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Aijima R, Yamashita Y. Effectiveness of perioperative oral hygiene management using a cetylpyridinium chloride-, dipotassium glycyrrhizinate, and tranexamic acid-based mouthwash as an adjunct to mechanical oral hygiene in patients with maxillomandibular fixation: A randomized controlled clinical trial. Clin Exp Dent Res 2023; 9:1044-1050. [PMID: 38018029 PMCID: PMC10728525 DOI: 10.1002/cre2.814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVES Maxillomandibular fixation requires the jawbones to remain static. Mechanical cleaning is also carried out by brushing or with a water flosser to maintain the oral cavity in a hygienic state, but this cannot be considered sufficient. Mouthwashes are used as a substitute for mechanical cleaning or in a supplementary role after such cleaning. The aim is to evaluate the effectiveness of HABITPRO mouthwash, which contains cetylpyridinium chloride, dipotassium glycyrrhizinate, and tranexamic acid in the specific environment created by maxillomandibular fixation used as an adjunct to mechanical cleaning. MATERIAL AND METHODS A total of 55 patients who had undergone maxillomandibular fixation were randomly allocated to either a HABITPRO group (n = 29) or a placebo group (n = 26). To investigate their oral hygiene status, their plaque control record (PCR) was reviewed, and the caries-related bacterial counts, pH, acid buffering capacity, white blood cell count, and ammonia in saliva were measured immediately before maxillomandibular fixation, on Day 10 of fixation, and immediately after fixation was released. RESULTS After approximately 2-3 weeks of mouthwash use, the PCR index also increased significantly in the placebo group compared with baseline, whereas it remained almost steady in the HABITPRO group. Additionally, salivary ammonia levels decreased significantly in the HABITPRO group compared to that of the placebo group. CONCLUSIONS Even with maxillomandibular fixation, continued gargling with HABITPRO mouthwash in the perioperative period as an adjunct to mechanical cleaning can help maintain better oral hygiene and reduce bacterial counts.
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Affiliation(s)
- Reona Aijima
- Department of Oral and Maxillofacial Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Yoshio Yamashita
- Department of Oral and Maxillofacial Surgery, Faculty of MedicineSaga UniversitySagaJapan
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Kyyak S, Jari A, Heimes D, Heider J, Kämmerer PW. Platelet-rich fibrin ensures hemostasis after single-tooth removal under factor Xa inhibitors - a clinical prospective randomized split-mouth study. Clin Oral Investig 2023; 27:7275-7283. [PMID: 37864605 PMCID: PMC10713775 DOI: 10.1007/s00784-023-05317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVES In this prospective, double-blinded, randomized split-mouth study, the local hemostatic effect of platelet-rich fibrin (PRF) inserted into the extraction socket in patients taking factor Xa (FXa) inhibitors (apixaban, rivaroxaban, edoxaban) was compared to a hemostatic gelatine sponge (GS) as the "therapeutic gold standard" without withdrawal of oral anticoagulant therapy. MATERIALS AND METHODS Single-tooth extraction was conducted under local anesthesia in n = 21 patients using a split-mouth design (42 teeth). Using a double-blind approach, the extraction socket on one side of the jaw was filled with PRF and on the other with a GS. Bleeding was assessed immediately after surgery, in 30 min, 1 h, 1.5 h, and on follow-up appointments in 24 h and on the 7th day. RESULTS In 67% of cases, mild postoperative oozing could be stopped 30-90 min after tooth extraction via gauze pressure without any delayed bleeding. Concerning bleeding events, there was no difference among the PRF and GS groups and no significant difference among rivaroxaban, apixaban, and edoxaban (all p > 0.15). CONCLUSION PRF and GS are reliable hemostatic methods in postextraction sockets of patients taking FXa inhibitors. CLINICAL RELEVANCE Consequently, there is no need to discontinue FXa inhibitors because of a single-tooth removal, eliminating the risk of thrombus formation.
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Affiliation(s)
- Solomiya Kyyak
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Ali Jari
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Diana Heimes
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Julia Heider
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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3
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Patient Assessment. J Oral Maxillofac Surg 2023; 81:E13-E34. [PMID: 37833021 DOI: 10.1016/j.joms.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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4
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Darwish G. The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review. BMC Oral Health 2023; 23:743. [PMID: 37821865 PMCID: PMC10566068 DOI: 10.1186/s12903-023-03427-8] [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: 12/04/2022] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) were developed to overcome the drawbacks of oral anticoagulants. However, not much has been discussed about the perioperative management of patients on DOACs during oral surgical procedures. Thus, we aim to determine the risk of perioperative and postoperative bleeding during oral surgical procedures in patients on DOACs. METHODS A detailed literature search was performed to find potentially relevant studies using the Cochrane Library, Clinical Key, ClinicalTrials.gov, Google Scholar, Ovid, ScienceDirect, and Scopus. Every article available for free in English literature for the past 10 years, between 2012 and 2022, was searched. RESULTS A total of 2792 abstracts were selected through a search strategy across various search engines. Based on inclusion and exclusion criteria, eleven clinical studies using DOACs as anticoagulants or studies comparing patients with and without DOACs under oral surgery procedures were found. The results were inconsistent and varied, with a few studies recommending DOAC administration with the bare minimum reported complications and others finding no statistically significant difference between discontinuation or continuation of drugs, especially across basic dental procedures. CONCLUSION Within the limitations of the study, it can be concluded that minor oral surgical procedures are safe for patients on DOAC therapy. However, the continuation or discontinuation of DOACs in patients undergoing oral surgical procedures remains controversial and requires further studies to extrapolate the results.
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Affiliation(s)
- Ghassan Darwish
- Department of Oral and Maxillofacial Surgery, School of Dentistry, King Abdulaziz University, 21589, Jeddah, Saudi Arabia.
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Guabello G, Zuffetti F, Ravidà A, Deflorian M, Carta G, Saleh MHA, Serroni M, Pommer B, Watzek G, Francetti L, Testori T. Avoiding implant-related complications in medically compromised patients with or without unhealthy lifestyle/Elevated oxidative stress. Periodontol 2000 2023; 92:329-349. [PMID: 37350348 DOI: 10.1111/prd.12503] [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: 03/07/2023] [Revised: 04/11/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
Increased human life expectancy broadens the alternatives for missing teeth and played a role in the widespread use of dental implants and related augmentation procedures for the aging population. Though, many of these patients may have one or more diseases. These systemic conditions may directly lead to surgical complications, compromise implant/bone healing, or influence long-term peri-implant health and its response to biologic nuisances. Offering patients credible expectations regarding intra- and postoperative complications and therapeutic prognosis is an ethical and legal obligation. Clear identification of potential types of adverse effects, complications, or errors is important for decision-making processes as they may be related to different local, systemic, and technical aspects. Therefore, the present review structures the underlying biological mechanisms, clinical evidence, and clinical recommendations for the most common systemic risk factors for implant-related complications.
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Affiliation(s)
- Gregorio Guabello
- Endocrinology Unit, IRCCS Galeazzi Sant'Ambrogio Hospital, Milan, Italy
| | - Francesco Zuffetti
- Section of Implant Dentistry and Oral Rehabilitation, IRCCS Galeazzi Sant'Ambrogio Hospital, Dental Clinic, Milan, Italy
| | - Andrea Ravidà
- Department of Periodontics and Preventive Dentistry, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania, USA
| | - Matteo Deflorian
- Section of Implant Dentistry and Oral Rehabilitation, IRCCS Galeazzi Sant'Ambrogio Hospital, Dental Clinic, Milan, Italy
| | - Giorgio Carta
- Argo Academy International Research Bologna, Bologna, Italy
- Private Practice, Bologna, Italy
- Lake Como Institute, Como, Italy
| | - Muhammad H A Saleh
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA
| | - Matteo Serroni
- Department of Innovative Technologies in Medicine & Dentistry, University 'G. D'Annunzio', Chieti-Pescara, Italy
| | - Bernhard Pommer
- Academy for Oral Implantology, Vienna, Austria
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
| | | | - Luca Francetti
- IRCCS Galeazzi Sant'Ambrogio Hospital, Dental Clinic, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
| | - Tiziano Testori
- Section of Implant Dentistry and Oral Rehabilitation, IRCCS Galeazzi Sant'Ambrogio Hospital, Dental Clinic, Milan, Italy
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
- Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, Massachusetts, USA
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dos Santos MCF, dos Santos Cavalcante LP, de Andrade KF, da Silva AF, de Araújo Ferreira Muniz I, de Lima JM, Aguiar RT, Tavares JF, Castellano LRC, da Silva SD, Bonan PRF. Chitosan sponges and polycaprolactone nanoparticles carrying tranexamic acid as hemostatic agent: Synthesis, characterization and bioapplication. POLYM ENG SCI 2022. [DOI: 10.1002/pen.26139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Maria Carolina Fernandes dos Santos
- Laboratory for Cell Culture and Analysis Federal University of Paraiba, Health Sciences Center—Campus I, Technical School of Health João Pessoa Paraíba Brazil
| | - Luiza Peixoto dos Santos Cavalcante
- Laboratory for Cell Culture and Analysis Federal University of Paraiba, Health Sciences Center—Campus I, Technical School of Health João Pessoa Paraíba Brazil
| | - Karlivânia Ferreira de Andrade
- Laboratory for Cell Culture and Analysis Federal University of Paraiba, Health Sciences Center—Campus I, Technical School of Health João Pessoa Paraíba Brazil
| | - Alan Frazão da Silva
- Laboratory for Cell Culture and Analysis Federal University of Paraiba, Health Sciences Center—Campus I, Technical School of Health João Pessoa Paraíba Brazil
| | | | - Jefferson Muniz de Lima
- Post Graduate Program in Dentistry Federal University of Pernambuco, Health Sciences Center Recife Prince Edward Island Brazil
| | - Rebeca Tibau Aguiar
- Integrated Laboratory of Biomaterials Federal University of Paraíba, Health Sciences Center João Pessoa Paraíba Brazil
| | - Josean Fechine Tavares
- Laboratory of Pharmaceutical Technology Federal University of Paraíba João Pessoa Paraíba Brazil
| | - Lúcio Roberto Cançado Castellano
- Laboratory for Cell Culture and Analysis Federal University of Paraiba, Health Sciences Center—Campus I, Technical School of Health João Pessoa Paraíba Brazil
| | | | - Paulo Rogério Ferreti Bonan
- Department of Clinical and Social Dentistry Federal University of Paraíba, Health Sciences Center João Pessoa Paraíba Brazil
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Römer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kämmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent 2022; 8:20. [PMID: 35429255 PMCID: PMC9013394 DOI: 10.1186/s40729-022-00418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 01/08/2023] Open
Abstract
Purpose Considering a high prevalence of congenital and especially acquired bleeding disorders, their heterogeneity and the multitude of possible treatments strategies, a review of the scientific data on this topic is needed to implement a treatment guide for healthcare professionals.
Methods A selective literature review was performed via PubMed for articles describing oral surgery / dental implant procedures in patients with congenital and acquired bleeding disorders. Out of the existing literature, potential treatment algorithms were extrapolated. Results In order to assess the susceptibility to bleeding, risk stratification can be used for both congenital and acquired coagulation disorders. This risk stratification, together with an appropriate therapeutic pathway, allows for an adequate and individualized therapy for each patient. A central point is the close interdisciplinary cooperation with specialists. In addition to the discontinuation or replacement of existing treatment modalities, local hemostyptic measures are of primary importance. If local measures are not sufficient, systemically administered substances such as desmopressin and blood products have to be used. Conclusions Despite the limited evidence, a treatment guide could be developed by means of this narrative review to improve safety for patients and practitioners. Prospective randomized controlled trials are needed to allow the implementation of official evidence-based guidelines.
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Risk factors for bleeding after dental extractions in patients receiving antithrombotic drugs - A case control study. J Dent Sci 2022; 17:780-786. [PMID: 35756819 PMCID: PMC9201513 DOI: 10.1016/j.jds.2021.10.005] [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: 09/22/2021] [Revised: 10/02/2021] [Indexed: 02/08/2023] Open
Abstract
Background/purpose Patients receiving antithrombotic drugs are more likely to suffer bleeding after tooth extraction and multiple factors are related to it. The aim of this study was to investigate the incidence of bleeding and risk factors for bleeding after dental extractions in patients receiving antithrombotic drugs. Materials and methods This retrospective case control study included patients receiving oral antithrombotic drugs or not. Tooth extractions were conducted under ECG monitoring and local hemostatic measures were performed. Risk factors for postoperative hemorrhage after tooth extraction were evaluated using univariate and multivariate analyses. Results Bleeding events were reported in 27 (27%) patients receiving antithrombotic drugs and 9 (9%) patients who didn't use antithrombotic drugs, the difference between which was significant (p < 0.01). Univariate analyses showed that age (OR = 2.717, p = 0.028), oral hygiene (OR = 4.110, p = 0.043), inferior nerve block (OR = 4.285, p = 0.038) and number of extracted tooth (OR = 4.758, p = 0.029) were significantly correlate with bleeding incidence. Multivariate analysis revealed that age (OR = 2.824, p = 0.036) and number of extracted tooth (OR = 5.268, p = 0.016) were significant risk factors for postextraction bleeding. Conclusion The results suggest that there is higher incidence of postextraction bleeding in patients receiving antithrombotic drugs compared to patients who don't. Age (>75 years), oral hygiene, inferior nerve block and number of extracted tooth may be related to bleeding after tooth extraction.
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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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Kämmerer PW, Wolf JM, Buttchereit I, Frerich B, Ottl P. Prospective clinical implementation of optional implant treatment into pregraduate dental education-mini implants for retention and support of mandibular overdentures. Int J Implant Dent 2021; 7:87. [PMID: 34505196 PMCID: PMC8429539 DOI: 10.1186/s40729-021-00371-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022] Open
Abstract
Background The primary aim of the study was to evaluate mini implant (MDI) survival, prosthodontic maintenance, and patient-reported outcome measures after conducting an optional pregraduate academic course on patients with mandibular edentulism including fabrication of overdentures and MDI planning and placement as well as chair-side incorporation of the respective restauration. In a prospective clinical study, 20 patients received 80 MDIs that were restored with mandibular overdentures. All treatment steps including placement of 40 MDIs were conducted by undergraduate students under strict guidance of a consultant. Next to students’ perceptions after participation, survival of MDIs, and prosthodontic maintenance, patients’ perceptions as well as peri-implant parameters were assessed after 4 weeks and 3 and 12 months. Results Three MDIs fractured (two during insertion and one after 3 months; total survival 96.25%). Two overdentures fractured and a total of 23 cases of minor prosthodontic maintenance were required. Over time, patients’ satisfaction significantly increased. Besides, questionnaires showed a high rate of students’ positive perception and high self-confidence to include MDI therapy into own practice. Conclusions The results are in accordance to those reported by postgraduate dentists. In accordance, therapy with MDI-retained mandibular overdentures seems to be feasible and successful at pregraduate level if the students receive guidance.
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Affiliation(s)
- Peer W Kämmerer
- Department of Oral, Maxillofacial and Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131, Mainz, Germany. .,Department of Oral, Maxillofacial and Facial Plastic Surgery, University Medical Centre Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Jens M Wolf
- Department of Prosthodontics and Materials Science, University Medical Centre Rostock, Strempelstraße 13, 18057, Rostock, Germany
| | - Ingo Buttchereit
- Department of Oral, Maxillofacial and Facial Plastic Surgery, University Medical Centre Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Bernhard Frerich
- Department of Oral, Maxillofacial and Facial Plastic Surgery, University Medical Centre Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Peter Ottl
- Department of Prosthodontics and Materials Science, University Medical Centre Rostock, Strempelstraße 13, 18057, Rostock, Germany.,Department Life, Light & Matter, University of Rostock, 18051, Rostock, Germany
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Dawoud BES, Kent S, Tabbenor O, George P, Dhanda J. Dental implants and risk of bleeding in patients on oral anticoagulants: a systematic review and meta-analysis. Int J Implant Dent 2021; 7:82. [PMID: 34430994 PMCID: PMC8385035 DOI: 10.1186/s40729-021-00364-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/01/2021] [Indexed: 12/02/2022] Open
Abstract
Background Dental implant placement is safe and predictable, yet optimal management of anticoagulated patients remains controversial. Whilst cessation of anticoagulation pre-operatively should decrease risks of bleeding, risk of thrombosis increases. We aim to define risk of bleeding in patients on oral anticoagulation who are undergoing dental implant placement, in order to establish best management. Methods This systematic review is registered with the National Institute for Health Research (NIHR) PROSPERO database (Registration No: CRD42021233929). We performed a systematic review as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Studies were identified using an agreed search strategy within the OVID Gateway (this included Pubmed, MEDLINE, Cochrane Collaborative). Studies assessing bleeding complications in patients who were undergoing dental implant placement were selected. The primary outcome was bleeding events in anticoagulated patients undergoing dental implant placement. Secondary outcomes included any complication requiring further intervention. Results We identified 182 studies through screening, and after review of titles and abstracts reduced this to 8 studies. In these studies, 1467 participants received at least 2366 implants. Studies were analysed for quality using the ROBINS-I risk of bias tool. Four studies were retrospective case reviews, and four were prospective reviews, three of which also blinded the operator to anticoagulation status. There was significant heterogeneity between the included studies. Meta-analysis showed an increased risk of bleeding (RR, 2.30; 95% CI, 1.25-4.24 p = 0.37 I = 7%) when implants were placed in the presence of anticoagulation however these were not clinically significant haemorrhagic events. Conclusion The continuation of anticoagulants peri-operatively during dental implant surgery does increase the risk of clinically non-significant peri- and post-operative bleeding. Dental implant surgery encompasses a broad spectrum of procedures ranging from minor to more invasive surgery with simple local haemostatic measures mitigating the risk of bleeding. The decision to discontinue anticoagulants prior to dental implant surgery must consider patient and surgical factors with the clinician undertaking a risk-balance assessment.
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Affiliation(s)
- Basim E S Dawoud
- Department of Oral & Maxillofacial Surgery, North Manchester General Hospital, Manchester Foundation Trust, Manchester, UK.
| | - Samuel Kent
- Department of Oral and Maxillofacial Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Oliver Tabbenor
- Department of Oral and Maxillofacial Surgery, Manchester Foundation Trust, Manchester, UK
| | - Pynadath George
- Department of Oral Surgery, Edinburgh Dental Institute, Edinburgh, UK
| | - Jagtar Dhanda
- Department of Oral and Maxillofacial Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
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Miziara LNB, Sendyk WR, Ortega KL, Gallottini M, Sendyk DI, Martins F. Risk of Bleeding during Implant Surgery in Patients Taking Antithrombotics: A Systematic Review. Semin Thromb Hemost 2021; 47:702-708. [PMID: 33971681 DOI: 10.1055/s-0041-1722845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this systematic review is to assess the risk of postoperative bleeding in oral surgery for implant placement in individuals taking antithrombotics (i.e., anticoagulants and/or antiplatelet agents). A literature search was performed in PubMed (MEDLINE), Web of Science, Scopus, and EMBASE databases for articles published until August 2020, with no date restriction, and manually completed. We included prospective clinical studies that provided information regarding the presence of an experimental group (i.e., implant placement), a control group (patients not under treatment with antithrombotics), and a well-established protocol for evaluating bleeding. Meta-analysis determined the risk of bleeding during the placement of implants in antithrombotic-treated patients. Of the 756 potentially eligible articles, 5 were included in the analysis with 4 ranked as high and 1 as medium quality. Antithrombotic treatment comprised the following drug classes: (1) anticoagulants: vitamin K antagonists, (2) nonvitamin K antagonist oral anticoagulants, (3) low-molecular-weight heparin, and (4) antiplatelet agents (not specified). The results suggest that the risk of bleeding is not substantially higher in antithrombotic-treated patients (odds ratio = 2.19; 95% confidence interval: 0.88-5.44, p = 0.09) compared with nontreated patients. This systematic review suggests that the absolute risk is low and there is no need to discontinue or alter the dose of the antithrombotic treatment for implant placement surgery.
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Affiliation(s)
| | - Wilson Roberto Sendyk
- Department of Oral Implantology, Dental School, University of Santo Amaro, São Paulo, Brazil
| | - Karem López Ortega
- Division of Oral Pathology, Department of Stomatology, Dental School, University of São Paulo, São Paulo, Brazil
| | - Marina Gallottini
- Division of Oral Pathology, Department of Stomatology, Dental School, University of São Paulo, São Paulo, Brazil
| | - Daniel Isaac Sendyk
- Division of Periodontics, Department of Stomatology, Dental School, University of São Paulo, São Paulo, Brazil
| | - Fabiana Martins
- Department of Oral Implantology, Dental School, University of Santo Amaro, São Paulo, Brazil
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Moreno-Drada JA, Abreu LG, Lino PA, Parreiras Martins MA, Pordeus IA, Nogueira Guimarães de Abreu MH. Effectiveness of local hemostatic to prevent bleeding in dental patients on anticoagulation: A systematic review and network meta-analysis. J Craniomaxillofac Surg 2021; 49:570-583. [PMID: 33994071 DOI: 10.1016/j.jcms.2021.04.014] [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: 01/05/2021] [Revised: 03/14/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022] Open
Abstract
This study aimed to determine the effectiveness of hemostatic protocols to prevent bleeding in dental procedures among individuals undergoing oral anticoagulation therapy. A systematic review and network meta-analysis were accomplished. Searches of literature and grey literature were performed in different electronic databases. Clinical trials were considered as part of the inclusion criteria. Data extraction and assessment of the risk of bias of the included articles were performed. Assessment of the certainty of evidence was also performed. As results we find that the N-butyl-2-cyanoacrylate [RR -35.00 (95% CI - 107.12, -5.78)], calcium sulfate (CaSO4) [RR -5.62 (95% CI -11.41, -1.03)], and tranexamic acid (TXA) [RR -3.46 (95% CI -7.63, -0.77)] showed beneficial effects compared to placebo. However, only TXA presented beneficial effects with moderate certainty evidence. N-butyl-2-cyanoacrylate and CaSO4 presented very low certainty evidence. In the comparisons between the hemostatic agents, no differences were observed. For the mean bleeding time, no significant difference in the comparisons was observed as well. Concluding, bleeding events in individuals on oral anticoagulation decreased with the use of TXA compared to placebo. N-butyl-2-cyanoacrylate and CaSO4 were also superior to placebo, but the certainty of evidence was low. For the mean bleeding time, no significant difference in hemostatic agents was observed.
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Moreno-Drada JA, Silva da Cruz AJ, Soares de Faria ML, Miranda Cota LO, Parreiras Martins MA, Almeida Pordeus I, Nogueira Guimarães de Abreu MH. Oral Health-Related Quality of Life in Anticoagulated Patients with Warfarin Treatment: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3714. [PMID: 33918224 PMCID: PMC8037600 DOI: 10.3390/ijerph18073714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022]
Abstract
To evaluate factors associated with oral health-related quality of life (OHRQoL) in patients under oral anticoagulant therapy with warfarin, a cross-sectional study was conducted. Validated questionnaires assessed self-reported periodontal disease, demographic variables, and OHRQoL using the short version of the Oral Health Impact Profile (OHIP-14) instrument. After calibration (Kappa > 0.60), an examiner evaluated patients' experience with dental caries and the need for dental prostheses. Statistical analysis involved proportions and measures of central tendency. Negative binomial regression models were used to estimate the rate ratios (RR) and the corresponding 95% confidence interval (CI). The sample consisted of 158 individuals, with a mean age of 58.8 years (SD = 12.1), of which 62.7% of the participants were women. The OHIP-14 mean was 10.62 (SD = 10.92). A higher OHIP-14 total score (worse OHRQoL) was associated with ethnic group, age, periodontal disease self-report, dental caries, and oral health self-report. Demographic and clinical factors can negatively influence the perception of anticoagulated patients on OHRQoL.
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Affiliation(s)
- Johana Alejandra Moreno-Drada
- School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte CEP 31270-901, Brazil; (A.J.S.d.C.); (M.L.S.d.F.); (L.O.M.C.); (I.A.P.); (M.H.N.G.d.A.)
| | - Alex Junio Silva da Cruz
- School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte CEP 31270-901, Brazil; (A.J.S.d.C.); (M.L.S.d.F.); (L.O.M.C.); (I.A.P.); (M.H.N.G.d.A.)
| | - Matheus Luis Soares de Faria
- School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte CEP 31270-901, Brazil; (A.J.S.d.C.); (M.L.S.d.F.); (L.O.M.C.); (I.A.P.); (M.H.N.G.d.A.)
| | - Luís Otávio Miranda Cota
- School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte CEP 31270-901, Brazil; (A.J.S.d.C.); (M.L.S.d.F.); (L.O.M.C.); (I.A.P.); (M.H.N.G.d.A.)
| | | | - Isabela Almeida Pordeus
- School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte CEP 31270-901, Brazil; (A.J.S.d.C.); (M.L.S.d.F.); (L.O.M.C.); (I.A.P.); (M.H.N.G.d.A.)
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Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing bridging with heparin versus unpaused vitamin K antagonist medication. BMC Oral Health 2021; 21:96. [PMID: 33663474 PMCID: PMC7934390 DOI: 10.1186/s12903-021-01464-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 11/27/2022] Open
Abstract
Background The aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin. Methods A retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/osteotomy/combined extraction and osteotomy) and the prothrombin time. Results
In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG versus VG p = 0.004; CG versus BG p < 0.001, BG versus VG p < 0.001. A significant correlation of number of the extracted teeth in the BG (p = 0.014) and no significance in VG (p = 0.298) and CG (p = 0.210) and in the BG versus VG and CG with p < 0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time. Conclusions Bridging with heparin increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well-coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences.
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Bajkin BV, Wahl MJ, Miller CS. Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:522-532. [DOI: 10.1016/j.oooo.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
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Moreno-Drada JA, Abreu LG, Martins MAP, Pordeus IA, de Abreu MHNG. Effectiveness of hemostatic protocols for the prevention of bleeding during oral procedures among individuals receiving anticoagulation therapy: a systematic review protocol. JBI Evid Synth 2020; 18:2409-2415. [PMID: 33181593 DOI: 10.11124/jbisrir-d-19-00342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to determine the effectiveness of hemostatic protocols for the prevention of bleeding during dental procedures among individuals receiving oral anticoagulation therapy. INTRODUCTION Dental procedures may increase the chance of bleeding in individuals receiving oral anticoagulation therapy. The literature suggests different hemostatic protocols for the prevention of bleeding in these individuals but offers no consensus regarding their effectiveness. INCLUSION CRITERIA Randomized controlled clinical trials comparing the effectiveness of different hemostatic protocols for the prevention of bleeding during oral procedures among individuals 18 years or older receiving oral anticoagulation therapy will be included. METHODS Computerized searches will be conducted in seven electronic databases. Gray literature and searches in the reference lists of the included articles will also be screened. Two independent reviewers will assess titles/abstracts for potential inclusion against the eligibility criteria. References that meet the eligibility criteria will be included without restriction on the language or date of publication. Assessment of the methodological quality of the included articles and data extraction will be performed. Statistical heterogeneity of meta-analysis will be assessed. In the event of high statistical heterogeneity, sensitivity analysis will be performed. Subgroup analysis will be planned. The certainty of the evidence will be evaluated with the Grading of Recommendations, Assessment, Development and Evaluation. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019136744.
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Affiliation(s)
| | - Lucas Guimarães Abreu
- Department of Pediatric Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Isabela Almeida Pordeus
- Department of Pediatric Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Brancaccio Y, Antonelli A, Barone S, Bennardo F, Fortunato L, Giudice A. Evaluation of local hemostatic efficacy after dental extractions in patients taking antiplatelet drugs: a randomized clinical trial. Clin Oral Investig 2020; 25:1159-1167. [PMID: 32613433 DOI: 10.1007/s00784-020-03420-3] [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: 04/25/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate clinical efficacy of four different local hemostatics in patients taking oral antiplatelet therapy, after multiple dental extractions without discontinuing drugs. MATERIALS AND METHODS Study sample included 102 patients (mean age 64.1 ± 17.4 years) in treatment with oral antiplatelet agents needing multiple dental extractions. After surgery, the sockets were randomly sealing with suture alone (control group), hemostatic plug (HEM), advanced platelet-rich fibrin (A-PRF+), and leukocyte-platelet-rich fibrin (L-PRF). Primary outcomes were post-operative bleeding, wound healing index, and possible complications. Secondary outcomes were correlation between primary outcomes and patient's comorbidities and voluptuous habits. Descriptive statistics, bivariate comparisons, and logistic regression analysis were performed (p < 0.05). RESULTS Both A-PRF+ and L-PRF showed a reduced bleeding risk when compared with suture alone (OR = 0.09, p = 0.001 for A-PRF+; OR = 0.09, p = 0.005 for L-PRF). Only L-PRF showed a reduced risk for incomplete wound healing when compared with the control site (OR = 0.43, p = 0.019). Patients affected by hypertension (OR 3.91, p = 0.015) and diabetes (OR 3.24, p = 0.026) had the highest bleeding risk. Smoking (OR 4.30, p = 0.016) and diabetes (OR 3.79, p = 0.007) interfered with healing process. CONCLUSION L-PRF and A-PRF represent a valid alternative to the traditional hemostatics, reducing post-surgical bleeding and promoting wound healing. CLINICAL RELEVANCE In patients taking antiplatelet drugs, different local hemostatics are useful to control potential post-operative bleeding and to favor wound healing. However, comorbidities and voluptuous habits may increase bleeding risk, interfering with healing process.
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Affiliation(s)
- Ylenia Brancaccio
- Department of Health Sciences, School of Dentistry, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Alessandro Antonelli
- Department of Health Sciences, School of Dentistry, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Selene Barone
- Department of Health Sciences, School of Dentistry, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Francesco Bennardo
- Department of Health Sciences, School of Dentistry, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Leonzio Fortunato
- Department of Health Sciences, School of Dentistry, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Amerigo Giudice
- Department of Health Sciences, Magna Graecia University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy.
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Implant Placement in Patients under Treatment with Rivaroxaban: A Retrospective Clinical Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124607. [PMID: 32604907 PMCID: PMC7345116 DOI: 10.3390/ijerph17124607] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
The management of patients under treatment with Direct Oral Anticoagulants (DOACs) has led clinicians to deal with two clinical issues, such as the hemorrhagic risk in case of non-interruption or the risk of thromboembolism in case of suspension of the treatment. The primary aim of this retrospective study was to evaluate the incidence of perioperative bleeding events and healing complications in patients who were under treatment with Rivaroxaban and who received dental implants and immediate prosthetic restoration. Patients treated with Rivaroxaban (Xarelto 20 mg daily) and who needed implant rehabilitation were selected. Four to six implants were placed in mandibular healed sites or fresh extraction sockets. All patients, in agreement with their physicians, interrupted the medication for 24 h and received implants and immediate restorations. Twelve patients and 57 implants were analyzed in the study. No major postoperative bleeding events were reported. Three patients (25%) presented slight immediate postoperative bleeding controlled with compression only. The implant and prosthetic survival rate were both 100% after 1 year. Within the limitations of this study, multiple implant placement with an immediate loading can be performed without any significant complication with a 24 h discontinuation of Rivaroxaban, in conjunction with the patient’s physician.
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Sohn JB, Lee H, Han YS, Jung DU, Sim HY, Kim HS, Oh S. When do we need more than local compression to control intraoral haemorrhage? J Korean Assoc Oral Maxillofac Surg 2020; 45:343-350. [PMID: 31966979 PMCID: PMC6955419 DOI: 10.5125/jkaoms.2019.45.6.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/05/2019] [Accepted: 10/28/2019] [Indexed: 11/07/2022] Open
Abstract
Objectives The aims of this study were to determine the effectiveness of local compression in patients presenting to the emergency room with intraoral bleeding and to identify when complex haemostatic measures may be required. Materials and Methods Five hundred forty patients who had experienced intraoral haemorrhage were retrospectively reviewed. The outcome variable was the haemostasis method used, i.e., simple (local compression with gauze) or complex (an alternative method after local compression has failed). Predictor variables were sex, age, American Society of Anesthesiologists (ASA) class, hepatic cirrhosis, bleeding disorder, use of antithrombotic agents, and site/cause of haemorrhage. Results The mean patient age was 48.9±23.9 years, 53.5% were male, 42.8% were ASA class II or higher, and 23.7% were taking antithrombotic agents. Local compression was used most often (68.1%), followed by local haemostatic agents, sutures, systemic tranexamic acid or blood products, and electrocautery. The most common site of bleeding was the gingiva (91.7%), and the most common cause was tooth extraction (45.7%). Risk factors for needing a complex haemostasis method were use of antithrombotic agents (odds ratio 2.047, P=0.009) and minor oral surgery (excluding extraction and implant procedures; odds ratio 6.081, P=0.001). Conclusion A haemostasis method other than local compression may be needed in patients taking antithrombotic agents or having undergone minor oral surgery.
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Affiliation(s)
- Jun-Bae Sohn
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Ho Lee
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Yoon-Sic Han
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Da-Un Jung
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hye-Young Sim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hee-Sun Kim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Sohee Oh
- Medical Research Collaborating Center, SMG-SNU Boramae Medical Center, Seoul, Korea
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Management of anticoagulated patients in dentoalveolar surgery: a clinical comparative study. Clin Oral Investig 2019; 24:2653-2662. [PMID: 31713746 DOI: 10.1007/s00784-019-03124-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This prospective, comparative, clinical study analyzed the postoperative bleeding risk of patients on anticoagulation therapy (AT) who were undergoing tooth extractions and osteotomies. MATERIALS AND METHODS Patients with the following ATs were included (test groups): (1.) platelet aggregation inhibitors (PAIs), (2.) vitamin K inhibitors, (3.) low molecular weight heparin (LMWH), and (4.) direct oral anticoagulants (DOACs). Patients in the control group were not on any AT (non-AT group). Patients were subdivided into the following treatment groups: (1.) single tooth extraction, (2.) serial extraction (≥ 2 adjacent teeth), and (3.) tooth osteotomy. Pre-, intra-, and postoperative data concerning the treatment, extent of the surgery, and bleeding were recorded and statistically evaluated. RESULTS There were 15 postoperative bleeding events in 838 patients (1.7%): four (0.7%) in the non-AT group (n = 603 patients) and 11 (4.7%) in the AT group (n = 235 patients). The surgical procedure had no statistically significant effect on postoperative bleeding frequencies. Patients taking vitamin K inhibitors had a significantly higher risk of postoperative bleeding compared with patients without AT (p < 0.00001). Four patients were hospitalized due to the severity of the bleeding (vitamin K inhibitor group). Postoperative bleeding events were all controlled with local hemostatic measures. CONCLUSIONS The postoperative bleeding risk after tooth extractions and osteotomies in patients continuing AT is low, and bleeding can be controlled with local hemostatic measures. CLINICAL RELEVANCE AT should be continued in patients undergoing tooth removal procedures under the provision that local hemostatic measures are applied.
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Wahl MJ. The mythology of anticoagulation therapy interruption for dental surgery. J Am Dent Assoc 2019; 149:e1-e10. [PMID: 29304913 DOI: 10.1016/j.adaj.2017.09.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/08/2017] [Accepted: 09/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Continuous anticoagulation therapy is used to prevent heart attacks, strokes, and other embolic complications. When patients receiving anticoagulation therapy undergo dental surgery, a decision must be made about whether to continue anticoagulation therapy and risk bleeding complications or briefly interrupt anticoagulation therapy and increase the risk of developing embolic complications. Results from decades of studies of thousands of dental patients receiving anticoagulation therapy reveal that bleeding complications requiring more than local measures for hemostasis have been rare and never fatal. However, embolic complications (some of which were fatal and others possibly permanently debilitating) sometimes have occurred in patients whose anticoagulation therapy was interrupted for dental procedures. PRACTICAL IMPLICATIONS AND CONCLUSIONS Although there is now virtually universal consensus among national medical and dental groups and other experts that anticoagulation therapy should not be interrupted for most dental surgery, there are still some arguments made supporting anticoagulation therapy interruption. An analysis of these arguments shows them to be based on a collection of myths and half-truths rather than on logical scientific conclusions. The time has come to stop anticoagulation therapy interruption for dental procedures.
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de Andrade NK, Motta RHL, Bergamaschi CDC, Oliveira LB, Guimarães CC, Araújo JDO, Lopes LC. Bleeding Risk in Patients Using Oral Anticoagulants Undergoing Surgical Procedures in Dentistry: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:866. [PMID: 31447671 PMCID: PMC6696826 DOI: 10.3389/fphar.2019.00866] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/08/2019] [Indexed: 01/21/2023] Open
Abstract
The management of patients who undergo dental surgical procedures and receive oral anticoagulant therapy requires particular attention due to the risk of bleeding that may occur during the procedure. Bleeding rates in these trans- or post-operative patients tend to be unpredictable. The aim of this study was to conduct a systematic review in order to assess the risk of bleeding during and after performing oral surgery in patients administered oral anticoagulants compared with a group that discontinued anticoagulant therapy. For the purposes of this review, we searched the databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), EMBASE (via Ovid), and the Virtual Health Library (VHL) from inception of the database to December 2018. The primary outcome was defined as the occurrence of local bleeding during and after oral surgical procedures. Four reviewers, independently and in pairs, screened titles and abstracts for full-text eligibility. Data regarding participant characteristics, interventions, and design and outcomes of the included studies were extracted. The data were pooled using random-effects meta-analyses and described as risk ratios (RRs) with a 95% confidence interval (95% CI). The confidence for the pooled estimates was ascertained through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and the protocol of this review was recorded in PROSPERO (CRD42017056986). A total of 58 eligible studies were identified, of which three randomized controlled trials were included in the meta-analysis, covering a total of 323 adult participants, among whom 167 were taking anticoagulants at the time they underwent dental surgery. Of these patients, 14.2% had reported bleeding. The risk of bleeding was found to be one to almost three times greater in patients taking warfarin compared with patients who discontinued the use of anticoagulant during the trans-operative period (RR = 1.67, 95% CI = 0.97 to 2.89) and in the post-operative period (RR = 1.44, 95% CI = 0.71 to 2.92), although the quality of evidence was very low. The results indicate that there is no evidence that the use of anticoagulants eliminates the risk of bleeding during surgical dental procedures.
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Affiliation(s)
- Natália Karol de Andrade
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Rogério Heládio Lopes Motta
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | | | - Luciana Butini Oliveira
- Division of Paediatric Dentistry, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Caio Chaves Guimarães
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Jimmy de Oliveira Araújo
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Luciane Cruz Lopes
- Pharmaceutical Science Graduate Course, University of Sorocaba, Sorocaba, Brazil
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Precht C, Demirel Y, Assaf AT, Pinnschmidt HO, Knipfer C, Hanken H, Friedrich RE, Wikner J. Perioperative Management in Patients With Undergoing Direct Oral Anticoagulant Therapy in Oral Surgery - A Multicentric Questionnaire Survey. In Vivo 2019; 33:855-862. [PMID: 31028208 PMCID: PMC6559883 DOI: 10.21873/invivo.11550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/13/2019] [Accepted: 03/27/2019] [Indexed: 01/04/2023]
Abstract
AIM The purpose of this study was to survey the current opinions of hospitals and medical practices concerning the perioperative management of patients undergoing direct oral anticoagulant therapy (DOAC) and discuss recommendations for the clinical practice. MATERIALS AND METHODS A questionnaire with 13 topics and multiple ordinal-polytomous subitems was designed and sent to 120 Departments of Oral and Maxillofacial Surgery in Austria, Switzerland and Germany, as well as to 85 oral and maxillofacial/oral surgeons in medical offices in Hamburg, Germany. The data were statistically evaluated by Chi-square, Fisher's exact and Jonckheere-Terpstra tests. RESULTS The rate of response was 42%. Thirty-seven percent of respondents reported treating over 50 patients per year with undergoing DOAC therapy and only 18% assess a high bleeding risk [33% for vitamin K antagonists (VKA)]. In contrast to that, 62% of respondents would interrupt the DOAC therapy for extraction of one tooth, while 94% would continue VKA therapy. Significantly more clinicians apply suture than those in a medical office. The use of additional hemostatic measures varied between clinic and medical practice. There was a clear request for more detailed guidelines. CONCLUSION The study shows the current opinion for perioperative management of patients undergoing DOAC therapy. Multi-centric studies under controlled conditions are needed for a safer treatment of anticoagulated patients as therapy strategies differ greatly between institutions and therefore a complication analysis is hardly possible.
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Affiliation(s)
- Clarissa Precht
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yeliz Demirel
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandre T Assaf
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Knipfer
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Hanken
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reinhard E Friedrich
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Wikner
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Secondary Bleedings in Oral Surgery Emergency Service: A Cross-Sectional Study. Int J Dent 2018; 2018:6595406. [PMID: 29971108 PMCID: PMC6008757 DOI: 10.1155/2018/6595406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/23/2018] [Accepted: 04/04/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Bleeding after dental surgery is still a common cause for emergency presentation in patients using anticoagulants. Our aim was to analyze pertinent characteristic features on the one hand and to bare existing problems in handling on the other. Materials and Methods The study included 76 patients. We documented basic data, anticoagulant medication, type of surgery, and tooth socket sutures in respective patients. Results The vast majority of patients took a coumarin derivative (41) and acetylsalicylic acid (27). Nine (12%) of the patients had to be hospitalized due to ongoing bleeding despite local haemostyptic steps and/or circulatory dysregulation. Most patients could be successfully treated in outpatient settings. No statistically significant correlation between bleeding, level of INR value, number of extracted teeth, and sewed alveoli could be shown. Sixty-five percent of cases with tooth extractions did not have suture of tooth sockets. Eighty-seven percent of the patients denied being informed about possible self-treatment options by their surgeon/dentist, and none of the patients got presurgical-fabricated bandage plate(s). Conclusions Patients taking coumarin derivative currently, furthermore, represent the biggest anticoagulant after-bleeding group in dentoalveolar surgery. The major part of after-bleedings (90%) can be handled in an outpatient setting with simplest surgical interventions. Unfortunately, the biggest part of the patient collective got no suture, no prefabricated dental bandage plate(s), and no explanation by their dentist how to handle in case of after-bleeding. Therefore, dental practitioners should furthermore get enlightenment on how to prevent after-bleeding situations.
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Zirk M, Zinser M, Buller J, Bilinsky V, Dreiseidler T, Zöller JE, Kreppel M. Supportive topical tranexamic acid application for hemostasis in oral bleeding events – Retrospective cohort study of 542 patients. J Craniomaxillofac Surg 2018; 46:932-936. [DOI: 10.1016/j.jcms.2018.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/14/2018] [Accepted: 03/13/2018] [Indexed: 12/26/2022] Open
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Tranexamic acid as a local hemostasis method after dental extraction in patients on warfarin: a randomized controlled clinical study. Clin Oral Investig 2018; 22:2281-2289. [DOI: 10.1007/s00784-017-2327-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
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Wahl MJ, Miller CS, Rhodus NL, Kämmerer P, Dinkova A, Lalla RV, Bajkin BV. Anticoagulants are dental friendly. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 125:103-106. [PMID: 29249522 DOI: 10.1016/j.oooo.2017.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 10/27/2017] [Accepted: 11/03/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Michael J Wahl
- Assistant Attending Dentist, Department of Oral and Maxillofacial Surgery and Hospital Dentistry, Christiana Care Health System, Wilmington, DE, USA
| | - Craig S Miller
- Professor of Oral Medicine, Chief, Division Oral Diagnosis, Oral Medicine, Oral Radiology, Department of Oral Health Practice, University of Kentucky College of Dentistry, Lexington, KY, USA
| | - Nelson L Rhodus
- Diplomate, American Board of Oral Medicine, Morse Distinguished Professor and Director, Division of Oral Medicine, School of Dentistry, Adjunct Professor, Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Peer Kämmerer
- Specialist Plastic Surgery, Specialist, Dental Oral Surgery, Fellow of the European Board of Oro-Maxillo-Facial Surgery, Specialist for Pain Therapy of Head and Neck, Specialist for Dental Implantology, Master of Arts Management of Health Care and Social Facilities, Vice Medical Director, Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, Germany
| | - Atanaska Dinkova
- Assistant Professor, Department of Oral Surgery, Faculty of Dental Medicine, Medical University - Plovdiv, Plovdiv, Bulgaria
| | - Rajesh V Lalla
- Associate Professor, Associate Dean for Research Diplomate, American Board of Oral Medicine, Division of Oral and Maxillofacial Diagnostic Sciences, School of Dental Medicine, University of Connecticut, Farmington, CT, USA
| | - Branislav V Bajkin
- Associate Professor, Vice Dean for PhD Studies at Faculty of Medicine Novi Sad, Department of Oral Surgery, Dental Clinic of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
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Motta RHL, Bergamaschi CDC, de Andrade NK, Guimaraes CC, Ramacciato JC, Araújo JDO, Lopes LC. Bleeding risk in patients using oral anticoagulants submitted to surgical procedures in dentistry: a systematic review protocol. BMJ Open 2017; 7:e019161. [PMID: 29259064 PMCID: PMC5778277 DOI: 10.1136/bmjopen-2017-019161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The management of patients undergoing oral surgical procedures using anticoagulants raises concerns regarding the risk of bleeding. Bleeding rates in those patients during or after oral surgical procedures are uncertain. The aim of this study will be to determine the bleeding rate during and after oral surgeries in patients using anticoagulants. METHODS AND ANALYSIS A systematic review will be conducted and if appropriate, a meta-analysis of randomised clinical trials evaluating the bleeding risk during and after oral surgical procedures in patients using anticoagulants were selected. The literature search will be conducted using electronic databases, such as the Cochrane Central Register of Controlled Trials, MEDLINE (via Ovid), Embase (via Ovid), Cumulative Index to Nursing and Allied Health Literature (via Ovid), LILACS (SciELO) and CAPES database, without restriction of languages or date of publication. The primary outcome will be the occurrence of local bleeding rate during and after oral surgical procedures, and as secondary outcome, the following complications will be considered: implant failure, healing problems and infections. Groups of two independent reviewers will select the titles and abstracts for full-text eligibility. For eligible studies, the same reviewers will perform data extraction, bias risk assessment and determination of the overall quality of evidence for each of the outcomes using the Grading of Recommendations Assessment, Development and Evaluation classification system. Meta-analysis and subgroup analyses will be conducted, to all outcomes, if appropriate. ETHICS AND DISSEMINATION The systematic review will be published in a peer-reviewed journal, and brief reports of the review's findings will be released directly to the intended audience. The results will help dentists in the decision-making process to minimise the risk of bleeding in patients using anticoagulants in their clinical practice. PROSPERO REGISTRATION NUMBER CRD42017056986.
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Affiliation(s)
- Rogério Heládio Lopes Motta
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | | | - Natalia Karol de Andrade
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Caio Chaves Guimaraes
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Juliana Cama Ramacciato
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Jimmy de Oliveira Araújo
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Luciane Cruz Lopes
- Department of Pharmaceutical Sciences Graduate Program, University of Sorocaba, Sorocaba, São Paulo, Brazil
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Bleeding Rate After Tooth Extraction in Patients Under Oral Anticoagulant Therapy. J Craniofac Surg 2017; 27:1228-33. [PMID: 27380567 DOI: 10.1097/scs.0000000000002713] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The aim of this single-cohort prospective study was to evaluate the risk of adverse outcomes after tooth extraction in patients suffering from cardiovascular disorders and under oral anticoagulant therapy with an international normalized ratio within the value of 3.0. METHODS Two hundred ninety-three patients (mean age of 58.7 years) were enrolled and 560 tooth extractions were performed. Fresh extraction sockets were treated with collagen tablets and sutures. The risk of increased bleeding rate was evaluated for type of drug therapy (acenocoumarol or warfarin), type of cardiovascular diseases, and number of tooth extractions. Level of significance was set at 0.05. RESULTS The overall bleeding event rate was 6.8%. Among patients who had bleeding events, 4 suffered from valvular disorders, whereas 11 suffered from arrhythmias (8) or cardiomyopathies (3). The remaining 5 patients had a history of cardiomyopathy and arrhythmia.The bleeding events in patients who had more than 2 tooth extractions were significantly higher than those observed in patients who had only 1 tooth extraction (P <0.05). CONCLUSION Patients who received more than 2 tooth extractions, who were under treatment with acenocoumarol, and who suffered from multiple cardiovascular diseases were at high risk for bleeding events.
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Shi Q, Xu J, Zhang T, Zhang B, Liu H. Post-operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-analysis of Observational Studies. Front Pharmacol 2017; 8:58. [PMID: 28228727 PMCID: PMC5296357 DOI: 10.3389/fphar.2017.00058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/26/2017] [Indexed: 01/19/2023] Open
Abstract
Background and Objective: Minor dental surgery is invasive and hemorrhagic. Thus, in patients treated with anticoagulants, the bleeding risk related to these invasive procedures is concerning. The aim of this meta-analysis is to evaluate this risk by comparing the post-operative bleeding rates of oral anticoagulation treatment (OAT) patients (without interrupted or altered anticoagulant intake) with non-OAT patients. Methods: PubMed, Embase and the Cochrane Library were searched for eligible studies that compared the post-operative (following minor dental surgery) bleeding rates of OAT patients without interrupted or altered therapy with those of non-OAT patients. Relative risk (RR) and 95% confidence interval (CI) were calculated. Subgroup analyses were used to identify the association between the bleeding rate and different dental surgeries or anticoagulants. Results: Thirty two full text articles were assessed for eligibility and 20 studies were excluded according to the selection criteria. Finally, 12 studies and a total of 2102 OAT patients and 2271 non-OAT patients were included. A pooled analysis indicated that the post-operative bleeding risk in OAT patients is higher than that of non-OAT patients (RR: 2.794, 95% CI: 1.722-4.532, P = 0.000). The pooled RRs in the dental implant surgery and dental extraction subgroups were 2.136 (95% CI: 0.825-5.531, P = 0.118) and 2.003 (95% CI: 0.987-4.063, P = 0.054), respectively. As for the different oral anticoagulants, the pooled RR in the subgroup of new oral anticoagulants (NOACs) was 1.603 (95% CI: 0.430-5.980, P = 0.482), while the pooled RR in the vitamin K antagonists subgroup was 3.067 (95% CI: 1.838-5.118, P = 0.000). Conclusion: Under current evidence, OAT patients were under a higher post-operative bleeding risk than the non-OAT patients following minor dental surgery. For the dental implant surgeries and dental extractions, our study failed to demonstrate a higher risk of bleeding in the OAT patients compared with the non-OAT patients. Besides, The NOACs might be safer than the vitamin K antagonists in dental implant surgery. However, more well-designed studies are required for future research.
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Affiliation(s)
- Quan Shi
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Juan Xu
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Tong Zhang
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Bin Zhang
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Hongchen Liu
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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de Vasconcellos SJDA, de Santana Santos T, Reinheimer DM, Faria-E-Silva AL, de Melo MDFB, Martins-Filho PRS. Topical application of tranexamic acid in anticoagulated patients undergoing minor oral surgery: A systematic review and meta-analysis of randomized clinical trials. J Craniomaxillofac Surg 2016; 45:20-26. [PMID: 27840121 DOI: 10.1016/j.jcms.2016.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/24/2016] [Accepted: 10/04/2016] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) investigating the efficacy and safety of topical tranexamic acid (TXA) to prevent postoperative bleeding in anticoagulated patients undergoing minor oral surgery. MATERIAL AND METHODS We analyzed RCTs comparing the use of topical TXA versus other topical hemostatic agents or placebo solutions for minor oral surgeries. We assessed the risk of bias and strength of evidence according to the Cochrane guidelines and GRADE rating system, respectively. The pooled relative risk (RR) was calculated for the effect of topical application of TXA on postsurgical bleeding. RESULTS Five RCTs were included in the study. The combined RR for the number of patients receiving TXA in comparison to the control group was 0.13 (95% CI 0.05-0.36; P = 0.01), indicating a protective effect of topical TXA on bleeding after minor oral surgeries. Subgroup analysis revealed that topical TXA was effective in preventing postsurgical bleeding compared to placebo and epsilon-aminocaproic acid. No cases of thromboembolic events were reported. CONCLUSIONS Currently available evidence suggests that surgical site irrigation with TXA followed by mouthwash during the first postoperative week is safe and may reduce the risk of bleeding after minor oral surgeries in anticoagulated patients.
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Clemm R, Neukam FW, Rusche B, Bauersachs A, Musazada S, Schmitt CM. Management of anticoagulated patients in implant therapy: a clinical comparative study. Clin Oral Implants Res 2015; 27:1274-1282. [PMID: 26592859 DOI: 10.1111/clr.12732] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This prospective clinical comparative study aimed to analyze the postoperative bleeding risk of patients continuing their anticoagulation therapy (AT) and undergoing implant surgery and bone grafting procedures. MATERIALS AND METHODS The treatments ranged from the insertion of single or multiple dental implants over implant exposures to sinus floor augmentation and vertical and/or lateral bone grafting with autologous bone grafts. The patients of the test groups (AT groups) were treated with platelet aggregation inhibitors (PAIs), Vitamin-K inhibitors, Vitamin-K inhibitor withdrawal bridged with heparin (LMWH), or new/direct oral anticoagulants (NOACs/DOACs). Patients of the control group were non-anticoagulated (non-AT group). Surgical procedures were performed in the same manner in all groups. Pre, intra, and postoperative data concerning the treatment, extent of the surgery and bleedings was recorded and statistically evaluated. RESULTS There were seven postoperative bleedings in 564 patients (1.2%), four in the AT groups (3.4%), and three in the non-AT group (0.6%). No thromboembolic complication occurred in the whole observation period. The invasiveness of the surgical procedure had no statistically significant effect on bleeding frequencies. Patients taking Vitamin-K inhibitors had a significantly higher risk of a postoperative bleeding compared to patients without any AT (P = 0.038). Two patients were hospitalized due to the severity of the bleeding as a precautionary measure (one in the non-AT and one in the PAI group). All bleedings were easily controllable with local hemostatic measures. There was no postoperative bleeding recorded for patients taking DOACs. CONCLUSIONS Anticoagulation therapy should be continued in patients undergoing implant surgery and bone grafting procedures avoiding thromboembolic complications. Surgeons should always apply the most minimally invasive approach to reduce postoperative risks and be able to apply local hemostatic measures in terms of a bleeding complication.
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Affiliation(s)
- R Clemm
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - F W Neukam
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - B Rusche
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - A Bauersachs
- Private Practice Prof. Schlegel and Colleagues, Munich, Germany
| | - S Musazada
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - C M Schmitt
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Postoperative bleeding risk for oral surgery under continued rivaroxaban anticoagulant therapy. Clin Oral Investig 2015; 20:1279-82. [PMID: 26498769 DOI: 10.1007/s00784-015-1627-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 09/20/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the risk of postoperative bleeding complications after oral procedures performed under continued mono or dual anticoagulation therapy with rivaroxaban (and aspirin). METHODS This retrospective single-center observational study included 52 oral procedures performed under continued oral anticoagulant therapy with rivaroxaban (20 mg/day). Among them, two procedures were performed under continued dual therapy with aspirin (100 mg/day) added to the regimen. Postoperative bleeding events were compared with 285 oral procedures in patients without any anticoagulation/antiplatelet therapy. RESULTS Postoperative bleeding complications after oral surgery occurred significantly more often in patients under continued rivaroxaban therapy (11.5 %) than in the control cases without anticoagulation/antiplatelet medication (0.7 %). All of the bleeding events were manageable: Two of them were treated with local compression, three by applying new fibrin glue with (one case) or without (two cases) secondary sutures, one occurred during a weekend and was therefore treated under inpatient conditions with suture replacement. All postoperative bleeding episodes occurred during the first postoperative week. CONCLUSIONS According to our data, continued anticoagulation therapy with rivaroxaban significantly increases postoperative bleeding risk for oral surgical procedures, although the bleeding events were manageable. CLINICAL RELEVANCE Oral surgeons, cardiologists, general physicians, and patients should be aware of the increased bleeding risk after oral surgical procedures. Close observation up to 1 week postoperatively is advisable to prevent excessive bleeding.
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