Review: An overview and analysis of novel oral anticoagulants and their dental implications

Platelet-rich fibrin ensures hemostasis after single-tooth removal under factor Xa inhibitors - a clinical prospective randomized split-mouth study

OBJECTIVES

In this prospective, double-blinded, randomized split-mouth study, the local hemostatic effect of platelet-rich fibrin (PRF) inserted into the extraction socket in patients taking factor Xa (FXa) inhibitors (apixaban, rivaroxaban, edoxaban) was compared to a hemostatic gelatine sponge (GS) as the "therapeutic gold standard" without withdrawal of oral anticoagulant therapy.

MATERIALS AND METHODS

Single-tooth extraction was conducted under local anesthesia in n = 21 patients using a split-mouth design (42 teeth). Using a double-blind approach, the extraction socket on one side of the jaw was filled with PRF and on the other with a GS. Bleeding was assessed immediately after surgery, in 30 min, 1 h, 1.5 h, and on follow-up appointments in 24 h and on the 7th day.

RESULTS

In 67% of cases, mild postoperative oozing could be stopped 30-90 min after tooth extraction via gauze pressure without any delayed bleeding. Concerning bleeding events, there was no difference among the PRF and GS groups and no significant difference among rivaroxaban, apixaban, and edoxaban (all p > 0.15).

CONCLUSION

PRF and GS are reliable hemostatic methods in postextraction sockets of patients taking FXa inhibitors.

CLINICAL RELEVANCE

Consequently, there is no need to discontinue FXa inhibitors because of a single-tooth removal, eliminating the risk of thrombus formation.

Bleeding Disorders and Dental Implants: Review and Clinical Indications

BACKGROUND

Bleeding disorders can be divided into three categories: congenital coagulation disorders (CCDs), antiplatelet-induced bleeding disorders (APBDs) and anticoagulant-induced bleeding disorders (ACBDs). Implant placement can be challenging in these kinds of patients. The aim of this study is to provide evidence on implant surgery in patients with bleeding disorders and to generate some practical recommendations for clinicians.

MATERIAL AND METHODS

Pubmed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were screened. The latest search was performed in July 2022. Case reports, case series, cohort studies, cross-sectional studies, case control studies, reviews, consensus reports, surveys and animal studies were included in the analysis.

RESULTS

Seventeen articles on CCDs were found, fourteen on APBDs and twenty-six on ACBDs. Most of these articles were case reports or case series. Patients with CCDs can be treated after the infusion of the missing coagulation factor. Patients with APBDs can be treated without withdrawing the therapy. Patients with ACBDs should be treated depending on the anticoagulative medication.

CONCLUSION

Despite the low level of evidence, dental implants can be safely placed in patients with bleeding disorders. However, careful preoperative evaluation and the adoption of local and post-operative bleeding control measures are mandatory.

A Knowledge and Practice Survey Among Dentists in Saudi Arabia Analysing Myths and Misconceptions in Dentistry and Oral Surgery: What Do Dentists Believe?

Introduction To ensure safe and effective practice, dental practitioners must stay up-to-date with all scientific updates involving their profession. In this regard, many outdated myths and misconceptions may be persistently believed and practiced. This study aimed to examine dental misconceptions circulating among dentists in Saudi Arabia. Methods An electronic survey was administered to Saudi Arabian dental practitioners classified and registered with the Saudi Commission of Health Specialties. It collected their demographics, career and experience details, and responses to 16 questions that targeted different myths. Logistic regression was used to analyze factors associated with their knowledge. Results A total of 519 dentists answered the survey, of which 54% were male with a mean age of 32 ± 9 years and a mean practice of 7 ± 8 years. More than half (57%) practiced general dentistry. In most (69%) of the questions, 40% of the respondents answered incorrectly. The proportion of incorrect answers to some questions reached 62%. Years of teaching, years in practice, and doctor rank had no association with the knowledge score. Conversely, the type of practice and specialty had multiple statistically significant associations (p < 0.05). Conclusion This study shows that many myths, despite being debunked for more than 20 years, are still circulating among Saudi Arabian dentists, including many young dentists. Academic institutions must urgently address these concepts and the science that disproves them; dentists must implement up-to-date, evidence-based knowledge in their practice.

The practices and beliefs of dental professionals regarding the management of patients taking anticoagulant and antiplatelet drugs

AIM

This study aimed to inform the implementation of the updated Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, 'Management of Dental Patients taking Anticoagulant or Antiplatelet Drugs', and to determine training needs by investigating dental professionals' current practice and beliefs regarding management of patients taking these medications.

METHODS

Dental professionals were recruited via the NHS Education for Scotland Portal. The online questionnaire collected demographic information, data on current practice and information about beliefs regarding behaviours related to the management of patients on anticoagulant or antiplatelet medication. Quantitative data were analysed using SPSS and subjected to frequency calculations, t-tests, one-way ANOVA and linear regression. Qualitative data were collected via free text boxes and analysed using thematic analysis.

RESULTS

One hundred and fifty-seven participants responded to the questionnaire. The majority of respondents stated they were aware of the guidance and always based their practice on it. The majority of respondents always assessed the patient's individual bleeding risk prior to dental procedures. Most respondents felt that they did not know how to appropriately manage patients taking low doses of low molecular weight heparins (LMWH), and only 38% of respondents always followed SDCEP guidance about direct oral anticoagulants (DOAC) medication and procedures with a low associated risk of bleeding.

DISCUSSION

This study demonstrates a need for further educational support surrounding LMWHs and management of patients on DOAC medication. Time and remuneration represent barriers to guidance implementation in primary care.

CONCLUSION

There is good awareness and adherence to the guidance in primary care settings, however training needs were identified to support implementation.

Managing direct oral anticoagulants in accordance with the Scottish Dental Clinical Effectiveness Programme guidance for patients undergoing dentoalveolar surgery

Introduction The Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance on the management of dental patients taking anticoagulant or antiplatelet drugs provides recommendations on the management of patients taking direct oral anticoagulants (DOACs). This guidance was developed by a multidisciplinary Guidance Development Group, based on available resources at the time of publication. We aim to describe our experience of managing a cohort of adult patients prescribed DOACs, undergoing dentoalveolar procedures in accordance with the SDCEP guidance, between April 2017 and March 2020.

Methods As part of our routine practice, patients received a telephone consultation one week following treatment, to assess any post-operative bleeding. Review of the clinical notes was used to assess clinician adherence to the guidance recommendations.

Results In total, 98 patients underwent 119 dentoalveolar procedures. Persistent bleeding followed 17 (14.3%) procedures, of which 11 (9.2%) procedures required specific intervention. Absolute compliance with the recommendations was 43.7%, supporting the recommendation for audit and staff education.

Discussion A diagnosis of heart failure and advanced age were identified as contributory factors to post-operative bleeding.

Conclusions The SDCEP guidance is safe to follow, with no patients experiencing major haemorrhage. Consulting a medical specialist for patients with heart failure of likely significance, based on the medical or drug history, in addition to those who report an advanced heart failure diagnosis and the frail/older person, could reduce the incidence of post-operative bleeding.

Details the SDCEP guidance recommendations, at the time of writing, regarding the management of dental patients taking DOACs.

Informs of the bleeding outcomes for patients taking DOACs who undergo dentoalveolar surgery.

Assesses the safety and appropriateness of the SDCEP guidance recommendations.

Highlights the determinants of post-operative bleeding risk.

Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery

OBJECTIVES

A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures.

MATERIALS AND METHODS

A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction.

RESULTS

33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants.

CONCLUSIONS

No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks.

CLINICAL RELEVANCE

direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.

Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques

INTRODUCTION

The purpose of this study was to review evidence-based recommendations for the safe perioperative management of patients undergoing endodontic microsurgery who are currently taking antiplatelet or anticoagulant medications. Using the PICO (Population, Intervention, Comparison, Outcome) format, the following scientific question was asked: In patients taking anticoagulant or antiplatelet agents, what is the available evidence in the management of endodontic microsurgery?

METHODS

MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov databases were searched to identify current recommendations regarding the management of antiplatelet and anticoagulant medications in the context of outpatient dental surgical procedures. Additionally, the authors hand searched the bibliographies of all relevant articles, the gray literature, and textbooks. Because of the lack of clinical studies and evidence on this subject, articles and guidelines from other organizations and association position statements were included.

RESULTS

Because any minor surgery can become a major surgery, the treating doctor needs to best assess the risk of bleeding, especially if the surgery is anticipated to take longer than 45 minutes. Every patient should be stratified on a case-by-case basis. Consultation with the patient's physician is highly recommended.

CONCLUSIONS

In order to maximize the effects of these medications (to prevent thrombosis) while minimizing the potential risks (procedural hemorrhage), clinicians should be aware of the best available evidence when considering continuation or discontinuation of antiplatelet and anticoagulant agents perioperatively for endodontic microsurgery. Ideally, a joint effort from an expert panel for microsurgery would be warranted.

Risk of Bleeding during Implant Surgery in Patients Taking Antithrombotics: A Systematic Review

The objective of this systematic review is to assess the risk of postoperative bleeding in oral surgery for implant placement in individuals taking antithrombotics (i.e., anticoagulants and/or antiplatelet agents). A literature search was performed in PubMed (MEDLINE), Web of Science, Scopus, and EMBASE databases for articles published until August 2020, with no date restriction, and manually completed. We included prospective clinical studies that provided information regarding the presence of an experimental group (i.e., implant placement), a control group (patients not under treatment with antithrombotics), and a well-established protocol for evaluating bleeding. Meta-analysis determined the risk of bleeding during the placement of implants in antithrombotic-treated patients. Of the 756 potentially eligible articles, 5 were included in the analysis with 4 ranked as high and 1 as medium quality. Antithrombotic treatment comprised the following drug classes: (1) anticoagulants: vitamin K antagonists, (2) nonvitamin K antagonist oral anticoagulants, (3) low-molecular-weight heparin, and (4) antiplatelet agents (not specified). The results suggest that the risk of bleeding is not substantially higher in antithrombotic-treated patients (odds ratio = 2.19; 95% confidence interval: 0.88-5.44, p = 0.09) compared with nontreated patients. This systematic review suggests that the absolute risk is low and there is no need to discontinue or alter the dose of the antithrombotic treatment for implant placement surgery.

Direct oral anticoagulants in oral surgery: a prospective cohort

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.

A review of drugs that contribute to bleeding risk in general dental practice

The risk of postoperative bleeding is a daily concern for many general dental practitioners. A thorough medical and medication history must be taken to consider all risk factors, particularly drugs, that contribute to bleeding risk. While the risk from drugs such as aspirin, warfarin and clopidogrel are well known, the extent to which new antiplatelet agents and direct oral anticoagulants affect bleeding risk is less well understood. In addition, there are drugs other than antithrombotics, such as antidepressants and complementary medicines that also impair haemostasis. The aim of this paper is to provide dentists with an updated overview of the drugs commonly encountered in general dental practice that can contribute to a patient's postoperative bleeding risk.