Bleeding evaluation during single tooth extraction in patients with coronary artery disease and acetylsalicylic acid therapy suspension: a prospective, double-blinded, and randomized study

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 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 role of hemostatic agents after tooth extractions: A systematic review and meta-analysis

BACKGROUND

Hemostatic agents are used to control bleeding after tooth extraction and have been compared with conventional measures (that is, sutures or gauze pressure) in several studies. The objective of this systematic review was to evaluate the benefits of topical hemostatic agents for controlling bleeding after tooth extractions, especially in patients receiving antithrombotic therapy.

TYPES OF STUDIES REVIEWED

The authors conducted a literature search in MEDLINE (PubMed), Scopus, and the Cochrane Central Register of Controlled Trials, including prospective human randomized clinical trials in which researchers compared hemostatic agents with conventional methods and reported the time to achieve hemostasis and postoperative bleeding events.

RESULTS

Seventeen articles were eligible for inclusion. Hemostatic agents resulted in a significantly shorter time to achieve hemostasis in both healthy patients and patients taking antithrombotic drugs (standardized mean difference, -1.02; 95% CI, -1.70 to -0.35; P = .003 and standardized mean difference, -2.30; 95% CI, -3.20 to -1.39; P < .00001, respectively). Significantly fewer bleeding events were noted when hemostatic agents were used (risk ratio, 0.62; 95% CI, 0.44 to 0.88; P = .007). All forms of hemostatic agents (that is, mouthrinse, gel, hemostatic plug, and gauze soaked with the agent) had better efficacy in reducing the number of postoperative bleeding events than conventional hemostasis measures, except for hemostatic sponges. However, this was based on a small number of studies in each subgroup.

CONCLUSIONS

The use of hemostatic agents seemed to offer better bleeding control after tooth extractions in patients on antithrombotic drugs than conventional measures.

PRACTICAL IMPLICATIONS

Findings of this systematic review may help clinicians attain more efficient hemostasis in patients requiring tooth extraction. This systematic review is registered in the PROSPERO database. The registration number is CRD42021256145.

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

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.

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.

Clinical Post-operative Bleeding During Minor Oral Surgical Procedure and In Vitro Platelet Aggregation in Patients on Aspirin Therapy: Are they Coherent?

Aim

The risk of excessive bleeding prompts physicians to discontinue aspirin in patients on low-dose, long-term therapy which in turn puts them at the risk from adverse cardiovascular and thrombotic events. Effect of low-dose aspirin therapy on platelet function was assessed using platelet aggregation method. The aim was to correlate the laboratory platelet function with cutaneous and clinical oral bleeding time (BT).

Materials and Methods

One hundred one patients were enrolled in this prospective trial and were allocated into two groups. Interventional or test group consisted of patients who were on aspirin therapy (75 mg/100 mg) for primary or secondary prevention of angina, myocardial infarction and stroke. Minor oral surgical procedure was performed in this group without discontinuing aspirin therapy. Control group consisted of healthy patients (under no medication) undergoing minor oral surgical procedure. Cutaneous and clinical oral BT were recorded in both the groups. Venous blood sample was drawn, and percentage platelet aggregation function was analysed using adenosine diphosphate (ADP) and arachidonic acid (AA) reagents. The percentage of platelet aggregation was then correlated with cutaneous and clinical oral BT.

Results

A significant decrease in percentage platelet aggregation using ADP (aspirin-74.7 21.39; control-89.2 13.70) and AA (aspirin-47.6 23.11; control-82.3 20.17) was observed. However, there were no significant difference in mean cutaneous BT (aspirin-1.5 0.65 min; control-1.6 0.71 min) and clinical oral BT (aspirin-5.0 2.48 min; control-4.8 2.60 min) in aspirin and control groups.

Conclusion

Majority of the minor oral surgical procedures can be carried out safely without discontinuing aspirin in patients on low-dose long-term therapy. This is possible because despite significant platelet aggregation evident in laboratory evaluation there is lack of its clinical corroboration owing to aspirin resistance.

Clinical Trial Registration

CTRI/2018/02/012055.

Antiplatelet therapy in patients undergoing oral surgery: A systematic review and meta-analysis

Background

The number of patients under antiplatelet therapy (APT) continues to raise as current recommendations foster this practice. Although some recommendations to manage this treatment during oral surgery procedures exist, these have methodological shortcomings that preclude them from being conclusive.

Material and Methods

A systematic review and meta-analysis of the best current evidence was carried out; The Cochrane Library, EMBASE and MEDLINE databases were searched for Randomized Controlled Trials (RCT) concerning patients undergoing oral surgery with APT, other relevant sources were searched manually.

Results

5 RCTs met the Inclusion criteria. No clear tendency was observed (RR= 0.97 CI 95%: 0,41–2,34; p=0,09; I2= 51%), moreover, they weren’t clinically significant.

Conclusions

According to these findings and as bleeding is a manageable complication it seems unreasonable to undermine the APT, putting the patient in danger of a thrombotic event and its high inherent morbidity, which isn’t comparable in severity and manageability to the former.”

Key words:Antiplatelet therapy, aspirin, oral surgery, platelet aggregation inhibitors, oral surgical procedures, systematic reviews.

Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery

BACKGROUND

Antiplatelet agents are recommended for people with myocardial infarction and acute coronary syndromes, transient ischaemic attack or stroke, and for those in whom coronary stents have been inserted. People who take antiplatelet agents are at increased risk of adverse events when undergoing non-cardiac surgery because of these indications. However, taking antiplatelet therapy also introduces risk to the person undergoing surgery because the likelihood of bleeding is increased. Discontinuing antiplatelet therapy before surgery might reduce this risk but subsequently it might make thrombotic problems, such as myocardial infarction, more likely.

OBJECTIVES

To compare the effects of continuation versus discontinuation for at least five days of antiplatelet therapy on the occurrence of bleeding and ischaemic events in adults undergoing non-cardiac surgery under general, spinal or regional anaesthesia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (1946 to January 2018), and Embase (1974 to January 2018). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials of adults who were taking single or dual antiplatelet therapy, for at least two weeks, and were scheduled for elective non-cardiac surgery. Included participants had at least one cardiac risk factor. We planned to include quasi-randomized studies.We excluded people scheduled for minor surgeries under local anaesthetic or sedation in which bleeding that required transfusion or additional surgery was unlikely. We included studies which compared perioperative continuation of antiplatelet therapy versus discontinuation of antiplatelet therapy or versus substitution of antiplatelet therapy with a placebo for at least five days before surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings. Our primary outcomes were: all-cause mortality at longest follow-up (up to six months); all-cause mortality (up to 30 days). Secondary outcomes included: blood loss requiring transfusion of blood products; blood loss requiring further surgical intervention; risk of ischaemic events. We used GRADE to assess the quality of evidence for each outcome MAIN RESULTS: We included five RCTs with 666 randomized adults. We identified three ongoing studies.All study participants were scheduled for elective general surgery (including abdominal, urological, orthopaedic and gynaecological surgery) under general, spinal or regional anaesthesia. Studies compared continuation of single or dual antiplatelet therapy (aspirin or clopidogrel) with discontinuation of therapy for at least five days before surgery.Three studies reported adequate methods of randomization, and two reported methods to conceal allocation. Three studies were placebo-controlled trials and were at low risk of performance bias, and three studies reported adequate methods to blind outcome assessors to group allocation. Attrition was limited in four studies and two studies had reported prospective registration with clinical trial registers and were at low risk of selective outcome reporting bias.We reported mortality at two time points: the longest follow-up reported by study authors up to six months, and time point reported by study authors up to 30 days. Five studies reported mortality up to six months (of which four studies had a longest follow-up at 30 days, and one study at 90 days) and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality up to six months (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.34 to 4.27; 659 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from eight fewer to 40 more). Combining the four studies with a longest follow-up at 30 days alone showed the same effect estimate, and we found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to mortality at 30 days after surgery (RR 1.21, 95% CI 0.34 to 4.27; 616 participants; low-certainty evidence); the absolute effect is three more deaths per 1000 with continuation of antiplatelets (ranging from nine fewer to 42 more).We found that either continuation or discontinuation of antiplatelet therapy probably makes little or no difference in incidences of blood loss requiring transfusion (RR 1.37, 95% CI 0.83 to 2.26; 368 participants; absolute effect of 42 more participants per 1000 requiring transfusion in the continuation group, ranging from 19 fewer to 119 more; four studies; moderate-certainty evidence); and may make little or no difference in incidences of blood loss requiring additional surgery (RR 1.54, 95% CI 0.31 to 7.58; 368 participants; absolute effect of six more participants per 1000 requiring additional surgery in the continuation group, ranging from seven fewer to 71 more; four studies; low-certainty evidence). We found that either continuation or discontinuation of antiplatelet therapy may make little or no difference to incidences of ischaemic events (to include peripheral ischaemia, cerebral infarction, and myocardial infarction) within 30 days of surgery (RR 0.67, 95% CI 0.25 to 1.77; 616 participants; absolute effect of 17 fewer participants per 1000 with an ischaemic event in the continuation group, ranging from 39 fewer to 40 more; four studies; low-certainty evidence).We used the GRADE approach to downgrade evidence for all outcomes owing to limited evidence from few studies. We noted a wide confidence in effect estimates for mortality at the end of follow-up and at 30 days, and for blood loss requiring transfusion which suggested imprecision. We noted visual differences in study results for ischaemic events which suggested inconsistency.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery may make little or no difference to mortality, bleeding requiring surgical intervention, or ischaemic events. We found moderate-certainty evidence that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery probably makes little or no difference to bleeding requiring transfusion. Evidence was limited to few studies with few participants, and with few events. The three ongoing studies may alter the conclusions of the review once published and assessed.

Interventions for treating post-extraction bleeding

BACKGROUND

Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. This is an update of a review published in June 2016.

OBJECTIVES

To assess the effects of interventions for treating different types of post-extraction bleeding.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 24 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 24 January 2018), Embase Ovid (1 May 2015 to 24 January 2018) and CINAHL EBSCO (1937 to 24 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We searched the reference lists of relevant systematic reviews.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment.

DATA COLLECTION AND ANALYSIS

Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis.

MAIN RESULTS

We did not find any randomised controlled trial suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).

Impact of Post-Exodontia Bleeding in Cardiovascular Patients: A New Classification Proposal

Background:

Exodontia (dental extraction), being the most frequent minor surgical procedure in the general population, inevitably involves a large number of patients on antithrombotic medication. Current experience shows that there is a degree of confusion in managing these patients.

Description:

Post-exodontia bleeding, a natural consequence of every dental extraction with no or minor clinical significance in the vast majority of cases, often appears to be of major concern to both patients and healthcare practitioners (dentists or physicians), either because of the alarming nature of oral bleeding itself or because of the distorted perception about its importance. These concerns are enhanced by the lack of a universal standardized definition of post-exodontia bleeding and by the fact that all currently available post-exodontia bleeding definitions bear intrinsic limitations and tend to overestimate its clinical significance.

Conclusion:

In order to overcome the aforementioned issues, this article presents an overview of post-extraction bleeding and proposes a classification, based on the well-recognized Bleeding Academic Research Consortium (BARC) bleeding definition, aiming at reducing heterogeneity in this field.

Direct oral anticoagulants and its implications in dentistry. A review of literature

BACKGROUND

Four novel direct oral anticoagulants (DOACs) named dabigatran, rivaroxaban, edoxaban and apixaban have been recently introduced to overcome some of the drawbacks of existing anticoagulants. They have less interactions and do not require routine monitoring. However, there is not enough scientific data about the protocol to apply in these patients on DOACs undergoing dental treatment. Thus is necessary to evaluate the potential bleeding risk of these drugs, the possibility of thromboembolic events occurring if they are withdrawn or the need to change to heparin previously.

MATERIAL AND METHODS

A comprehensive search of the PubMed, Scopus and ISI Web of Science databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The quality of the reported information was assessed following the PRISMA statement.

RESULTS

Eleven studies that met the inclusion criteria were included in the review: 2 randomized clinical trials, 3 prospective studies, 3 retrospective studies, 2 case series and 1 case report.

CONCLUSIONS

DOACs are safe drugs in terms of bleeding. The possible postoperative bleeding complications are manageable with conventional haemostasis measurements. The bridging approach with heparin does not seem to be recommended. Consensus among the professionals involved in the management of the patient is fundamental in invasive dental treatments and in complex patients. Key words:Oral anticoagulants, DOAC, NOAC, dabigatran, rivaroxaban, apixaban, edoxaban, bleeding, oral surgery.

Effect of Low-Dose Aspirin on Bleeding Following Exodontia: A Prospective Clinical Study

Purpose

This research aims to study the effects of low-dose aspirin on bleeding after exodontia and to compare statistically and analyze perioperative blood loss during exodontia in patients on aspirin therapy and healthy patients and also to discuss the various measures if required necessary for controlling postoperative bleeding in simple and uncomplicated exodontia.

Materials and Methods

The study included 100 patients, ranging in age from 30 to 60 years. The patients were divided into two groups, a test group consisting of 50 patients who were on a daily dose of 75-150 mg of aspirin and a control group consisting of 50 patients not on any antiplatelet therapy. All extraction procedures were performed on outpatient basis. Patients were operated under local anesthesia. Post-extraction sockets were checked for bleeding immediately (30 min) and followed up at 24, 48, and 72 h, and 1 week, after the procedure.

Results

Amount of intraoperative blood loss was similar in both test and control groups, and there was no excessive postoperative bleeding in any case. Out of 100 patients, only three patients of test group and two patients of control group required level II hemostatic measures and two patients of test group needed level III measures.

Conclusion

We could reach a conclusion and recommend that patients on long-term low-dose aspirin (75-150 mg) need not to discontinue their aspirin dose prior to routine exodontia and can be carried out safely with enhanced local hemostatic measures, if required.

Interventions for treating post-extraction bleeding

BACKGROUND

Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes.

OBJECTIVES

To assess the effects of interventions for treating different types of post-extraction bleeding.

SEARCH METHODS

We searched the following electronic databases: The Cochrane Oral Health Group Trials Register (to 22 March 2016); The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, Issue 2); MEDLINE via OVID (1946 to 22 March 2016); CINAHL via EBSCO (1937 to 22 March 2016). Due to the ongoing Cochrane project to search EMBASE and add retrieved clinical trials to CENTRAL, we searched only the last 11 months of EMBASE via OVID (1 May 2015 to 22 March 2016). We placed no further restrictions on the language or date of publication. We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov), and the WHO Clinical Trials Registry Platform for ongoing trials (http://apps.who.int/trialsearch/default.aspx). We also checked the reference lists of excluded trials.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment.

DATA COLLECTION AND ANALYSIS

Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis.

MAIN RESULTS

We did not find any randomised controlled trial suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).

Clinical Trial Evaluating the Risk of Thromboembolic Events During Dental Extractions

PURPOSE

Discontinuation of anti-platelet therapy increases the risk of thrombotic complications whereas its continuation is believed to increase the risk of prolonged post-extraction bleeding. We therefore, performed this study to evaluate the risk of significant bleeding following dental extractions and also to assess the necessity of discontinuing anti-platelet therapy.

PATIENTS AND METHODS

Three hundred patients requiring dental extraction were included in the study in which 200 patients were on anti-platelet therapy. Patients were divided into three groups of 100 patients each. Group 1 consisted of patients continuing their anti-platelet therapy, Group 2 consisted of patients whose anti-platelet therapy was interrupted and Group 3 comprised of healthy patients not on anti-platelet therapy. Preoperative bleeding and clotting time were determined for all patients. The procedure involved single or multiple teeth (>3 teeth) extractions under local anesthesia with a vasoconstrictor. Pressure pack was given in all cases as in routine dental extractions and bleeding was checked after 15, 30 min, 1, 24, 48 h and 1 week. Immediate post-extraction bleeding was considered to be prolonged if it continued beyond 30 min in spite of the pressure pack. Late and very late bleeding was considered to be clinically significant if it extended beyond 12 and 24 h respectively.

RESULTS

The mean bleeding time in Groups 1, 2, and 3 were 1 min and 32 s, 1 min and 25 s, and 1 min and 27 s, respectively. Prolonged immediate post-extraction bleeding (bleeding after 30 min) was present among 9 patients in Group 1 (9 %) and 15 patients in Group 2 (15 %) whereas it was not seen in any patient of Group 3. Bleeding after 1 h was present in 9 patients of Group 2 (9 %) and was controlled with gelatin sponge within half an hour thereafter. None of the patients in any group reported with bleeding after 24, 48 h and 1 week.

CONCLUSION

Dental extractions can be safely carried out in patients on anti-platelet therapy without the risk of significant post-extraction bleeding thus averting the risk of thromboembolic events that might take place on temporary discontinuation of antiplatelet therapy.

Bleeding after tooth extraction in patients taking aspirin and clopidogrel (Plavix®) compared with healthy controls

The risk of perioperative bleeding is high in patients who take aspirin and clopidogrel after a percutaneous coronary intervention, and whether to stop the drugs is a matter of concern for dentists. The aim of this study was to answer the specific question: should aspirin and clopidogrel bisulphate (Plavix®) be discontinued during a conventional forceps extraction? We studied 64 patients during the first year after percutaneous insertion of coronary stents who were taking aspirin (ASA) 80mg and clopidogrel (Plavix(®)) 75mg, and 50 healthy patients who were to have a conventional forceps extraction at this polyclinic in 2013-2014 and acted as controls. Clinical details (underlying diseases; number of roots; type of tooth; type of haemostasis; and bleeding immediately, 30minutes, and 48hours after intervention) were compared. We evaluated 114 patients with the mean (range) age of 56 (43-76) years, and there were no significant differences in demographic data, underlying diseases, type of tooth, number of roots, and dose of anaesthetic between the groups. There were also no significant differences in the number of bleeds immediately and 30minutes after intervention (P=0.310 and 0.205). The time that the last dose of aspirin had been taken correlated with 30-minute haemostasis (20 compared with 12hours, p=0.037). During the 48hours after the intervention, there were no uncontrolled bleeds or emergency referrals. We conclude that using aspirin and Plavix® simultaneously has no considerable effect on the risk of bleeding in patients having conventional forceps extraction of a single tooth.

Should aspirin be stopped before tooth extraction? A meta-analysis

OBJECTIVE

To carry out a standard meta-analysis to determine if aspirin should be stopped before tooth extraction.

STUDY DESIGN

The PubMed, ScienceDirect, EBSCOhost, and Science Citation Index databases were searched for studies published up to September 30, 2014. Eligible studies were restricted to randomized controlled trials (RCTs) and controlled, nonrandomized trials.

RESULTS

Three RCTs and seven controlled trials met the inclusion criteria (covering 1752 patients: 529 on aspirin therapy and 1223 not on aspirin therapy). The results showed that the risk of postoperative hemorrhage was significantly higher in patients on aspirin therapy (relative risk [RR] = 2.46; 95% confidence interval [CI]: 1.45-4.81) but that bleeding time (BT) was not significantly different between the two groups (standardized mean difference [SMD] = 0.63; 95% CI: -0.04 to 1.31). Sensitivity analyses showed that the results were unstable.

CONCLUSIONS

We could reach a conclusion that BT is prolonged or hemorrhage is exacerbated by long-term use of aspirin. We recommend not stopping long-term aspirin use before tooth extraction but enhancing hemostasis methods, if necessary.

Dental surgery and antiplatelet agents: bleed or die

In patients taking antiplatelet medications who are undergoing dental surgery, physicians and dentists must weigh the bleeding risks in continuing antiplatelet medications versus the thrombotic risks in interrupting antiplatelet medications. Bleeding complications requiring more than local measures for hemostasis are rare after dental surgery in patients taking antiplatelet medications. Conversely, the risk for thrombotic complications after interruption of antiplatelet therapy for dental procedures apparently is significant, although small. When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to "bleed or die." That is, there is a remote chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus a small but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is simple: It is time to stop interrupting antiplatelet therapy for dental surgery.

Dental extraction can be performed safely in patients on aspirin therapy: a timely reminder

Cardiac patients on aspirin therapy may require extractions for their diseased teeth. It is a common practice among physicians and treating surgeons to stop aspirin prior to tooth extraction because of fear of bleeding complications. This practice often predisposes the patient to adverse thromboembolic events. This practice is based on theoretical risk of bleeding and on isolated case reports of excessive bleeding with aspirin therapy. The current consensus and recommendations are in favor of continuing aspirin therapy during simple tooth extraction as the bleeding complication incidence is very less and if it occurs can be controlled efficiently with local hemostasis measures.

Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: a prospective study

Controversy exists concerning the suspension or maintenance of anti-platelet drugs before elective surgical procedures. We assessed the association of the risk of prolonged postoperative bleeding with anti-platelet therapy by type of minor surgical procedure and the association between anti-platelet therapy and the level of hemostatic measures required. Five hundred and forty-six patients were included in the study group: those on aspirin (n = 310), clopidogrel (n = 97), and aspirin + clopidogrel dual therapy (n = 139); the control group comprised 575 healthy individuals. Cramer's V test was significant (P < 0.05) but showed a weak association between anti-platelet therapy and prolonged immediate postoperative bleeding. Compared to controls, the odds ratio revealed that the risk of prolonged bleeding in the immediate postoperative period was significantly higher with dual therapy, followed by clopidogrel and aspirin. Prolonged bleeding occurred in 22 patients in the study group and 20 in the control group, and was successfully controlled with local hemostatic measures. Fisher's exact test showed a significant association between dual therapy and higher levels of hemostatic measures (P = 0.004; P = 0.035). Prolonged bleeding in patients on anti-platelet therapy was independent of the type of minor surgical procedure. The greatest risk of prolonged bleeding was found in patients on dual therapy; this required higher levels of hemostatic measures.