Use of INR to assess degree of anticoagulation in patients who have dental procedures

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

Aims and Objective

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

Study Design

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

Results

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

Conclusion

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

Causes and timing of delayed bleeding after oral surgery

OBJECTIVES

This study examines a cohort of patients who suffered bleeding requiring hemostatic intervention after oral surgery. The reasons for bleeding and the interval between surgery and onset of bleeding are investigated.

MATERIALS AND METHODS

Between 1998 and 2009, 1,819 cases were eligible for this retrospective study. Factors (independent parameters) influencing the interval (dependent variable) were analyzed using negative binomial count regression models (NegBin II). The significance of each regressor's effect was tested using Wald's test and the total effect using likelihood ratio test.

RESULTS

Of the patients examined, 1,101 (60.1 %) did not take anticoagulants, 394 (21.5 %) took phenprocoumon, 233 (12.7 %) took acetylsalicylic acid, 33 (1.8 %) took clopidogrel, 17 (0.9 %) took more than one anticoagulant, and 78 (4.3 %) had a congenital blood disorder. After simple tooth extraction, 95.3 % suffered bleeding; 69.7 % of extractions were performed in the molar region. Later that day of surgery, 66.0 % of all patients showed bleeding. The bleeding interval was significantly prolonged by anticoagulant therapy with phenprocoumon, by congenital clotting disorders.

CONCLUSIONS

Normal tooth extractions are underestimated for their risk for postoperative bleeding, especially in the molar region. Anticoagulant therapy or congenital blood disorders present oral surgeons with a further challenge.

CLINICAL RELEVANCE

Performing surgery before midday allows surgeons managing postoperative bleeding themselves for a better patient satisfaction. Intensified information about correct postoperative behavior is crucial. Prolonged blood coagulation should intensify follow-up checks. Patients with congenital blood disorders and patients at high risk for bleeding with the need for substitution of platelets or clotting factors should receive inpatient care. More potent, local applicable coagulant agents are required for these patients.

Management of dental patients taking common hemostasis-altering medications

OBJECTIVE

Millions of patients worldwide are taking medications that alter hemostasis and decrease the risk for thromboembolic events. This systematic review is intended to provide recommendations regarding optimal management of such patients undergoing invasive dental procedures. The primary focus of this report is on warfarin therapy, although issues related to heparin and aspirin are briefly discussed because of the frequency with which they are encountered in dental practice.

STUDY DESIGN

The review of literature and development of recommendations was based on the Reference Manual for Management Recommendations for the World Workshop in Oral Medicine IV (WWOM IV). A total of 64 publications were identified for initial review. From these publications, the following types of articles were critically analyzed using WWOM standard forms: randomized controlled trials (RCT), non-RCT studies that assess effects of interventions, and studies that assess modifiable risk factors. Development of recommendations was based on the findings of these reviews as well as expert opinion.

RESULTS

The following evidence-based recommendations were developed: (1) For patients within the therapeutic range of International Normalized Ratio (INR) below or equal to 3.5, warfarin therapy need not be modified or discontinued for simple dental extractions. Nevertheless, the clinician's judgment, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision. Patients with INR greater than 3.5 should be referred to their physician for consideration for possible dose adjustment for significantly invasive procedures. (2) A 2-day regimen of postoperative 4.8% tranexamic acid mouthwash is beneficial after oral surgical procedures in patients on warfarin. (3) It is not necessary to interrupt low-dose aspirin therapy (100 mg/day or less) for simple dental extractions.

CONCLUSION

For most patients undergoing simple single dental extractions, the morbidity of potential thromboembolic events if anticoagulant therapy is discontinued clearly outweighs the risk of prolonged bleeding if anticoagulant therapy is continued.

Hemostatic effect of n-butyl-2-cyanoacrylate (histoacryl) glue in warfarin-treated patients undergoing oral surgery

PURPOSE

Our goal was to evaluate the local hemostatic effect of n-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) glue in warfarin-treated patients who undergo outpatient oral surgery without a change in their level of anticoagulation.

MATERIALS AND METHODS

Thirty consecutive warfarin-treated patients randomly assigned to study and control groups and 10 patients who had never been on anticoagulant therapy serving as the negative control group were included in this trial. Before multiple teeth extractions, all patients had a prothrombin time and the international normalized ratio (INR) determined. To gain hemostasis and primary closure, gelatin sponge and multiple interrupted resorbable sutures were used in the control and negative control groups, and Histoacryl glue and the minimal number of interrupted resorbable sutures were used in the study group. Postoperatively, patients were to contact the oral surgeon if abnormal bleeding occurred. Patients who did not have postoperative bleeding were seen on the 10th postoperative day. Data were collected, and statistical differences in age and gender distributions, number of teeth extracted, INR levels, and bleeding that required treatment were analyzed with the Mantel-Haenzel test. Statistical significance was defined as a value of P <.05.

RESULTS

Local hemostasis was obtained immediately in study patients and only after 10 to 20 minutes in the control and negative control patients. In relation to bleeding complications, there were no cases of postoperative bleeding requiring treatment in both the negative control patients and study patients. In the control patients, 5 cases had postoperative spontaneous bleeding that required treatment. This difference was statistically significant. No patient had wound infection and the healing process appeared to be normal.

CONCLUSION

Multiple extractions can be performed in patients taking oral anticoagulant therapy without a change in their level of anticoagulation provided an efficient local hemostatic measure is instituted. And, in this regard, Histoacryl glue, used as a topical adhesive over approximated wound edges, is an effective and easily applicable local hemostatic for oral surgery in such patients.

Dental management considerations for the patient with an acquired coagulopathy. Part 2: Coagulopathies from drugs

Dental patients often give a medical history that suggests the possibility of a coagulopathy from drugs, with a corresponding risk for prolonged bleeding during and following an invasive procedure. Identification of patients who may be prone to oral bleeding requires specific medical history information and the proper use of laboratory tests. Some NSAIDs are reported to cause prolonged oral bleeding, but scientific evidence is lacking. Likewise, the risk of oral bleeding from anticoagulants such as warfarin is often over stated, and unnecessary adjustment of NSAID or warfarin dosage puts patients at risk for significant morbidity and mortality. Some commonly employed laboratory tests such as the prothrombin time provide helpful information when used in the appropriate setting, but others, such as the bleeding time test, provide little or no predictive value in the determination of patients at risk for oral bleeding. Dental management of patients with potential coagulopathies from medications requires an understanding of basic principles of coagulation. The vast majority of these patients can be managed in the community setting without risk and without alteration of anticoagulant drug regimes.

Oral surgery in patients on anticoagulant therapy

OBJECTIVE

Surgery is the main oral healthcare hazard to the patient with a bleeding tendency, which is mostly caused by the use of anticoagulants. The traditional management entails the interruption of anticoagulant therapy for dental surgery to prevent hemorrhage. However, this practice may increase the risk of a potentially life-threatening thromboembolism. Because this issue is still controversial, it is the aim of this paper to review the evidence, to highlight the areas of major concern, and to suggest management regimens for patients on the 3 main types of anticoagulants: coumarins, heparins, and aspirin. MATERIALS REVIEWED: The pertinent literature and clinical protocols of hospital dentistry departments have been extensively reviewed and discussed.

RESULTS

Several evolving clinical practices in the last years have been detected: anticoagulant use is generally not discontinued; oral surgery is performed despite laboratory values showing significant bleeding tendency; new effective local methods are used to prevent bleeding; and patients at risk are referred to hospital-based clinics.

CONCLUSION

The management of oral surgery procedures on patients treated with anticoagulants should be influenced by several factors: extent and urgency of surgery, laboratory values, treating physician's recommendation, available facilities, dentist expertise, and patient's oral, medical, and general condition.

Antithrombotic agents: implications in dentistry

Thrombosis and the complicating emboli that can result are important causes of illness and death. Thrombosis is of greater overall clinical importance in terms of morbidity and mortality than all of the hemorrhagic disorders combined. Agents such as heparin, low-molecular weight heparin, warfarin, aspirin, ticlopidine, clopidogrel, and tirofiban are used to prevent venous or arterial thrombosis. Patients taking these antithrombotic agents may be at risk for excessive bleeding after invasive dental procedures. The current antithrombotic agents used in medicine are reviewed, and the dental management of patients taking these agents is discussed.

Efficacy of fibrin sealant in patients on various levels of oral anticoagulant undergoing oral surgery

OBJECTIVE

The purpose of this study was to investigate the efficacy of fibrin sealant in patients on oral anticoagulant therapy undergoing oral surgery with varying degrees of surgical trauma and various intensities of anticoagulation.

STUDY DESIGN

A consecutive series of 69 subjects on oral anticoagulant therapy undergoing oral surgery without changing anticoagulation intensity is presented. For each subject, indication for anticoagulation, international normalized ratio on day of treatment (low, 1.0-2.0; medium, 2.1-3.0; high, 3.1-5.0), degree of surgical trauma (on a scale of 1-12), and complications were recorded and correlated.

RESULTS

There were 32 (46.4%) patients with prosthetic valves, 23 (33.3%) with atrial fibrillation and rheumatic or ischemic heart disease, and 14 (20.3%) with previous thromboembolism. Twenty (29%) patients were on low-intensity anticoagulation (international normalized ratio, 1.0-2.0), 26 (37.7%) were on medium-intensity anticoagulation (international normalized ratio, 2.1-3.0), and 23 (33.3%) were on high-intensity anticoagulation (international normalized ratio, 3.1-5.0). Each of 39 (56.5%) patients was in surgical trauma category 1, 2, or 3; the remaining 30 (43.5%) patients were in surgical trauma categories 4 through 12. Complications occurred in 3 (4.3%) patients and took the form of minor postoperative bleeding. No correlation was found between complications and international normalized ratio or degree of surgical trauma.

CONCLUSIONS

The use of fibrin sealant in oral surgery for patients on oral anticoagulant therapy is safe, and it can be provided in an international normalized ratio range of 1.0 through 5.0 and in a surgical trauma scale range of 1 through 12.

Current perspectives on dental patients receiving coumarin anticoagulant therapy

Despite approximately 40 years of experience with oral anticoagulant drugs, controversy still exists about the safety of dental treatment in a patient receiving this therapy. The authors review the topic in depth and offer detailed recommendations for the dental management of patients receiving coumarin anticoagulant therapy.

Amoxicillin-related postextraction bleeding in an anticoagulated patient with tranexamic acid rinses

This report describes a patient who had significant postoperative bleeding 4 days after undergoing surgery while using a tranexamic acid (4.8%) mouth rinse protocol for local control of hemostatis. Patients undergoing dentoalveolar surgery who are receiving chronic oral anticoagulants are treated with a tranexamic acid mouth rinse at our hospital. No systemic modification of their coagulation status is attempted. The postoperative bleeding problem that developed was determined to be caused by an antibiotic-induced vitamin K deficiency rather than a failure of the tranexamic acid protocol.

Altering anticoagulation therapy: a survey of physicians

Patients who take antithrombotic medications, such as warfarin sodium or aspirin, are more likely than others to experience bleeding problems after some dental treatments. Withdrawing the medication before treatment, however, may place these patients at risk of medical complications. The authors surveyed physicians about the conditions under which such pharmacotherapies should be altered. They not only found a difference of opinion among the respondents, but also learned that many respondents misunderstood the nature of certain dental procedures and the likelihood that those procedures would cause significant postoperative bleeding.