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de Abreu de Vasconcellos SJ, Souza Dos Santos Marques R, Gomes Magalhães de Melo E, Silva de Almeida C, de Almeida Góes Silva JV, de Almeida Souza LM, Martins-Filho PR. Risk of bleeding in anticoagulated patients undergoing dental extraction treated with topical tranexamic acid compared to collagen-gelatin sponge: Randomized clinical trial. J Craniomaxillofac Surg 2023:S1010-5182(23)00102-6. [PMID: 37422339 DOI: 10.1016/j.jcms.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/05/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023] Open
Abstract
This two-arm, parallel-group, double-blind, randomized clinical trial design evaluated the risk of postoperative bleeding in anticoagulated patients undergoing dental extraction treated with topical TXA in comparison to collagen-gelatin sponge. Forty patients were randomly included in one of the study groups: (1) topical use of 4.8% TXA solution; and (2) resorbable hydrolyzed collagen-gelatin sponge applied to the surgical alveolus. Primary outcomes were postoperative bleeding episodes and secondary outcomes were thromboembolic events and postoperative INR values. The relative risk (RR), the absolute risk reduction (RAR) and the number needed to treat (NNT) were used as effect estimates and calculated from the counting of bleeding episodes observed during the first postoperative week. The bleeding rate under the TXA treatment was 22.2%, while in the collagen-gelatin sponge group it was 45.7%, resulting in a RR of 0.49 (95% CI 0.24-099; p = 0.046), RAR 23.5% and NNT 4.3. TXA was more effective in reducing bleeding in surgical sites located in the mandible (RR = 0.10; 95% CI 0.01-0.71; p = 0.021) and the posterior region (RR = 0.39; 95% CI 0.18-0.84; p = 0.016). Within the limitations of the study it seems that topical TXA is more effective in controlling bleeding after tooth extractions in anticoagulated patients than collagen-gelatin sponge. CLINICAL TRIAL REGISTRATION: RBR-83qw93.
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Affiliation(s)
- Sara Juliana de Abreu de Vasconcellos
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil; Department of Dentistry, Tiradentes University, Sergipe, Brazil
| | | | | | | | | | | | - Paulo Ricardo Martins-Filho
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil; Graduate Program in Dentistry, Federal University of Sergipe, Sergipe, Brazil.
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Wahl MJ. The mythology of anticoagulation therapy interruption for dental surgery. J Am Dent Assoc 2019; 149:e1-e10. [PMID: 29304913 DOI: 10.1016/j.adaj.2017.09.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/08/2017] [Accepted: 09/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Continuous anticoagulation therapy is used to prevent heart attacks, strokes, and other embolic complications. When patients receiving anticoagulation therapy undergo dental surgery, a decision must be made about whether to continue anticoagulation therapy and risk bleeding complications or briefly interrupt anticoagulation therapy and increase the risk of developing embolic complications. Results from decades of studies of thousands of dental patients receiving anticoagulation therapy reveal that bleeding complications requiring more than local measures for hemostasis have been rare and never fatal. However, embolic complications (some of which were fatal and others possibly permanently debilitating) sometimes have occurred in patients whose anticoagulation therapy was interrupted for dental procedures. PRACTICAL IMPLICATIONS AND CONCLUSIONS Although there is now virtually universal consensus among national medical and dental groups and other experts that anticoagulation therapy should not be interrupted for most dental surgery, there are still some arguments made supporting anticoagulation therapy interruption. An analysis of these arguments shows them to be based on a collection of myths and half-truths rather than on logical scientific conclusions. The time has come to stop anticoagulation therapy interruption for dental procedures.
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da Silva R, Gadelha T, Luiz R, Torres S. Intra-alveolar epsilon-aminocaproic acid for the control of post-extraction bleeding in anticoagulated patients: randomized clinical trial. Int J Oral Maxillofac Surg 2018; 47:1138-1144. [DOI: 10.1016/j.ijom.2018.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 02/14/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Zirk M, Fienitz T, Edel R, Kreppel M, Dreiseidler T, Rothamel D. Prevention of post-operative bleeding in hemostatic compromised patients using native porcine collagen fleeces-retrospective study of a consecutive case series. Oral Maxillofac Surg 2016; 20:249-54. [PMID: 27139018 DOI: 10.1007/s10006-016-0560-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/25/2016] [Indexed: 04/16/2023]
Abstract
INTRODUCTION Various anticoagulant therapy regimes bear the risk of postsurgical bleeding events after dental extractions. Local hemostyptic measures, e.g., collagen fleeces, are applied by surgeons to prevent such bleedings. No standard protocol in prevention of bleeding events has met general acceptance among surgeons yet. PURPOSE The purpose of this retrospective study was to determine if post-operative bleeding can be prevented by suturing native collagen fleeces into extraction wounds immediately after teeth removal, regardless what anticoagulant regime is performed. METHODS A total of 741 extraction units were removed from 200 consecutive in-ward patients with or without alternation of different anticoagulant therapy regimes. Anti-vitamin K agents were the most prescribed drugs (n = 104, 52 %), followed by Acetylsalicylate (ASS) (n = 78, 39 %). Nineteen (9.5 %) patients received a dual anti-platelet therapy. Out of 104 patients receiving an anti-vitamin K agent (phenprocoumon), 84 patients were bridged, 20 patients continued to their anticoagulant therapy without alterations. Following careful tooth extraction, extraction sockets were filled using a native type I and III porcine collagen sponge (Collacone, Botiss Biomaterials, Berlin), supported by single and mattress sutures for local hemostasis. Post-operative bleeding events were rated according to their clinical relevance. RESULTS In the post-operative phase, 8 out of 200 consecutively treated patients experienced a post-operative bleeding event. All of them had been designated for a long-term anti-vitamin K therapy (p ≤ 0.05), and extractions were performed under a heparin bridging regime (n = 6) or an uninterrupted anti-vitamin K agent therapy (n = 2). No bleeding events occurred in patients with ASS 100 therapy or low-dose LMWH therapy (p ≤ 0.05), or in patients with dual anti-platelet therapy (0 out of 24). None of the bleeding events put patients' health at risk or required systemic intervention. CONCLUSION Sufficiently performed local hemostyptic measures, like the application of collagen fleeces in combination with atraumatic surgery, bears a great potential for preventing heavy bleeding events in hemostatic compromised patients, regardless of their anticoagulant therapy.
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Affiliation(s)
- Matthias Zirk
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany.
| | - Tim Fienitz
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Robin Edel
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Matthias Kreppel
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Timo Dreiseidler
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
| | - Daniel Rothamel
- Department of Craniomaxillofacial and Plastic Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany
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Shah AH, Khalil HS, Kola MZ. Dental management of a patient fitted with subcutaneous Implantable Cardioverter Defibrillator device and concomitant warfarin treatment. Saudi Dent J 2015; 27:165-70. [PMID: 26236132 PMCID: PMC4501466 DOI: 10.1016/j.sdentj.2014.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/18/2014] [Accepted: 11/19/2014] [Indexed: 11/16/2022] Open
Abstract
Automated Implantable Cardioverter Defibrillators (AICD), simply known as an Implantable Cardioverter Defibrillator (ICD), has been used in patients for more than 30 years. An Implantable Cardioverter Defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at a risk of sudden cardiac death due to ventricular fibrillation, ventricular tachycardia or any such related event. Typically, patients with these types of occurrences are on anticoagulant therapy. The desired International Normalized Ratio (INR) for these patients is in the range of 2–3 to prevent any subsequent cardiac event. These patients possess a challenge to the dentist in many ways, especially during oral surgical procedures, and these challenges include risk of sudden death, control of post-operative bleeding and pain. This article presents the dental management of a 60 year-old person with an ICD and concomitant anticoagulant therapy. The patient was on multiple medications and was treated for a grossly neglected mouth with multiple carious root stumps. This case report outlines the important issues in managing patients fitted with an ICD device and at a risk of sudden cardiac death.
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Affiliation(s)
- Altaf Hussain Shah
- Department of Preventive Dental Sciences, Salman bin Abdulaziz University, AlKharj, Saudi Arabia
| | - Hesham Saleh Khalil
- Department of Maxillofacial Surgery, College of Dentistry, King Saud University, Saudi Arabia
| | - Mohammed Zaheer Kola
- Department of Prosthodontic Dental Sciences, College of Dentistry, Salman bin Abdulaziz University, AlKharj, Saudi Arabia
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Shah AH, Khalil HS, Alshahrani FA, Khan SQ, AlQthani NR, Bukhari IA, Kola MZ. Knowledge of medical and dental practitioners towards dental management of patients on anticoagulant and/or anti-platelet therapy. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.sjdr.2014.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Dental surgery in anticoagulated patients—stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119:136-57. [DOI: 10.1016/j.oooo.2014.10.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/06/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023]
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Iwabuchi H, Imai Y, Asanami S, Shirakawa M, Yamane GY, Ogiuchi H, Kurashina K, Miyata M, Nakao H, Imai H. Evaluation of postextraction bleeding incidence to compare patients receiving and not receiving warfarin therapy: a cross-sectional, multicentre, observational study. BMJ Open 2014; 4:e005777. [PMID: 25510886 PMCID: PMC4267073 DOI: 10.1136/bmjopen-2014-005777] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES We investigated incidence and risk factors for postextraction bleeding in patients receiving warfarin and those not receiving anticoagulation therapy. DESIGN Cross-sectional, multicentre, observational study. SETTING 26 hospitals where an oral surgeon is available. PARTICIPANTS Data on 2817 teeth (from 496 patients receiving warfarin, 2321 patients not receiving warfarin; mean age (SD): 62.2 (17.6)) extracted between 1 November 2008 and 31 March 2010, were collected. Warfarin-receiving patients were eligible when prothrombin time-international normalised ratio (PT-INR) measured within 7 days prior to the extraction was less than 3.0. INTERVENTIONS Simple dental extraction was performed, and incidence of postextraction bleeding and comorbidities were recorded. PRIMARY AND SECONDARY OUTCOME MEASURES Postextraction bleeding not controlled by basic haemostasis procedure was clinically significant. RESULTS Bleeding events were reported for 35 (7.1%) and 49 (2.1%) teeth, of which 18 (3.6%) and 9 (0.4%) teeth were considered clinically significant, in warfarin and non-warfarin groups, respectively, the difference between which was 3.24% (CI 1.58% to 4.90%). The incidence rates by patients were 2.77% and 0.39%, in warfarin and non-warfarin groups, respectively (incidence difference 2.38%, CI 0.65% to 4/10%). Univariate analyses showed that age (OR 0.197, p=0.001), PT-INR (OR 3.635, p=0.003), mandibular foramen conduction anaesthesia (OR 4.854, p=0.050) and formation of abnormal granulation tissue in extraction socket (OR 2.900, p=0.031) significantly correlate with bleeding incidence. Multivariate analysis revealed that age (OR 0.126, p=0.001), antiplatelet drugs (OR 0.100, p=0.049), PT-INR (OR 7.797, p=0.001) and history of acute inflammation at extraction site (OR 3.722, p=0.037) were significant risk factors for postextraction bleeding. CONCLUSIONS Our results suggest that there is slight but significant increase in the incidences of postextraction bleeding in patients receiving warfarin. Although absolute incidence was low in both groups, the bleeding risk is not negligible.
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Affiliation(s)
- Hiroshi Iwabuchi
- Department of Oral and Maxillofacial Surgery, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
| | - Yutaka Imai
- Department of Oral & Maxillofacial Surgery, Dokkyo Medical University School of Medicine, Shimotsuga-gun, Tochigi, Japan
| | - Soichiro Asanami
- Department of Dentistry and Implant Center, Sanno Hospital, Minato-ku, Tokyo, Japan
| | | | | | - Hideki Ogiuchi
- Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kenji Kurashina
- Oral & Dental Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Masaru Miyata
- Department of Dentistry and Oral Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Nakao
- Department of Epidemiology, National Institute of Public Health of Japan, Wako, Saitama, Japan
| | - Hirohisa Imai
- Department of Epidemiology, National Institute of Public Health of Japan, Wako, Saitama, Japan
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Abstract
Background Warfarin is one of the most common oral anticoagulants used to prevent thromboembolic episodes. The benefits of discontinuation of this drug before simple surgical procedures are not clear and this approach could be associated with complications. The aim of this study was to evaluate the risk of bleeding in a series of 35 patients (in cases where the international normalized ratio [INR] is less than 4) following simple tooth extraction without modification of the warfarin dose given to patients. Methods Thirty-five patients taking warfarin who had been referred to the Oral and Maxillofacial Department, College of Dentistry, King Saud University, for dental extractions were included in the study. Exclusion criteria included patients with an INR of ≥4 or with a history of liver disease or coagulopathies. No alteration was made in warfarin dose, and the CoaguChek System was used to identify the INR on the same day of dental extraction. Bleeding from the extraction site was evaluated and recorded immediately after extraction until the second day. Results A total of 35 patients (16 women and 19 men) aged between 38 and 57 years (mean =48.7) were included in the present study. All patients underwent simple one-tooth extraction while undergoing warfarin treatment. Oozing, considered mild bleeding and which did not need intervention was seen in 88.6% of patients. Moderate bleeding occurred in 11.4% of all cases. The INR of the patients ranged from 2.00 to 3.50, with 77.2% of patients having INR between 2.0 and 2.5 on the day of extraction. No severe bleeding which needed hospital management was encountered after any of the extractions. The patients who suffered moderate bleeding were returned to the clinic where they received local treatment measures to control bleeding. Moderate bleeding occurred only in four patients, where three had INR between 3.1 and 3.5, and one with INR less than 3. Conclusion In the present study, we have shown that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.
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Affiliation(s)
- Walid Ahmed Abdullah
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia ; Department of Oral and Maxillofacial Surgery, College of Dentistry, Mansoura University, Mansoura, Egypt
| | - Hesham Khalil
- Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Cho YW, Kim E. Is stopping of anticoagulant therapy really required in a minor dental surgery? - How about in an endodontic microsurgery? Restor Dent Endod 2013; 38:113-8. [PMID: 24010076 PMCID: PMC3761118 DOI: 10.5395/rde.2013.38.3.113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/10/2013] [Accepted: 06/17/2013] [Indexed: 11/11/2022] Open
Abstract
Nowadays, oral anticoagulants are commonly prescribed to numerous patients for preventing cardiovascular accident such as thromboembolism. An important side effect of anticoagulant is anti-hemostasis. In a major surgery, the oral anticoagulant therapy (OAT) regimen must be changed before the surgery for proper post-operative bleeding control. However, in a minor dental surgery and endodontic surgery, the necessity for changing or discontinuing the OAT is open to debate. In this study, risks of the consequences were weighed and analyzed. In patients who stop the OAT, the occurrence of thromboembolic complication is rare but the result is fatal. In patients who continuing the OAT, post-operative bleeding can be controlled well with the local hemostatic measures. In the endodontic surgery, there are almost no studies about this issue. The intra-operative bleeding control is particularly important in the endodontic surgery because of its delicate and sensitive procedures such as inspection of resected root surface using dental microscope and retrograde filling. Further studies are necessary about this issue in the viewpoint of endodontic surgery.
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Affiliation(s)
- Yong-Wook Cho
- Department of Conservative Dentistry, Yonsei University College of Dentistry, Seoul, Korea
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Hong C, Napenas JJ, Brennan M, Furney S, Lockhart P. Risk of postoperative bleeding after dental procedures in patients on warfarin: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:464-8. [DOI: 10.1016/j.oooo.2012.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/25/2012] [Accepted: 04/30/2012] [Indexed: 10/27/2022]
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Firriolo FJ, Hupp WS. Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:431-41. [DOI: 10.1016/j.oooo.2011.10.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 09/17/2011] [Accepted: 10/13/2011] [Indexed: 01/19/2023]
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Wahl MJ. Bleed or die? A bloody simple decision. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:147-8; author reply 150-2. [DOI: 10.1016/j.tripleo.2011.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 01/13/2011] [Indexed: 10/16/2022]
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Balevi B. Should warfarin be discontinued before a dental extraction? Oral Surg Oral Med Oral Pathol Oral Radiol 2012. [DOI: 10.1016/j.tripleo.2011.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lalla RV, Peterson DE, Aframian DJ. Should warfarin be discontinued before a dental extraction? Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:149-50; author reply 150-2. [DOI: 10.1016/j.tripleo.2011.02.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 02/22/2011] [Indexed: 10/15/2022]
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Evidence does not support the discontinuation of warfarin before a dental extraction. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:148-9; author reply 150-2. [DOI: 10.1016/j.tripleo.2011.02.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 02/01/2011] [Indexed: 11/18/2022]
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Should warfarin be discontinued before a dental extraction? A decision-tree analysis. Br Dent J 2011. [DOI: 10.1038/sj.bdj.2011.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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