Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants

Bleeding Disorders and Dental Implants: Review and Clinical Indications

BACKGROUND

Bleeding disorders can be divided into three categories: congenital coagulation disorders (CCDs), antiplatelet-induced bleeding disorders (APBDs) and anticoagulant-induced bleeding disorders (ACBDs). Implant placement can be challenging in these kinds of patients. The aim of this study is to provide evidence on implant surgery in patients with bleeding disorders and to generate some practical recommendations for clinicians.

MATERIAL AND METHODS

Pubmed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were screened. The latest search was performed in July 2022. Case reports, case series, cohort studies, cross-sectional studies, case control studies, reviews, consensus reports, surveys and animal studies were included in the analysis.

RESULTS

Seventeen articles on CCDs were found, fourteen on APBDs and twenty-six on ACBDs. Most of these articles were case reports or case series. Patients with CCDs can be treated after the infusion of the missing coagulation factor. Patients with APBDs can be treated without withdrawing the therapy. Patients with ACBDs should be treated depending on the anticoagulative medication.

CONCLUSION

Despite the low level of evidence, dental implants can be safely placed in patients with bleeding disorders. However, careful preoperative evaluation and the adoption of local and post-operative bleeding control measures are mandatory.

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.

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.

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.

Efficacy of Feracrylum as Topical Hemostatic Agent in Therapeutically Anticoagulated Patients Undergoing Dental Extraction: A Comparative Study

Aims and Objective

To compare the efficacy of feracrylum with tranexamic acid (TXA), following dental extraction in patients who are therapeutically anticoagulated with warfarin.

Study Design

Sixty patients on warfarin were randomly divided into three groups. Groups 1 and 2 patients were given feracrylum (1%), and TXA (5%) solution pressure pack and a control group (Group 3) was given normal saline (NS) pressure pack after extraction. Postoperative bleeding was assessed and graded numerically and periodically (0, 1, 2, 5 and 7 days). The values were statistically analyzed.

Results

Sixty patients (M:F::37:23) with a mean age of 56 years who were therapeutically anticoagulated for different medical conditions were included. The mean warfarin dosage was 3.5 mg, and the mean INR was 2.83. Out of 27 patients who showed bleeding on day of extraction, eight, ten and nine patients belonged to groups I, II and III, respectively, and the difference was nonsignificant. Out of 15 patients who showed bleeding on post-extraction day 1, one, five and nine patients belonged to groups I, II and III, respectively. The difference was statistically significant on day 1 and nonsignificant in the next follow-ups.

Conclusion

Local hemostatic agents like TXA and feracrylum arrest bleeding without having any systemic action and without the necessity of altering the anticoagulant regimen. Feracrylum has an added advantage of a single application, formation of a mechanical barrier and an additional antimicrobial effect. These agents should be incorporated in the protocol for managing patients on oral anticoagulants.

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.

Secondary Bleedings in Oral Surgery Emergency Service: A Cross-Sectional Study

Introduction

Bleeding after dental surgery is still a common cause for emergency presentation in patients using anticoagulants. Our aim was to analyze pertinent characteristic features on the one hand and to bare existing problems in handling on the other.

Materials and Methods

The study included 76 patients. We documented basic data, anticoagulant medication, type of surgery, and tooth socket sutures in respective patients.

Results

The vast majority of patients took a coumarin derivative (41) and acetylsalicylic acid (27). Nine (12%) of the patients had to be hospitalized due to ongoing bleeding despite local haemostyptic steps and/or circulatory dysregulation. Most patients could be successfully treated in outpatient settings. No statistically significant correlation between bleeding, level of INR value, number of extracted teeth, and sewed alveoli could be shown. Sixty-five percent of cases with tooth extractions did not have suture of tooth sockets. Eighty-seven percent of the patients denied being informed about possible self-treatment options by their surgeon/dentist, and none of the patients got presurgical-fabricated bandage plate(s).

Conclusions

Patients taking coumarin derivative currently, furthermore, represent the biggest anticoagulant after-bleeding group in dentoalveolar surgery. The major part of after-bleedings (90%) can be handled in an outpatient setting with simplest surgical interventions. Unfortunately, the biggest part of the patient collective got no suture, no prefabricated dental bandage plate(s), and no explanation by their dentist how to handle in case of after-bleeding. Therefore, dental practitioners should furthermore get enlightenment on how to prevent after-bleeding situations.

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.

Bleeding during and after dental extractions in patients with liver cirrhosis

Little is known about the prevention and management of acquired coagulopathies, such as those affecting cirrhotic patients. The objective of this analytic retrospective observational study was to evaluate patients on the liver transplant waiting list according to the following outcomes: (1) presence of unusual intraoperative bleeding (>10min after routine haemostatic procedures); and (2) presence of postoperative haemorrhagic complications. The outcomes were analysed according to clinical and laboratory variables. A total of 190 visits were performed for extraction of 333 teeth (ranging from 1 to 9 teeth per visit), with platelet count ranging from 16,000 to 216,000 and international normalized ratio (INR) below 3. Twelve cases (6.31%) had unusual intraoperative bleeding and 12 had postoperative haemorrhagic complications. All the events were controlled by local measures. Intraoperative bleeding was associated with low count of platelets (P=0.026). However, this counting could explain only 16% (adjusted R²=0.16) of the cases of bleeding (P=0.44), meaning that platelet function changes might be involved. Our results show that cirrhotic patients presenting platelet count above 16,000 and INR below 3 need no previous blood transfusion, with local measures being enough to manage haemorrhagic events.

Do antiplatelet drugs increase the risk of bleeding after tooth extraction? A case-crossover study

The aim of this study was to assess the risk of bleeding after tooth extraction in patients taking aspirin or clopidogrel. This case-crossover study evaluated patients taking aspirin (80mg/day) or clopidogrel (75mg/day) and undergoing tooth extraction. In the first session, extraction was performed without discontinuing aspirin (group 1) or clopidogrel (group 2). In the second session, patients ceased using antiplatelet drugs 5days prior to tooth extraction. Bleeding was evaluated using a visual analogue scale (VAS) for 72h after tooth extraction. The platelet function assay (PFA) was performed for group 1 and flow cytometry assessment of vasodilator-stimulated phosphoprotein (VASP) was performed for group 2, in both sessions. Thirty-eight patients were studied: 20 in group 1 and 18 in group 2. Analysis of the data did not demonstrate any difference in bleeding severity between sessions 1 and 2 in either group (P>0.05). There was a significant difference between sessions 1 and 2 in group 1 for the mean collagen/epinephrine membrane closure time (PFA) (P=0.001). A significant difference in platelet reactivity index (flow cytometry for VASP) was noted between sessions 1 and 2 in group 2 (P=0.001). According to this case-crossover study, dental extraction can be performed safely without withdrawal of aspirin or clopidogrel.

Predictors of oral cavity bleeding and clinical outcome after dental procedures in patients on vitamin K antagonists. A cohort study

Patients on vitamin K antagonists (VKA) often undergo invasive dental procedures. International guidelines consider all dental procedures as low-risk procedures, while bleeding risk may differ between standard low-risk (e. g. extraction 1-3 elements) and extensive high-risk (e. g. extraction of >3 elements) procedures. Therefore current guidelines may need refinement. In this cohort study, we identified predictors of oral cavity bleeding (OCB) and evaluated clinical outcome after low-risk and high-risk dental procedures in patients on VKA. Perioperative management strategy, procedure risk, and 30-day outcomes were assessed for each procedure. We identified 1845 patients undergoing 2004 low-risk and 325 high-risk procedures between 2013 and 2015. OCB occurred after 67/2004 (3.3 %) low-risk and 21/325 (6.5 %) high-risk procedures (p=0.006). In low-risk procedures, VKA continuation with tranexamic acid mouthwash was associated with a lower OCB risk compared to continuation without mouthwash [OR=0.41, 95 %CI 0.23-0.73] or interruption with bridging [OR=0.49, 95 %CI 0.24-1.00], and a similar risk as interruption without bridging [OR=1.44, 95 %CI 0.62-3.64]. In high-risk procedures, VKA continuation was associated with an increased OCB risk compared to interruption [OR=3.08, 95 %CI 1.05-9.04]. Multivariate analyses revealed bridging, antiplatelet therapy, and a supratherapeutic or unobjectified INR before the procedure as strongest predictors of OCB. Non-oral cavity bleeding (NOCB) and thromboembolic event (TE) rates were 2.1 % and 0.2 %. Bridging therapy was associated with a two-fold increased risk of NOCB [OR=1.93, 95 %CI 1.03-3.60], but not with lower TE rates. In conclusion, predictors of OCB were mostly related to perioperative management and differed between low-risk and high-risk procedures. Perioperative management should be differentiated accordingly.

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.

Topical application of tranexamic acid in anticoagulated patients undergoing minor oral surgery: A systematic review and meta-analysis of randomized clinical trials

PURPOSE

To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) investigating the efficacy and safety of topical tranexamic acid (TXA) to prevent postoperative bleeding in anticoagulated patients undergoing minor oral surgery.

MATERIAL AND METHODS

We analyzed RCTs comparing the use of topical TXA versus other topical hemostatic agents or placebo solutions for minor oral surgeries. We assessed the risk of bias and strength of evidence according to the Cochrane guidelines and GRADE rating system, respectively. The pooled relative risk (RR) was calculated for the effect of topical application of TXA on postsurgical bleeding.

RESULTS

Five RCTs were included in the study. The combined RR for the number of patients receiving TXA in comparison to the control group was 0.13 (95% CI 0.05-0.36; P = 0.01), indicating a protective effect of topical TXA on bleeding after minor oral surgeries. Subgroup analysis revealed that topical TXA was effective in preventing postsurgical bleeding compared to placebo and epsilon-aminocaproic acid. No cases of thromboembolic events were reported.

CONCLUSIONS

Currently available evidence suggests that surgical site irrigation with TXA followed by mouthwash during the first postoperative week is safe and may reduce the risk of bleeding after minor oral surgeries in anticoagulated patients.