Dental surgery and antiplatelet agents: bleed or die

Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2

Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.

Causes of Emergency Bleeding after Nonsurgical Periodontal Therapy in Adult Periodontitis Patients: A Retrospective Analysis

Background

Emergency gingival uncontrollable bleeding after nonsurgical periodontal therapy (NSPT) could be caused by a variety of factors; local oral factors are the main cause of gingival bleeding in most patients. Because the doctor will do a good job of evaluating the patient's physical condition before nonsurgical periodontal therapy. This study is subjected to evaluate the possible factors associated with emergency uncontrollable bleeding within 24-48 hours after NSPT. Material and Methods. A total of fifty-eight patients with emergency bleeding after NSPT in the past four years were enrolled. The related factors in patients, such as age, gender, clotting function, systemic diseases, and baseline periodontitis severity, were analyzed. The site-related factors, such as tooth type, tooth distribution, and alveolar bone resorption at the bleeding site, were compared. The possible relationship of the parameters to the causes of emergency bleeding with NSPT was also evaluated.

Results

Gingival bleeding after NSPT was registered. In this retrospective study, a total of 58 patients were selected. There were 29 males and 29 females, aged from 20 to 67 years old, with an average age of 35.21 ± 10.09 years. Among them, 8.6% were over 50 years old, and 91.4% were under 50 years old. Completed evaluations were performed in 15.5% gingivitis and 84.5% periodontitis. The causes of emergency bleeding after nonsurgical periodontal therapy in this study were residual subgingival calculus or granulation tissue in 63.79% of cases: severe gingival inflammation, 29.32%; gum trauma, 3.45%; and poor compliance, 3.45%. The therapy method before bleeding includes supragingival scaling accounted for 72.4% and subgingival scaling accounted for 27.6%. 23 cases of horizontal absorption at the bleeding site accounted for 39.66%, and 35 cases of angular absorption accounted for 60.34%. Bleeding of maxillary posterior teeth accounted for 34.48%; mandibular anterior teeth accounted for 15.52%; mandibular anterior teeth accounted for 8.62%; and mandibular posterior teeth accounted for 18.97%; multiple sites accounted for 22.41%; eliminating residual subgingival calculus and granulation tissue were the main and most effective hemostatic methods, 86.21%.

Conclusion

Residual subgingival calculus or granulation tissue and severe gingival inflammation were the main causes of emergency gingival bleeding after nonsurgical periodontal therapy. Severe gingival inflammation causing emergency bleeding was more common in maxillary posterior teeth areas. Angular alveolar bone resorption was more likely to cause bleeding than horizontal resorption. Careful debridement of residual subgingival calculus and granulation tissue was the main hemostatic method.

Assessment of Bleeding in Patients on Antiplatelets Undergoing Dental Implants

Introduction

Antiplatelet drugs are used for the secondary prevention of cardiac and cerebrovascular diseases. Clopidogrel and Aspirin are the most commonly prescribed drugs for these patients. Physicians and dentists have to weigh bleeding risks versus thrombotic risks in interrupting antiplatelet regimen. The balance of these risks for an individual patient is the primary consideration in management of dental patients who are taking antiplatelet drugs and require dental implants. The study was undertaken to assess the risk of bleeding in patients on single and dual antiplatelets undergoing dental implants.

Materials and method

65 patients were assessed for bleeding after placement of dental implants. They were divided into 2 groups: group I included 48 patients on single antiplatelets (Aspirin) and group II included 17 patients on dual antiplatelets (Aspirin and Clopidogrel) based upon the timing of coronary intervention. Bleeding was evaluated intra-operatively and post-operatively.

Results

Significant difference in bleeding was noted between group I and group II based on the Visual Analog Scale (VAS) for bleeding severity after implant placement both intra-operatively (P = 0.000) and post-operatively (P = 0.004) within 24 h. However, post-operative complication after 24 h was non-significant (P = 0.277).

Conclusion

Dental implants can be safely placed in patients on single antiplatelet drugs without discontinuing them. In patients on dual antiplatelets, risk of bleeding is mild to moderate if the drugs are continued. Consultation with treating cardiologist is a must before any kind of dental invasive surgery in patients on antiplatelets.

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).

Prospective Comparative Evaluation of Post-extraction Bleeding in Cardiovascular-Compromised Patients with and without Antiplatelet Medications

BACKGROUND AND OBJECTIVE

A considerable number of patients consulting a dental surgeon are on antiplatelet therapy, and an interruption of these agents for 3 to 7 days has been practised by majority of them prior to dental surgical intervention fearing excessive bleeding, risking the patient for the occurrence of adverse thrombotic events. The dental and medical literature shows a very low risk of excessive bleeding associated on the continuation of antiplatelet therapy. The objective of this study is to compare the bleeding following single-firm molar tooth extraction in patients who interrupt and those who continue antiplatelet therapy perioperatively.

METHODOLOGY

This is a prospective descriptive study on 170 patients on long-term low-dose antiplatelet therapy with 2 groups, each containing 85 patients-Group 1 with patients who interrupted antiplatelet therapy for 5 days before extraction and Group 2, patients who continued it perioperatively. A single molar tooth extraction was done under local anaesthesia with a vasoconstrictor. Gauze pressure pack was placed for 60 min. Socket was observed every 15 min for 1 h to look for excessive post-extraction bleeding.

RESULTS

No statistically significant differences were found in post-extraction bleeding between the patients who stopped antiplatelet therapy and those who continued it.

CONCLUSION

The bleeding risk when continuing long-term low-dose antiplatelet therapy following a single molar tooth extraction is minimal. Bleeding, if excessive, can be easily controlled by gauze pressure pack or other local haemostatic agents. Thus, dental extractions can be performed on these patients without interrupting the antiplatelet drug pre-operatively provided a thorough medical history, physician's consent and coagulation profile have been obtained prior to the procedure.

A longitudinal study to evaluate the bleeding pattern of patients on low dose aspirin therapy following dental extraction

Background and Aims:

Antiplatelet dugs are often interrupted preceding invasive dental extraction because of concern of bleeding complications. The fear of uncontrolled bleeding often prompts medical and dental practitioners to stop aspirin intake for 7 to 10 days before any surgical procedure, which puts the patient at risk from adverse thrombotic events. The aim of the study conducted was to evaluate the bleeding pattern after routine dental extraction among patients on low dose long term aspirin therapy.

Methods:

A total of 104 subjects in the age group of 30-65 years, who continued to have aspirin intake during extraction were included in the study. Dental extraction was performed without stopping aspirin therapy under local anesthesia. The post-operative blood loss was quantified by weighing the gauze pre and post operatively and adding total volume of fluid in the suction jar.

Results:

Of these 104 patients treated, 87% of patients had mild bleeding (<20 ml) and 13% of patients had moderate bleeding (20-30 ml). The total study population showed a mean blood loss of 16.15 ± 3.5 ml.

Conclusion:

Within in the limitations, our study concluded that the routine dental extraction in patients under low dose aspirin therapy did not cause clinically significant post extraction hemorrhage. Aspirin intake can be continued during routine dental extraction as post extraction bleeding encountered will be negligible.

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.

Tooth extraction without discontinuation of oral antithrombotic treatment: A prospective study

OBJECTIVE

To identify which variable, among those related to surgeries, to patients, or to antithrombotic treatments, could be considered as a bleeding indicator, and to analyze effectiveness of the local hemostatic protocols used, incidence of bleeding and healing index, depending on the number of extracted teeth, and patient antithrombotic treatment.

METHODS

Patients who underwent tooth extractions without interruption or reduction of antithrombotic treatment were prospectively followed. The exact two-tailed Fisher test was used to investigate the relationship between presence/absence of bleeding and type of hemostatic material. The effect of variables on the probability of bleeding and healing index was assessed by means of a multivariate logistic regression.

RESULTS

Two hundred and fifty-four procedures were analyzed. The incidence of bleeding was 15.75%. Severe bleeding occurred in only 6 patients (2.34%). The number of involved dental quadrants and pre-surgical antibiotic treatments were found to be positively related with bleeding. The use of vasoconstrictors during surgery resulted in a reduction of healing index scores.

CONCLUSIONS

Tooth extractions in patients on antithrombotic treatment were found to be free from significant bleeding although the involvement of more than 1 quadrant in the same procedure should be avoided.

A review of drugs that contribute to bleeding risk in general dental practice

The risk of postoperative bleeding is a daily concern for many general dental practitioners. A thorough medical and medication history must be taken to consider all risk factors, particularly drugs, that contribute to bleeding risk. While the risk from drugs such as aspirin, warfarin and clopidogrel are well known, the extent to which new antiplatelet agents and direct oral anticoagulants affect bleeding risk is less well understood. In addition, there are drugs other than antithrombotics, such as antidepressants and complementary medicines that also impair haemostasis. The aim of this paper is to provide dentists with an updated overview of the drugs commonly encountered in general dental practice that can contribute to a patient's postoperative bleeding risk.

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

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.

Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis

Bleeding is a feared complication of minor oral surgery in patients on treatment with antiplatelet agents and there is no agreed strategy regarding the cessation or not of antiplatelet treatment. The aim of this systematic review was to evaluate bleeding with minor oral surgery in patients on dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), or no antiplatelet therapy (no APT). The PubMed, Embase, Web of Science, and Cochrane Library databases were screened. Sixteen studies were included. DAPT was continued in all studies. The perioperative bleeding risk was significantly higher for DAPT than for SAPT (risk ratio (RR) 10.16, P= 0.010; risk difference (RD) 0.35, P= 0.269), but not higher compared to no APT (RR 6.50, P= 0.057; RD 0.19, P= 0.060). The postoperative bleeding risk was significantly elevated for DAPT compared to SAPT (RR 2.61, P= 0.010) and no APT (RR 3.63, P= 0.035), but only by 1% (RD 0.01, P= 0.103) and 1% (RD 0.01, P= 0.421), respectively. Clinically, this may be considered quite similar. Additionally, local haemostatic measures could control all reported bleeding and no lethal events occurred. Therefore, DAPT interruption is not advised before minor oral surgery.

Management of dental extractions in patients on warfarin and antiplatelet therapy

BACKGROUND/PURPOSE

Planning dental extractions for Taiwanese patients on antithrombotic therapy remains controversial. This study aimed to examine management of dental extraction in patients on warfarin and antiplatelet therapy.

METHODS

Subjects comprised 1331 patients, with (1) 60 on warfarin with intentional normalized ratio (INR) below 4.0 (warfarin continued: 28 patients/33 occasions; warfarin stopped and switched to heparin under hospitalization: 32 patients/37 occasions); (2) 183 on antiplatelet therapy (aspirin: 125 patients/185 occasions; clopidogrel: 42 patients/65 occasions; dual therapy: 16 patients/24 occasions); and (3) a control group of 1088 patients/1472 occasions without any antithrombotic therapy. The patient's clinico-demographic parameters, warfarin effectiveness (dose and INR levels) and antiplatelet therapy, number and type of dental extraction and incidence of postoperative bleeding were investigated.

RESULTS

Incidence of postoperative bleeding in the warfarinized group (warfarin continued: 9.1%; warfarin stopped: 8.1%) was higher than in the antiplatelet group (aspirin: 1.1%; clopidogrel: 3.1%; dual antiplatelet: 4.2%), and the control group (0.7%), but these differences were not significant and unrelated to INR or number and type of dental extraction. Postoperative hemorrhage was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in most patients.

CONCLUSION

The study indicated that there is no need to interrupt warfarin (INR<4.0) and antiplatelet therapy before dental extractions in Taiwanese patients. A sufficient hemostasis could be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin.

The Influence of Antiplatelet Drug Medication on Spine Surgery

Background

The incidence of cardiovascular and neurovascular diseases has been increasing with the aging of the population, and antiplatelet drugs (APDs) are more frequently used than in the past. With the average age of spinal surgery patients also increasing, there has been a great concern on the adverse effects of APD on spine surgery. To our knowledge, though there have been many studies on this issue, their results are conflicting. In this study, we aimed to determine the influence of APDs on spine surgery in terms of intraoperative bleeding and postoperative spinal epidural hematoma complication.

Methods

Patients who underwent posterior thoracolumbar decompression and instrumentation at our institution were reviewed. There were 34 APD takers (APDT group). Seventy-nine non-APD takers (NAPDT group) were selected as a control group in consideration of demographic and surgical factors. There were two primary endpoints of this study: the amount of bleeding per 10 minutes and cauda equina compression by epidural hematoma measured at the cross-sectional area of the thecal sac in the maximal compression site on the axial T2 magnetic resonance imaging scans taken on day 7.

Results

Both groups were homogeneous regarding age and sex (demographic factors), the number of fused segments, operation time, and primary/revision operation (surgical factors), and the number of platelets, prothrombin time, and activated partial thromboplastin time (coagulation-related factors). However, the platelet function analysis-epinephrine was delayed in the APDT group than in the NAPDT group (203.6 seconds vs. 170.0 seconds, p = 0.050). Intraoperative bleeding per 10 minutes was 40.6 ± 12.8 mL in the APDT group and 43.9 ± 9.9 mL in the NAPDT group, showing no significant difference between the two groups (p = 0.154). The cross-sectional area of the thecal sac at the maximal compression site by epidural hematoma was 120.2 ± 48.2 mm² in the APDT group and 123.2 ± 50.4 mm² in the NAPDT group, showing no significant difference between the two groups (p = 0.766).

Conclusions

APD medication did not increase intraoperative bleeding and postoperative spinal epidural hematoma. Therefore, it would be safer to perform spinal surgery without discontinuation of APD therapy in patients who are vulnerable to cardiovascular and neurovascular complications.

Do Antiplatelet Drugs Increase the Risk of Bleeding After Dental Implant Surgery? A Case-and-Crossover Study

PURPOSE

Cessation versus continuation of antiplatelet drugs in patients undergoing dental implant surgery is a controversial issue. The present study evaluated postoperative bleeding during and after dental implant surgery in patients taking aspirin (ASA) or clopidogrel.

MATERIAL AND METHODS

The present study is a case-and-crossover study. Patients who were using antiplatelet drugs and receiving 2 bilateral dental implants in the posterior region of the mandible were studied. During session 1, dental implants were placed without stopping the intake of antiplatelet drugs. During session 2, antiplatelet drugs were stopped for 5 days. In group 1, platelet activity was measured by an assay based on flow cytometry and represented the platelet reactivity index. In group 2, platelet function analysis was used to monitor the antiplatelet effect of ASA. Bleeding severity was assessed using a visual analog scale for 72 hours after dental implant placement during sessions 1 and 2. Use of antiplatelet drugs was the predictive factor of the study and bleeding severity and platelet function were the outcomes of the study.

RESULTS

Twenty-two patients composed group 1 (clopidogrel 75 mg) and 20 composed group 2 (ASA 80 mg). In group 1, bleeding severity was 4.86 ± 0.77 during session 1 and 4.59 ± 0.66 during session 2. Data analysis showed no difference in bleeding severity between sessions 1 and 2 in group 1 (P = .72). In group 2, bleeding severity was 4.05 ± 0.94 during session 1 and 3.9 ± 0.85 during session 2. There was no difference in bleeding severity between sessions 1 and 2 in patients taking ASA (P = .19).

CONCLUSION

The results suggest that continuing the intake of antiplatelet drugs did not increase bleeding after placement of dental implants.

Risk of Hemorrhage Attributed to Underlying Chronic Diseases and Uninterrupted Aspirin Therapy of Patients Undergoing Minor Oral Surgical Procedures: A Retrospective Cohort Study

Objectives

This study aimed to estimate the risk of bleeding following minor oral surgical procedures and uninterrupted aspirin therapy in high-risk patients or patients with existing chronic diseases compared to patients who did not use aspirin during minor oral surgery at a public hospital.

Methods

This retrospective cohort study analyzed the data of 2912 patients, aged 20 years or older, who underwent 5251 minor oral surgical procedures at a district hospital in Thailand. The aspirin group was comprised of patients continuing aspirin therapy during oral surgery. The non-aspirin group (reference) included all those who did not use aspirin during surgery. Immediate and late-onset bleeding was evaluated in each procedure. The risk ratio of bleeding was estimated using a multilevel Poisson regression.

Results

The overall cumulative incidence of immediate bleeding was 1.3% of total procedures. No late-onset bleeding was found. A significantly greater incidence of bleeding was found in the aspirin group (5.8% of procedures, p<0.001). After adjusting for covariates, a multilevel Poisson regression model estimated that the bleeding risk in the aspirin group was 4.5 times higher than that of the non-aspirin group (95% confidence interval, 2.0 to 10.0; p<0.001). However, all bleeding events were controlled by simple hemostatic measures.

Conclusions

High-risk patients or patients with existing chronic diseases who continued aspirin therapy following minor oral surgery were at a higher risk of hemorrhage than general patients who had not used aspirin. Nonetheless, bleeding complications were not life-threatening and could be promptly managed by simple hemostatic measures. The procedures could therefore be provided with an awareness of increased bleeding risk, prepared hemostatic measures, and postoperative monitoring, without the need for discontinuing aspirin, which could lead to more serious complications.

Clopidogrel is not associated with increased bleeding complications after full-mouth extraction: A retrospective study

BACKGROUND

To the authors' knowledge, the effect of clopidogrel on bleeding complications during full-mouth extraction has not been studied. The authors aimed to determine the safety of continued use of clopidogrel during full-mouth extraction.

METHODS

The authors performed a retrospective study of consecutive patients undergoing full-mouth extraction who were taking aspirin, clopidogrel, a combination of aspirin and clopidogrel, or neither. The main study outcomes in the 4 study groups were estimated blood loss, transfusion requirements, and complications. The authors also examined the correlation between the number of teeth extracted and estimated blood loss in various groups.

RESULTS

Seventy-one patients underwent full-mouth extraction with removal of an average of 19 teeth. The authors excluded 3 patients owing to lack of data regarding blood loss. Of the remaining 68 patients, 25 were using aspirin, 12 were using clopidogrel, 9 were using both aspirin and clopidogrel, and 22 had discontinued the use of antiplatelets. There was no significant difference in the number of teeth extracted (P = .283) and estimated blood loss (P = .111) among the 4 groups. The authors found a significant moderate correlation between the number of teeth extracted and estimated blood loss in the group using aspirin (r = 0.537; P = .006) and in the group using clopidogrel, whether alone or in combination with aspirin (r = 0.535; P = .012), but not in the group who discontinued the use of antiplatelets. There was no need for blood transfusion in any patient.

CONCLUSIONS

The results of this study provide limited evidence to suggest that continuation of clopidogrel during full-mouth extraction and preprosthetic surgery may be safe and does not appear to be associated with a significant risk of bleeding.

PRACTICAL IMPLICATIONS

Clopidogrel therapy during full-mouth extraction is not associated with significant bleeding complications and may be continued in patients who have a high risk of experiencing a cardiac event.

Prevention of post-operative bleeding in hemostatic compromised patients using native porcine collagen fleeces-retrospective study of a consecutive case series

INTRODUCTION

Various anticoagulant therapy regimes bear the risk of postsurgical bleeding events after dental extractions. Local hemostyptic measures, e.g., collagen fleeces, are applied by surgeons to prevent such bleedings. No standard protocol in prevention of bleeding events has met general acceptance among surgeons yet.

PURPOSE

The purpose of this retrospective study was to determine if post-operative bleeding can be prevented by suturing native collagen fleeces into extraction wounds immediately after teeth removal, regardless what anticoagulant regime is performed.

METHODS

A total of 741 extraction units were removed from 200 consecutive in-ward patients with or without alternation of different anticoagulant therapy regimes. Anti-vitamin K agents were the most prescribed drugs (n = 104, 52 %), followed by Acetylsalicylate (ASS) (n = 78, 39 %). Nineteen (9.5 %) patients received a dual anti-platelet therapy. Out of 104 patients receiving an anti-vitamin K agent (phenprocoumon), 84 patients were bridged, 20 patients continued to their anticoagulant therapy without alterations. Following careful tooth extraction, extraction sockets were filled using a native type I and III porcine collagen sponge (Collacone, Botiss Biomaterials, Berlin), supported by single and mattress sutures for local hemostasis. Post-operative bleeding events were rated according to their clinical relevance.

RESULTS

In the post-operative phase, 8 out of 200 consecutively treated patients experienced a post-operative bleeding event. All of them had been designated for a long-term anti-vitamin K therapy (p ≤ 0.05), and extractions were performed under a heparin bridging regime (n = 6) or an uninterrupted anti-vitamin K agent therapy (n = 2). No bleeding events occurred in patients with ASS 100 therapy or low-dose LMWH therapy (p ≤ 0.05), or in patients with dual anti-platelet therapy (0 out of 24). None of the bleeding events put patients' health at risk or required systemic intervention.

CONCLUSION

Sufficiently performed local hemostyptic measures, like the application of collagen fleeces in combination with atraumatic surgery, bears a great potential for preventing heavy bleeding events in hemostatic compromised patients, regardless of their anticoagulant therapy.

Dental extraction without stopping single or dual antiplatelet therapy: results of a retrospective cohort study

The aim of this study was to investigate the incidence of bleeding after dental extraction without stopping antiplatelet therapy. Postoperative bleeding was assessed in a total of 1271 patients who were divided into two groups: a study group comprising 183 patients on antiplatelet therapy (aspirin 125 patients/185 occasions; clopidogrel 42 patients/65 occasions; dual therapy 16 patients/24 occasions) who underwent 548 dental extractions on 274 occasions, and a control group comprising 1088 patients who were not receiving any antiplatelet or anticoagulant therapy and underwent 2487 dental extractions on 1472 occasions. The incidence of postoperative bleeding was higher in the study group (5/274, 1.8%) than in the control group (10/1472, 0.7%), and also in the dual antiplatelet subgroup (1/24, 4.2%) than in the single antiplatelet subgroups (clopidogrel: 2/65, 3.1%; aspirin: 2/185, 1.1%); however, these differences were not significant. Postoperative bleeding was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in 12 patients and by resuturing in three of the control patients undergoing extraction of impacted teeth with flap elevation. These findings indicate that there is no need to interrupt antiplatelet drugs before dental extraction.

A New Generation of Antiplatelet, and Anticoagulant Medication and the Implications for the Dental Surgeon

The management of dental patients taking either antiplatelet medication, anticoagulant medication or both has been well established in the previous literature. Recently, new generations of drugs have emerged which are becoming increasingly common, including direct thrombin inhibitors, factor X inhibitors and a new class of oral thienopyridines. The implications of these drugs for the dental surgeon are not yet fully known. Awareness remains low and there is very little information available within the literature on safe use during surgery. This review paper aims to provide some guidance for dental practitioners performing invasive procedures. CPD/CLINICAL RELEVANCE: A new generation of anticoagulant and antiplatelet drugs have serious implications for patients undergoing surgery and their use is increasing.

Oral surgery during therapy with anticoagulants-a systematic review

OBJECTIVES

Oral anticoagulation therapy (OAT) with vitamin K inhibitors protects the patients from thromboembolic events. It may however lead to excessive hemorrhage during and after an oral surgery procedure. The aim of this systematic review was to evaluate the justifications to reduce, withdraw, or alter OATs prior to minor oral surgery procedures to manage bleeding events.

MATERIALS AND METHODS

A systematic MEDLINE search was conducted for clinical studies in English or German language from 1994 to 2014 comparing patients treated with OAT, without OAT, as well as patients with altered OAT for oral surgery purposes. Relevant outcome parameters were: postoperative local hemostasis, bleeding episodes, occurrence of thromboembolic events, and other complications due to the anticoagulation medication. A hand search for references cited in the identified publications completed the review.

RESULTS

After screening of 1755 abstracts, 16 clinical studies were identified according to the selection criteria. Due to the heterogeneity of the obtained data, aggregation and synthesis were not possible. There was no significant difference in bleeding events comparing patients under continued OAT to those with reduced, altered, and/or discontinued OAT medications. Minor bleeding events in the test and control groups were successfully stopped with local measures. However, no superiority of a single hemostatic measure could be identified. Neither the international normalized ratio (INR), within the therapeutic range (2-4), nor the extent of the minor oral surgery procedure had an influence on postoperative bleeding episodes.

DISCUSSION

There is strong evidence that OAT patients undergoing minor oral surgery should not discontinue their medication in order to prevent thromboembolic complications.

CLINICAL RELEVANCE

Nonetheless, INR should be less than 4, local hemostatic measures are of high importance and patients need to be instructed and closely monitored as minor bleedings might occur more often in OAT patients.