Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature

Bioinspired chitosan based functionalization of biomedical implant surfaces for enhanced hemocompatibility, antioxidation and anticoagulation potential: an in silico and in vitro study

Endowing implanted biomaterials with better hemocompatibility, anticoagulation, antioxidant and antiplatelet adhesion is necessary because of their potential to trigger activation of multiple reactive mechanisms including coagulation cascade and potentially causing serious adverse clinical events like late thrombosis. Active ingredients from natural sources including Foeniculum vulgare, Angelica sinensis, and Cinnamomum verum have the ability to inhibit the coagulation cascade and thrombus formation around biomedical implants. These properties are of interest for the development of a novel drug for biomedical implants to potentially solve the current blood clotting and coagulation problems which lead to stent thrombosis. The objective of this study was to incorporate different anticoagulants from natural sources into a degradable matrix of chitosan with varying concentrations ranging from 5% to 15% and a composite containing all three drugs. The presence of anticoagulant constituents was identified using GC-MS. Subsequently, all the compositions were characterized principally by using Fourier transform infrared spectroscopy and scanning electron microscopy while the drug release profile was determined using UV-spectrometry for a 30 days immersion period. The results indicated an initial burst release which was subsequently followed by the sustained release pattern. Compared to heparin loaded chitosan, DPPH and hemolysis tests revealed better blood compatibility of natural drug loaded films. Moreover, the anticoagulation activity of natural drugs was equivalent to the heparin loaded film; however, through docking, the mechanism of inhibition of the coagulation cascade of the novel drug was found to be through blocking the extrinsic pathway. The study suggested that the proposed drug composite expresses an optimum composition which may be a practicable and appropriate candidate for biomedical implant coatings.

Risk of post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants: a cohort study using the common data model

This retrospective study aimed to determine risk factors associated with post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants. Patients taking anticoagulants who were planned to undergo periodontal flap operation, tooth extraction or implant surgery were included. Patients were divided into two subgroups according to the maintenance of anticoagulants following medical consultation: (1) maintenance group and (2) discontinuation group. The analysed patient-related factors included systemic diseases, maintenance of anticoagulants and types of anticoagulant. Intra- and post-operative treatment-related factors, haemostatic methods and post-operative bleeding were collected for statistical analyses. There were 35 post-operative bleeding complications (6.5%) in the 537 included patients: 21 (8.6%) in maintenance group and 14 (4.8%) in discontinuation group. The type of anticoagulant (p = 0.037), tooth extraction combined with bone grafting (p = 0.016) and type of implant surgery (p = 0.032) were significantly related to the post-operative bleeding rate. In the maintenance group, atrial fibrillation [odds ratio (OR) = 6.051] and vitamin K inhibitors (OR = 3.679) were associated with a significantly higher bleeding risk. From this result, it can be inferred that the decision to continue anticoagulants should be made carefully based on the types of anticoagulant and the characteristics of dentoalveolar surgeries performed: extraction with bone grafting, multiple implantations and involvement of maxillary arch.

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.

Effect of direct oral anticoagulant dabigatran on early bone healing: An experimental study in rats

Background

Dabigatran belongs to the new generation of direct oral anticoagulants (DOACs). Its advantages are oral administration and no need for international normalized ratio (INR) monitoring. Although its use has increased, its potential side effects on bone healing and remodeling have not been fully investigated. The present study aimed to evaluate the possible effects of dabigatran on early bone healing.

Methods

Sixteen male Wistar rats were divided into two groups; in group A, 20-mg/kg dabigatran dose was administered orally daily for 15 days, while group B served as a control. Two circular bone defects (d=6 mm) were created on either side of the parietal bones. Two weeks after surgery and euthanasia of the animals, tissue samples (parietal bones that contained the defects) were harvested for histological and histomorphometric analysis. Statistical analysis was performed with a significance level of α=0.5.

Results

No statistically significant differences were found between the two groups regarding the regenerated bone (21.9% vs. 16.3%, P=0.172) or the percentage of bone bridging (63.3% vs. 53.5%, P=0.401).

Conclusion

Dabigatran did not affect bone regeneration, suggesting that it might be a safer drug compared to older anticoagulants known to lead to bone healing delay.

Edoxaban use in the context of dental procedures: analysis from the EMIT-AF/VTE database

INTRODUCTION

Literature reviews support continuing anticoagulation during dental procedures. However, studies often present grouped anticoagulation data, and information on individual anticoagulant management would be helpful to dentists. The Edoxaban Management in Diagnostic and Therapeutic Procedures (EMIT-AF/VTE) programme (NCT02950168; NCT02951039) demonstrated low periprocedural bleeding and thrombotic event rates in patients with atrial fibrillation receiving edoxaban.

AIMS

To report periprocedural edoxaban interruption and clinical events in patients from EMIT-AF/VTE who underwent dental procedures.

METHODS

Dental procedures were categorised by type (cleaning/noncleaning). Edoxaban interruption, bleeding events, and thrombotic events were observed 5 days preprocedure through 29 days postprocedure.

RESULTS

Overall, 196 patients underwent 350 cleaning and/or noncleaning procedures; most patients (171/196 [87.2%]) underwent noncleaning procedures (282/350 [80.6%]), whereas 48/196 (24.5%) underwent 68/350 (19.4%) cleaning procedures. Edoxaban was uninterrupted for most cleanings (53/68 [77.9%]). Preprocedural interruption was common for single and multiple tooth extractions (single, 67/100 [67.0%]; multiple, 16/30 [53.3%]). The only major bleeding occurred after an unrelated cleaning. Minor bleeding occurred in 1/68 (1.5%) cleaning and 4/282 (1.4%) noncleaning procedures. There were no thrombotic events.

CONCLUSIONS

For most cleanings, edoxaban was not interrupted, whereas preprocedural interruption was more common for tooth extractions. Overall, bleeding rates were low, and no thrombotic events occurred.

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.

Accuracy Analysis of Computer-Assisted and Guided Dental Implantology by Comparing 3D Planning Data and Actual Implant Placement in a Mandibular Training Model: A Monocentric Comparison between Dental Students and Trained Implantologists

The aim of this study was to investigate how precisely implantation can be realized by participants on a phantom head according to preliminary planning. Of particular interest here was the influence of participants' previous knowledge and surgical experience on the precision of the implant placement. The placed implants were scanned using an intraoral scanner, saved as STL files, and superimposed with the 3D-planned implant placement. Deviations from the planning were indicated in millimeters and degrees. We were able to show that on average, the deviations from computer-assisted 3D planning were less than 1 mm for implantologists, and the students also did not deviate more than 1.78 mm on average from 3D planning. This study shows that guided implantology provides predictable and reproducible results in dental implantology. Incorrect positioning, injuries to anatomical structures, and implant positions that cannot be prosthetically restored can thus be avoided.

Risk of bleeding with dental implant surgery in patients on anticoagulant or antiplatelet drugs: a systematic review and meta-analysis

INTRODUCTION

A large number of patients under oral anticoagulant (OAC) or antiplatelet (AP) therapy require dental implantation. We systematically reviewed evidence on the risk of bleeding after implant placement with continued OAC or AP therapy.

METHODS

PubMed, Embase and CENTRAL were searched for studies comparing bleeding outcomes after implant placement between OAC/AP therapy vs. controls or OAC vs. AP therapy.

RESULTS

Seven studies were included. Pooled analysis showed no significant difference in the risk of bleeding with continued OAC therapy vs. control (RR 1.81 95% confidence interval [CI] 0.70, 4.63 I² = 14% p = .22). Subgroup analysis depending on the type of OAC showed there was a non-significant tendency of increased risk of bleeding with Vitamin K antagonists (VKAs) (RR 3.42 95% CI 1.00, 11.67 I² = 23% p = .05) but not with direct oral anticoagulants (DOACs) (RR 1.67 95% CI 0.49, 5.70 I² = 0% p = .41). Limited data suggest an increased risk of bleeding with OAC as compared to AP (RR 0.08 95% CI 0.01, 0.76 I² = 0% p = .03).

CONCLUSIONS

Continuation of OAC therapy in patients undergoing implant surgery does not increase the risk of bleeding provided local haemostatic measures are used. The indirect comparison suggests bleeding tendency may be higher with VKAs as compared to DOAC.

Local Tranexamic Acid for Preventing Hemorrhage in Anticoagulated Patients Undergoing Dental and Minor Oral Procedures: A Systematic Review and Meta-Analysis

Dental procedures have posed challenges in managing anticoagulated patients due to early reports of oral hemorrhage. This study aims to evaluate the risks of postoperative bleeding with the local application of tranexamic acid. A systematic search was conducted until 31 March 2022, with keywords including tranexamic acid, oral hemorrhage, dental, and/or coagulation. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane Library. Statistical analysis was conducted using Review Manager 5.4. In total, 430 patients were pooled in with the local application of tranexamic acid using mouthwash, irrigation, and compression with a gauze/gauze pad. The mean age was 61.8 years in the intervention group and 58.7 in the control group. Only 4 patients in the intervened group out of the 210 discontinued the trial due to non-drug-related adverse events. The risk difference was computed as -0.07 (p = 0.05), meaning that patients administered with local antifibrinolytic therapy for postoperative bleeding reduction for dental procedures were at a 7% less risk of oral bleeding. Current evidence on managing anticoagulated patients undergoing dental or oral procedures remains unclear. The present study presents favorable outcomes of postoperative bleeding with local tranexamic acid used in the postoperative period.

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.