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Kyyak S, Jari A, Heimes D, Heider J, Kämmerer PW. Platelet-rich fibrin ensures hemostasis after single-tooth removal under factor Xa inhibitors - a clinical prospective randomized split-mouth study. Clin Oral Investig 2023; 27:7275-7283. [PMID: 37864605 PMCID: PMC10713775 DOI: 10.1007/s00784-023-05317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVES In this prospective, double-blinded, randomized split-mouth study, the local hemostatic effect of platelet-rich fibrin (PRF) inserted into the extraction socket in patients taking factor Xa (FXa) inhibitors (apixaban, rivaroxaban, edoxaban) was compared to a hemostatic gelatine sponge (GS) as the "therapeutic gold standard" without withdrawal of oral anticoagulant therapy. MATERIALS AND METHODS Single-tooth extraction was conducted under local anesthesia in n = 21 patients using a split-mouth design (42 teeth). Using a double-blind approach, the extraction socket on one side of the jaw was filled with PRF and on the other with a GS. Bleeding was assessed immediately after surgery, in 30 min, 1 h, 1.5 h, and on follow-up appointments in 24 h and on the 7th day. RESULTS In 67% of cases, mild postoperative oozing could be stopped 30-90 min after tooth extraction via gauze pressure without any delayed bleeding. Concerning bleeding events, there was no difference among the PRF and GS groups and no significant difference among rivaroxaban, apixaban, and edoxaban (all p > 0.15). CONCLUSION PRF and GS are reliable hemostatic methods in postextraction sockets of patients taking FXa inhibitors. CLINICAL RELEVANCE Consequently, there is no need to discontinue FXa inhibitors because of a single-tooth removal, eliminating the risk of thrombus formation.
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Affiliation(s)
- Solomiya Kyyak
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Ali Jari
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Diana Heimes
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Julia Heider
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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Römer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kämmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent 2022; 8:20. [PMID: 35429255 PMCID: PMC9013394 DOI: 10.1186/s40729-022-00418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 01/08/2023] Open
Abstract
Purpose Considering a high prevalence of congenital and especially acquired bleeding disorders, their heterogeneity and the multitude of possible treatments strategies, a review of the scientific data on this topic is needed to implement a treatment guide for healthcare professionals.
Methods A selective literature review was performed via PubMed for articles describing oral surgery / dental implant procedures in patients with congenital and acquired bleeding disorders. Out of the existing literature, potential treatment algorithms were extrapolated. Results In order to assess the susceptibility to bleeding, risk stratification can be used for both congenital and acquired coagulation disorders. This risk stratification, together with an appropriate therapeutic pathway, allows for an adequate and individualized therapy for each patient. A central point is the close interdisciplinary cooperation with specialists. In addition to the discontinuation or replacement of existing treatment modalities, local hemostyptic measures are of primary importance. If local measures are not sufficient, systemically administered substances such as desmopressin and blood products have to be used. Conclusions Despite the limited evidence, a treatment guide could be developed by means of this narrative review to improve safety for patients and practitioners. Prospective randomized controlled trials are needed to allow the implementation of official evidence-based guidelines.
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Sun Z, da Fontoura CSG, Moreno M, Holton NE, Sweat M, Sweat Y, Lee MK, Arbon J, Bidlack FB, Thedens DR, Nopoulos P, Cao H, Eliason S, Weinberg SM, Martin JF, Moreno-Uribe L, Amendt BA. FoxO6 regulates Hippo signaling and growth of the craniofacial complex. PLoS Genet 2018; 14:e1007675. [PMID: 30286078 PMCID: PMC6197693 DOI: 10.1371/journal.pgen.1007675] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/22/2018] [Accepted: 08/31/2018] [Indexed: 12/17/2022] Open
Abstract
The mechanisms that regulate post-natal growth of the craniofacial complex and that ultimately determine the size and shape of our faces are not well understood. Hippo signaling is a general mechanism to control tissue growth and organ size, and although it is known that Hippo signaling functions in neural crest specification and patterning during embryogenesis and before birth, its specific role in postnatal craniofacial growth remains elusive. We have identified the transcription factor FoxO6 as an activator of Hippo signaling regulating neonatal growth of the face. During late stages of mouse development, FoxO6 is expressed specifically in craniofacial tissues and FoxO6-/- mice undergo expansion of the face, frontal cortex, olfactory component and skull. Enlargement of the mandible and maxilla and lengthening of the incisors in FoxO6-/- mice are associated with increases in cell proliferation. In vitro and in vivo studies demonstrated that FoxO6 activates Lats1 expression, thereby increasing Yap phosphorylation and activation of Hippo signaling. FoxO6-/- mice have significantly reduced Hippo Signaling caused by a decrease in Lats1 expression and decreases in Shh and Runx2 expression, suggesting that Shh and Runx2 are also linked to Hippo signaling. In vitro, FoxO6 activates Hippo reporter constructs and regulates cell proliferation. Furthermore PITX2, a regulator of Hippo signaling is associated with Axenfeld-Rieger Syndrome causing a flattened midface and we show that PITX2 activates FoxO6 expression. Craniofacial specific expression of FoxO6 postnatally regulates Hippo signaling and cell proliferation. Together, these results identify a FoxO6-Hippo regulatory pathway that controls skull growth, odontogenesis and face morphology.
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Affiliation(s)
- Zhao Sun
- Department of Anatomy and Cell Biology, and the Craniofacial Anomalies Research Center, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Clarissa S. G. da Fontoura
- Iowa Institute for Oral Health Research, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
| | - Myriam Moreno
- Department of Anatomy and Cell Biology, and the Craniofacial Anomalies Research Center, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Nathan E. Holton
- Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
| | - Mason Sweat
- Department of Anatomy and Cell Biology, and the Craniofacial Anomalies Research Center, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Yan Sweat
- Department of Anatomy and Cell Biology, and the Craniofacial Anomalies Research Center, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Myoung Keun Lee
- Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh PA, United States of America
| | - Jed Arbon
- Private practice, Cary, North Carolina United States of America
| | | | - Daniel R. Thedens
- Department of Psychiatry, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Peggy Nopoulos
- Department of Psychiatry, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Huojun Cao
- Iowa Institute for Oral Health Research, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
| | - Steven Eliason
- Department of Anatomy and Cell Biology, and the Craniofacial Anomalies Research Center, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
| | - Seth M. Weinberg
- Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh PA, United States of America
| | - James F. Martin
- Department of Physiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Lina Moreno-Uribe
- Iowa Institute for Oral Health Research, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
- Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
| | - Brad A. Amendt
- Department of Anatomy and Cell Biology, and the Craniofacial Anomalies Research Center, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States of America
- Iowa Institute for Oral Health Research, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
- Department of Orthodontics, College of Dentistry, The University of Iowa, Iowa City, IA, United States of America
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Weinstock RJ, Onyejiuwa A, Shnayder G, Clarkson EI. Use of recombinant factor VII for tooth extractions in a patient with severe congenital factor VII deficiency: a case report. J Am Dent Assoc 2016; 146:271-5. [PMID: 25819659 DOI: 10.1016/j.adaj.2014.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 11/12/2014] [Accepted: 12/11/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OVERVIEW Patients with factor VII deficiency have an increased risk of prolonged perioperative hemorrhage. In this article, the authors present a case of severe factor VII deficiency in a patient who required tooth extraction. CASE DESCRIPTION A 44-year-old woman with severe congenital factor VII deficiency sought care for a symptomatic, carious, and nonrestorable maxillary right second molar that required extraction. The authors obtained hematologic consultation, and the patient underwent the extraction under general anesthesia in the inpatient setting. Perioperative management included performing relevant laboratory studies, preoperative recombinant factor VII infusion, and postoperative intravenous aminocaproic acid administration. No hemorrhagic complications occurred throughout the perioperative course. CONCLUSIONS AND PRACTICAL IMPLICATIONS The degree of factor VII deficiency correlates poorly with bleeding risk. Perioperative management is variable, requiring preoperative consultation with a hematologist.
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Sprenker C, Omar HR, Powless RA, Mangar D, Camporesi E. Massive oral bleeding after full-mouth extraction in a patient with B-cell lymphocytic leukemia/small lymphocytic lymphoma reversed with recombinant activated factor VII. J Am Dent Assoc 2015; 147:142-5. [PMID: 26562728 DOI: 10.1016/j.adaj.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/28/2015] [Accepted: 09/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OVERVIEW Full-mouth extraction can be associated with intraoral bleeding, which usually is controlled with local hemostatic measures. Recombinant activated factor VII (rFVIIa) occasionally is used to stop bleeding in a variety of off-label indications, with the main argument curtailing its use being thrombotic events. The authors describe the use of rFVIIa for bleeding after full-mouth extraction in a patient with undiagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma. CASE DESCRIPTION A 72-year-old man underwent full-mouth extraction (18 teeth). The next day, the patient experienced massive oral bleeding. The authors administered tranexamic acid, aminocaproic acid, and a total of 12 units of packed red blood cells in addition to local hemostatic measures without control of bleeding. On postoperative day 10, the authors administered 5,000 micrograms of rFVIIa, and within 2 hours oral the bleeding ceased. The authors performed flow cytometry and diagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma. CONCLUSIONS AND PRACTICAL IMPLICATIONS Unexplained massive oral bleeding despite adequate local hemostatic measures should prompt further investigations for underlying bleeding or coagulation disorders. The authors describe the successful use of rFVIIa in massive oral bleeding. Further studies are mandatory to study the effectiveness of this drug for this off-label indication.
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Rodríguez Martínez S, Talaván Serna J, Silvestre FJ. [Dental management in patients with cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 39:224-32. [PMID: 26541210 DOI: 10.1016/j.gastrohep.2015.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 07/14/2015] [Accepted: 07/27/2015] [Indexed: 01/03/2023]
Abstract
The present article makes a brief review about dental management of the patients with cirrhosis. It focus on problems related with infections, haemorrhagic events and treatment with drugs of common use in odontology.
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Affiliation(s)
| | - Julio Talaván Serna
- Servicio de Anestesiología y Reanimación, Hospital General d́Ontinyent, Valencia, España
| | - Francisco-Javier Silvestre
- Departamento de Estomatología, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España
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Fillmore WJ, Leavitt BD, Arce K. Dental extraction in the thrombocytopenic patient is safe and complications are easily managed. J Oral Maxillofac Surg 2013; 71:1647-52. [PMID: 23932116 DOI: 10.1016/j.joms.2013.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/09/2013] [Accepted: 05/10/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To characterize bleeding risk and management of bleeding in thrombocytopenic patients undergoing dental extraction. MATERIALS AND METHODS This retrospective cohort study included 68 patients with hematologic disease and concomitant thrombocytopenia undergoing dental extractions. The inclusion criterion was a platelet count of 100,000/μL or less at the time of consultation or extraction. Patients using anticoagulation therapy were excluded from the study. Predictors measured were age, gender, platelet count, platelet transfusion before or during surgery, local hemostatic measurements at the time of surgery (absorbable hemostat or antifibrinolytic rinse), number of teeth extracted, diagnosis, and extraction type. The primary outcome was postoperative bleeding requiring intervention. A secondary outcome was surgical site infection. Descriptive and bivariate statistics were computed and the P value was set at .05. No logistic regression was used based on the distribution of outcomes. RESULTS Sixty-eight patients underwent extraction of 200 teeth. Five (7.4%) had postoperative bleeding that was always controlled with routine intervention. Mean platelet count was 44,647/μL. Bleeding was more frequent with lower platelet levels (P = .048). Thirty-two patients received platelet transfusion and 26 received local measures. Platelet transfusion and local hemostatic measures had no effect on bleeding outcomes. CONCLUSION Surgical and routine extractions are safe procedures in patients with thrombocytopenia, and postoperative bleeding is typically well handled with simple local measures. The benefits of pre- or intraoperative platelet transfusion are unclear in this population. Likewise, the benefit of prophylactic local hemostatic measures is unclear and should be based on the surgeon's discretion and experience.
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Affiliation(s)
- W Jonathan Fillmore
- Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
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