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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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Aslam RD, Liew J, Besi E. Is 1:1000 adrenaline as a topical haemostat an effective alternative to control bleeding in dentistry and oral surgery? Br Dent J 2023; 235:29-34. [PMID: 37443224 PMCID: PMC10344775 DOI: 10.1038/s41415-023-6010-7] [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: 02/19/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 07/15/2023]
Abstract
Minor oral surgery can give rise to bleeding intra- and post-operatively. This can be minimal in most patients; however, it can be more problematic in patients with impaired clotting disorders, liver disease, or taking any form of anticoagulation therapy. Haemostatic agents are available to overcome such bleeding risks. The topical application of 1:1000 adrenaline used in medicine can be considered for use in dentistry. Adrenaline is widely used within medicine, surgery and dentistry. Examples include its use in local anaesthetic agents, in the management of anaphylaxis and as part of the cardiopulmonary resuscitation algorithm. 1:1000 adrenaline used topically for ear, nose and throat surgeries has shown improved visual fields during surgery with better surgical outcomes. It is relatively safe, but in patients with cardiovascular comorbidities, it should be practised with caution. This has precipitated the idea for its use within oral surgical procedures, including canine exposures, third molar surgery, root displacement into the antrum and periapical surgery. The haemostatic effect of 1:1000 adrenaline as an alternative should be considered in operative dentistry and oral surgery to aid in haemostasis and improve intra-operative visualisation, reducing the risk of iatrogenic damage and bleeding, thereby improving treatment outcomes.
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Affiliation(s)
- Raj D Aslam
- Dental Core Trainee 2 in Oral Surgery, Edinburgh Dental Institute, UK.
| | - Jonathan Liew
- Specialty Registrar in Oral Surgery, St Luke´s Hospital, UK
| | - Eleni Besi
- Senior Clinical Lecturer and Honorary Consultant in Oral Surgery, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, UK
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Mahardawi B, Jiaranuchart S, Rochanavibhata S, Arunjaroensuk S, Mattheos N, Pimkhaokham A. The role of hemostatic agents after tooth extractions: A systematic review and meta-analysis. J Am Dent Assoc 2023:S0002-8177(23)00277-5. [PMID: 37367710 DOI: 10.1016/j.adaj.2023.05.003] [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: 11/08/2022] [Revised: 04/20/2023] [Accepted: 05/06/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Hemostatic agents are used to control bleeding after tooth extraction and have been compared with conventional measures (that is, sutures or gauze pressure) in several studies. The objective of this systematic review was to evaluate the benefits of topical hemostatic agents for controlling bleeding after tooth extractions, especially in patients receiving antithrombotic therapy. TYPES OF STUDIES REVIEWED The authors conducted a literature search in MEDLINE (PubMed), Scopus, and the Cochrane Central Register of Controlled Trials, including prospective human randomized clinical trials in which researchers compared hemostatic agents with conventional methods and reported the time to achieve hemostasis and postoperative bleeding events. RESULTS Seventeen articles were eligible for inclusion. Hemostatic agents resulted in a significantly shorter time to achieve hemostasis in both healthy patients and patients taking antithrombotic drugs (standardized mean difference, -1.02; 95% CI, -1.70 to -0.35; P = .003 and standardized mean difference, -2.30; 95% CI, -3.20 to -1.39; P < .00001, respectively). Significantly fewer bleeding events were noted when hemostatic agents were used (risk ratio, 0.62; 95% CI, 0.44 to 0.88; P = .007). All forms of hemostatic agents (that is, mouthrinse, gel, hemostatic plug, and gauze soaked with the agent) had better efficacy in reducing the number of postoperative bleeding events than conventional hemostasis measures, except for hemostatic sponges. However, this was based on a small number of studies in each subgroup. CONCLUSIONS The use of hemostatic agents seemed to offer better bleeding control after tooth extractions in patients on antithrombotic drugs than conventional measures. PRACTICAL IMPLICATIONS Findings of this systematic review may help clinicians attain more efficient hemostasis in patients requiring tooth extraction. This systematic review is registered in the PROSPERO database. The registration number is CRD42021256145.
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von Beckerath O, Kröger K, Santosa F, Nasef A, Kowall B, Stang A. Increasing Use of Anticoagulants in Germany and Its Impact on Hospitalization for Tooth Extraction. Hamostaseologie 2021; 42:174-179. [PMID: 34814217 DOI: 10.1055/a-1528-0513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES This article aimed to compare nationwide time trends of oral anticoagulant prescriptions with the time trend of hospitalization for tooth extraction (TE) in Germany from 2006 through 2017. PATIENTS AND METHODS We derived the annual number of hospital admissions for TE from the Nationwide Hospital Referral File of the Federal Bureau of Statistics and defined daily doses (DDD) of prescribed anticoagulants in outpatients from reports of the drug information system of the statutory health insurance. RESULTS From 2005 to 2017, annual oral anticoagulation (OAC) treatment rates increased by 143.7%. In 2017, direct oral anticoagulants (DOACs) represented 57.1% of all OAC treatments. The number of cases hospitalized for TE increased by 28.0 only. From all the cases hospitalized for TE in Germany in 2006, 14.2% had a documented history of long-term use of OACs. This proportion increased to 19.6% in 2017. Age-standardized hospitalization rates for all TE cases with long-term use of OACs increased from 6.6 in 2006 to 10.5 cases per 100,000 person-years in 2014 and remained almost unchanged thereafter. CONCLUSION Our comparison showed that the large increase in OAC treatment rates in general from 2006 to 2017 had only a small impact on hospitalized TE cases with long-term use of OAC which flattens since 2014.
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Affiliation(s)
| | - Knut Kröger
- Clinic of Vascular Medicine, HELIOS Klinik Krefeld, Krefeld, Germany
| | - Frans Santosa
- Faculty of Medicine, Universitas Pembangunan Nasional Veteran Jakarta, Jakarta, Indonesia
| | - Ayat Nasef
- Clinic of Vascular Medicine, HELIOS Klinik Krefeld, Krefeld, Germany
| | - Bernd Kowall
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States
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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: 0] [Impact Index Per Article: 0] [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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Costa-Tort J, Schiavo-Di Flaviano V, González-Navarro B, Jané-Salas E, Estrugo-Devesa A, López-López J. Update on the management of anticoagulated and antiaggregated patients in dental practice: Literature review. J Clin Exp Dent 2021; 13:e948-e956. [PMID: 34603625 PMCID: PMC8464381 DOI: 10.4317/jced.58586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Oral antiplatelet and anticoagulant drugs are widely used in a large number of patients visiting the dentist, and there has been much controversy over the years towards their clinical management. The aim to carry out a literature review in order to develop an update on dental management in anticoagulated and / or anti aggregated patients, focusing on oral surgery.
Material and Methods A bibliographic search was carried out in PubMed on studies published between January 1, 2018, until December 10, 2020, using the keywords (“antiplatelet” OR “antiplatelets”) AND (“dentistry”), and (“anticoagulant” OR “anticoagulants”) AND (“dentistry”).
Results The number of studies included in this review was 13, and the number of patients among all of them was 3.497 patients under treatment with some type of antithrombotic drug, who underwent different oral surgery treatments.
Conclusions There is a low risk of peri- and postoperative bleeding events during basic oral surgery treatments in antiplatelet or anticoagulated patients, which can be easily managed through the use of local haemostatic measures. Key words:Oral surgery, antiplatelet drugs, anticoagulant drugs, dental treatment.
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Affiliation(s)
- Jesús Costa-Tort
- DDS, Master's student. School of Dentistry, University of Barcelona. University Campus of Bellvitge, Barcelona, Spain
| | - Verónica Schiavo-Di Flaviano
- DDS, Master's degree. School of Dentistry, University of Barcelona. University Campus of Bellvitge, Barcelona, Spain
| | - Beatriz González-Navarro
- DDS, Professor of Master's degree. School of Dentistry, University of Barcelona. University Campus of Bellvitge, Barcelona, Spain
| | - Enric Jané-Salas
- PhD, DDS, MD. Professor of Oral Pathology. Department of Odontostomatology. Faculty of Medicine and Health Sciences (Dentistry), University of Barcelona. University Campus of Bellvitge, Barcelona, Spain / Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Estrugo-Devesa
- PhD, DDS, MD. Professor of Oral Pathology. Department of Odontostomatology. Faculty of Medicine and Health Sciences (Dentistry), University of Barcelona. University Campus of Bellvitge, Barcelona, Spain / Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José López-López
- DDS, MD, PhD, Department of Odontoestomatology. Faculty of Medicine and Health Sciences (School of Dentistry), University of Barcelona. University Campus of Bellvitge, Barcelona, Spain. / Dental Hospital University of Barcelona, (Barcelona University) / Oral Health and Masticatory System Group (Bellvitge Biomedical Research Institute) IDIBELL, Barcelona, Spain
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Lupi SM, Baena ARY. Patients Taking Direct Oral Anticoagulants (DOAC) Undergoing Oral Surgery: A Review of the Literature and a Proposal of a Peri-Operative Management Protocol. Healthcare (Basel) 2020; 8:healthcare8030281. [PMID: 32825272 PMCID: PMC7551164 DOI: 10.3390/healthcare8030281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/16/2022] Open
Abstract
Patients on anticoagulant therapy for the prevention of cardiovascular accidents present an increased risk of bleeding following dental and oral surgery. Four recently introduced non-vitamin K antagonist oral anticoagulants, namely dabigatran etexilate (direct thrombin inhibitor), rivaroxaban, apixaban, and edoxaban (Xa factor direct inhibitor), are widely spreading for convenience of use compared to the older drug class. Dental management of patients taking these drugs has substantial differences compared to patients on vitamin K antagonist therapy. Anticoagulation is not assessed directly through a hematological test, but indirectly by renal function. The interventions must be scheduled at the time of minimum blood concentration of the drug. Bleeding can occur even after several days following the surgery. The interaction with drugs administered for dental care must be carefully evaluated. The peri-operative diet can influence the risk of bleeding. Local measures favoring coagulation must be adopted. The interventions with higher risk must be divided into multiple less invasive interventions. Although antidotes exist for these drugs, their use does not seem necessary for dental interventions that have been planned optimally. Furthermore, in this review of the literature a decision protocol is proposed for the evaluation of the suspension of the anticoagulant drug before oral surgery. Cessation of any anticoagulant should only be made in consultation with the patient’s general practitioner/cardiologist, who will weigh up the risk of bleeding from the proposed procedure with the risk of thrombosis/stroke in each individual patient.
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Affiliation(s)
- Saturnino Marco Lupi
- Department of Clinical Surgical, Pediatric and Diagnostic Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-382-516-255
| | - Arianna Rodriguez y Baena
- Department of Dentistry, IRCCS San Raffaele Hospital, 20123 Milan, Italy;
- Dental School, Vita Salute University, 20132 Milan, Italy
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Severe Enoral Bleeding with a Direct Oral Anticoagulant after Tooth Extraction and Heparin Bridging Treatment. Case Rep Emerg Med 2019; 2019:6208604. [PMID: 31781415 PMCID: PMC6875271 DOI: 10.1155/2019/6208604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/18/2019] [Accepted: 08/08/2019] [Indexed: 12/04/2022] Open
Abstract
Background The number of patients receiving direct oral anticoagulants (DOACs) is increasing, however, this treatment is associated with the risk of bleeding. More than 10 percent of patients on DOACs have to interrupt their anticoagulation for an invasive procedure every year. For this reason, the correct management of DOACs in the perioperative setting is mandatory. Case Presentation An 81-year-old male patient, with known impaired renal function, presented to our emergency department with a severe enoral bleeding after tooth extraction. The DOAC therapy—indicated by known atrial fibrillation—was interrupted perioperatively and bridged with Low Molecular Weight Heparin (LMWH). The acute bleeding was stopped by local surgery. The factors contributing to the bleeding complication were bridging of DOAC treatment, together with prolonged drug action in chronic kidney disease. Conclusion In order to decide whether it is necessary to stop DOAC medication for tooth extraction, it is important to carefully weigh up the individual risks of bleeding and thrombosis. If DOAC therapy is interrupted, bridging should be reserved for thromboembolic high-risk situations. Particular caution is required in patients with impaired kidney function, due to the risk of accumulation and prolonged anticoagulant effect of both DOACs and LMWH.
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