Risk factors for bleeding after oral surgery in patients who continued using oral anticoagulant therapy

A "Tie-Over" Hemostatic Approach in Emergency Department: An Alternative Option for Recurrent Episodes of Postoperative Intraoral Hemorrhage

Objective

This case series aimed to describe a hemostatic technique that has been applied in patients admitted to emergency department (ED) of a tertiary hospital due to recurrent episodes of intraoral hemorrhage (IOH) after various dentoalveolar operations. The "tie-over" approach involved the intraoral use of Xeroform® gauze (as compressive bolster dressing) and the oral rinsing with a liquid mixture of hemostatic agents.

Materials and Methods

Between February 1, 2014, and July 31, 2017, we retrospectively reviewed the medical data and records of patients in ED who chiefly complained about IOH. The inclusion criteria were cases secondary to dentoalveolar surgeries that have been exclusively treated by tie-over bolster approach. Data such as frequency and severity of hemorrhage episodes, pain, and discomfort were assessed pre- and postoperatively.

Results

The presented technique was applied in 23 patients, but 20 of them complied with follow-up evaluation. The mean age of those patients was 60.57 years (15-82 years) with a mean follow-up time of 5.05 days. Eighteen patients were taking antithrombotic medications, either per os (oral antiplatelets and anticoagulants-OAA group) or subcutaneously (heparin group). One patient from OAA group and 2 from heparin group experienced in total 4 bleeding events postoperatively. Three of those events were recorded as minimal (oozing) and did not last over 20 min. All the patients declared satisfaction about the non-bleeding oral status.

Conclusions

In addition to its compelling outcomes, we advocate that this approach conferred physiological benefits on patients who visited ED with symptoms of anxiety and malaise, secondary to multiple, lasting, or uncontrolled episodes of IOH related to extensive surgical trauma. The presence of the gauze intraorally was short-term and created minimal discomfort.

Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications

PURPOSE

The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists.

METHODS

The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control.

RESULTS

The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period.

CONCLUSION

Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.

The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review

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.

The effect of different hemostatic agents following dental extraction in patients under oral antithrombotic therapy: a network meta-analysis

This network meta-analysis was done to thoroughly evaluate the available literature on the use of different hemostatic agents for dental extraction in patients under oral antithrombotic therapy, aiming to identify the agent with the best/worst performance in bleeding control. Considering that such patients have a higher risk of bleeding, choosing the right hemostatic is essential. Twenty-three randomized clinical trials articles were included after completing the literature search. Cyanoacrylate tissue adhesive showed a reduction in the odds of postoperative bleeding events compared with conventional methods (i.e., gauze/cotton pressure, sutures), with a tendency toward a statistical significance (OR 0.03, P = 0.051). Tranexamic acid was the only agent that demonstrated a significantly lower risk of developing postoperative bleeding events (OR 0.27, P = 0.007). Interestingly, chitosan dental dressing and collagen plug had the shortest time to reach hemostasis. However, they ranked last among all hemostatic agents, regarding bleeding events, revealing higher odds than conventional measures. Therefore, it is concluded that the use of cyanoacrylate tissue adhesive and tranexamic acid gives favorable results in reducing postoperative bleeding events following dental extractions. Although chitosan dental dressing and collagen exhibited a faster time to reach hemostasis, they led to a higher occurrence of bleeding events.

The incidence of postoperative hemorrhage after tooth extraction in patients with thrombocytopenia

Objectives

The risk of bleeding after tooth extraction in thrombocytopenia patients remains unclear. Therefore, the present study aimed to assess the risk of bleeding after tooth extraction in patients with thrombocytopenia.

Materials and Methods

The study included 220 patients who had a medical history of thrombocytopenia and underwent tooth extraction (330 teeth). The patients were divided into those who had thrombocytopenia (platelet count <150k) immediately before the tooth extraction, and those who had platelet counts that were between 150k and 250k before the extraction. Bleeding complications were recorded and compared between the patient groups.

Results

Of the 220 patients, 130 underwent tooth extractions while having thrombocytopenia (platelet count <150k), and 90 had platelet counts that were between 150k and 250k before tooth extractions. Bleeding complications occurred in 11 patients (5.0%) of the 220 patients. Among those 11 patients with bleeding complications, 10 patients (7.7%) had thrombocytopenia (platelet count <150k) of the 130 patients, and 1 patient (1.1%) had a normal platelet count of the 90 patients. There was a significant difference between the patient groups regarding bleeding after extractions (P<0.001). No significant difference in the incidence of post-extraction bleeding was found between the subgroups by platelet count within the thrombocytopenia group.

Conclusion

Thrombocytopenia (platelet count <150k) increases the risk of post-tooth extraction bleeding. Therefore, bleeding control under the proper evaluation of hemostasis and performing delicate tooth extraction procedures using hemostatic plugs is necessary during the tooth extraction of patients with thrombocytopenia.

Risk of Bleeding during Implant Surgery in Patients Taking Antithrombotics: A Systematic Review

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.

Is alteration in single drug anticoagulant/antiplatelet regimen necessary in patients who need minor oral surgery? A systematic review with meta-analysis

OBJECTIVE

This study aimed to systematically review literature about the effect of alteration of the pharmacological regimen in adult patients using anticoagulants or antiplatelets who need minor oral surgery.

MATERIAL AND METHODS

A search strategy was performed in three databases-PubMed-Medline, Scopus, and Embase-and included randomized clinical trials (either parallel or crossover), involving individuals under anticoagulant or antiplatelet therapy who underwent oral surgeries. Studies comprised two groups: those who stopped their medication prior to the dental procedure (control) or those who did not (test). Meta-analyses were conducted for the pooled risk ratio (RR) between the groups. Subgroup analyses were performed for anticoagulant and antiplatelet therapies.

RESULTS

Thirteen studies were included. It was found that patients who did not stop therapy had 157% higher intraoperative bleeding occurrences (95%CI: 1.40-4.71). In the subgroup analysis, warfarinazed patients showed significantly higher occurrences of intraoperative bleeding when compared with the control (RR: 1.79; 95%CI: 1.00-3.21). Conversely, there was no statistically significant difference in postoperative bleeding between the groups (RR: 0.81; 95%CI: 0.54-1.22; p = 0.42).

CONCLUSION

Minor oral surgeries can be safely performed in patients under antiplatelets or anticoagulants without drug regimen modification. Because these patients tend to bleed more during procedures, use of local hemostatic measures is strongly advised.

CLINICAL RELEVANCE

Management of patients under antiplatelet or anticoagulant drugs is still challenging in clinical practice. However, clinicians may perform minor oral surgeries safely without changing the pharmacological regimen. Use of local hemostatic measures is strongly advised during these procedures.

The Dentoalveolar Surgical Patient: Perioperative Principles Based on Contemporary Controversies

Dentoalveolar surgery comprises more than 50% of the practice of oral and maxillofacial surgeons worldwide and is the most commonly performed category of surgical procedure. Optimal strategies for management of many medical problems, however, remain unclear. Remaining current on medical and surgical perioperative strategies is a standard for best practice. This article provides contemporary approaches for the perioperative management of patients presenting for dentoalveolar surgery. Attention will be directed to the perioperative management of cardiovascular disease, diabetes, and obesity. These diseases are chosen owing to controversies with respect to good scientific evidence that supports a standard of perioperative care.

Effect of warfarin discontinuation on the incidence of postoperative bleeding in tooth extraction

Objectives

The number of patients undergoing oral anticoagulant therapy for cardiovascular and cerebrovascular disease is increasing. However, the risk of bleeding after tooth extraction in patients receiving warfarin is unclear. Here, we assess the risk of bleeding after tooth extraction in patients on warfarin.

Materials and Methods

The study included 260 patients taking warfarin who underwent tooth extraction (694 teeth). The patients were divided into those whose teeth were extracted while they were taking warfarin, those who discontinued warfarin before extraction, and those who underwent extraction while receiving heparin bridging therapy. Bleeding complications in the two groups were compared.

Results

Of the 260 patients, 156 underwent extraction while taking warfarin, 70 stopped taking warfarin before extractions, and 34 received heparin bridging therapy and stopped taking either medication before extractions. Bleeding complications occurred in 9 patients (3.5%) and 9 tooth sites (1.3%). Among the 9 patients with bleeding complications, 6 underwent extraction while taking warfarin, 2 stopped warfarin before extraction, and 1 underwent extraction after receiving heparin bridging therapy. No significant difference was seen between patient groups regarding bleeding after extractions (P=0.917).

Conclusion

Warfarin use does not increase the risk of post-extraction bleeding and can therefore be continued during tooth extraction.

Overnight hospital stay and/or extended recovery period may allow long-duration oral and maxillofacial surgeries in the operating room of a dental hospital in an outpatient setting: a single-center experience

Objectives

The requirement for overnight hospital stay should be considered preoperatively according to patient-related factors, type of surgery, and anesthetic management plan. In this study, we aimed to define the major factors that influence consideration of overnight hospital stay in patients undergoing oral and maxillofacial (OMF) surgery in an operating room (OR) of a dental hospital in an outpatient setting.

Materials and Methods

The records of patients who underwent oral procedures under general anesthesia between 2014-2017 were reviewed.

Results

A total of 821 patients underwent oral procedures under general anesthesia; 631 of them underwent OMF surgery in the OR of a dental hospital, and 174 of these patients were hospitalized for overnight stay. There was no significant difference in the number of patients with comorbidities between the outpatient and hospitalized patient groups (P=0.389). The duration of surgery was longer in the hospitalized patient group (105.25±57.48 vs 189.62±82.03 minutes; P<0.001). Double-jaw (n=15; 310.00±54.21 minutes) and iliac crest grafting surgeries (n=59; 211.86±61.02 minutes) had the longest durations. Patients who underwent iliac crest grafting had the highest rates of hospitalization (79%). The overall recovery period was longer in outpatients (119.40±41.60 vs 149.83±52.04; P<0.001).

Conclusion

Duration of surgery was the main determinant in considering whether a patient required overnight hospital stay. However, patients with an American Society of Anesthesiology physical status score <3 may be scheduled for OMF surgery in the OR of a dental hospital in an outpatient setting regardless of duration of surgery if overnight hospital stay is planned or an extended recovery period is provided until patients meet the discharge criteria.

Treatment of the Dental Patient with Bleeding Dyscrasias: Etiologies and Management Options for Surgical Success in Practice

The oral health care provider sees a significant number of patients in his or her practice who suffer from systemic diseases affecting the ability to clot. These medical issues can be acquired or inherited bleeding dyscrasias requiring pharmacologic therapy during the perioperative period. Patients with inherited or acquired bleeding disorders require careful attention with respect to the assessment of bleeding risk. This article develops algorithms to manage acquired and inherited bleeding dyscrasias. These approaches include a discussion of the epidemiology of bleeding disorders in surgical patients, mechanism of hemostasis, and strategies for patient management based on the etiology of bleeding disorder.

Oral Health Status of Hospitalized Patients With Type 2 Diabetes

BACKGROUND

Diabetes is associated with poor oral health, as well as reduced access to dental care. A large percentage of patients hospitalized in the United States carry a diagnosis of diabetes; however, the oral health status of patients with diabetes who are hospitalized is unknown.

METHODS

All patients meeting inclusion criteria on the general medicine service of a tertiary care hospital were invited to participate. Subjects were asked about their access to dental care and perceptions of their oral health. A dental hygienist conducted examinations, including decayed, missing, and filled teeth (DMFT) and periodontal screening and recording (PSR) indices on a subset of subjects.

RESULTS

The 105 subjects had a mean age of 69 ± 12 years and a median A1C of 7.5 ± 2.1%. Rates of comorbidity and polypharmacy were high. The mean number of DMFT was 23.0 ± 7.2, with 10.1 ± 7.2 missing teeth. Forty- four percent of subjects had a removable prosthesis. Sixty-eight percent had a PSR index ≥4 in at least one sextant, indicating moderate periodontal disease.

CONCLUSION

Rates of missing teeth, removable prostheses, and periodonal inflammation were high among hospitalized patients with diabetes, but patients did not perceive their oral health to be poor. Health care providers should be aware of the oral health risks of patients with diabetes during hospitalization, and dentists should consider screening patients with diabetes for recent hospitalization.

Factors Influencing the Onset of Intra- and Post- Operative Complications Following Tooth Exodontia: Retrospective Survey on 1701 Patients

Complications after tooth extraction may occur because of several factors correlated to the patient's medical history, surgical site or type of intervention. The aim of this retrospective cohort study was to evaluate type and frequency of complications after exodontic surgery, its correlation with antibiotic administration and between patient's related systemic factors. From June 2015 until February 2016 1701 exodontic interventions, for a total of 2322 extracted teeth, were carried out at the Unit of Oral Surgery in Trieste. Descriptive statistic, and backward multiple logistic regressions were performed to identify the variables associated with the presence of post-operative alveolitis or any other post-operative complication. The presence of coagulopathy and smoking habit were related to high risk of post-operative alveolitis (OR = 5.51, p = 0.035 and OR = 2.5, p = 0.029, respectively). Tooth fracture was found to be correlated with higher probability of post-operative alveolitis (p = 0.001) and concomitant chemotherapy put at a higher risk post-operative complications, including alveolitis (OR = 29.5, p = 0.018). According to the present results, antibiotic consumption did not seem to reduce the incidence of post-operative infective complications (alveolitis). A careful analysis of medical history, the adequate surgical technique, and the correct instructions in post-surgical behavior, prevent the insurgence of intra and post-operative complications.

Prevalence of and risk factors for postoperative hemorrhage after lower third molar extraction on warfarin therapy: a multicenter retrospective study in Japan

Postoperative hemorrhage after tooth extraction is a critical and clinically important issue for clinicians and patients receiving anticoagulants. The purpose of the present study was to investigate the prevalence of and risk factors for postoperative hemorrhage after lower third molar extraction in Japanese patients receiving warfarin therapy. A total of 142 patients who underwent lower third molar extraction between January 2010 and December 2016 were included, and their medical records were retrospectively reviewed. The prevalence of and risk factors for postoperative hemorrhage were investigated. The prevalence of postoperative hemorrhage after lower third molar extraction was significantly higher in patients receiving warfarin than in healthy subjects (21.8% vs 0.7%, P < 0.001). The cutoff value for PT-INR was 2.11 based on a receiver-operating characteristic analysis. A multivariate analysis indicated that an elevated PT-INR value [hazard ratio (HR) 3.798, 95% confidence interval (CI) 1.400-10.467, P < 0.01], preoperative antibiotic administration (HR 4.434, 95% CI 1.591-14.775, P < 0.01), difficulties with intraoperative hemostasis (HR 16.298, 95% CI 2.986-110.677, P < 0.01), and higher serum creatinine levels (HR 7.465, 95% CI 1.616-39.576, P < 0.05) are significant predictors of postoperative hemorrhage after lower third molar extraction. Multivariate correlations were observed between risk factors including an elevated PT-INR value, preoperative antibiotic administration, and higher serum creatinine levels, and postoperative hemorrhage after lower third molar extraction in patients receiving warfarin therapy. Clinicians need to consider these risk factors for postoperative hemorrhage after the lower third molar extraction and monitor PT-INR in patients receiving warfarin therapy.

Bleeding Risk in Patients Using Oral Anticoagulants Undergoing Surgical Procedures in Dentistry: A Systematic Review and Meta-Analysis

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.

Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review

OBJECTIVE

The interruption of antithrombotics prior to tooth removal because of the fear of bleeding or following postoperative bleeding increases the risk of thromboembolic events. The aim of this systematic review was to investigate which local haemostatic measures can effectively prevent postoperative bleeding in patients continuing oral antithrombotics.

METHODS

A systematic review was conducted by running a search in PubMed, Embase, Web of Science and Cochrane Library. Clinical randomised trials investigating bleeding and haemostatics after tooth removal in patients on antithrombotics were identified.

RESULTS

In total, 15 articles were included. The investigated haemostatics included gauze pressure, tranexamic acid-soaked gauze, sponges, glue, calcium sulfate, plant extract Ankaferd Blood Stopper, epsilon-aminocaproic acid and tranexamic acid. In patients treated with vitamin K antagonists, tranexamic acid mouthwash significantly reduced bleeding compared to placebo. Further, histoacryl glue was proven better than gelatin sponges. Other studies failed to show significant differences between haemostatics, but bleeding events were low.

CONCLUSIONS

Tranexamic acid seems to effectively reduce bleeding, although its superiority to other haemostatics was not proven. In view of the rapidly changing landscape of antithrombotics and the lack of standardization of bleeding outcome, adequately powered clinical studies are required to optimise postoperative management in patients on antithrombotics.

CLINICAL RELEVANCE

In order to optimise postoperative management, the best haemostatics over different patient groups have to be identified and implemented in guidelines.

Oral anticoagulant therapy and tooth extraction, does the evidence support drug holidays?

Data sourcesPubMed, EMBASE, Web of Science, Cochrane library, China Biology Medicine Disc (CBM), China National Knowledge infrastructure (CNKI).Study SelectionThis study included only human randomised controlled trials (RCTs) and clinical controlled trials (CCTs). To be included studies had to include patients prescribed oral anticoagulant therapy (OAT) requiring dental extraction(s). Comparison was made between patients discontinuing OAT for the dental extraction(s) and those continuing with their OAT. The outcome measured was post-operative bleeding identified by clinician or patient.Data extraction and synthesisThe methods of data extraction were based on the Cochrane Handbook for Systematic Reviews of Interventions. The search was carried out by two reviewers from the data sources listed above. There was no indication of hand searching references of relevant studies or reputable publications, nor any mention of contacting clinical experts or researchers in this field. Language restrictions were unclear. The included studies were assessed for bias using a seven point classification, and a clear traffic light diagram was included to demonstrate the risk of bias of the included studies.ResultsNine hundred and sixty-eight studies were identified with six meeting the inclusion and exclusion criteria. Of the six studies, four were RCTs and two were CCTs encompassing 314 subjects who continued their OAT during tooth extraction(s) and 277 who discontinued their OAT to allow for tooth extraction(s). Five of the six studies were found to have high risk of bias.A meta-analysis of the six studies was conducted. The incidence of post-operative bleeding was 10.8% where OAT was continued and 8.3% where it was discontinued, showing no statistically significant difference. The relative risk ratio to continuing OAT during tooth extraction was 1.31 and 95% confidence interval, albeit with a wide range of 0.79-2.14.ConclusionsAccording to the current literature available on this subject, the results of this meta-analysis suggest that patients continuing OAT during tooth extraction do not have an increased incidence of post-operative bleeding following tooth extraction compared to patients who discontinue their OAT.

Bleeding risk in patients using oral anticoagulants submitted to surgical procedures in dentistry: a systematic review protocol

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.

The risk factors associated with postoperative hemorrhage after tooth extraction: a multi-center retrospective study of patients receiving oral antithrombotic therapy

The purpose of this study was to retrospectively investigate the multivariate relationships between specific risk factors and postoperative hemorrhage after tooth extraction in patients who were prescribed oral antithrombotic therapy. Risk factors for postoperative hemorrhage after tooth extraction were evaluated using univariate and multivariate analyses. Patient characteristics such as age and gender; the presence or absence of known comorbidities such as diabetes mellitus, hypertension, cerebral infarction, and alcohol consumption; and perioperative diarrhea were assessed. The drug used for antithrombotic therapy, preoperative blood test results, the presence or absence of preoperative antibiotics or nonsteroidal anti-inflammatory drug (NSAID) administration, the total number of extracted teeth, and the type of surgical procedures were also evaluated. We found that the preoperative administration of antibiotics (odds ratio (OR) = 2.52), an increased prothrombin time international normalized ratio (PT-INR) value (OR = 1.94), and the extraction of multiple teeth (OR = 2.10) were significantly associated with postoperative hemorrhage. There was no significant association between postoperative hemorrhage and any other demographic factors or comorbidities, including concomitant alcohol use. We demonstrated the multivariate relationship between the risk factors and postoperative hemorrhage after tooth extraction in patients receiving oral antithrombotic therapy. Surgeons should be aware of these risks and monitor the PT-INR of anticoagulated patients.

Bleeding Rate After Tooth Extraction in Patients Under Oral Anticoagulant Therapy

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.

Post-operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-analysis of Observational Studies

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.

Electrocauterization and no packing may be comparable with nasal packing for postoperative hemorrhage after endoscopic sinus surgery

BACKGROUND

Nasal packing is commonly performed after functional endoscopic sinus surgery (FESS). However, nasal packing is associated with higher cost (owing to the cost of packing materials), patient discomfort, delayed wound healing, and concern about toxic shock syndrome. Some surgeons have been performing FESS without packing, but there are few studies that show its safety.

OBJECTIVE

The purpose of this study was to evaluate the safety of electrocauterization and no packing.

METHODS

A total of 490 patients who underwent bilateral FESS for chronic rhinosinusitis were included in this retrospective study, 242 in the nasal packing group and 248 in the electrocauterization and no-packing group. Electrocauterization was performed by using a suction coagulator. Rates of immediate (first 24 hours after surgery) and delayed postoperative bleeding were compared. Patient characteristics, including concomitant disease and medication history, and Lund-Mackay computed tomography score were also assessed Results: There were no significant differences in age; sex; Lund-Mackay score; use of anticoagulant drugs; or prevalence of hypertension, diabetes, or asthma between the two groups. In the electrocauterization and no-packing group, there were fewer patients with allergic rhinitis and more smokers. Primary bleeding did not occur in the nasal packing group, but 11 patients (4.4%) had delayed bleeding. Primary bleeding occurred in four patients (1.7%) in the electrocauterization and no-packing group, and five patients (2.1%) had delayed bleeding. There were no significant differences in primary (p = 0.058) and secondary bleeding (p = 0.142) between the two groups. All bleeding was minor and easily controlled. Multivariate logistic regression analysis ruled out significant correlation between no packing and postoperative bleeding.

CONCLUSION

This study provided evidence that, in terms of postoperative hemorrhage, the safety of the electrocauterization and no-packing technique after FESS was comparable with that of nasal packing.

Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery

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.

The BRIDGE trial: What the hospitalist should know

Atrial fibrillation patients often require warfarin interruption for an invasive procedure or surgery. Heparin bridging therapy has been frequently used during warfarin interruption under the premise of providing a theoretical mitigation against thromboembolism that overweighs expected higher rates of bleeding. Up until recently, little definite clinical evidence was available to guide the hospitalist on optimal perioperative anticoagulant management. The landmark BRIDGE (Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation) trial provided high-quality evidence that a simple interruption of warfarin in the average atrial fibrillation patient undergoing an elective procedure or surgery is noninferior to bridging therapy for efficacy and superior to bridging therapy in preventing major bleeding. To guide the hospitalist, we propose a treatment algorithm based on these recent data. We review the literature that led to the trial and highlight its practice-changing implications as a proof of concept that calls to question the premise of heparin bridging therapy beyond the atrial fibrillation population. Journal of Hospital Medicine 2016;11:652-657. © 2016 Society of Hospital Medicine.

Oral surgery in a patient with cirrhosis and thrombocytopenia: a case report

PURPOSE

While most oral surgical procedures can be safely performed in an outpatient setting, certain medical conditions may present a higher chance of postoperative complications. In particular, those predisposing the patient to bleeding abnormalities pose a potential risk when performing such treatments. The authors report a case involving full-mouth extractions in a patient with cirrhosis and thrombocytopenia after obtaining a platelet transfusion.

METHODS/CASE

A 62-year-old Caucasian female presented to a university special care dental clinic requiring extractions. Her pertinent medical history was remarkable for cirrhosis and thrombocytopenia, with a platelet count of 32,000/uL. Upon medical consultation, the patient was appointed for a prophylactic platelet transfusion. The surgery was rendered uneventfully, and the patient achieved adequate hemostasis without hospitalization.

CONCLUSION/CLINICAL RELEVANCE

Patients with cirrhosis pose a potential bleeding risk with dental surgical procedures. Pre-operative medical consultation, review of pertinent laboratory values, and prophylactic platelet transfusion allow these patients to be managed safely in an outpatient setting.