [67.0%]; multiple, 16/30 [53.3%]). The only major bleeding occurred after an unrelated cleaning. Minor bleeding occurred in 1/68 (1.5%) cleaning and 4/282 (1.4%) noncleaning procedures. There were no thrombotic events. CONCLUSIONS For most cleanings, edoxaban was not interrupted, whereas preprocedural interruption was more common for tooth extractions. Overall, bleeding rates were low, and no thrombotic events occurred.
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Affiliation(s)
- Cathy Chen
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
| | - Manish Saxena
- Barts NIHR Cardiovascular Biomedical Research Centre, London, UK.
| | - Christian von Heymann
- Department of Anaesthesia & Intensive Care Medicine, Emergency Medicine, and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University Hospitals (UZ) Leuven, Leuven, Belgium
| | - James Jin
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
| | | | | | - Amparo Santamaria
- Hematology Department, University Hospital Vinalopó y Torrevieja, Alicante, Spain
| | | | - Paolo Colonna
- Department of Cardiology, Polyclinic of Bari - Hospital, Bari, Italy
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Johansson K, Götrick B, Holst J, Tranæus S, Naimi-Akbar A. Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 135:333-346. [PMID: 36100547 DOI: 10.1016/j.oooo.2022.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The recommendations for the management of direct oral anticoagulants (DOACs) in oral surgery are inconsistent. The present review evaluated whether DOACs increase the risk of bleeding during oral surgery and postoperative complications. STUDY DESIGN The patients undergoing oral surgery and receiving a DOAC were compared with the patients receiving a DOAC different from the exposure, a vitamin K antagonist (VKA), or no anticoagulant. Three electronic databases were searched for eligible clinical trials and systematic reviews. The risk of bias was assessed, data were extracted, a meta-analysis was done, and the Grading of Recommendations, Assessment, Development and Evaluations certainty-of-evidence ratings were determined. RESULTS Three clinical trials comparing patients receiving DOAC medication with patients on a VKA were eligible. A meta-analysis of bleeding 7 days postoperatively detected no significant differences between patients continuing DOAC or VKA medication during and after surgery. All of the point estimates favored uninterrupted DOAC over VKA therapy. Tranexamic acid was topically administered to some patients. CONCLUSIONS Based on an interpreted trend among 3 studies with mixed patient populations, the risk of bleeding during the first 7 postoperative days may be lower for patients on uninterrupted DOAC than VKA therapy (⨁⨁⭘⭘), but the effect size of the risk is unclear. 80 of 274 included patients experienced postoperative bleeding.
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Affiliation(s)
- Krister Johansson
- Department of Oral and Maxillofacial Surgery and Oral Medicine, Faculty of Odontology, Malmö University, Malmö, Sweden.
| | - Bengt Götrick
- Department of Oral Diagnostics, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Jan Holst
- Department of Vascular Diseases and HTA Syd, Skåne University Hospital, Malmö/Lund, Sweden
| | - Sofia Tranæus
- Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Aron Naimi-Akbar
- Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö, Sweden
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Zou L, Hua L. Risk of bleeding with dental implant surgery in patients on anticoagulant or antiplatelet drugs: a systematic review and meta-analysis. Acta Odontol Scand 2023; 81:98-104. [PMID: 35763663 DOI: 10.1080/00016357.2022.2085324] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION A large number of patients under oral anticoagulant (OAC) or antiplatelet (AP) therapy require dental implantation. We systematically reviewed evidence on the risk of bleeding after implant placement with continued OAC or AP therapy. METHODS PubMed, Embase and CENTRAL were searched for studies comparing bleeding outcomes after implant placement between OAC/AP therapy vs. controls or OAC vs. AP therapy. RESULTS Seven studies were included. Pooled analysis showed no significant difference in the risk of bleeding with continued OAC therapy vs. control (RR 1.81 95% confidence interval [CI] 0.70, 4.63 I2 = 14% p = .22). Subgroup analysis depending on the type of OAC showed there was a non-significant tendency of increased risk of bleeding with Vitamin K antagonists (VKAs) (RR 3.42 95% CI 1.00, 11.67 I2 = 23% p = .05) but not with direct oral anticoagulants (DOACs) (RR 1.67 95% CI 0.49, 5.70 I2 = 0% p = .41). Limited data suggest an increased risk of bleeding with OAC as compared to AP (RR 0.08 95% CI 0.01, 0.76 I2 = 0% p = .03). CONCLUSIONS Continuation of OAC therapy in patients undergoing implant surgery does not increase the risk of bleeding provided local haemostatic measures are used. The indirect comparison suggests bleeding tendency may be higher with VKAs as compared to DOAC.
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Affiliation(s)
- Lilin Zou
- Department of Stomatology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, PR China
| | - Li Hua
- Department of Stomatology, The First Affiliated Hospital of Soochow University, Suzhou, PR China
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Ono S, Ishimaru M, Yokota I, Konishi T, Okada A, Ono Y, Matsui H, Itai S, Yonenaga K, Tonosaki K, Watanabe R, Hoshi K, Yasunaga H. Risk of post-extraction bleeding with direct oral anticoagulant compared with warfarin: Retrospective cohort study using large scale claims data in Japan. Thromb Res 2023; 222:24-30. [PMID: 36563522 DOI: 10.1016/j.thromres.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/22/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Comparative safety of direct oral anticoagulants vs. warfarin in patients undergoing tooth extraction remains unclear. We compared the incidence of post-extraction bleeding between patients taking warfarin and those taking direct oral anticoagulants (DOACs) using administrative claims data. MATERIALS AND METHODS We identified outpatients on anticoagulant therapy who underwent permanent tooth extraction between 2015 and 2020 and categorized them into the warfarin and DOAC groups based on medication prescribed within six months prior to tooth extraction. We used the overlap propensity score weighting method to balance the baseline characteristics between the groups and compared the incidence of post-extraction bleeding within seven days after tooth extraction. RESULTS Among 5253 eligible patients, those in the DOAC group (n = 3696) were older and less frequently prescribed antiplatelets than those in the warfarin group (n = 1557). The distribution of tooth extraction type and number of teeth extracted in a single procedure did not differ between the groups. The unadjusted incidences of post-extraction bleeding in the warfarin and DOAC groups were 35 (2.2 %) and 71 (1.9 %), respectively. Moreover, the overlap weighting analysis showed that the adjusted odds ratio of post-extraction bleeding in the DOAC group in comparison with that in the warfarin group was 0.84 (95 % confidence interval, 0.54-1.31). CONCLUSION The incidence of post-extraction bleeding in patients taking DOACs was comparable to that in patients taking warfarin. The findings suggest that dentists and physicians should exercise the same degree of caution when extracting teeth in patients on DOACs and those on warfarin in terms of post-extraction bleeding.
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Affiliation(s)
- Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Miho Ishimaru
- Department of Oral Health Promotion, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo 060-8638, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shunsuke Itai
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazumichi Yonenaga
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kanata Tonosaki
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Rinji Watanabe
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kazuto Hoshi
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Deglovič J, Remková A. Dental interventions in oral antithrombotic therapy. VNITRNI LEKARSTVI 2023; 69:31-36. [PMID: 36931879 DOI: 10.36290/vnl.2023.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Dentists commonly encounter patients taking oral antithrombotic agents who require invasive dental procedures. Although antithrombotics can cause an increase in bleeding, there is consensus that treatment regimens with antiplatelet agents, older anticoagulants (warfarin) and direct oral anticoagulants should not be altered before routine dental procedures when the risk of bleeding is low. Thromboembolic risk of their discontinuing likely outweighs potential bleeding complications associated with surgery. Therefore, the risks of stopping or reducing these medications must be weighed against the potential consequences of prolonged bleeding, which can be controlled with local measures such as mechanical pressure, suturing, haemostatic agents or antifibrinolytics. Some patients who are taking antithrombotic medications may have additional comorbid conditions or receive other therapy that can increase the risk of prolonged bleeding after dental treatment. Where a patient is believed to be at high bleeding risk, the dentist should consider a consultation with the patient's physician to discuss temporarily discontinuing the antithrombotic therapy.
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Chen AT, Patel M, Douketis JD. Perioperative management of antithrombotic therapy: a case-based narrative review. Intern Emerg Med 2022; 17:25-35. [PMID: 34652572 DOI: 10.1007/s11739-021-02866-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
The periprocedural management of patients who are receiving vitamin K antagonists, direct oral anticoagulants and antiplatelet therapy is a common and challenging clinical scenario as the decision to interrupt or continue these medications is anchored on patient and procedure-related risks for bleeding and thrombosis. Adding to the complexity of clinical management is the fact that anticoagulants have varied pharmacokinetic and pharmacodynamic properties and indications for clinical use. In many minimal-bleed-risk procedures, anticoagulants can be safely continued, without interruption, whereas in cases where anticoagulants cannot be safely continued, the timing of interruption and resumption, as well as the need for heparin bridging requires consideration. Perioperative antithrombotic management scenarios occur most often in patients with atrial fibrillation, mechanical heart valves, coronary stents, and cerebrovascular disease as such patients are likely to be prescribed anticoagulant and/or antiplatelet therapy. The objective of this case-based narrative review is to provide a practical evidence-based approach to the perioperative management of patients on anticoagulation and antiplatelet therapy. Four clinical scenarios will be provided: (1) managing patients in whom anticoagulants can be continued; (2) perioperative management of direct oral anticoagulants; (3) management of patients on dual antiplatelet therapy; and (4) anticoagulant management for emergency or urgent surgery.
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Affiliation(s)
- Andrew Tiger Chen
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - Matthew Patel
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - James Demetrios Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada.
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Song J. Consideration of NOACs (novel or non-vitamin K-dependent oral anticoagulants) in dental procedure. J Korean Assoc Oral Maxillofac Surg 2021; 47:409-410. [PMID: 34969013 PMCID: PMC8721418 DOI: 10.5125/jkaoms.2021.47.6.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Jiyoung Song
- Department of Oral and Maxillofacial Surgery, School of Medicine, Jeju National University, Jeju, Korea
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Manfredini M, Poli PP, Creminelli L, Porro A, Maiorana C, Beretta M. Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery. J Clin Med 2021; 10:5526. [PMID: 34884228 PMCID: PMC8658703 DOI: 10.3390/jcm10235526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. MATERIALS AND METHODS A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. RESULTS 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. CONCLUSIONS No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. CLINICAL RELEVANCE direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.
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Affiliation(s)
| | | | | | - Alberto Porro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Implant Center for Edentulism and Jawbone Atrophies, Maxillofacial Surgery and Odontostomatology Unit, University of Milan, Via della Commenda 10, 20122 Milan, Italy; (M.M.); (P.P.P.); (L.C.); (C.M.); (M.B.)
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Hua W, Huang Z, Huang Z. Bleeding Outcomes After Dental Extraction in Patients Under Direct-Acting Oral Anticoagulants vs. Vitamin K Antagonists: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:702057. [PMID: 34776943 PMCID: PMC8585494 DOI: 10.3389/fphar.2021.702057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The current systematic review aimed to compare bleeding outcomes in dental extraction patients receiving uninterrupted Direct-acting oral anticoagulant (DOAC) or Vitamin K antagonists (VKAs) for various systemic diseases. Methods: PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for randomized controlled trials, controlled clinical trials, prospective and retrospective cohort studies, and case control studies, conducted on adult patients undergoing dental extraction under uninterrupted DOAC or VKAs therapy and reporting bleeding outcomes. The search was conducted up to March 31, 2021. We pooled data to calculate risk ratios (RR) with 95% confidence intervals (CI) in a random-effects model. Results: Eight studies comparing 539 patients on DOAC therapy and 574 patients on VKAs were included. Meta-analysis indicated a statistically significant lower bleeding risk in patients under DOAC therapy (RR 0.68 95% CI 0.49, 0.95 I2 = 0%). However, on sensitivity analysis, the results were statistically non-significant after exclusion of any of the included studies. On pooled analysis of limited number of studies, we found no statistically significant difference in the risk of bleeding between apixaban (RR 0.85 95% CI 0.45, 1.60 I2 = 0%), rivaroxaban (RR 0.95 95% CI 0.36, 2.48 I2 = 45%), dabigatran (RR 0.49 95% CI 0.19, 1.28 I2 = 5%), edoxaban (RR 0.41 95% CI 0.13, 1.27 I2 = 0%) and VKAs. Conclusion: The results of the first review comparing bleeding outcomes after dental extraction in patients on uninterrupted DOAC or VKA therapy indicates that patients on DOAC may have a reduced risk of hemorrhage. Current evidence is of very low-quality and should be interpreted with caution. Data on individual DOAC is scarce and at this point, the difference in the risk of bleeding between these drugs cannot be elucidated. Further studies with a large sample size shall supplement our conclusion.
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Affiliation(s)
- Wenbing Hua
- Department of Stomatoogy, Shanghai PuDong Guangming Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Zhengmei Huang
- Department of Stomatoogy, Renji Hospital, School of Medcine, Shanghai Jiao Tong Universty, Shanghai, China
| | - Zhuoli Huang
- Department of Implantology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai, China
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Buchbender M, Schlee N, Kesting MR, Grimm J, Fehlhofer J, Rau A. A prospective comparative study to assess the risk of postoperative bleeding after dental surgery while on medication with direct oral anticoagulants, antiplatelet agents, or vitamin K antagonists. BMC Oral Health 2021; 21:504. [PMID: 34620135 PMCID: PMC8499467 DOI: 10.1186/s12903-021-01868-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/21/2021] [Indexed: 12/03/2022] Open
Abstract
Background The aim of this prospective study was to investigate the occurrence and severity of postoperative bleeding following dentoalveolar surgery in patients with uninterrupted anticoagulation therapy (AT). Methods Patients receiving AT (vitamin k antagonist (VK), direct oral anticoagulants (DOAC) or antiplatelet therapy (APT) and in need of surgical intervention classified as A, B or C (single or serial tooth extraction, osteotomy, or implant placement) were studied between 2019 and 2021. A healthy, non-anticoagulated cohort (CG) served as a control group. The main outcomes measured were the frequency of postoperative bleeding, the classification of the severity of postoperative bleeding (1a, 1b, 1c, 2, 3), and the correlation with the AT surgical intervention classification. Results In total, 195 patients were included in the study, with 95 patients in the AT group and 100 in the CG. Postoperative bleeding was significant in the AT group vs. the CG (p = 0.000), with a significant correlation with surgical intervention class C (p = 0.013) and the severity class of bleeding 1a (p = 0.044). There was no significant correlation with procedures of type A, B or C for the other postoperative bleeding gradations (1b, 1c, 2 and 3). There was a statistically significant difference in the occurrence of postoperative bleeding events between the DOAC/APT group and the VK group (p = 0.036), but there were no significant differences regarding the other AT agents. Conclusion The continuation of anticoagulation therapy for surgical interventions also seems reasonable for high-risk interventions. Although significantly more postoperative bleeding occurs, the severity of bleeding is low. The perioperative management of anticoagulated patients requires well-coordinated interdisciplinary teamwork and detailed instruction of patients. Clinical trial registration The study is registered (29.03.2021) at the German clinical trial registry (DRKS00024889).
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Affiliation(s)
- Mayte Buchbender
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany.
| | - Nicola Schlee
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Marco R Kesting
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Jannik Grimm
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Jakob Fehlhofer
- Department of Oral and Maxillofacial Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Andrea Rau
- Department of Oral and Maxillofacial Surgery, Universitätsmedizin Greifswald, Greifswald, Germany
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Aminoshariae A, Donaldson M, Horan M, Kulild JC, Baur D. Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques. J Endod 2021; 47:1557-1565. [PMID: 34265324 DOI: 10.1016/j.joen.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of this study was to review evidence-based recommendations for the safe perioperative management of patients undergoing endodontic microsurgery who are currently taking antiplatelet or anticoagulant medications. Using the PICO (Population, Intervention, Comparison, Outcome) format, the following scientific question was asked: In patients taking anticoagulant or antiplatelet agents, what is the available evidence in the management of endodontic microsurgery? METHODS MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov databases were searched to identify current recommendations regarding the management of antiplatelet and anticoagulant medications in the context of outpatient dental surgical procedures. Additionally, the authors hand searched the bibliographies of all relevant articles, the gray literature, and textbooks. Because of the lack of clinical studies and evidence on this subject, articles and guidelines from other organizations and association position statements were included. RESULTS Because any minor surgery can become a major surgery, the treating doctor needs to best assess the risk of bleeding, especially if the surgery is anticipated to take longer than 45 minutes. Every patient should be stratified on a case-by-case basis. Consultation with the patient's physician is highly recommended. CONCLUSIONS In order to maximize the effects of these medications (to prevent thrombosis) while minimizing the potential risks (procedural hemorrhage), clinicians should be aware of the best available evidence when considering continuation or discontinuation of antiplatelet and anticoagulant agents perioperatively for endodontic microsurgery. Ideally, a joint effort from an expert panel for microsurgery would be warranted.
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Affiliation(s)
- Anita Aminoshariae
- Departments of Endodontics, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio.
| | - Mark Donaldson
- School of Pharmacy, University of Montana, Missoula, Montana; School of Dentistry, Oregon Health and Sciences University, Portland, Oregon
| | - Michael Horan
- Oral and Maxillofacial Surgery, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio
| | - James C Kulild
- UKMC Dental School, University of Missouri-Kansas City, Kansas City, Missouri
| | - Dale Baur
- Oral and Maxillofacial Surgery, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio
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Bleeding Complications in Anticoagulated and/or Antiplatelet-Treated Patients at the Dental Office: A Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041609. [PMID: 33567762 PMCID: PMC7915452 DOI: 10.3390/ijerph18041609] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bleeding complications in patients undergoing antiplatelet and/or anticoagulant therapy have been one of the main concerns in dental practice. Upon the introduction of new antiplatelet and anticoagulant drugs, there is a search for new protocols that respond to a secure treatment. The aim of the present study was to evaluate bleeding complications in anticoagulated and antiplatelet-treated patients after performing simple dental extractions, in a period of 4 years. MATERIAL AND METHODS 147 clinical records of anticoagulated and/or antiplatelet-treated patients undergoing a simple dental extraction over a period of 4 years (October 2015 to September 2019) were studied. Within the sample, 63 patients were antiplatelet-treated, 83 were anticoagulated, and 1 patient was under both therapies. Within the anticoagulated patients, 70 took classic anticoagulants and 14 new oral anticoagulants (NOACs). Quantitative data were studied with arithmetic mean and standard deviation (SD). The chi-square test was used for the qualitative variables. ANOVA tests were used to compare age and anticoagulated or antiplatelet-treated patients. Statistical significance was determined when p < 0.05. RESULTS From the 418 dental extractions performed, five severe bleeding complications took place in three patients (2.11%). From the five events, four were in patients treated with NOACs (1.68%) and one occurred in a patient anticoagulated with acenocoumarol (0.42%; p = 0.003). CONCLUSIONS Considering the results of this retrospective clinical study, we can conclude that bleeding complications in anticoagulated and/or antiplatelet-treated patients after tooth extractions were low, with a higher incidence recorded in patients treated with NOACs, followed by classic anticoagulants, and there were no complications in antiplatelet-treated patients.
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Kulkarni MR, Shettar LG, Bakshi PV, Nikhil K. Palatal pre-suturing for perioperative hemostasis at free gingival graft donor sites-A randomized controlled clinical trial. J Periodontol 2021; 92:1441-1447. [PMID: 33543476 DOI: 10.1002/jper.20-0754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/26/2020] [Accepted: 01/19/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The palatal suture has been well known in literature as a method for palatal hemostasis but has not been validated for its efficacy. The aim of this parallel-arm randomized controlled clinical trial was to evaluate the efficacy of palatal pre-suturing using the greater palatine compression suture (GPCS) in reducing the perioperative hemorrhage associated with the palatal free gingival graft (FGG) procedure. METHODS Twenty-four patients requiring the FGG procedure for recession coverage or augmentation of keratinized tissue were recruited in the study and randomized to the GPCS group and the control group. The GPCS was placed using a previously described protocol by a single operator in all the participants in the GPCS group. Perioperative blood loss was estimated by weighing the gauze used to mop the palatal hemorrhage, before and after the procedure. The time required for the surgery was also recorded by an independent observer. RESULTS Significantly lesser blood loss was observed in the GPCS group (4.33 ± 0.89 g) as compared with the control group (8.91 ± 4.16 g). The difference in the time taken for the surgical procedure for the GPCS group (73.25 ± 22.35 minutes) was not significantly different from that required for the control group (76.08 ± 14.47 minutes). CONCLUSION This study demonstrates that pre-suturing of the palate using the GPCS is an effective technique to reduce the perioperative blood loss associated with the palatal FGG procedure.
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Affiliation(s)
- Mihir Raghavendra Kulkarni
- Department of Periodontics, SDM College of Dental Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, India
| | - Leena Gangadhar Shettar
- Department of Periodontics, SDM College of Dental Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, India
| | - Purva Vijay Bakshi
- Department of Periodontics, SDM College of Dental Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, India
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Inokoshi M, Kubota K, Yamaga E, Ueda K, Minakuchi S. Postoperative bleeding after dental extraction among elderly patients under anticoagulant therapy. Clin Oral Investig 2020; 25:2363-2371. [PMID: 32875384 DOI: 10.1007/s00784-020-03559-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study aimed to assess and compare postoperative bleeding occurrence after dental extraction in medically compromised elderly patients under anticoagulant therapy. MATERIALS AND METHODS This retrospective study included medically compromised elderly patients aged ≥ 65 years who were taking apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin and had undergone single or multiple dental extractions. The primary outcome measure was postoperative bleeding occurrence, which was defined as oozing or marked hemorrhage from 24 h to 7 days after dental extraction. Postoperative bleeding occurrence was calculated for each anticoagulant and compared using Fisher's exact test, followed by multiple comparisons. RESULTS Two hundred thirty-two patients met the inclusion criteria. The highest postoperative bleeding occurrence was recorded for rivaroxaban (12/37: 32.4%), followed by apixaban (8/44: 18.2%), warfarin (17/98: 17.3%), and edoxaban (2/35: 5.7%). Patients taking dabigatran did not present postoperative bleeding (0/18: 0%). Fisher's exact test, followed by multiple comparison tests, revealed a significant among-anticoagulant difference (p = 0.0095). Postoperative bleeding was significantly higher in patients taking rivaroxaban than in those taking edoxaban or dabigatran (p = 0.03088). CONCLUSIONS Within the limitations of this retrospective study design, these findings suggest that different anticoagulants may affect postoperative bleeding occurrence after dental extraction among medically compromised elderly patients. CLINICAL RELEVANCE Clinicians should carefully consider postoperative bleeding after dental extraction in patients taking anticoagulant therapy, especially rivaroxaban.
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Affiliation(s)
- Masanao Inokoshi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Kazumasa Kubota
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan.
| | - Eijiro Yamaga
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Kaori Ueda
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Shunsuke Minakuchi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
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