Management of anticoagulated patients in dentoalveolar surgery: a clinical comparative study

Risk of post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants: a cohort study using the common data model

This retrospective study aimed to determine risk factors associated with post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants. Patients taking anticoagulants who were planned to undergo periodontal flap operation, tooth extraction or implant surgery were included. Patients were divided into two subgroups according to the maintenance of anticoagulants following medical consultation: (1) maintenance group and (2) discontinuation group. The analysed patient-related factors included systemic diseases, maintenance of anticoagulants and types of anticoagulant. Intra- and post-operative treatment-related factors, haemostatic methods and post-operative bleeding were collected for statistical analyses. There were 35 post-operative bleeding complications (6.5%) in the 537 included patients: 21 (8.6%) in maintenance group and 14 (4.8%) in discontinuation group. The type of anticoagulant (p = 0.037), tooth extraction combined with bone grafting (p = 0.016) and type of implant surgery (p = 0.032) were significantly related to the post-operative bleeding rate. In the maintenance group, atrial fibrillation [odds ratio (OR) = 6.051] and vitamin K inhibitors (OR = 3.679) were associated with a significantly higher bleeding risk. From this result, it can be inferred that the decision to continue anticoagulants should be made carefully based on the types of anticoagulant and the characteristics of dentoalveolar surgeries performed: extraction with bone grafting, multiple implantations and involvement of maxillary arch.

Controversies in Stoppage of Antiplatelet and Anticoagulant Medications Prior to Oral Surgery

Dental procedures can pose a risk of bleeding, and it is not uncommon for dentists to consult prescribing physicians regarding a mutual patient's antiplatelet and anticoagulant medication to prevent excessive bleeding during or after an upcoming procedure. However, there has been a growing controversy in the dental community surrounding the stoppage of these medications prior to dental procedures. Some believe that stopping these medications prior to dental procedures is necessary to reduce the risk of bleeding complications, while others argue that stopping them can increase the risk of stroke or other thromboembolic events. The debate has left many dentists and specialists unsure about the best course of action when it comes to managing bleeding risk during dental procedures.In this article, we will review the antithrombotic medications, indications, mechanism of action, and its effects on the coagulation pathway, laboratory testing and reversal agents. Also, we will explore the controversy surrounding the stoppage of novel anitplatelets (eg,: prasurgrel and ticagrelor), dual-antiplatelets, triple-antiplatelet, vitamin K antagonists (eg,: wafarin, coumadin), and direct oral anticoagulants (eg,: dabigatran, rivaroxaban, xarelto and endoxaban) in dentistry and examine the current evidence and guidelines for managing dental patients undergoing oral surgery.

Is L-PRF an effective hemostatic agent in single tooth extractions? A cohort study on VKA and DOAC patients

OBJECTIVES

The aim of this clinical observational study was to assess the efficacy of L-PRF as a hemostatic agent in patients under treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs).

MATERIALS AND METHODS

Patients under oral anticoagulant therapy (VKA or DOACs) who needed a single simple tooth extraction were enrolled. L-PRF plug was positioned inside the alveolus and secured with non-absorbable sutures. Surgical time, pain-VAS, paracetamol intake, intra-operative, post-operative biological complications, and bleeding events have been registered.

RESULTS

A total of 112 patients (59 patients for DOAC and 53 for VKA group) were enrolled. Post-operative bleeding was recorded in nine patients (17%) for VKA group and nine patients (15.3%) for DOACs group. None of the patients needed a medical support for managing of bleeding. Seven days after surgery, no cases of post-extractive complications occurred.

CONCLUSIONS

The use of L-PRF resulted in limited mild late post-operative bleedings without the need of medical intervention.

CLINICAL RELEVANCE

The use of L-PRF can be adopted for an uneventful post-operative curse in anticoagulated patients without chasing their therapy for single tooth extraction.

Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies

OBJECTIVE

The recommendations for the management of direct oral anticoagulants (DOACs) in oral surgery are inconsistent. The present review evaluated whether DOACs increase the risk of bleeding during oral surgery and postoperative complications.

STUDY DESIGN

The patients undergoing oral surgery and receiving a DOAC were compared with the patients receiving a DOAC different from the exposure, a vitamin K antagonist (VKA), or no anticoagulant. Three electronic databases were searched for eligible clinical trials and systematic reviews. The risk of bias was assessed, data were extracted, a meta-analysis was done, and the Grading of Recommendations, Assessment, Development and Evaluations certainty-of-evidence ratings were determined.

RESULTS

Three clinical trials comparing patients receiving DOAC medication with patients on a VKA were eligible. A meta-analysis of bleeding 7 days postoperatively detected no significant differences between patients continuing DOAC or VKA medication during and after surgery. All of the point estimates favored uninterrupted DOAC over VKA therapy. Tranexamic acid was topically administered to some patients.

CONCLUSIONS

Based on an interpreted trend among 3 studies with mixed patient populations, the risk of bleeding during the first 7 postoperative days may be lower for patients on uninterrupted DOAC than VKA therapy (⨁⨁⭘⭘), but the effect size of the risk is unclear. 80 of 274 included patients experienced postoperative bleeding.

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

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).

Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing bridging with heparin versus unpaused vitamin K antagonist medication

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.