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Chisci G, Chisci D, Chisci E, Chisci V, Stumpo M, Chisci E. The Management of a Geriatric Patient Using Dabigatran Therapy on Dentigerous Cyst with Oral Bleeding. J Clin Med 2024; 13:1499. [PMID: 38592423 PMCID: PMC10934523 DOI: 10.3390/jcm13051499] [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: 02/06/2024] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Jaw cysts represent a great matter of interest in oral and maxillofacial surgery. Jaw cyst surgery is a common intervention in oral surgery but, in the case of a multidisciplinary patient, the oral surgeon needs to meet with other specialists. A cyst is an epithelium-lined sac containing fluid and/or semisolid material due to epithelial cell proliferation, degeneration, and liquefaction; the hypertonic solution withdraws liquids from the surrounding tissues, while internal pressure exerts an equal strength on the cyst walls. Dentigerous cysts are the second most common odontogenic cysts after radicular cysts, and commonly few or no symptoms are reported. However, the most common diagnosis for dentigerous cyst is represented by eruption of the affected tooth or accidental diagnosis. Commonly, dentigerous cysts may be related to impacted third molars; in the case of impacted third molars and a dentigerous cyst, the tooth should be removed along with the cyst in the same intervention. Mandibular dentigerous cysts are common in children and adults, while dentigerous cysts are a rare neoformation in elderly patients. Treatment usually involves removal of the entire cyst and the associated unerupted tooth. This intervention may be more difficult if the cyst is large, the third molar is in contact with the mandibular nerve, and/or the patient has a medical history that may represent a relative or absolute contraindication. We present the case of a rare symptomatic manifestation of dentigerous cyst in an elderly patient in treatment with dabigatran therapy; for the treatment of dentigerous cysts in the elderly, we suggest a multidisciplinary approach with the use of the histological examination and a careful follow-up.
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Affiliation(s)
- Glauco Chisci
- Centro Dentistico Chisci, Via Ricasoli 18, 58100 Grosseto, Italy; (D.C.); (E.C.)
| | - Dafne Chisci
- Centro Dentistico Chisci, Via Ricasoli 18, 58100 Grosseto, Italy; (D.C.); (E.C.)
| | - Enea Chisci
- Department of Ophthalmology, University of Palermo, 90133 Palermo, Italy;
| | - Viola Chisci
- Department of Ophthalmology, Greifswald University Hospital, 17475 Greifswald, Germany
| | - Michela Stumpo
- Department of Pathology, USL Toscana Sudest—Grosseto, Misericordia Hospital, 58100 Grosseto, Italy
| | - Elettra Chisci
- Centro Dentistico Chisci, Via Ricasoli 18, 58100 Grosseto, Italy; (D.C.); (E.C.)
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Chan MH, Sun F, Malakan J. Controversies in Stoppage of Antiplatelet and Anticoagulant Medications Prior to Oral Surgery. Dent Clin North Am 2024; 68:21-45. [PMID: 37951634 DOI: 10.1016/j.cden.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Dental procedures can pose a risk of bleeding, and it is not uncommon for dentists to consult prescribing physicians regarding a mutual patient's antiplatelet and anticoagulant medication to prevent excessive bleeding during or after an upcoming procedure. However, there has been a growing controversy in the dental community surrounding the stoppage of these medications prior to dental procedures. Some believe that stopping these medications prior to dental procedures is necessary to reduce the risk of bleeding complications, while others argue that stopping them can increase the risk of stroke or other thromboembolic events. The debate has left many dentists and specialists unsure about the best course of action when it comes to managing bleeding risk during dental procedures.In this article, we will review the antithrombotic medications, indications, mechanism of action, and its effects on the coagulation pathway, laboratory testing and reversal agents. Also, we will explore the controversy surrounding the stoppage of novel anitplatelets (eg,: prasurgrel and ticagrelor), dual-antiplatelets, triple-antiplatelet, vitamin K antagonists (eg,: wafarin, coumadin), and direct oral anticoagulants (eg,: dabigatran, rivaroxaban, xarelto and endoxaban) in dentistry and examine the current evidence and guidelines for managing dental patients undergoing oral surgery.
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Affiliation(s)
- Michael H Chan
- Oral & Maxillofacial Surgery, Department of Veterans Affairs, New York Harbor Healthcare System (Brooklyn Campus), 800 Poly Place (Bk-160), Brooklyn, NY 11209, USA; Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue (Box-187), Brooklyn, NY 11201, USA.
| | - Feiyi Sun
- Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
| | - Jonathan Malakan
- Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue, Brooklyn, NY 11201, USA
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3
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Colella A, Yu E, Sambrook P, Hughes T, Goss A. What is the Risk of Developing Osteonecrosis Following Dental Extractions for Patients on Denosumab for Osteoporosis? J Oral Maxillofac Surg 2023; 81:232-237. [PMID: 36442534 DOI: 10.1016/j.joms.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Osteonecrosis of the jaws (ONJ) occurs in patients on antiresorptive drugs for osteoporosis with the risk with oral bisphosphonates being known to be of the order of 0.1 to 0.3% while the risk for patients on denosumab for osteoporosis is not known. The aim of this study was to determine the risk of developing ONJ in a consecutive series of patients on denosumab for osteoporosis having dental extractions. MATERIAL AND METHODS A prospective cohort study of patients on denosumab for osteoporosis having dental extractions in the period January 1, 2017 and June 30, 2021 were compared to a control group not on antiresorptives. Detailed demographic records including length of time on antiresorptives and CTX values were obtained. Comparison to further define risk factors was made between those patients developing ONJ to those who didn't. RESULTS The treatment group included 427 patients who were on denosumab for osteoporosis; they collectively underwent 561 episodes of dental treatment involving extractions for a total of 1081 extractions, with 10 developing ONJ (risk 2.3%). The control group consisted of 299 patients who were not taking denosumab; they collectively underwent 315 episodes of dental treatment for a total of 669 extractions, and none of them developed ONJ. There were significant differences in age and sex, but not medical comorbidities between the treatment and control groups. Within the treatment group, there were no significant differences in any of these characteristics between those who did, and those who didn't, develop ONJ. Within the treatment group, the number of extractions modified the risk of developing ONJ (odds ratio, 1.35; confidence interval, 1.1-1.7). Of the 76 patients who had extractions between 6 and 7 months after the last denosumab injection, none developed ONJ. CONCLUSIONS The risk of ONJ in patients on denosumab for osteoporosis is a magnitude greater than for patients on the oral bisphosphonates 2.3% v 0 - 0.3%, which is 7.7 times more likely. Number of extractions and early resumption of the next dose of denosumab increases the risk of ONJ.
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Affiliation(s)
- Anthony Colella
- Medical student, Medical School, The University of Adelaide, Adelaide, Australia
| | - Elaine Yu
- House Surgeon, Monash Medical Centre Clayton, Monash University, Melbourne, Australia
| | - Paul Sambrook
- Head of Unit, Oral & Maxillofacial Surgery Unit, Adelaide, South Australia, Australia
| | - Toby Hughes
- Professor and Postgraduate Coordinator, School of Dentistry, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alastair Goss
- Emeritus Professor and Consultant, Oral & Maxillofacial Surgery Unit, The University of Adelaide, Adelaide, South Australia, Australia.
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4
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Hiroshi I, Natsuko SY, Yutaka I, Masayori S, Hiroyuki N, Hirohisa I. Frequency of hemorrhage after tooth extraction in patients treated with a direct oral anticoagulant: A multicenter cross-sectional study. PLoS One 2022; 17:e0266011. [PMID: 35390010 PMCID: PMC8989216 DOI: 10.1371/journal.pone.0266011] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 03/11/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Few studies have compared the frequency of hemorrhages after tooth extraction between patients taking direct oral anticoagulants (DOACs) and those taking warfarin or no anticoagulants. Further, the effects of the timing of DOAC administration and tooth extraction on the frequency of post-extraction hemorrhage have not been demonstrated. Therefore, we compared the frequency of post-extraction hemorrhages in patients in these different conditions and examined the effects of the timing of DOAC administration and tooth extraction on the frequency. DESIGN Prospective multicenter study. SETTING Eighty-six Japanese hospitals. PARTICIPANTS In total, 182 teeth extracted from 145 individuals (119 teeth from adult males) receiving dabigatran and 88 teeth from individuals (62 teeth from adult males) receiving rivaroxaban were included. INTERVENTION Tooth extraction was followed by a 7-day observational period between November 1, 2008 and December 31, 2015. Dabigatran was administered twice daily; rivaroxaban was administered once a day. PRIMARY OUTCOME MEASURE Hemorrhage after tooth extraction. RESULTS The frequency of hemorrhage after tooth extraction was 1.65%, 3.41%, and 3.63% in those treated with dabigatran, rivaroxaban, and warfarin, respectively, and 0.39% in those who did not receive anticoagulants. Hemorrhages after tooth extraction were significantly higher in the rivaroxaban group than in patients who did not receive anticoagulants (P = 0.008). These frequencies did not differ significantly in the dabigatran and rivaroxaban groups compared to the warfarin group (P = 0.221 and P = 1.000, respectively). CONCLUSIONS The frequency of hemorrhaging after tooth extraction appeared to be similar in patients receiving continuous dabigatran or rivaroxaban and in those receiving continuous warfarin.
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Affiliation(s)
- Iwabuchi Hiroshi
- Kanagawa Dental University, Yokosuka-shi, Japan
- Department of Dentistry and Oral Surgery International University of Health and Welfare Hospital, Nasushiobara-shi, Japan
| | - Sawai Y. Natsuko
- Department of Education Planning, Faculty of Dentistry, Kanagawa Dental University, Yokosuka-shi, Japan
| | - Imai Yutaka
- Dokkyo Medical University School of Medicine, Shimotsuga-gun, Japan
| | - Shirakawa Masayori
- First Department of Oral and Maxillofacial Surgery, Meikai University School of Dentistry, Saitama, Japan
| | - Nakao Hiroyuki
- Faculty of Nursing, Miyazaki Prefectural Nursing University, Miyazaki, Japan
| | - Imai Hirohisa
- Department of Medical and Pharmaceutical Community Healthcare, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Al-Ansari A. Acquired bleeding disorders through antithrombotic therapy: the implications for dental practitioners. Br Dent J 2020; 229:729-734. [PMID: 33311678 DOI: 10.1038/s41415-020-2399-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/28/2020] [Indexed: 11/09/2022]
Abstract
Antithrombotic medications are one of the most common causes of an acquired bleeding disorder. The majority of these medications are administered orally for a variety of clinical indications. It is important that dental surgeons are aware of these medications, their mechanisms of action and how they can influence the dental management of patients, particularly when undertaking procedures which carry a risk of bleeding.
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Affiliation(s)
- Anmar Al-Ansari
- Dental Core Trainee 1 in Oral and Maxillofacial Surgery, Forth Valley Royal Hospital, Stirling Rd, Larbert, FK5 4WR, UK.
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6
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Lupi SM, Baena ARY. Patients Taking Direct Oral Anticoagulants (DOAC) Undergoing Oral Surgery: A Review of the Literature and a Proposal of a Peri-Operative Management Protocol. Healthcare (Basel) 2020; 8:healthcare8030281. [PMID: 32825272 PMCID: PMC7551164 DOI: 10.3390/healthcare8030281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/16/2022] Open
Abstract
Patients on anticoagulant therapy for the prevention of cardiovascular accidents present an increased risk of bleeding following dental and oral surgery. Four recently introduced non-vitamin K antagonist oral anticoagulants, namely dabigatran etexilate (direct thrombin inhibitor), rivaroxaban, apixaban, and edoxaban (Xa factor direct inhibitor), are widely spreading for convenience of use compared to the older drug class. Dental management of patients taking these drugs has substantial differences compared to patients on vitamin K antagonist therapy. Anticoagulation is not assessed directly through a hematological test, but indirectly by renal function. The interventions must be scheduled at the time of minimum blood concentration of the drug. Bleeding can occur even after several days following the surgery. The interaction with drugs administered for dental care must be carefully evaluated. The peri-operative diet can influence the risk of bleeding. Local measures favoring coagulation must be adopted. The interventions with higher risk must be divided into multiple less invasive interventions. Although antidotes exist for these drugs, their use does not seem necessary for dental interventions that have been planned optimally. Furthermore, in this review of the literature a decision protocol is proposed for the evaluation of the suspension of the anticoagulant drug before oral surgery. Cessation of any anticoagulant should only be made in consultation with the patient’s general practitioner/cardiologist, who will weigh up the risk of bleeding from the proposed procedure with the risk of thrombosis/stroke in each individual patient.
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Affiliation(s)
- Saturnino Marco Lupi
- Department of Clinical Surgical, Pediatric and Diagnostic Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-382-516-255
| | - Arianna Rodriguez y Baena
- Department of Dentistry, IRCCS San Raffaele Hospital, 20123 Milan, Italy;
- Dental School, Vita Salute University, 20132 Milan, Italy
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7
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Rocha AL, Oliveira SR, Souza AF, Travassos DV, Abreu LG, Ribeiro DD, Silva TA. Direct oral anticoagulants in oral surgery: a prospective cohort. ACTA ACUST UNITED AC 2020; 69:384-393. [PMID: 32698567 DOI: 10.23736/s0026-4970.20.04389-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Quantitative assessment of bleeding in dental extractions is rarely reported in the literature. The assessment of bleeding might provide additional evidence to predict and minimize postoperative outcomes. The aim of this study was to evaluate the pattern of bleeding in individuals taking direct oral anticoagulants (DOACs) submitted to dental extractions. METHODS Intraoperative bleeding was evaluated by using total collected bleeding corrected by absorbance reading (dental bleeding score). To monitoring bleeding episodes from the day of surgery, this cohort was followed up until the seventh postoperative day. RESULTS Forty-five procedures were performed in three comparative groups, patients under DOACs, individuals taking vitamin K antagonists (VKAs) and without anticoagulant therapy. No bleeding events were observed in procedures carried out in individuals of the DOAC group. Additional hemostatic measures were required in two procedures in the VKA group and one in the non-anticoagulated group. The dental bleeding scores obtained for the DOAC and VKA groups were similar. CONCLUSIONS Our data suggest that the DOAC therapy did not result in increased bleeding outcomes in this sample.
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Affiliation(s)
- Amanda L Rocha
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Sicilia R Oliveira
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Alessandra F Souza
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Denise V Travassos
- Department of Community and Preventive Dentistry, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Lucas G Abreu
- Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Daniel D Ribeiro
- Department of Hematology, Faculty of Medicine, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Tarcília A Silva
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil -
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8
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Management of anticoagulated patients in dentoalveolar surgery: a clinical comparative study. Clin Oral Investig 2019; 24:2653-2662. [PMID: 31713746 DOI: 10.1007/s00784-019-03124-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This prospective, comparative, clinical study analyzed the postoperative bleeding risk of patients on anticoagulation therapy (AT) who were undergoing tooth extractions and osteotomies. MATERIALS AND METHODS Patients with the following ATs were included (test groups): (1.) platelet aggregation inhibitors (PAIs), (2.) vitamin K inhibitors, (3.) low molecular weight heparin (LMWH), and (4.) direct oral anticoagulants (DOACs). Patients in the control group were not on any AT (non-AT group). Patients were subdivided into the following treatment groups: (1.) single tooth extraction, (2.) serial extraction (≥ 2 adjacent teeth), and (3.) tooth osteotomy. Pre-, intra-, and postoperative data concerning the treatment, extent of the surgery, and bleeding were recorded and statistically evaluated. RESULTS There were 15 postoperative bleeding events in 838 patients (1.7%): four (0.7%) in the non-AT group (n = 603 patients) and 11 (4.7%) in the AT group (n = 235 patients). The surgical procedure had no statistically significant effect on postoperative bleeding frequencies. Patients taking vitamin K inhibitors had a significantly higher risk of postoperative bleeding compared with patients without AT (p < 0.00001). Four patients were hospitalized due to the severity of the bleeding (vitamin K inhibitor group). Postoperative bleeding events were all controlled with local hemostatic measures. CONCLUSIONS The postoperative bleeding risk after tooth extractions and osteotomies in patients continuing AT is low, and bleeding can be controlled with local hemostatic measures. CLINICAL RELEVANCE AT should be continued in patients undergoing tooth removal procedures under the provision that local hemostatic measures are applied.
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9
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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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Manfredi M, Dave B, Percudani D, Christoforou J, Karasneh J, Diz Dios P, Glick M, Kumar N, Lockhart PB, Patton LL. World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta‐analysis. Oral Dis 2019; 25 Suppl 1:157-173. [DOI: 10.1111/odi.13086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Affiliation(s)
| | - Bella Dave
- Department of Oral MedicineLeeds Dental Institute Leeds West Yorkshire UK
| | | | | | - Jumana Karasneh
- Department of Oral Medicine and SurgeryFaculty of DentistryJordan University of Science and Technology Irbid Jordan
| | - Pedro Diz Dios
- Medical‐Surgical Dentistry Research Group (OMEQUI)Health Research Institute of Santiago de Compostela (IDIS)University of Santiago de Compostela Santiago de Compostela Spain
| | - Michael Glick
- School of Dental MedicineUniversity at Buffalo, The State University of New York Buffalo New York
| | - Navdeep Kumar
- Cert Surg & Pros ImplantologyEastman Dental Hospital for Oral Healthcare Sciences London UK
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Precht C, Demirel Y, Assaf AT, Pinnschmidt HO, Knipfer C, Hanken H, Friedrich RE, Wikner J. Perioperative Management in Patients With Undergoing Direct Oral Anticoagulant Therapy in Oral Surgery - A Multicentric Questionnaire Survey. In Vivo 2019; 33:855-862. [PMID: 31028208 PMCID: PMC6559883 DOI: 10.21873/invivo.11550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/13/2019] [Accepted: 03/27/2019] [Indexed: 01/04/2023]
Abstract
AIM The purpose of this study was to survey the current opinions of hospitals and medical practices concerning the perioperative management of patients undergoing direct oral anticoagulant therapy (DOAC) and discuss recommendations for the clinical practice. MATERIALS AND METHODS A questionnaire with 13 topics and multiple ordinal-polytomous subitems was designed and sent to 120 Departments of Oral and Maxillofacial Surgery in Austria, Switzerland and Germany, as well as to 85 oral and maxillofacial/oral surgeons in medical offices in Hamburg, Germany. The data were statistically evaluated by Chi-square, Fisher's exact and Jonckheere-Terpstra tests. RESULTS The rate of response was 42%. Thirty-seven percent of respondents reported treating over 50 patients per year with undergoing DOAC therapy and only 18% assess a high bleeding risk [33% for vitamin K antagonists (VKA)]. In contrast to that, 62% of respondents would interrupt the DOAC therapy for extraction of one tooth, while 94% would continue VKA therapy. Significantly more clinicians apply suture than those in a medical office. The use of additional hemostatic measures varied between clinic and medical practice. There was a clear request for more detailed guidelines. CONCLUSION The study shows the current opinion for perioperative management of patients undergoing DOAC therapy. Multi-centric studies under controlled conditions are needed for a safer treatment of anticoagulated patients as therapy strategies differ greatly between institutions and therefore a complication analysis is hardly possible.
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Affiliation(s)
- Clarissa Precht
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yeliz Demirel
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandre T Assaf
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Knipfer
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Hanken
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reinhard E Friedrich
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Wikner
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Strategy of Dabigatran Reversal Drug in Emergency. J Craniofac Surg 2019; 30:1320-1321. [PMID: 30882580 DOI: 10.1097/scs.0000000000005457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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13
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Yoshikawa H, Yoshida M, Yasaka M, Yoshida H, Murasato Y, Fukunaga D, Shintani A, Okada Y. Safety of tooth extraction in patients receiving direct oral anticoagulant treatment versus warfarin: a prospective observation study. Int J Oral Maxillofac Surg 2019; 48:1102-1108. [PMID: 30745243 DOI: 10.1016/j.ijom.2019.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/14/2018] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
Abstract
The aim of this study was to compare the safety of tooth extraction in patients receiving direct oral anticoagulants (DOACs) or warfarin without cessation of their antithrombotic treatment. This prospective observational study included 367 patients undergoing tooth extraction (119 receiving DOACs and 248 receiving warfarin). All extractions in DOAC patients were performed 6-7h after taking DOACs in consideration of the half-life in blood under continued antithrombotic treatment. To examine the potential postoperative bleeding risk related to the time of extraction and the drug concentration of blood, activated partial thromboplastin time (APTT) in dabigatran and prothrombin time (PT) in rivaroxaban were measured three times after administration. A total of 390 tooth extractions were performed: 128 in the DOAC patients and 262 in warfarin patients. Postoperative bleeding occurred in four extractions (3.1%) in the DOAC group and in 23 (8.8%) in the warfarin group. There was no statistically significant difference between the two groups (odds ratio: 2.362, 95% confidence interval (CI) 0.819-6.815, p=0.112). APTT and PT prolongation in almost all cases decreased with time after taking the medicine. Our findings suggest that interruption of DOAC therapy is not necessary for tooth extraction if the procedure is performed at least 6h after the last dose.
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Affiliation(s)
- H Yoshikawa
- Department of Dentistry and Oral Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
| | - M Yoshida
- Department of Dentistry and Oral Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - M Yasaka
- Cerebrovascular Medicine and Neurology, Cerebrovascular Center, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - H Yoshida
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Y Murasato
- Department of Cardiology, Cardiovascular Center, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - D Fukunaga
- Department of Dentistry and Oral Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - A Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Y Okada
- Cerebrovascular Medicine and Neurology, Cerebrovascular Center, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Cocero N, Basso M, Grosso S, Carossa S. Direct Oral Anticoagulants and Medical Comorbidities in Patients Needing Dental Extractions: Management of the Risk of Bleeding. J Oral Maxillofac Surg 2018; 77:463-470. [PMID: 30347201 DOI: 10.1016/j.joms.2018.09.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE The purpose of this study was to measure the frequency of bleeding during and after tooth extraction in patients exposed to direct oral anticoagulants (DOACs) and identify risk factors for prolonged or excessive bleeding. MATERIALS AND METHODS This retrospective cohort study involved 100 patients who underwent tooth extractions according to the European Heart Rhythm Association protocol: continuation of DOAC therapy for extractions of up to 3 teeth in the same session performed at the (presumed) time of DOAC trough concentration. We respected an interval of at least 4 hours between extraction and last DOAC intake. The outcome of interest was incidence of mild, moderate, and severe bleeding during the intervention and in the 7-day follow-up period. Data analysis considered the presence of comorbidities as the primary predictor for bleeding; additional predictors were age, gender, type of comorbidity, indication for DOAC therapy, DOAC agent, and extraction of contiguous teeth. RESULTS Of the patients, 64 had comorbidities (diabetes in 50%). The distributions of demographic, clinical, and dental variables were similar for patients with and without comorbidities. We observed 4 bleeding episodes (1 moderate episode 1 hour after the extraction and 3 mild episodes the day after the extraction) in the comorbidity group and none in the non-comorbidity group (4 of 64 vs 0 of 36, P = .29; overall bleeding rate, 4 of 100). The factor significantly triggering bleeding in patients with comorbidity was extractions of couples and triplets of multirooted teeth (P = .004). CONCLUSIONS Tooth extractions in patients with comorbidities taking DOACs may be safely managed as long as they are performed at least 4 hours after the last DOAC intake and do not involve 2 or 3 contiguous premolars and molars.
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Affiliation(s)
- Nadia Cocero
- Senior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy.
| | - Michele Basso
- Senior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy
| | - Simona Grosso
- Junior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy
| | - Stefano Carossa
- Department Head, Department of Surgical Sciences, Dental School, University of Torino, Turin, Italy
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15
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Miller SG, Miller CS. Direct oral anticoagulants: A retrospective study of bleeding, behavior, and documentation. Oral Dis 2018; 24:243-248. [PMID: 29480605 DOI: 10.1111/odi.12698] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 06/07/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To examine the effects of direct oral anticoagulants (DOACs) on bleeding complications following dental surgeries. SUBJECTS AND METHODS This 6-year retrospective study collected data from records of patients undergoing oral surgical procedures within a university setting. An electronic health record database was searched using current procedural terminology codes for oral surgical procedures. Information regarding patient, procedural factors, and postoperative complications were extracted. Data were analyzed by Fisher's exact test. RESULTS Of patients who had a procedural code associated with oral surgery, only 0.11% (12/11,320) took a DOAC. Twelve patients (10 males, age ranging from 44 to 90 years) underwent 17 surgeries by nine different practitioners involving 98 extractions, 14 alveoloplasties, two tuberosity reductions, and two tori removals. In nine cases, the DOAC was discontinued a mean of 52.5 hrs prior to surgery (range 12-120 hrs). Bleeding complications were not reported for patients whose drug was discontinued or continued. Documentation of drug continuation/discontinuation was poor. CONCLUSIONS Bleeding was not observed with direct oral anticoagulation use in this oral surgery cohort. Drug discontinuation/continuation was not a factor in bleeding outcomes, and direct oral anticoagulation interruption was variable and poorly documented.
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Affiliation(s)
- S G Miller
- Department of Oral Health Practice, Division of Oral Medicine, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - C S Miller
- Department of Oral Health Practice, Division of Oral Medicine, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
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16
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Affiliation(s)
- Paul Sambrook
- Dental Therapeutics Committee, Australian Dental Association, Sydney
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17
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Andrade MVS, Andrade LAP, Bispo AF, Freitas LDA, Andrade MQS, Feitosa GS, Feitosa-Filho GS. Evaluation of the Bleeding Intensity of Patients Anticoagulated with Warfarin or Dabigatran Undergoing Dental Procedures. Arq Bras Cardiol 2018; 111:394-399. [PMID: 30088558 PMCID: PMC6173350 DOI: 10.5935/abc.20180137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/25/2018] [Indexed: 12/23/2022] Open
Abstract
Background Thrombotic disorders remain one of the leading causes of death in the Western
world. Dabigatran appeared as an alternative to warfarin for anticoagulation
in the treatment of atrial fibrillation (AF). The risk associated with
bleeding due to its use has been documented in several randomized clinical
trials, but no large study has examined in detail the risk of bleeding
during dental extraction and other dental procedures involving bleeding. Objective To compare the intensity of bleeding in individuals taking dabigatran or
vitamin K antagonist (warfarin) and undergoing dental procedures. Methods Prospective, single-center, controlled study with one single observer.
Patients diagnosed with nonvalvular AF, on warfarin or dabigatran, cared for
at a cardiology referral center, and requiring single or multiple dental
extractions, were evaluated up to seven days post-extraction. The following
outcomes were assessed: bleeding time between the beginning and the end of
suture and complete hemostasis; bleeding before the procedure, after 24
hours, 48 hours, 7 days, during and after suture removal (late); p<0.05
was defined as of statistical relevance. Results We evaluated 37 individuals, 25 in the warfarin group and 12 in the
dabigatran group. Age, sex, weight, height, blood pressure, color,
schooling, family income and comorbidities were similar between the two
groups. Regarding bleeding after 24 hours of the procedure, no one in the
dabigatran group had bleeding, whereas 32% in the warfarin group had
documented bleeding (p = 0.028). The other variables analyzed did not differ
between the groups. Conclusions This study suggests that, regarding dental extraction, there is no
statistically significant difference in the intensity of bleeding of
patients taking dabigatran as compared to those taking warfarin. Bleeding 24
hours after the procedure was less frequent among patients on
dabigatran.
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Affiliation(s)
- Marcus Vinicius Santos Andrade
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brazil.,Hospital Santa Izabel da Santa Casa de Misericórdia da Bahia, Salvador, BA - Brazil.,Centro de Referência em Doenças Cardiovasculares - Dr. Adriano Pondé, Salvador, BA - Brazil
| | - Luciana Azevedo Prata Andrade
- Hospital Santa Izabel da Santa Casa de Misericórdia da Bahia, Salvador, BA - Brazil.,Centro de Referência em Doenças Cardiovasculares - Dr. Adriano Pondé, Salvador, BA - Brazil
| | - Alan Freitas Bispo
- Centro de Referência em Doenças Cardiovasculares - Dr. Adriano Pondé, Salvador, BA - Brazil
| | | | | | - Gilson Soares Feitosa
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brazil.,Hospital Santa Izabel da Santa Casa de Misericórdia da Bahia, Salvador, BA - Brazil
| | - Gilson Soares Feitosa-Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brazil.,Hospital Santa Izabel da Santa Casa de Misericórdia da Bahia, Salvador, BA - Brazil
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18
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Bleeding related to dental treatment in patients taking novel oral anticoagulants (NOACs): a retrospective study. Clin Oral Investig 2018; 23:477-484. [DOI: 10.1007/s00784-018-2458-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 04/17/2018] [Indexed: 12/19/2022]
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19
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Lababidi E, Breik O, Savage J, Engelbrecht H, Kumar R, Crossley CW. Assessing an oral surgery specific protocol for patients on direct oral anticoagulants: a retrospective controlled cohort study. Int J Oral Maxillofac Surg 2018; 47:940-946. [PMID: 29653869 DOI: 10.1016/j.ijom.2018.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 01/30/2018] [Accepted: 03/14/2018] [Indexed: 11/29/2022]
Abstract
Chronic therapy with the new direct oral anticoagulants (DOACs) poses new challenges for dental practitioners assessing the risk versus benefit of cessation versus non-cessation of anticoagulant therapy for dentoalveolar procedures. A retrospective controlled cohort study was designed to evaluate a non-cessation protocol for patients taking DOACs in the setting of dental extractions. A records review covering the period 1 January 2016 to 31 December 2016 identified 43 patients on DOAC therapy; 53 dentoalveolar procedures were performed under local anaesthesia, of which 15 included varying degrees of peri-procedural cessation. A control group of 50 patients on uninterrupted warfarin therapy undergoing 59 dentoalveolar procedures was identified. The incidence, severity, and timing of bleeding events were recorded for each group. Four (10.5%) minor bleeding events were recorded in the non-cessation DOAC group and nine (15.3%) minor bleeding events in the warfarin group. No bleeding events were recorded in the DOAC cessation group. Comparison of the incidence of bleeding events between the non-cessation DOAC group and the warfarin group showed no statistically significant difference (odds ratio 0.65, P=0.56). Within the limitations of this study, dental extractions in the context of continuing DOAC therapy can be performed safely provided extra local haemostatic measures are applied.
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Affiliation(s)
- E Lababidi
- Oral and Maxillofacial Surgery Unit, Royal Dental Hospital of Melbourne, Melbourne, Victoria, Australia.
| | - O Breik
- Oral and Maxillofacial Surgery Unit, Royal Dental Hospital of Melbourne, Melbourne, Victoria, Australia
| | - J Savage
- Oral and Maxillofacial Surgery Unit, Royal Dental Hospital of Melbourne, Melbourne, Victoria, Australia
| | - H Engelbrecht
- Oral and Maxillofacial Surgery Unit, Royal Dental Hospital of Melbourne, Melbourne, Victoria, Australia
| | - R Kumar
- Oral and Maxillofacial Surgery Unit, Royal Dental Hospital of Melbourne, Melbourne, Victoria, Australia
| | - C W Crossley
- Oral and Maxillofacial Surgery Unit, Royal Dental Hospital of Melbourne, Melbourne, Victoria, Australia
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20
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Bensi C, Belli S, Paradiso D, Lomurno G. Postoperative bleeding risk of direct oral anticoagulants after oral surgery procedures: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2018; 47:923-932. [PMID: 29627150 DOI: 10.1016/j.ijom.2018.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 01/15/2018] [Accepted: 03/18/2018] [Indexed: 01/24/2023]
Abstract
Direct oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban; DOACs) have been introduced to improve safety and superior therapeutic value compared to their predecessors such as warfarin or enoxaparin. The aim of this systematic review and meta-analysis was to assess the postoperative bleeding risk of DOACs during oral surgery procedures. Systematic searches were performed in electronic databases including PubMed, Scopus, Web of Science and Cochrane Library. Thirteen studies were included in the qualitative synthesis: two retrospective case-control studies, five prospective case-control studies, three cross-sectional studies, two case series and a case report; while only six studies were statistically analysed. The risk ratio of postoperative bleeding in DOACs patients was significantly greater than in healthy patients (3.04; 95% confidence interval (CI)=1.31-7.04). This is especially true for rivaroxaban (4.13; 95% CI=1.25-13.69), and less so for dabigatran which presented a risk ratio similar to that of healthy patients (1.00; 95% CI=0.21-4.82). However, further research is required to support these results. Both apixaban and edoxaban were excluded from statistical analysis due to the lack of clinical studies.
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Affiliation(s)
- C Bensi
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy.
| | - S Belli
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - D Paradiso
- S.S.D. of Oral Surgery and Ambulatory, S. Maria della Misericordia Hospital, Perugia, Italy
| | - G Lomurno
- Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy; S.S.D. of Oral Surgery and Ambulatory, S. Maria della Misericordia Hospital, Perugia, Italy
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21
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Affiliation(s)
- PJ Sambrook
- Oral & Maxillofacial Surgery Unit; Faculty of Health Sciences; The University of Adelaide; Adelaide South Australia Australia
| | - AN Goss
- Oral & Maxillofacial Surgery Unit; Faculty of Health Sciences; The University of Adelaide; Adelaide South Australia Australia
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22
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Nathwani S, Wanis C. Novel oral anticoagulants and exodontia: the evidence. Br Dent J 2018; 222:623-628. [PMID: 28428567 DOI: 10.1038/sj.bdj.2017.364] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2017] [Indexed: 11/09/2022]
Abstract
Background Haemostasis is crucial for the success of oral surgical treatment as bleeding problems can cause complications both pre- and post-operatively. Patients on anticoagulant drugs present a challenge due to their increased risk of bleeding.Aims To review the evidence for the management of oral surgery patients on novel oral anticoagulant therapy.Methods A literature review was conducted in May 2016 of free-text and MESH searches (keywords: apixaban, dabigatran, rivaroxaban and dental extractions) in the Cochrane Library, PubMed and CINAHL. Trial registers, professional bodies for guidelines and OpenGrey for unpublished literature were also searched. Studies were selected for appraisal after limits were applied (adult, human and English only studies) and inclusion/exclusion criteria imposed.Results Five studies were identified for critical appraisal using the CASP tools. These were a combination of systematic reviews and case series. Two case series were excluded due to low quality evidence. Curtin et al., Davis et al. and Constantinides et al. together with guidelines from the Scottish Dental Clinical Effectiveness Programme, have highlighted a protocol in managing these patients in a dental surgical setting.Conclusion Patients on novel anticoagulant therapy requiring dental surgery can be managed appropriately either without discontinuation of therapy or a delay in dose. For those patients at higher risks of postoperative bleeding complications, it is advised to liaise with the specialist physician.
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Affiliation(s)
- S Nathwani
- Luton and Dunstable NHS Foundation Trust Hospital, Oral and Maxillofacial Surgery, Lewsey Road, Luton, LU4 0DZ
| | - C Wanis
- Oral and Maxillofacial Surgery, Barnet and Chase Farm NHS Hospitals, 127 The Ridgeway, Enfield, EN2 8JL
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23
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Fortier K, Shroff D, Reebye UN. Review: An overview and analysis of novel oral anticoagulants and their dental implications. Gerodontology 2018; 35:78-86. [DOI: 10.1111/ger.12327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Kevin Fortier
- Boston University Henry M. Goldman School of Dental Medicine; Boston MA USA
| | | | - Uday N. Reebye
- Oral and Maxillofacial Surgeon with Triangle Implant Center; Durham NC USA
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24
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Hassona Y, Malamos D, Shaqman M, Baqain Z, Scully C. Management of dental patients taking direct oral anticoagulants: Dabigatran. Oral Dis 2018; 24:228-232. [DOI: 10.1111/odi.12755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/15/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Y Hassona
- Department of Oral and Maxillofacial Surgery; Oral Medicine and Periodontics; School of Dentistry; The University of Jordan; Amman Jordan
- Department of Dentistry; The University of Jordan Hospital; Amman Jordan
| | - D Malamos
- Oral Medicine Clinic; 1 Regional Health District of Attica; National Organization for the Provision of Health Services; Athens Greece
| | - M Shaqman
- Department of Oral and Maxillofacial Surgery; Oral Medicine and Periodontics; School of Dentistry; The University of Jordan; Amman Jordan
- Department of Dentistry; The University of Jordan Hospital; Amman Jordan
| | - Z Baqain
- Department of Oral and Maxillofacial Surgery; Oral Medicine and Periodontics; School of Dentistry; The University of Jordan; Amman Jordan
- Department of Dentistry; The University of Jordan Hospital; Amman Jordan
| | - C Scully
- University College London; London UK
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25
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Miller CS. A perspective on “The mythology of anticoagulation interruption for dental surgery”. J Am Dent Assoc 2018; 149:3-6. [DOI: 10.1016/j.adaj.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 11/26/2022]
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26
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Caliskan M, Tükel HC, Benlidayi ME, Deniz A. Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants? Med Oral Patol Oral Cir Bucal 2017; 22:e767-e773. [PMID: 29053656 PMCID: PMC5813996 DOI: 10.4317/medoral.21942] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 09/09/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The number of patients using direct oral anticoagulants (DOACs) instead of vitamin K antagonists (VKA) is increasing and there is limited data on the safety of tooth extractions in patients taking DOACs. The aim of this study was to compare the amount of bleeding (AOB) and postoperative complications after tooth extractions between patients taking VKAs and patients taking DOACs without altering the anticoaguation therapy. MATERIAL AND METHODS The study consisted of four groups: Direct thrombin inhibitor group, factor Xa inhibitor group, warfarin group and a control group. A single tooth was extracted in each patient and routine coagulation test values were recorded prior to extraction. AOB was measured for 20 minutes after tooth extraction. The patients were evaluated on 2nd and 7th days after extraction for bleeding. Status of bleeding was classified as no bleeding, mild bleeding controlled by gauze pads, moderate bleeding controlled by hemostatic agents and severe bleeding required hospitalization. Analysis of variance, chi square test and correlation analysis were used for statistical analysis of data. RESULTS A total of 84 patients (48 male, 36 female) were included in this study. The mean age of patients was 57 (38-87) years. Mean AOB was 1388.6±913.0, 1909.29±1063.1, 3673±1415.4, 1593.33±672.5 mg for direct thrombin inhibitor, factor Xa inhibitor, warfarin and control groups respectively. Mean AOB was significantly higher for warfarin group, compared to other groups (p<0.05). The number of patients showing mild and moderate bleeding was significantly higher in warfarin group compared to other groups on the 2nd postextraction day (p=0.001). No bleeding was occurred in control group on 2nd and 7th postextraction days and no bleeding was occurred in direct thrombin inhibitor group on 7th postextraction day. The number of bleeding events among groups was not statistically significant on 7th postextraction day (p=0.251). CONCLUSIONS Patients taking warfarin had more bleeding compared to patients taking direct oral anticoagulants after tooth extractions. In patients taking direct oral anticoagulants simple tooth extractions can be safely carried out without altering the anticaogulant regimen with the use of local hemostatic agents.
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Affiliation(s)
- M Caliskan
- Oral and Maxillofacial Surgery, Faculty of Dentistry, Cukurova University, Diş Hekimliği Fakültesi, Ağiz ve Çene Cerrahisi ABD, 01330 Sariçam, Adana, Türkiye,
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27
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Lanau N, Mareque J, Giner L, Zabalza M. Direct oral anticoagulants and its implications in dentistry. A review of literature. J Clin Exp Dent 2017; 9:e1346-e1354. [PMID: 29302288 PMCID: PMC5741849 DOI: 10.4317/jced.54004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/05/2017] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Neus Lanau
- DDS, PhD Student. Faculty of Dentistry. Universitat Internacional de Catalunya, Spain
| | - Javier Mareque
- MD, DDS, PhD. Vice-dean for Research. Faculty of Dentistry. Universitat Internacional de Catalunya, Spain
| | - Lluis Giner
- MD, DDS, PhD. Dean of the Faculty of Dentistry. Universitat Internacional de Catalunya, Spain
| | - Michel Zabalza
- MD, PhD. Faculty of Medicine and Dentistry. Universitat Internacional de Catalunya, Spain
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28
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Kim C, Dam C, Jeong J, Kwak EJ, Park W. Delayed bleeding after implant surgery in patients taking novel oral anticoagulants: a case report. J Dent Anesth Pain Med 2017; 17:143-147. [PMID: 28879343 PMCID: PMC5564149 DOI: 10.17245/jdapm.2017.17.2.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 06/16/2017] [Accepted: 06/18/2017] [Indexed: 11/15/2022] Open
Abstract
The use of novel oral anticoagulants (NOACs) has increased in recent times in an effort to overcome the shortcomings of warfarin. They are being used primarily for the prevention of thrombosis caused by atrial fibrillation and offer the advantages of having fewer drug interactions than warfarin, no dietary restrictions, and no requirement for regular blood tests. Although there is reportedly less postoperative bleeding even if the drug is not discontinued during procedures that can cause local bleeding, such as dental procedures, no well-designed clinical studies have assessed postoperative bleeding associated with the use of these drugs. This article reports a case of a 74-year-old male patient who was taking rivaroxaban. The patient underwent a dental implant procedure after discontinuing rivaroxaban for one day and subsequently suffered delayed bleeding on postoperative day 6. Accordingly, this article also reports that the use of NOACs may also lead to delayed bleeding.
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Affiliation(s)
- Chihun Kim
- Department of Advanced General Dentistry, Yonsei University, Seoul, Korea
| | - Chugeum Dam
- Department of Advanced General Dentistry, Yonsei University, Seoul, Korea
| | - Jieun Jeong
- Department of Advanced General Dentistry, Yonsei University, Seoul, Korea
| | - Eun-Jung Kwak
- Department of Advanced General Dentistry, Yonsei University, Seoul, Korea
| | - Wonse Park
- Department of Advanced General Dentistry, Yonsei University, Seoul, Korea
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29
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Lusk KA, Snoga JL, Benitez RM, Sarbacker GB. Management of Direct-Acting Oral Anticoagulants Surrounding Dental Procedures With Low-to-Moderate Risk of Bleeding. J Pharm Pract 2017; 31:202-207. [DOI: 10.1177/0897190017707126] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The purpose of this article is to review the available evidence regarding how to safely manage direct-acting oral anticoagulant (DOAC) therapy in patients requiring dental procedures with low-to-moderate risk of bleeding. A literature search was performed using MEDLINE and PubMed. Each author performed an independent search to ensure all pertinent articles were identified. The reference sections of each article were also reviewed. Pertinent articles were evaluated by each author for inclusion. Articles were eligible for inclusion if the participants were taking DOAC therapy surrounding a dental procedure known to have low-to-moderate risk of bleeding. Studies could be prospective or retrospective and included case reports, case series, and clinical trials. Articles were excluded if they assessed dental procedures known to carry a high risk of bleeding or were review articles. Twenty-five articles were identified, 5 of which met inclusion criteria including 2 case series, 1 retrospective study, and 2 prospective trials. Variation in the management of DOAC therapy surrounding these procedures was found. Among patients undergoing low-to-moderate risk dental procedures while receiving DOAC therapy, bleeding rates were low regardless of whether the DOAC was held or continued surrounding the procedure. Documented bleeding was mild and easily controlled by local hemostatic measures. Patients can safely continue DOAC therapy surrounding these dental procedures.
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Affiliation(s)
- Kathleen A. Lusk
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
| | - Jenna L. Snoga
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
| | - Rebekah M. Benitez
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
| | - G. Blair Sarbacker
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
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30
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Patel JP, Woolcombe SA, Patel RK, Obisesan O, Roberts LN, Bryant C, Arya R. Managing direct oral anticoagulants in patients undergoing dentoalveolar surgery. Br Dent J 2017; 222:245-249. [DOI: 10.1038/sj.bdj.2017.165] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 11/09/2022]
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31
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Curto A, Albaladejo A, Alvarado A. Dental management of patients taking novel oral anticoagulants (NOAs): Dabigatran. J Clin Exp Dent 2017; 9:e289-e293. [PMID: 28210451 PMCID: PMC5303333 DOI: 10.4317/jced.53219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/22/2016] [Indexed: 11/24/2022] Open
Abstract
Background A new group of oral anticoagulants (dabigatran, rivaroxaban, apixaban and edoxaban) with clear advantages over classic dicoumarin oral anticoagulants (warfarin and acenocoumarol) has been developed in recent years. Patients being treated with oral anticoagulants are at higher risk for bleeding when undergoing dental treatments. Material and Methods A literature search was conducted through April 2016 for publications in the ISI Web of Knowledge, PubMed and Cochrane Library using the keywords “dabigatran”, “rivaroxaban”, “apixaban”, “edoxaban”, “new oral anticoagulants”, “novel oral anticoagulants”, “bleeding” and “dental treatment”. Results There is no need for regular coagulation monitoring of patients on dabigatran therapy. Whether or not to temporarily discontinue dabigatran must be assessed according to the bleeding risk involved in the dental procedure to be performed. Conclusions The number of patients under treatment with new oral anticoagulants will increase in the coming years. It is essential to know about the pharmacokinetics and pharmacodynamics of new oral anticoagulants and about their interactions with other drugs. It is necessary to develop clinical guidelines for the perioperative and postoperative management of these new oral anticoagulants in oral surgical procedures, and to carefully evaluate the bleeding risk of dental treatment, as well as the thrombotic risk of suppressing the new oral anticoagulant. Key words:Dabigatran, rivaroxaban, apixaban, edoxaban, novel oral anticoagulants, bleeding.
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Affiliation(s)
- Adrian Curto
- Department of Surgery, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Alberto Albaladejo
- Department of Surgery, Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Alfonso Alvarado
- Department of Surgery, Faculty of Medicine, University of Salamanca, Salamanca, Spain
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Curto A, Curto D, Sanchez J. Managing patients taking edoxaban in dentistry. J Clin Exp Dent 2017; 9:e308-e311. [PMID: 28210454 PMCID: PMC5303336 DOI: 10.4317/jced.53431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/31/2016] [Indexed: 11/25/2022] Open
Abstract
Background Anticoagulation therapy is used in several conditions to prevent or treat thromboembolism. A new group of oral anticoagulants with clear advantages over classic dicoumarin oral anticoagulants (warfarin and acenocoumarol) has been developed in recent years. The Food and Drug Administration has approved edoxaban, dabigatran, rivaroxaban and apixaban. Their advantages include: predictable pharmacokinetics, drug interactions and limited food, rapid onset of action and short half-life. However, they lack a specific reversal agent. Material and Methods This paper examines the available evidence regarding rivaroxaban and sets out proposals for clinical guidance of dental practitioners treating these patients in primary dental care. A literature search was conducted through July 2016 for publications in PubMed and Cochrane Library using the keywords “edoxaban”, “dabigatran”, “rivaroxaban”, “apixaban”, “new oral anticoagulants”, “novel oral anticoagulants”, “bleeding” and “dental treatment” with the “and” boolean operator in the last 10 years. Results The number of patients taking edoxaban is increasing. There is no need for regular coagulation monitoring of patients on edoxaban therapy. For patients requiring minor oral surgery procedures, interruption of edoxaban is not generally necessary. Management of patients on anticoagulation therapy requires that dentists can accurately assess the patient prior to dental treatments. Conclusions Their increased use means that oral care clinicians should have a sound understanding of the mechanism of action, pharmacology, reversal strategies and management of bleeding in patients taking edoxaban. There is a need for further clinical studies in order to establish more evidence-based guidelines for dental patients requiring edoxaban. Key words:Edoxaban, dabigatran, rivaroxaban, apixaban, novel oral anticoagulants, bleeding.
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Affiliation(s)
- Adrian Curto
- Proffesor in Pediatric Dentistry. Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - Daniel Curto
- Student in Medicine. University of Salamanca, Salamanca, Spain
| | - Jorge Sanchez
- Master in Oral Surgery. Alfonso X El Sabio University, Madrid, Spain
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Affiliation(s)
- Christopher Daly
- Chair Dental Therapeutics Committee Australian Dental Association Sydney
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Mauprivez C, Khonsari RH, Razouk O, Goudot P, Lesclous P, Descroix V. Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:e146-e155. [DOI: 10.1016/j.oooo.2016.06.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/05/2016] [Indexed: 01/18/2023]
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Muñoz-Corcuera M, Ramírez-Martínez-Acitores L, López-Pintor RM, Casañas-Gil E, Hernández-Vallejo G. Dabigatran: A new oral anticoagulant. Guidelines to follow in oral surgery procedures. A systematic review of the literature. Med Oral Patol Oral Cir Bucal 2016; 21:e679-e688. [PMID: 27694780 PMCID: PMC5116109 DOI: 10.4317/medoral.21202] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 07/21/2016] [Indexed: 11/09/2022] Open
Abstract
Background Dabigatran is a newly commercialized drug that is replacing other anticoagulants in the prevention of venous thromboembolism, stroke and systemic arterial valve embolism. It acts directly on thrombin presenting in a dynamic and predictable way, which does not require monitoring these patients. Therefore, we consider the need to assess whether their use increases the risk of bleeding involved before any dental treatment. Material and Methods We performed a systematic review with a bibliographic search in PubMed/Medline along with the Cochrane Library. We excluded articles dealing with all anticoagulants other than dabigatran, and works about surgical treatments in anatomical locations other than the oral cavity. Results We included a total of 13 papers of which 1 was a randomized clinical trial, 9 narrative literature reviews, 1 case series, 2 clinical cases and 1 expert opinion. Because we did not obtain any properly designed clinical trials, we were unable to conduct a meta-analysis. Conclusions Currently, there is no consensus on the procedure to be followed in patients taking dabigatran. However, all authors agree to treat each case individually in accordance to the risk of embolism, postoperative bleeding and renal function. Also, it is necessary to perform minimally invasive interventions, and take the appropriate local anti-hemolytic measures. Key words:Oral anticoagulants, dabigatran, risk of bleeding, oral surgery, dentistry.
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Affiliation(s)
- M Muñoz-Corcuera
- Departamento de Medicina y Cirugía Bucofacial, Facultad de Odontología, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain,
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I nuovi anticoagulanti orali e la loro gestione nella pratica clinica odontoiatrica. DENTAL CADMOS 2016. [DOI: 10.1016/s0011-8524(16)30078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Thean D, Alberghini M. Anticoagulant therapy and its impact on dental patients: a review. Aust Dent J 2016; 61:149-56. [DOI: 10.1111/adj.12344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 12/31/2022]
Affiliation(s)
- D Thean
- Private Practice; Gold Coast Queensland Australia
| | - M Alberghini
- Royal Perth Hospital; Perth Western Australia Australia
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An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery. Int J Oral Maxillofac Surg 2016; 45:618-30. [DOI: 10.1016/j.ijom.2015.12.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/05/2015] [Accepted: 12/11/2015] [Indexed: 11/19/2022]
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Green B, Mendes RA, Van der Valk R, Brennan PA. Novel anticoagulants - an update on the latest developments and management for clinicians treating patients on these drugs. J Oral Pathol Med 2016; 45:551-6. [PMID: 27028407 DOI: 10.1111/jop.12441] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
Abstract
There are several novel anticoagulant agents that are being increasingly used as an alternative to warfarin, with these drugs being reported to be at least as effective if not better. Their increased use means that oral care clinicians should have a sound understanding of the mechanism of action, pharmacology, reversal strategies and management of bleeding in patients taking these drugs. Surprisingly, there is little published in the current literature specific to professionals involved in oral health care. In this review, we provide an overview of these drugs and discuss the management of patients who need an oral procedure based on currently available literature and clinical trials.
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Affiliation(s)
- Ben Green
- Department of Gastroenterology, Torbay Hospital, Torquay, UK
| | - Rui Amaral Mendes
- Department of Oral and Maxillofacial Medicine and Diagnostic Sciences, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ruben Van der Valk
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Peter A Brennan
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
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Dziedzic A. Pharmacology: Dual therapy guidance. Br Dent J 2016; 220:45. [DOI: 10.1038/sj.bdj.2016.40] [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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Morimoto Y, Yokoe C, Imai Y, Sugihara M, Futatsuki T. Tooth extraction in patients taking nonvitamin K antagonist oral anticoagulants. J Dent Sci 2015; 11:59-64. [PMID: 30894947 PMCID: PMC6395147 DOI: 10.1016/j.jds.2015.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 08/28/2015] [Indexed: 01/26/2023] Open
Abstract
Background/purpose The nonvitamin K antagonist oral anticoagulants direct-thrombin inhibitor dabigatran and the Xa inhibitors rivaroxaban and apixaban are now being used clinically. The course of the patients on these anticoagulants who underwent tooth extraction was assessed. Materials and methods The medical charts of these patients were investigated. Tooth extraction was performed while maintaining conventional anticoagulant therapy. Results Twenty-three teeth were extracted in 19 patients, including two surgical extractions. Among the 19 patients, nine patients ingested rivaroxaban, six apixaban, and four dabigatran. One patient on rivaroxaban showed persistent postoperative bleeding following two surgical extractions. Mild oozing was observed in five patients (two on rivaroxaban and three on apixaban). There was no bleeding episode in the patients on dabigatran. Conclusion The patients on rivaroxaban with a prolonged prothrombin time value have a higher risk of bleeding, especially undergoing surgical extraction. Apixaban correlates to neither activated partial thromboplastin time nor prothrombin time values and the countermeasures should be employed based on the clinical findings.
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Affiliation(s)
- Yoshinari Morimoto
- Department of Anesthesiology, Graduate School of Dentistry, Kanagawa Dental University, Kanagawa, Japan
- Special Patient Oral Care Unit, Kyushu University Hospital, Fukuoka, Japan
- Corresponding author. Department of Anesthesiology, Graduate School of Dentistry, Kanagawa Dental University, 82, Inaoka-cho, Yokosuka, Kanagawa, 238-8580, Japan.
| | - Chizuko Yokoe
- Department of Anesthesiology, Graduate School of Dentistry, Kanagawa Dental University, Kanagawa, Japan
| | - Yuko Imai
- Special Patient Oral Care Unit, Kyushu University Hospital, Fukuoka, Japan
| | - Megumi Sugihara
- Special Patient Oral Care Unit, Kyushu University Hospital, Fukuoka, Japan
| | - Toshiko Futatsuki
- Special Patient Oral Care Unit, Kyushu University Hospital, Fukuoka, Japan
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Elad S, Marshall J, Meyerowitz C, Connolly G. Novel anticoagulants: general overview and practical considerations for dental practitioners. Oral Dis 2015; 22:23-32. [DOI: 10.1111/odi.12371] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/20/2015] [Accepted: 09/05/2015] [Indexed: 11/28/2022]
Affiliation(s)
- S Elad
- Division of Oral Medicine; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
- Wilmot Cancer Center; Strong Memorial Hospital; University of Rochester Medical Center; Rochester NY USA
| | - J Marshall
- Division of Oral Medicine; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
| | - C Meyerowitz
- Division of Oral Medicine; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
- Division of General Dentistry; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
| | - G Connolly
- Division of Hematology/Oncology; Department of Medicine; University of Rochester Medical Center; Wilmot Cancer Center; Rochester NY USA
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Sivolella S, De Biagi M, Brunello G, Berengo M, Pengo V. Managing dentoalveolar surgical procedures in patients taking new oral anticoagulants. Odontology 2015; 103:258-63. [DOI: 10.1007/s10266-015-0195-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 12/01/2014] [Indexed: 12/14/2022]
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Protocol in managing oral surgical patients taking dabigatran. Br Dent J 2014. [DOI: 10.1038/sj.bdj.2014.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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