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Lee JY, Park SH, Kim DM, Ko KA, Park JY, Lee JS, Jung UW, Cha JK. Risk of post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants: a cohort study using the common data model. Sci Rep 2024; 14:7787. [PMID: 38565933 PMCID: PMC10987490 DOI: 10.1038/s41598-024-57881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
This retrospective study aimed to determine risk factors associated with post-operative bleeding after dentoalveolar surgery in patients taking anticoagulants. Patients taking anticoagulants who were planned to undergo periodontal flap operation, tooth extraction or implant surgery were included. Patients were divided into two subgroups according to the maintenance of anticoagulants following medical consultation: (1) maintenance group and (2) discontinuation group. The analysed patient-related factors included systemic diseases, maintenance of anticoagulants and types of anticoagulant. Intra- and post-operative treatment-related factors, haemostatic methods and post-operative bleeding were collected for statistical analyses. There were 35 post-operative bleeding complications (6.5%) in the 537 included patients: 21 (8.6%) in maintenance group and 14 (4.8%) in discontinuation group. The type of anticoagulant (p = 0.037), tooth extraction combined with bone grafting (p = 0.016) and type of implant surgery (p = 0.032) were significantly related to the post-operative bleeding rate. In the maintenance group, atrial fibrillation [odds ratio (OR) = 6.051] and vitamin K inhibitors (OR = 3.679) were associated with a significantly higher bleeding risk. From this result, it can be inferred that the decision to continue anticoagulants should be made carefully based on the types of anticoagulant and the characteristics of dentoalveolar surgeries performed: extraction with bone grafting, multiple implantations and involvement of maxillary arch.
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Affiliation(s)
- Joo-Yeon Lee
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung-Hyun Park
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Da-Mi Kim
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyung-A Ko
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jin-Young Park
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jung-Seok Lee
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ui-Won Jung
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jae-Kook Cha
- Department of Periodontology, Research Institute for Periodontal Regeneration, Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Darwish G. The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review. BMC Oral Health 2023; 23:743. [PMID: 37821865 PMCID: PMC10566068 DOI: 10.1186/s12903-023-03427-8] [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] [Received: 12/04/2022] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) were developed to overcome the drawbacks of oral anticoagulants. However, not much has been discussed about the perioperative management of patients on DOACs during oral surgical procedures. Thus, we aim to determine the risk of perioperative and postoperative bleeding during oral surgical procedures in patients on DOACs. METHODS A detailed literature search was performed to find potentially relevant studies using the Cochrane Library, Clinical Key, ClinicalTrials.gov, Google Scholar, Ovid, ScienceDirect, and Scopus. Every article available for free in English literature for the past 10 years, between 2012 and 2022, was searched. RESULTS A total of 2792 abstracts were selected through a search strategy across various search engines. Based on inclusion and exclusion criteria, eleven clinical studies using DOACs as anticoagulants or studies comparing patients with and without DOACs under oral surgery procedures were found. The results were inconsistent and varied, with a few studies recommending DOAC administration with the bare minimum reported complications and others finding no statistically significant difference between discontinuation or continuation of drugs, especially across basic dental procedures. CONCLUSION Within the limitations of the study, it can be concluded that minor oral surgical procedures are safe for patients on DOAC therapy. However, the continuation or discontinuation of DOACs in patients undergoing oral surgical procedures remains controversial and requires further studies to extrapolate the results.
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Affiliation(s)
- Ghassan Darwish
- Department of Oral and Maxillofacial Surgery, School of Dentistry, King Abdulaziz University, 21589, Jeddah, Saudi Arabia.
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Bacci C, Schiazzano C, Zanon E, Stellini E, Sbricoli L. Bleeding Disorders and Dental Implants: Review and Clinical Indications. J Clin Med 2023; 12:4757. [PMID: 37510872 PMCID: PMC10380778 DOI: 10.3390/jcm12144757] [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: 06/26/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Christian Bacci
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Claudia Schiazzano
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35128 Padua, Italy
| | - Edoardo Stellini
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
| | - Luca Sbricoli
- Department of Neurosciences, School of Dentistry, University of Padua, 35128 Padua, Italy
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Zou L, Hua L. Risk of bleeding with dental implant surgery in patients on anticoagulant or antiplatelet drugs: a systematic review and meta-analysis. Acta Odontol Scand 2023; 81:98-104. [PMID: 35763663 DOI: 10.1080/00016357.2022.2085324] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION A large number of patients under oral anticoagulant (OAC) or antiplatelet (AP) therapy require dental implantation. We systematically reviewed evidence on the risk of bleeding after implant placement with continued OAC or AP therapy. METHODS PubMed, Embase and CENTRAL were searched for studies comparing bleeding outcomes after implant placement between OAC/AP therapy vs. controls or OAC vs. AP therapy. RESULTS Seven studies were included. Pooled analysis showed no significant difference in the risk of bleeding with continued OAC therapy vs. control (RR 1.81 95% confidence interval [CI] 0.70, 4.63 I2 = 14% p = .22). Subgroup analysis depending on the type of OAC showed there was a non-significant tendency of increased risk of bleeding with Vitamin K antagonists (VKAs) (RR 3.42 95% CI 1.00, 11.67 I2 = 23% p = .05) but not with direct oral anticoagulants (DOACs) (RR 1.67 95% CI 0.49, 5.70 I2 = 0% p = .41). Limited data suggest an increased risk of bleeding with OAC as compared to AP (RR 0.08 95% CI 0.01, 0.76 I2 = 0% p = .03). CONCLUSIONS Continuation of OAC therapy in patients undergoing implant surgery does not increase the risk of bleeding provided local haemostatic measures are used. The indirect comparison suggests bleeding tendency may be higher with VKAs as compared to DOAC.
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Affiliation(s)
- Lilin Zou
- Department of Stomatology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, PR China
| | - Li Hua
- Department of Stomatology, The First Affiliated Hospital of Soochow University, Suzhou, PR China
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Wang D, Sun Y, Zhang D, Kong X, Wang S, Lu J, Liu F, Lu S, Qi H, Zhou Q. Root-shaped antibacterial alginate sponges with enhanced hemostasis and osteogenesis for the prevention of dry socket. Carbohydr Polym 2023; 299:120184. [PMID: 36876799 DOI: 10.1016/j.carbpol.2022.120184] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 09/20/2022] [Accepted: 09/29/2022] [Indexed: 11/09/2022]
Abstract
Tooth extraction commonly causes uncontrolled bleeding, loss of blood clots, and bacterial infection, leading to the dry socket and bone resorption. Thus, it is highly attractive to design a bio-multifunctional scaffold with outstanding antimicrobial, hemostatic, and osteogenic performances for avoiding dry sockets in clinical applications. Herein, alginate (AG)/quaternized chitosan (Qch)/diatomite (Di) sponges were fabricated via electrostatic interaction, Ca2+ cross-linking, as well as lyophilization methods. The composite sponges are facilely made into the shape of the tooth root, which could be well integrated into the alveolar fossa. The sponge shows a highly interconnected and hierarchical porous structure at the macro/micro/nano levels. The prepared sponges also possess enhanced hemostatic and antibacterial abilities. Moreover, in vitro cellular assessment indicates that the developed sponges have favorable cytocompatibility and significantly facilitate osteogenesis by upregulating the formation of alkaline phosphatase and calcium nodules. The designed bio-multifunctional sponges display great potential for trauma treatment after tooth extraction.
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Affiliation(s)
- Danyang Wang
- Department of Stomatology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, China; School of Stomatology, Qingdao University, Qingdao 266003, China; Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266021, China
| | - Yinyin Sun
- Oral Medicine, The People's Hospital of Jimo, Qingdao, Qingdao 266200, China
| | - Dongjie Zhang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Xiaowen Kong
- School of Stomatology, Qingdao University, Qingdao 266003, China
| | - Sainan Wang
- School of Stomatology, Qingdao University, Qingdao 266003, China; Oral Department of Qingdao Municipal Hospital, Qingdao 266011, China
| | - Jinglin Lu
- School of Stomatology, Qingdao University, Qingdao 266003, China
| | - Fengyuan Liu
- School of Stomatology, Qingdao University, Qingdao 266003, China
| | - Shulai Lu
- Oral Department of Qingdao Municipal Hospital, Qingdao 266011, China
| | - Hongzhao Qi
- Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266021, China.
| | - Qihui Zhou
- Department of Stomatology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266003, China; Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao 266021, China; School of Rehabilitation Sciences and Engineering, University of Health and Rehabilitation Sciences, Qingdao 266071, China.
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El Halawany M, Latif R, AbouGhaly MHH. Hemostatic Alginate/Nano-Hydroxyapatite Composite Aerogel Loaded with Tranexamic Acid for the Potential Protection against Alveolar Osteitis. Pharmaceutics 2022; 14:pharmaceutics14102255. [PMID: 36297689 PMCID: PMC9608763 DOI: 10.3390/pharmaceutics14102255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 11/21/2022] Open
Abstract
Wound control in patients on anticoagulants is challenging and often leads to poor hemostasis. They have a higher tendency to develop alveolar osteitis after tooth extraction. The application of a hemostatic dressing that has a high absorbing capacity and is loaded with an antifibrinolytic drug could help in controlling the bleeding. Alginate/nano-hydroxyapatite (SA/Nano-HA) composite aerogels loaded with tranexamic acid (TXA) were prepared. Nano-HA served as a reinforcing material for the alginate matrix and a source of calcium ions that helps in blood clotting. It influenced the porosity and the water uptake capacity. TXA release from SA/Nano-HA aerogels showed a biphasic profile for up to 4 h. Blood coagulation studies were performed on human whole blood. The TXA-loaded aerogel significantly reduced the clotting time by 69% compared to the control (p < 0.0001). Recalcification time was significantly reduced by 80% (p < 0.0001). Scanning electron microscopy analysis revealed the porous nature of the aerogels and the ability of the optimum aerogel to activate and adhere platelets to its porous surface. The cell migration assay showed that there was a delay in wound healing caused by the TXA aerogel compared to the control sample after treating human fibroblasts. Results suggest that the developed aerogel is a promising dressing that will help in hemostasis after tooth extraction.
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Affiliation(s)
- Mai El Halawany
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Ainy Street, Cairo 11562, Egypt
- Correspondence: ; Tel.: +20-10-0846-3596; Fax: +20-22-362-8246
| | - Randa Latif
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Ainy Street, Cairo 11562, Egypt
| | - Mohamed H. H. AbouGhaly
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Kasr El-Ainy Street, Cairo 11562, Egypt
- Department of Pharmaceutics and Industrial Pharmacy, School of Pharmacy, Newgiza University, Km. 22 Cairo-Alex Road, Giza P.O. Box 12577, Egypt
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van Dijk WEM, van Es RJJ, Correa MEP, Schutgens REG, van Galen KPM. Dentoalveolar Procedures in Immune Thrombocytopenia; Systematic Review and an Institutional Guideline. TH OPEN 2021; 5:e489-e502. [PMID: 34805736 PMCID: PMC8595053 DOI: 10.1055/a-1641-7770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background
Dentoalveolar procedures in immune thrombocytopenia (ITP) pose a risk of bleeding due to thrombocytopenia and infection due to immunosuppressive treatments. We aimed to systematically review the safety and management of dentoalveolar procedures in ITP patients to create practical recommendations.
Methods
PubMed, Embase, Cochrane, and Cinahl were searched for original studies on dentoalveolar procedures in primary ITP patients. We recorded bleeding- and infection-related outcomes and therapeutic strategies. Clinically relevant bleeding was defined as needing medical attention.
Results
Seventeen articles were included, of which 12 case reports/series. Overall, the quality of the available evidence was poor. Outcomes and administered therapies (including hemostatic therapies and prophylactic antibiotics) were not systematically reported. At least 73 dentoalveolar procedures in 49 ITP patients were described. The range of the preoperative platelet count was 2 to 412 × 10
9
/L. Two clinically relevant bleedings (2%) were reported in the same patient of which one was life-threatening. Strategies used to minimize the risk of bleeding were heterogeneous and included therapies to increase platelet count, antifibrinolytics, local measures, and minimally invasive techniques. Reports on the occurrence of bleedings due to anesthetics or infection were lacking.
Conclusion
Based on alarmingly limited data, clinically relevant bleedings and infections after dentoalveolar procedures in ITP patients seem rare. Awaiting prospective and controlled studies to further evaluate these risks and the efficacy of therapeutic interventions, we provided our institutional guideline to guide the management of dentoalveolar procedures in ITP patients.
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Affiliation(s)
- Wobke E M van Dijk
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert J J van Es
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria E P Correa
- Oral Medicine Ambulatory, Hematology and Hemotherapy Center, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin P M van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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Dawoud BES, Kent S, Tabbenor O, George P, Dhanda J. Dental implants and risk of bleeding in patients on oral anticoagulants: a systematic review and meta-analysis. Int J Implant Dent 2021; 7:82. [PMID: 34430994 PMCID: PMC8385035 DOI: 10.1186/s40729-021-00364-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/01/2021] [Indexed: 12/02/2022] Open
Abstract
Background Dental implant placement is safe and predictable, yet optimal management of anticoagulated patients remains controversial. Whilst cessation of anticoagulation pre-operatively should decrease risks of bleeding, risk of thrombosis increases. We aim to define risk of bleeding in patients on oral anticoagulation who are undergoing dental implant placement, in order to establish best management. Methods This systematic review is registered with the National Institute for Health Research (NIHR) PROSPERO database (Registration No: CRD42021233929). We performed a systematic review as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Studies were identified using an agreed search strategy within the OVID Gateway (this included Pubmed, MEDLINE, Cochrane Collaborative). Studies assessing bleeding complications in patients who were undergoing dental implant placement were selected. The primary outcome was bleeding events in anticoagulated patients undergoing dental implant placement. Secondary outcomes included any complication requiring further intervention. Results We identified 182 studies through screening, and after review of titles and abstracts reduced this to 8 studies. In these studies, 1467 participants received at least 2366 implants. Studies were analysed for quality using the ROBINS-I risk of bias tool. Four studies were retrospective case reviews, and four were prospective reviews, three of which also blinded the operator to anticoagulation status. There was significant heterogeneity between the included studies. Meta-analysis showed an increased risk of bleeding (RR, 2.30; 95% CI, 1.25-4.24 p = 0.37 I = 7%) when implants were placed in the presence of anticoagulation however these were not clinically significant haemorrhagic events. Conclusion The continuation of anticoagulants peri-operatively during dental implant surgery does increase the risk of clinically non-significant peri- and post-operative bleeding. Dental implant surgery encompasses a broad spectrum of procedures ranging from minor to more invasive surgery with simple local haemostatic measures mitigating the risk of bleeding. The decision to discontinue anticoagulants prior to dental implant surgery must consider patient and surgical factors with the clinician undertaking a risk-balance assessment.
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Affiliation(s)
- Basim E S Dawoud
- Department of Oral & Maxillofacial Surgery, North Manchester General Hospital, Manchester Foundation Trust, Manchester, UK.
| | - Samuel Kent
- Department of Oral and Maxillofacial Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Oliver Tabbenor
- Department of Oral and Maxillofacial Surgery, Manchester Foundation Trust, Manchester, UK
| | - Pynadath George
- Department of Oral Surgery, Edinburgh Dental Institute, Edinburgh, UK
| | - Jagtar Dhanda
- Department of Oral and Maxillofacial Surgery, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
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Does Platelet-Rich Fibrin Prevent Hemorrhagic Complications After Dental Extractions in Patients Using Oral Anticoagulant Therapy? J Oral Maxillofac Surg 2021; 79:2215-2226. [PMID: 34343502 DOI: 10.1016/j.joms.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE The number of anticoagulated patients requiring dental extractions and other minor dentoalveolar surgical procedures has increased significantly. The purpose of this study was to determine whether the use of platelet-rich fibrin (PRF) prevents hemorrhagic complications after dental extractions in patients being treated with oral anticoagulants. METHODS A 2-phase PROSPERO-registered systematic review of published within-subject controlled trials (CRD42020186678) was conducted in accordance with the PRISMA statement. Searches were conducted through Medline via PubMed, Web of Science, LILACS, Central Cochrane, Scopus, DOSS, and Google Scholar, until May 2020. The predictor variable was the study group (PRF vs use/non-use of other hemostatic agents). The main outcome of interest was the risk of bleeding after tooth extraction and the covariates were postoperative complications. Data analysis included synthesis of results, risk of bias (RoB) evaluation, meta-analysis (random effects; I²-based heterogeneity; 95% confidence), and certainty of evidence assessment. RESULTS From a total of 216 articles, 3 articles (low-moderate RoB) were included for evaluation in this systematic review and meta-analysis. A total of 130 patients were involved. The outcomes of the meta-analysis showed that the use of PRF in extraction wounds did not reduce the risk of bleeding after extraction in anticoagulated patients (P= .330; I² = 99%). Furthermore, the use of PRF did not improve pain scores (P = .470; I² = 96%) or the risk of postoperative alveolitis (P = .4300; I² = 38%) in anticoagulated patients. The certainty of the evidence ranged from moderate to low. CONCLUSIONS The findings of this systematic review and meta-analysis suggest that PRF does not prevent hemorrhagic complications after tooth extraction in patients using oral anticoagulant therapy.
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Single-visit chairside adjustment of a metal-acrylic resin implant-supported fixed complete dental prosthesis on an unloaded implant using a novel fixed attachment system: a case report. J Med Case Rep 2021; 15:236. [PMID: 33990229 PMCID: PMC8122563 DOI: 10.1186/s13256-021-02854-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background Implant-supported prosthetic treatment options are reliable for elderly edentulous patients with systemic health problems. These patients often need cost- and time-efficient solutions to avoid complications. However, it is a challenge for clinicians to treat these patients without surgical interventions, placement of additional implants, or the need to renew existing prostheses. Case presentation A 75-year-old medically compromised caucasian male patient using multiple medications was referred for prosthetic rehabilitation of his edentulous maxilla after several implant failures. Because the patient’s health was compromised, further surgical interventions were ruled out and the treatment was centered on the use of the remaining implants by placing a fixed attachment system and altering the existing prosthesis. The stepwise management of the patient’s situation through the use of a new attachment system and adjustment of existing prosthesis is described in the present case report. Conclusions Although implant therapy is not always contraindicated for medically compromised patients, it is preferable not to perform extensive surgeries to avoid complications. This clinical report describes an alternative, safe option based on a novel fixed attachment system to salvage an existing maxillary implant-supported fixed complete dental prosthesis of a patient with systemic health problems.
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Miziara LNB, Sendyk WR, Ortega KL, Gallottini M, Sendyk DI, Martins F. Risk of Bleeding during Implant Surgery in Patients Taking Antithrombotics: A Systematic Review. Semin Thromb Hemost 2021; 47:702-708. [PMID: 33971681 DOI: 10.1055/s-0041-1722845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
| | - Wilson Roberto Sendyk
- Department of Oral Implantology, Dental School, University of Santo Amaro, São Paulo, Brazil
| | - Karem López Ortega
- Division of Oral Pathology, Department of Stomatology, Dental School, University of São Paulo, São Paulo, Brazil
| | - Marina Gallottini
- Division of Oral Pathology, Department of Stomatology, Dental School, University of São Paulo, São Paulo, Brazil
| | - Daniel Isaac Sendyk
- Division of Periodontics, Department of Stomatology, Dental School, University of São Paulo, São Paulo, Brazil
| | - Fabiana Martins
- Department of Oral Implantology, Dental School, University of Santo Amaro, São Paulo, Brazil
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Bajkin BV, Wahl MJ, Miller CS. Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:522-532. [DOI: 10.1016/j.oooo.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
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Manor Y, Peleg O, Mijiritsky E, Manor A, Reiter S. A retrospective analysis of dental implantation under anticoagulant treatment. Clin Oral Investig 2020; 25:1001-1009. [PMID: 32506326 DOI: 10.1007/s00784-020-03389-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To present our experience treating patients who have undergone dental implantation under no change in their constant anticoagulant treatment. PATIENTS AND METHODS A retrospective study on patients who have undergone dental implantation. The study group consisted of patients under oral anticoagulants for at least 6 months before dental implantation. The control group was consisted of healthy patients with no oral anticoagulant treatment. Bleeding events were recorded and treated during the first 2 weeks postoperatively. RESULTS A total of 193 patients were included in the study. Seventy-two of them who were under anticoagulants served as a study group and the rest (121 patients) served as a control group. Mean age: 65 years old in the study group and 59 years old in the control group. Gender: male to female ratio was higher in the study group and lower in the control group. Four patients in the study group and 7 patients in the control group presented postoperative bleeding and were treated successfully by additional local hemostasis methods. CONCLUSION With the limitation of this study, it can be concluded that patients under oral anticoagulant treatment can undergo dental implantation safely. Bleeding events are rare and can be controlled by local hemostasis. CLINICAL RELEVANCE Prior to dental implant insertion, patients under oral anticoagulants can continue their constant medical treatment. The procedure can be performed on outpatient basis under local hemostasis.
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Affiliation(s)
- Yifat Manor
- Department of Oral and Maxillofacial Surgery, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Oren Peleg
- Department of Oral and Maxillofacial Surgery, Sorasky Medical Center, Tel Aviv, Israel
| | - Eithan Mijiritsky
- Department of Oral and Maxillofacial Surgery, Sorasky Medical Center, Tel Aviv, Israel
| | - Alexander Manor
- Economical Unit, Edith Wolfson Medical Center, Holon, Israel
| | - Shoshana Reiter
- Department of Oral Medicine, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
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Sanz M, Marco del Castillo A, Jepsen S, Gonzalez‐Juanatey JR, D’Aiuto F, Bouchard P, Chapple I, Dietrich T, Gotsman I, Graziani F, Herrera D, Loos B, Madianos P, Michel J, Perel P, Pieske B, Shapira L, Shechter M, Tonetti M, Vlachopoulos C, Wimmer G. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol 2020; 47:268-288. [PMID: 32011025 PMCID: PMC7027895 DOI: 10.1111/jcpe.13189] [Citation(s) in RCA: 594] [Impact Index Per Article: 148.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/13/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. MATERIAL AND METHODS There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations RESULTS AND CONCLUSIONS: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.
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Affiliation(s)
- Mariano Sanz
- Department of Dental Clinical SpecialtiesETEP Research GroupFaculty of OdontologyUniversity Complutense of MadridMadridSpain
| | | | - Søren Jepsen
- Department of Periodontology, Operative and Preventive DentistryUniversity of BonnBonnGermany
| | - Jose R. Gonzalez‐Juanatey
- Cardiology DepartmentUniversity HospitalIDISCIBERCVUniverity of Santiago de CompostelaSantiago de CompostelaSpain
| | - Francesco D’Aiuto
- Department of PeriodontologyEastman Dental Institute and HospitalUniversity College LondonLondonUK
| | - Philippe Bouchard
- U.F.R. d'odontologieUniversité Paris DiderotHôpital Rothschild AP‐HPParisFrance
| | - Iain Chapple
- School of DentistryInstitute of Clinical SciencesCollege of Medical & Dental SciencesThe University of BirminghamBirminghamUK
| | - Thomas Dietrich
- School of DentistryInstitute of Clinical SciencesCollege of Medical & Dental SciencesThe University of BirminghamBirminghamUK
| | - Israel Gotsman
- Heart InstituteHadassah University HospitalJerusalemIsrael
| | - Filippo Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care MedicineUniversity of PisaPisaItaly
| | - David Herrera
- Department of Dental Clinical SpecialtiesETEP Research GroupFaculty of OdontologyUniversity Complutense of MadridMadridSpain
| | | | - Phoebus Madianos
- Department of PeriodontologySchool of DentistryNational and Kapodistrian University of AthensAthensGreece
| | - Jean‐Baptiste Michel
- Inserm Unit 1148Laboratory for Translational CV ScienceX. Bichat HospitalParisFrance
| | - Pablo Perel
- World Heart FederationGenevaSwitzerland
- Centre for Global Chronic ConditionsLondon School of Hygiene & Tropical MedicineLondonUK
| | - Burkert Pieske
- Department of Internal Medicin & CardiologyCharité Universitätsmedizin BerlinBerlinGermany
- DZHK (German Center for Cardiovascular Research) Partnersite BerlinGerman Heart Institut BerlinBerlinGermany
| | - Lior Shapira
- Department of PeriodontologyHebrew University – Hadassah Faculty of Dental MedicineJerusalemIsrael
| | - Michael Shechter
- Leviev Heart CenterChaim Sheba Medical Centertel Hashomer and the Sackler Faculty of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
| | - Maurizio Tonetti
- Department of PeriodontologyPrince Philip Dental HospitalThe University of Hong KongHong KongHong Kong
| | | | - Gernot Wimmer
- Department of Prosthetic DentistrySchool of Dental MedicineKarl‐Franzens University GrazGrazAustria
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15
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Sanz M, del Castillo AM, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, Chapple I, Dietrich T, Gotsman I, Graziani F, Herrera D, Loos B, Madianos P, Michel JB, Perel P, Pieske B, Shapira L, Shechter M, Tonetti M, Vlachopoulos C, Wimmer G. Periodontitis and Cardiovascular Diseases. Consensus Report. Glob Heart 2020; 15:1. [PMID: 32489774 PMCID: PMC7218770 DOI: 10.5334/gh.400] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022] Open
Abstract
Background In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. Material and Methods There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations. Results and Conclusions The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.
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Affiliation(s)
- M. Sanz
- Department of Dental Clinical Specialties and ETEP Research Group, Faculty of Odontology, University Complutense of Madrid, Plaza Ramon y Cajal, Madrid, ES
| | | | - S. Jepsen
- Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, DE
| | - J. R. Gonzalez-Juanatey
- Cardiology Department, University Hospital, University of Santiago de Compostela, IDIS, CIBERCV, ES
| | - F. D’Aiuto
- Department of Periodontology, Eastman Dental Institute and Hospital, University College London, London, UK
| | - P. Bouchard
- U.F.R. d’odontologie, Université Paris Diderot, Hôpital Rothschild AP-HP, Paris, FR
| | - I. Chapple
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - T. Dietrich
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, UK
| | - I. Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, IL
| | - F. Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, IT
| | - D. Herrera
- Department of Dental Clinical Specialties and ETEP Research Group, Faculty of Odontology, University Complutense of Madrid, Plaza Ramon y Cajal, Madrid, ES
| | - B. Loos
- ACTA University, Amsterdam, NL
| | - P. Madianos
- Department of Periodontology, School of Dentistry, National and Kapodistrian University of Athens, GR
| | - J. B. Michel
- Inserm Unit 1148, laboratory for translational CV science, X. Bichat hospital, Paris, FR
| | - P. Perel
- World Heart Federation, Geneva, CH
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, UK
| | - B. Pieske
- Charité Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology, Berlin, DE
- DZHK (German Center for Cardiovascular Research) Partnersite Berlin, German Heart Institut Berlin, DE
| | - L. Shapira
- Department of Periodontology, Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, IL
| | - M. Shechter
- Leviev Heart Center, Chaim Sheba Medical Center, tel Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, IL
| | - M. Tonetti
- Department of Periodontology, The University of Hong Kong, Prince Philip Dental Hospital, HK
| | - C. Vlachopoulos
- Department of Cardiology, National and Kapodistrian University of Athens, GR
| | - G. Wimmer
- Department of Prosthetic Dentistry, School of Dental Medicine, Karl-Franzens University Graz, AT
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Sohn JB, Lee H, Han YS, Jung DU, Sim HY, Kim HS, Oh S. When do we need more than local compression to control intraoral haemorrhage? J Korean Assoc Oral Maxillofac Surg 2020; 45:343-350. [PMID: 31966979 PMCID: PMC6955419 DOI: 10.5125/jkaoms.2019.45.6.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/05/2019] [Accepted: 10/28/2019] [Indexed: 11/07/2022] Open
Abstract
Objectives The aims of this study were to determine the effectiveness of local compression in patients presenting to the emergency room with intraoral bleeding and to identify when complex haemostatic measures may be required. Materials and Methods Five hundred forty patients who had experienced intraoral haemorrhage were retrospectively reviewed. The outcome variable was the haemostasis method used, i.e., simple (local compression with gauze) or complex (an alternative method after local compression has failed). Predictor variables were sex, age, American Society of Anesthesiologists (ASA) class, hepatic cirrhosis, bleeding disorder, use of antithrombotic agents, and site/cause of haemorrhage. Results The mean patient age was 48.9±23.9 years, 53.5% were male, 42.8% were ASA class II or higher, and 23.7% were taking antithrombotic agents. Local compression was used most often (68.1%), followed by local haemostatic agents, sutures, systemic tranexamic acid or blood products, and electrocautery. The most common site of bleeding was the gingiva (91.7%), and the most common cause was tooth extraction (45.7%). Risk factors for needing a complex haemostasis method were use of antithrombotic agents (odds ratio 2.047, P=0.009) and minor oral surgery (excluding extraction and implant procedures; odds ratio 6.081, P=0.001). Conclusion A haemostasis method other than local compression may be needed in patients taking antithrombotic agents or having undergone minor oral surgery.
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Affiliation(s)
- Jun-Bae Sohn
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Ho Lee
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Yoon-Sic Han
- Department of Oral and Maxillofacial Surgery, Seoul Metropolitan Government-Seoul National University (SMG-SNU) Boramae Medical Center, Seoul, Korea
| | - Da-Un Jung
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hye-Young Sim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hee-Sun Kim
- Section of Dentistry, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Sohee Oh
- Medical Research Collaborating Center, SMG-SNU Boramae Medical Center, Seoul, Korea
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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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18
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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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19
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de Andrade NK, Motta RHL, Bergamaschi CDC, Oliveira LB, Guimarães CC, Araújo JDO, Lopes LC. Bleeding Risk in Patients Using Oral Anticoagulants Undergoing Surgical Procedures in Dentistry: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:866. [PMID: 31447671 PMCID: PMC6696826 DOI: 10.3389/fphar.2019.00866] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/08/2019] [Indexed: 01/21/2023] Open
Abstract
The management of patients who undergo dental surgical procedures and receive oral anticoagulant therapy requires particular attention due to the risk of bleeding that may occur during the procedure. Bleeding rates in these trans- or post-operative patients tend to be unpredictable. The aim of this study was to conduct a systematic review in order to assess the risk of bleeding during and after performing oral surgery in patients administered oral anticoagulants compared with a group that discontinued anticoagulant therapy. For the purposes of this review, we searched the databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), EMBASE (via Ovid), and the Virtual Health Library (VHL) from inception of the database to December 2018. The primary outcome was defined as the occurrence of local bleeding during and after oral surgical procedures. Four reviewers, independently and in pairs, screened titles and abstracts for full-text eligibility. Data regarding participant characteristics, interventions, and design and outcomes of the included studies were extracted. The data were pooled using random-effects meta-analyses and described as risk ratios (RRs) with a 95% confidence interval (95% CI). The confidence for the pooled estimates was ascertained through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and the protocol of this review was recorded in PROSPERO (CRD42017056986). A total of 58 eligible studies were identified, of which three randomized controlled trials were included in the meta-analysis, covering a total of 323 adult participants, among whom 167 were taking anticoagulants at the time they underwent dental surgery. Of these patients, 14.2% had reported bleeding. The risk of bleeding was found to be one to almost three times greater in patients taking warfarin compared with patients who discontinued the use of anticoagulant during the trans-operative period (RR = 1.67, 95% CI = 0.97 to 2.89) and in the post-operative period (RR = 1.44, 95% CI = 0.71 to 2.92), although the quality of evidence was very low. The results indicate that there is no evidence that the use of anticoagulants eliminates the risk of bleeding during surgical dental procedures.
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Affiliation(s)
- Natália Karol de Andrade
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Rogério Heládio Lopes Motta
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | | | - Luciana Butini Oliveira
- Division of Paediatric Dentistry, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Caio Chaves Guimarães
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Jimmy de Oliveira Araújo
- Division of Pharmacology, Anesthesiology and Therapeutics, Faculdade São Leopoldo Mandic, Instituto de Pesquisas São Leopoldo Mandic, Campinas, Brazil
| | - Luciane Cruz Lopes
- Pharmaceutical Science Graduate Course, University of Sorocaba, Sorocaba, Brazil
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Gandhi Y, Bhatavdekar N. MIDAS (Minimally Invasive Drilling And Styptic) protocol - A modified approach to treating patients under therapeutic anticoagulants. J Oral Biol Craniofac Res 2019; 9:208-211. [PMID: 31193025 DOI: 10.1016/j.jobcr.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/14/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022] Open
Abstract
Patients with cardiac or allied medical conditions mandating long term oral anticoagulant therapy form a sizeable database in an implant practice today. The management of such patients during surgical and dental procedures has always been debatable. Literature has documented evidence that indicates towards stopping the anticoagulant for a finite period. However, discontinuing anticoagulants is not always possible, given the risks of greater significance than the edentulous state. In such patients a minimally invasive flapless approach is preferred, having the potential to reduce bleeding, surgical time and postoperative edema. The purpose of this case series is to show a possible modified approach for dental implant placement using a CAD-CAM stent guided flapless approach without stopping of therapeutic anticoagulant medication.
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Affiliation(s)
- Yazad Gandhi
- Oral & Maxillofacial Surgeon, Saifee Hospital, Mumbai, India
| | - Neel Bhatavdekar
- Clarus Dental Specialities, Pune, Adjunct Faculty, University of North Carolina, Chapel Hill, USA
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van Galen KPM, Engelen ET, Mauser‐Bunschoten EP, van Es RJJ, Schutgens REG. Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions. Cochrane Database Syst Rev 2019; 4:CD011385. [PMID: 31002742 PMCID: PMC6474399 DOI: 10.1002/14651858.cd011385.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease (VWD). The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date. This is an update of a previously published Cochrane Review. OBJECTIVES Primarily, we aim to assess the efficacy of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or VWD undergoing oral or dental procedures.Secondary objectives are to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or VWD and to establish the effects of these agents on bleeding in oral or dental procedures for each of these patient populations. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase, Cinahl and the Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 01 March 2019. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in people with haemophilia or VWD undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid (EACA)) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardised forms. MAIN RESULTS While there were no eligible trials in people with VWD identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of EACA published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference (RD) of -0.64 (95% confidence interval (CI) -0.93 to - 0.36) and the EACA trial a RD of -0.50 (95% CI 0.77 to -0.22). The combined RD of both trials was -0.57 (95% CI -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping EACA (combined RD of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the EACA trial, but overall the risk of bias appeared to be low for both trials. AUTHORS' CONCLUSIONS Despite the discovery of a beneficial effect of systemically administered tranexamic acid and EACA in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with VWD.
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Affiliation(s)
- Karin PM van Galen
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CT
| | - Eveline T Engelen
- University Medical Centre UtrechtPoortstraat 95UtrechtNetherlands3572HG
| | - Evelien P Mauser‐Bunschoten
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CT
| | - Robert JJ van Es
- University Medical Center UtrechtOral and Maxillofacial SurgeryHeidelberglaan 100UtrechtNetherlands3584CX
| | - Roger EG Schutgens
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CT
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Abstract
There are few absolute contraindications to dental implant placement. Relative contraindications include cognitive decline, American Society of Anesthesiology patient status IV or higher categories, or medical conditions that may jeopardize the life or lifespan of the patient. Precautions for placing dental implants should be viewed with respect to the evidence-based exposures that can contribute to risk of failure, including but not limited to local, behavioral, and medical factors. Risk for dental implant failure increases in association with (1) past history of periodontal disease, (2) bruxism, (3) smoking, and (4) radiation therapy.
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Affiliation(s)
- Amritpal S Kullar
- Division of Oral Diagnosis, Oral Medicine, Oral Radiology, MN324 College of Dentistry, University of Kentucky, 800 Rose Street, Lexington, KY 40356-0297, USA
| | - Craig S Miller
- Division of Oral Diagnosis, Oral Medicine, Oral Radiology, MN324 College of Dentistry, University of Kentucky, 800 Rose Street, Lexington, KY 40356-0297, USA.
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Sahar-Helft S, Chackartchi T, Polak D, Findler M. Dental treatment in the era of new anti-thrombotic agents. Int Dent J 2018; 68:131-137. [DOI: 10.1111/idj.12322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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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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Catanzano O, D'Esposito V, Formisano P, Boateng JS, Quaglia F. Composite Alginate-Hyaluronan Sponges for the Delivery of Tranexamic Acid in Postextractive Alveolar Wounds. J Pharm Sci 2018; 107:654-661. [DOI: 10.1016/j.xphs.2017.09.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 09/15/2017] [Accepted: 09/22/2017] [Indexed: 11/24/2022]
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Wahl MJ, Miller CS, Rhodus NL, Kämmerer P, Dinkova A, Lalla RV, Bajkin BV. Anticoagulants are dental friendly. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 125:103-106. [PMID: 29249522 DOI: 10.1016/j.oooo.2017.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 10/27/2017] [Accepted: 11/03/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Michael J Wahl
- Assistant Attending Dentist, Department of Oral and Maxillofacial Surgery and Hospital Dentistry, Christiana Care Health System, Wilmington, DE, USA
| | - Craig S Miller
- Professor of Oral Medicine, Chief, Division Oral Diagnosis, Oral Medicine, Oral Radiology, Department of Oral Health Practice, University of Kentucky College of Dentistry, Lexington, KY, USA
| | - Nelson L Rhodus
- Diplomate, American Board of Oral Medicine, Morse Distinguished Professor and Director, Division of Oral Medicine, School of Dentistry, Adjunct Professor, Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Peer Kämmerer
- Specialist Plastic Surgery, Specialist, Dental Oral Surgery, Fellow of the European Board of Oro-Maxillo-Facial Surgery, Specialist for Pain Therapy of Head and Neck, Specialist for Dental Implantology, Master of Arts Management of Health Care and Social Facilities, Vice Medical Director, Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, Germany
| | - Atanaska Dinkova
- Assistant Professor, Department of Oral Surgery, Faculty of Dental Medicine, Medical University - Plovdiv, Plovdiv, Bulgaria
| | - Rajesh V Lalla
- Associate Professor, Associate Dean for Research Diplomate, American Board of Oral Medicine, Division of Oral and Maxillofacial Diagnostic Sciences, School of Dental Medicine, University of Connecticut, Farmington, CT, USA
| | - Branislav V Bajkin
- Associate Professor, Vice Dean for PhD Studies at Faculty of Medicine Novi Sad, Department of Oral Surgery, Dental Clinic of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
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Motta RHL, Bergamaschi CDC, de Andrade NK, Guimaraes CC, Ramacciato JC, Araújo JDO, Lopes LC. Bleeding risk in patients using oral anticoagulants submitted to surgical procedures in dentistry: a systematic review protocol. BMJ Open 2017; 7:e019161. [PMID: 29259064 PMCID: PMC5778277 DOI: 10.1136/bmjopen-2017-019161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The management of patients undergoing oral surgical procedures using anticoagulants raises concerns regarding the risk of bleeding. Bleeding rates in those patients during or after oral surgical procedures are uncertain. The aim of this study will be to determine the bleeding rate during and after oral surgeries in patients using anticoagulants. METHODS AND ANALYSIS A systematic review will be conducted and if appropriate, a meta-analysis of randomised clinical trials evaluating the bleeding risk during and after oral surgical procedures in patients using anticoagulants were selected. The literature search will be conducted using electronic databases, such as the Cochrane Central Register of Controlled Trials, MEDLINE (via Ovid), Embase (via Ovid), Cumulative Index to Nursing and Allied Health Literature (via Ovid), LILACS (SciELO) and CAPES database, without restriction of languages or date of publication. The primary outcome will be the occurrence of local bleeding rate during and after oral surgical procedures, and as secondary outcome, the following complications will be considered: implant failure, healing problems and infections. Groups of two independent reviewers will select the titles and abstracts for full-text eligibility. For eligible studies, the same reviewers will perform data extraction, bias risk assessment and determination of the overall quality of evidence for each of the outcomes using the Grading of Recommendations Assessment, Development and Evaluation classification system. Meta-analysis and subgroup analyses will be conducted, to all outcomes, if appropriate. ETHICS AND DISSEMINATION The systematic review will be published in a peer-reviewed journal, and brief reports of the review's findings will be released directly to the intended audience. The results will help dentists in the decision-making process to minimise the risk of bleeding in patients using anticoagulants in their clinical practice. PROSPERO REGISTRATION NUMBER CRD42017056986.
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Affiliation(s)
- Rogério Heládio Lopes Motta
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | | | - Natalia Karol de Andrade
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Caio Chaves Guimaraes
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Juliana Cama Ramacciato
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Jimmy de Oliveira Araújo
- Pharmacology, Anesthesiology and Therapeutics, São Leopoldo Mandic Dental School and Research Center, Campinas, São Paulo, Brazil
| | - Luciane Cruz Lopes
- Department of Pharmaceutical Sciences Graduate Program, University of Sorocaba, Sorocaba, São Paulo, Brazil
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Zushi Y, Takaoka K, Tamaoka J, Ueta M, Noguchi K, Kishimoto H. Treatment with teriparatide for advanced bisphosphonate-related osteonecrosis of the jaw around dental implants: a case report. Int J Implant Dent 2017; 3:11. [PMID: 28361376 PMCID: PMC5374080 DOI: 10.1186/s40729-017-0074-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/12/2017] [Indexed: 12/12/2022] Open
Abstract
We report a case of a 66-year-old severely osteoporotic woman with bisphosphonate-related osteonecrosis of the jaw (BRONJ) around her dental implants, who was treated successfully with teriparatide and sequestrectomy of the mandible. After 5 months of teriparatide therapy, the sequestrum separation had progressed and a sequestrectomy was performed under general anesthesia. Five months after the operation, new bone formation was observed around the bone defect in the region of the sequestrectomy. A repeat computed tomographic image revealed improvement in the bone defect in the mandible. These results suggest that teriparatide provides beneficial effects in the treatment of advanced BRONJ around dental implants.
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Affiliation(s)
- Yusuke Zushi
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
| | - Kazuki Takaoka
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
| | - Joji Tamaoka
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
| | - Miho Ueta
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
| | - Kazuma Noguchi
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
| | - Hiromitsu Kishimoto
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
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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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Bleeding Rate After Tooth Extraction in Patients Under Oral Anticoagulant Therapy. J Craniofac Surg 2017; 27:1228-33. [PMID: 27380567 DOI: 10.1097/scs.0000000000002713] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The aim of this single-cohort prospective study was to evaluate the risk of adverse outcomes after tooth extraction in patients suffering from cardiovascular disorders and under oral anticoagulant therapy with an international normalized ratio within the value of 3.0. METHODS Two hundred ninety-three patients (mean age of 58.7 years) were enrolled and 560 tooth extractions were performed. Fresh extraction sockets were treated with collagen tablets and sutures. The risk of increased bleeding rate was evaluated for type of drug therapy (acenocoumarol or warfarin), type of cardiovascular diseases, and number of tooth extractions. Level of significance was set at 0.05. RESULTS The overall bleeding event rate was 6.8%. Among patients who had bleeding events, 4 suffered from valvular disorders, whereas 11 suffered from arrhythmias (8) or cardiomyopathies (3). The remaining 5 patients had a history of cardiomyopathy and arrhythmia.The bleeding events in patients who had more than 2 tooth extractions were significantly higher than those observed in patients who had only 1 tooth extraction (P <0.05). CONCLUSION Patients who received more than 2 tooth extractions, who were under treatment with acenocoumarol, and who suffered from multiple cardiovascular diseases were at high risk for bleeding events.
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Stopping Anticoagulation Therapy Before Implant and Bone Grafting Surgery May Not Be Necessary to Prevent Bleeding Events. J Evid Based Dent Pract 2017; 17:122-124. [PMID: 28501059 DOI: 10.1016/j.jebdp.2017.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Management of anticoagulated patients in implant therapy: a clinical comparative study. Clemm R, Neukam FW, Rusche B, Bauersachs A, Musazada S, Schmitt CM. Clin Oral Implants Res 2016;27(10):1274-82. SOURCE OF FUNDING Information not available TYPE OF STUDY/DESIGN: Cohort study.
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Shi Q, Xu J, Zhang T, Zhang B, Liu H. Post-operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-analysis of Observational Studies. Front Pharmacol 2017; 8:58. [PMID: 28228727 PMCID: PMC5296357 DOI: 10.3389/fphar.2017.00058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/26/2017] [Indexed: 01/19/2023] Open
Abstract
Background and Objective: Minor dental surgery is invasive and hemorrhagic. Thus, in patients treated with anticoagulants, the bleeding risk related to these invasive procedures is concerning. The aim of this meta-analysis is to evaluate this risk by comparing the post-operative bleeding rates of oral anticoagulation treatment (OAT) patients (without interrupted or altered anticoagulant intake) with non-OAT patients. Methods: PubMed, Embase and the Cochrane Library were searched for eligible studies that compared the post-operative (following minor dental surgery) bleeding rates of OAT patients without interrupted or altered therapy with those of non-OAT patients. Relative risk (RR) and 95% confidence interval (CI) were calculated. Subgroup analyses were used to identify the association between the bleeding rate and different dental surgeries or anticoagulants. Results: Thirty two full text articles were assessed for eligibility and 20 studies were excluded according to the selection criteria. Finally, 12 studies and a total of 2102 OAT patients and 2271 non-OAT patients were included. A pooled analysis indicated that the post-operative bleeding risk in OAT patients is higher than that of non-OAT patients (RR: 2.794, 95% CI: 1.722-4.532, P = 0.000). The pooled RRs in the dental implant surgery and dental extraction subgroups were 2.136 (95% CI: 0.825-5.531, P = 0.118) and 2.003 (95% CI: 0.987-4.063, P = 0.054), respectively. As for the different oral anticoagulants, the pooled RR in the subgroup of new oral anticoagulants (NOACs) was 1.603 (95% CI: 0.430-5.980, P = 0.482), while the pooled RR in the vitamin K antagonists subgroup was 3.067 (95% CI: 1.838-5.118, P = 0.000). Conclusion: Under current evidence, OAT patients were under a higher post-operative bleeding risk than the non-OAT patients following minor dental surgery. For the dental implant surgeries and dental extractions, our study failed to demonstrate a higher risk of bleeding in the OAT patients compared with the non-OAT patients. Besides, The NOACs might be safer than the vitamin K antagonists in dental implant surgery. However, more well-designed studies are required for future research.
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Affiliation(s)
- Quan Shi
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Juan Xu
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Tong Zhang
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Bin Zhang
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
| | - Hongchen Liu
- Institute of Stomatology, Chinese PLA General Hospital Beijing, China
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Chinnaswami R, Bagadia RK, Mohan A, Kandaswamy E, Chandrasekaran D. Dentists' Knowledge, Attitude and Practice in Treating Patients Taking Oral Antithrombotic Medications - A Survey. J Clin Diagn Res 2017; 11:ZC88-ZC91. [PMID: 28274053 DOI: 10.7860/jcdr/2017/23648.9236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 11/11/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION India lists high on patients suffering from diabetes, hypertension, stroke and myocardial infarction. Hence, a large proportion of the population is on long term Oral Antithrombotic Medications (OAM). Though several guidelines exist on dental management of these patients, previous surveys have shown variation among the dentists. AIM The purpose of this study was to assess the knowledge, attitude and practice of dentists in Chennai, India, towards dental management of patients taking OAM using a questionnaire survey. MATERIALS AND METHODS The survey was conducted among 256 dentists in Chennai, India using a printed questionnaire containing 16 questions, at their university location. Descriptive statistical analysis was used to analyze the data. RESULTS Of the final population of dentists who were included in the survey (n =212), majority of them were aware about drugs such as warfarin and aspirin compared to other newer drugs (dabigatran, rivaroxaban). Most participants took physician's opinion before proceeding with any invasive dental procedure and thromboembolic events were their major concern while treating patients on OAM. CONCLUSION The survey revealed dentists are knowledgeable about management of patients on OAM. However, they tend to overestimate the bleeding risk, thus being cautious in their treatment approach. Based on the results of the study, the authors suggest that continuing dental education programs and further training on management of such medically complex patients will be beneficial in order to provide optimum dental care to people taking OAM.
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Affiliation(s)
- Ravindran Chinnaswami
- Professor and Head, Department of Oral and Maxillofacial Surgery, Sri Ramachandra University , Chennai, Tamil Nadu, India
| | - Ritvi K Bagadia
- Postgraduate Student, Department of Oral and Maxillofacial Surgery, Sri Ramachandra University , Chennai, Tamil Nadu, India
| | - Anusha Mohan
- Postgraduate Student, Department of Paedodontics and Preventive Dentistry, Sri Ramachandra University , Chennai, Tamil Nadu, India
| | - Eswar Kandaswamy
- Former Undergraduate Student, Faculty of Dental Sciences, Sri Ramachandra University , Chennai, Tamil Nadu, India
| | - Deepak Chandrasekaran
- Senior Lecturer, Department of Oral and Maxillofacial Surgery, Sri Ramachandra University , Chennai, Tamil Nadu, India
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Omar HR, Socias SM, Powless RA, Sprenker C, Karlnoski R, Mangar D, Camporesi EM. Clopidogrel is not associated with increased bleeding complications after full-mouth extraction: A retrospective study. J Am Dent Assoc 2016; 146:303-9. [PMID: 25925522 DOI: 10.1016/j.adaj.2015.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 01/02/2015] [Accepted: 01/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND To the authors' knowledge, the effect of clopidogrel on bleeding complications during full-mouth extraction has not been studied. The authors aimed to determine the safety of continued use of clopidogrel during full-mouth extraction. METHODS The authors performed a retrospective study of consecutive patients undergoing full-mouth extraction who were taking aspirin, clopidogrel, a combination of aspirin and clopidogrel, or neither. The main study outcomes in the 4 study groups were estimated blood loss, transfusion requirements, and complications. The authors also examined the correlation between the number of teeth extracted and estimated blood loss in various groups. RESULTS Seventy-one patients underwent full-mouth extraction with removal of an average of 19 teeth. The authors excluded 3 patients owing to lack of data regarding blood loss. Of the remaining 68 patients, 25 were using aspirin, 12 were using clopidogrel, 9 were using both aspirin and clopidogrel, and 22 had discontinued the use of antiplatelets. There was no significant difference in the number of teeth extracted (P = .283) and estimated blood loss (P = .111) among the 4 groups. The authors found a significant moderate correlation between the number of teeth extracted and estimated blood loss in the group using aspirin (r = 0.537; P = .006) and in the group using clopidogrel, whether alone or in combination with aspirin (r = 0.535; P = .012), but not in the group who discontinued the use of antiplatelets. There was no need for blood transfusion in any patient. CONCLUSIONS The results of this study provide limited evidence to suggest that continuation of clopidogrel during full-mouth extraction and preprosthetic surgery may be safe and does not appear to be associated with a significant risk of bleeding. PRACTICAL IMPLICATIONS Clopidogrel therapy during full-mouth extraction is not associated with significant bleeding complications and may be continued in patients who have a high risk of experiencing a cardiac event.
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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Abstract
Several systemic diseases (and relative medications) have been reported to impair or in some cases complicate dental implant surgery. In broader terms, when dealing with patients suffering from systemic diseases, the monitoring of the medical condition and of the related post-operative complications is of great importance in order to avoid risks which could jeopardise the health of the patient. In this review, the available evidence on implant survival/success, as well as relevant surgical recommendations in patients affected by systemic diseases, are evaluated and when possible, practical suggestions for the clinician are provided.
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Marković A, Đinić A, Calvo Guirado JL, Tahmaseb A, Šćepanović M, Janjić B. Randomized clinical study of the peri-implant healing to hydrophilic and hydrophobic implant surfaces in patients receiving anticoagulants. Clin Oral Implants Res 2016; 28:1241-1247. [DOI: 10.1111/clr.12948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Aleksa Marković
- Department of Oral Surgery; School of Dental Medicine; University of Belgrade; Belgrade Serbia
| | - Ana Đinić
- Department of Oral Surgery; School of Dental Medicine; University of Belgrade; Belgrade Serbia
| | - José Luis Calvo Guirado
- Department of Research; International Dentistry Research Cathedra; UCAM Universidad Catolica San Antonio de Murcia; Murcia Spain
| | - Ali Tahmaseb
- Department of Oral Implantology and Prosthetic Dentistry; Academic Center for Dentistry Amsterdam (ACTA); Move Research Institute; Amsterdam The Netherlands
| | - Miodrag Šćepanović
- Department of Prosthodontics; School of Dental Medicine; University of Belgrade; Belgrade Serbia
| | - Bojan Janjić
- Department of Oral Surgery; School of Dental Medicine; University of Belgrade; Belgrade Serbia
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Haraji A, Rakhshan V, Hosseini V. Local heating of the wound with dressings soaked in saline at 42°C can reduce postoperative bleeding: a single-blind, split-mouth, randomised controlled clinical trial. Br J Oral Maxillofac Surg 2016; 54:266-9. [DOI: 10.1016/j.bjoms.2016.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 01/16/2016] [Indexed: 10/22/2022]
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Gómez-Moreno G, Fernández-Cejas E, Aguilar-Salvatierra A, de Carlos F, Delgado-Ruiz RA, Calvo-Guirado JL. Dental implant surgery in patients in treatment by dabigatran. Clin Oral Implants Res 2016; 29:644-648. [DOI: 10.1111/clr.12785] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gerardo Gómez-Moreno
- Department of Special Care in Dentistry; Pharmacological Research in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Esther Fernández-Cejas
- International Research Cathedra in Dentistry; San Antonio Catholic University of Murcia; UCAM; Murcia Spain
| | - Antonio Aguilar-Salvatierra
- Department of Pharmacological Research in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Félix de Carlos
- Department of Surgery and Medical-Surgical Specialities; Area of Orthodontics; Faculty of Medicine; University of Oviedo; Oviedo Spain
| | | | - José Luis Calvo-Guirado
- International Research Cathedra in Dentistry; San Antonio Catholic University of Murcia; UCAM; Murcia Spain
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van Galen KPM, Engelen ET, Mauser-Bunschoten EP, van Es RJJ, Schutgens REG. Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions. Cochrane Database Syst Rev 2015:CD011385. [PMID: 26704192 DOI: 10.1002/14651858.cd011385.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease. The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date. OBJECTIVES The primary objective was to assess the efficacy of local or systemic use of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures. Secondary objectives were to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or Von Willebrand disease and to further establish the effects of these agents on bleeding in oral or dental procedures for each of these populations. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and The Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2015. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. MAIN RESULTS While there were no eligible trials in people with Von Willebrand disease identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of epsilon aminocaproic acid published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference of -0.64 (95% confidence interval -0.93 to - 0.36) and the EACA trial a risk difference of -0.50 (95% confidence interval 0.77 to -0.22). The combined risk difference of both trials was -0.57 (95% confidence interval -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping epsilon aminocaproic acid (combined risk difference of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the epsilon aminocaproic acid trial, but overall the risk of bias appeared to be low for both trials. AUTHORS' CONCLUSIONS Despite the discovery of a beneficial effect of systemically administered tranexamic acid and epsilon aminocaproic acid in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with Von Willebrand disease.
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Affiliation(s)
- Karin P M van Galen
- Van Creveldkliniek / Department of Haematology, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, Netherlands, 3584CT
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Clemm R, Neukam FW, Rusche B, Bauersachs A, Musazada S, Schmitt CM. Management of anticoagulated patients in implant therapy: a clinical comparative study. Clin Oral Implants Res 2015; 27:1274-1282. [PMID: 26592859 DOI: 10.1111/clr.12732] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This prospective clinical comparative study aimed to analyze the postoperative bleeding risk of patients continuing their anticoagulation therapy (AT) and undergoing implant surgery and bone grafting procedures. MATERIALS AND METHODS The treatments ranged from the insertion of single or multiple dental implants over implant exposures to sinus floor augmentation and vertical and/or lateral bone grafting with autologous bone grafts. The patients of the test groups (AT groups) were treated with platelet aggregation inhibitors (PAIs), Vitamin-K inhibitors, Vitamin-K inhibitor withdrawal bridged with heparin (LMWH), or new/direct oral anticoagulants (NOACs/DOACs). Patients of the control group were non-anticoagulated (non-AT group). Surgical procedures were performed in the same manner in all groups. Pre, intra, and postoperative data concerning the treatment, extent of the surgery and bleedings was recorded and statistically evaluated. RESULTS There were seven postoperative bleedings in 564 patients (1.2%), four in the AT groups (3.4%), and three in the non-AT group (0.6%). No thromboembolic complication occurred in the whole observation period. The invasiveness of the surgical procedure had no statistically significant effect on bleeding frequencies. Patients taking Vitamin-K inhibitors had a significantly higher risk of a postoperative bleeding compared to patients without any AT (P = 0.038). Two patients were hospitalized due to the severity of the bleeding as a precautionary measure (one in the non-AT and one in the PAI group). All bleedings were easily controllable with local hemostatic measures. There was no postoperative bleeding recorded for patients taking DOACs. CONCLUSIONS Anticoagulation therapy should be continued in patients undergoing implant surgery and bone grafting procedures avoiding thromboembolic complications. Surgeons should always apply the most minimally invasive approach to reduce postoperative risks and be able to apply local hemostatic measures in terms of a bleeding complication.
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Affiliation(s)
- R Clemm
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - F W Neukam
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - B Rusche
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - A Bauersachs
- Private Practice Prof. Schlegel and Colleagues, Munich, Germany
| | - S Musazada
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - C M Schmitt
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Gómez-Moreno G, Aguilar-Salvatierra A, Fernández-Cejas E, Delgado-Ruiz RA, Markovic A, Calvo-Guirado JL. Dental implant surgery in patients in treatment with the anticoagulant oral rivaroxaban. Clin Oral Implants Res 2015; 27:730-3. [DOI: 10.1111/clr.12653] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gerardo Gómez-Moreno
- Department of Special Care in Dentistry; Pharmacological Research in Dentistry; Director of Master in Periodontology and Implant Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Antonio Aguilar-Salvatierra
- Department of Pharmacological Research in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Esther Fernández-Cejas
- Department of Pharmacological Research in Dentistry Group; Faculty of Dentistry; University of Granada; Granada Spain
| | | | - Aleksa Markovic
- Department of Clinic of Oral Surgery; Faculty of Stomatology; University of Belgrade; Belgrade Serbia
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van Galen KPM, Engelen ET, Mauser-Bunschoten EP, van Es RJJ, Schutgens REG. Antifibrinolytic therapy for preventing oral bleeding in patients with a hemophilia or Von Willebrand disease undergoing oral or dental procedures. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Pérez-Chrzanowska H, Figueredo-Zalve R. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am 2014; 96:1937-44. [PMID: 25471907 DOI: 10.2106/jbjs.n.00060] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Abundant literature regarding the use of intravenous tranexamic acid (TXA) in primary total knee replacement is available. Randomized controlled trials have confirmed the efficacy of topical TXA compared with placebo, but the comparison between topical and intravenous TXA is unclear. The present study was designed to verify noninferior efficacy and safety of topical intra-articular TXA compared with intravenous TXA in primary total knee replacement with cemented implants. METHODS A Phase-III, single-center, double-blind, randomized, controlled clinical trial was performed to compare topical intra-articular TXA (3 g of TXA in 100 mL of physiological saline solution) with two intravenous doses of TXA (15 mg/kg in 100 mL of physiological saline solution, one dose before tourniquet release and another three hours after surgery) in a multimodal protocol for blood loss prevention. The primary outcome was the blood transfusion rate, and the secondary outcomes included visible blood loss (as measured in the drain) at twenty-four hours postoperatively and invisible blood loss (as estimated from the Nadler formula) at forty-eight hours postoperatively. The sample size of seventy-eight patients was calculated to give a statistical power of 99% for demonstrating noninferiority. Thirty-nine patients each were allocated to receive topical intra-articular TXA (the experimental group) and intravenous TXA (the control group); there were no significant differences in demographics or preoperative laboratory values between the groups. Noninferiority was estimated by comparing the confidence intervals with a delta of 10%. Student t and Mann-Whitney tests were used to assess the significance of any differences. RESULTS The transfusion rate was zero in both groups; thus, noninferiority was demonstrated for the primary efficacy end point, suggesting equivalence. Noninferiority was also demonstrated for the secondary efficacy end points. Drain blood loss at twenty-four hours was 315.6 mL (95% confidence interval [CI], 248.5 to 382.7 mL) in the experimental group and 308.1 mL (95% CI, 247.6 to 368.5 mL) in the control group (p = 0.948, Mann-Whitney). Also, estimated blood loss at forty-eight hours was 1259.0 mL (95% CI, 1115.6 to 1402.3 mL) in the experimental group and 1317.9 mL (95% CI, 1175.4 to 1460.4 mL) in the control group (p = 0.837, Mann-Whitney). No significant safety differences were seen between groups. CONCLUSIONS Topical administration of TXA according to the described protocol demonstrated noninferiority compared with intravenous TXA, with no safety concerns. This randomized controlled trial supports the topical intra-articular administration of TXA in primary total knee replacement with cemented implants. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Enrique Gomez-Barrena
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario "La Paz"-IdiPAZ-UAM, Traumatología 1ª planta, Paseo de la Castellana 261, 28046 Madrid, Spain. E-mail address for E. Gomez-Barrena: ,
| | - Miguel Ortega-Andreu
- Departments of Orthopaedic Surgery and Traumatology (M.O.-A.) and Anaesthesiology (H.P.-C. and R.F.-Z.), Hospital La Paz-Cantoblanco, Carretera de Colmenar Viejo Km 14, 28049 Madrid, Spain
| | - Norma G Padilla-Eguiluz
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario "La Paz"-IdiPAZ-UAM, Traumatología 1ª planta, Paseo de la Castellana 261, 28046 Madrid, Spain. E-mail address for E. Gomez-Barrena: ,
| | - Hanna Pérez-Chrzanowska
- Departments of Orthopaedic Surgery and Traumatology (M.O.-A.) and Anaesthesiology (H.P.-C. and R.F.-Z.), Hospital La Paz-Cantoblanco, Carretera de Colmenar Viejo Km 14, 28049 Madrid, Spain
| | - Reyes Figueredo-Zalve
- Departments of Orthopaedic Surgery and Traumatology (M.O.-A.) and Anaesthesiology (H.P.-C. and R.F.-Z.), Hospital La Paz-Cantoblanco, Carretera de Colmenar Viejo Km 14, 28049 Madrid, Spain
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Oral surgery during therapy with anticoagulants-a systematic review. Clin Oral Investig 2014; 19:171-80. [PMID: 25413495 DOI: 10.1007/s00784-014-1366-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/13/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Oral anticoagulation therapy (OAT) with vitamin K inhibitors protects the patients from thromboembolic events. It may however lead to excessive hemorrhage during and after an oral surgery procedure. The aim of this systematic review was to evaluate the justifications to reduce, withdraw, or alter OATs prior to minor oral surgery procedures to manage bleeding events. MATERIALS AND METHODS A systematic MEDLINE search was conducted for clinical studies in English or German language from 1994 to 2014 comparing patients treated with OAT, without OAT, as well as patients with altered OAT for oral surgery purposes. Relevant outcome parameters were: postoperative local hemostasis, bleeding episodes, occurrence of thromboembolic events, and other complications due to the anticoagulation medication. A hand search for references cited in the identified publications completed the review. RESULTS After screening of 1755 abstracts, 16 clinical studies were identified according to the selection criteria. Due to the heterogeneity of the obtained data, aggregation and synthesis were not possible. There was no significant difference in bleeding events comparing patients under continued OAT to those with reduced, altered, and/or discontinued OAT medications. Minor bleeding events in the test and control groups were successfully stopped with local measures. However, no superiority of a single hemostatic measure could be identified. Neither the international normalized ratio (INR), within the therapeutic range (2-4), nor the extent of the minor oral surgery procedure had an influence on postoperative bleeding episodes. DISCUSSION There is strong evidence that OAT patients undergoing minor oral surgery should not discontinue their medication in order to prevent thromboembolic complications. CLINICAL RELEVANCE Nonetheless, INR should be less than 4, local hemostatic measures are of high importance and patients need to be instructed and closely monitored as minor bleedings might occur more often in OAT patients.
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Dental implants in patients at high risk for infective endocarditis: a preliminary study. Int J Oral Maxillofac Surg 2014; 43:1282-5. [DOI: 10.1016/j.ijom.2014.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 02/27/2014] [Accepted: 04/16/2014] [Indexed: 11/17/2022]
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Quirynen M, Herrera D, Teughels W, Sanz M. Implant therapy: 40 years of experience. Periodontol 2000 2014; 66:7-12. [DOI: 10.1111/prd.12060] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2013] [Indexed: 12/30/2022]
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Mingarro-de-León A, Chaveli-López B, Gavaldá-Esteve C. Dental management of patients receiving anticoagulant and/or antiplatelet treatment. J Clin Exp Dent 2014; 6:e155-61. [PMID: 24790716 PMCID: PMC4002346 DOI: 10.4317/jced.51215] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 12/01/2013] [Indexed: 11/13/2022] Open
Abstract
Introduction: Adequate hemostasis is crucial for the success of invasive dental treatment, since bleeding problems can give rise to complications associated with important morbidity-mortality. The dental treatment of patients who tend to an increased risk of bleeding due to the use of anticoagulant and/or antiplatelet drugs raises a challenge in the daily practice of dental professionals. Adequate knowledge of the mechanisms underlying hemostasis, and the optimized management of such patients, are therefore very important issues.
Objectives: A study is made of the anticoagulant / antiplatelet drugs currently available on the market, with evaluation of the risks and benefits of suspending such drugs prior to invasive dental treatment. In addition, a review is made of the current management protocols used in these patients.
Material and Methods: A literature search was made in the PubMed, Cochrane Library and Scopus databases, covering all studies published in the last 5 years in English and Spanish. Studies conducted in humans and with scientific evidence levels 1 and 2 (metaanalyses, systematic reviews, randomized phase 1 and 2 trials, cohort studies and case-control studies) were considered. The keywords used for the search were: tooth extraction, oral surgery, hemostasis, platelet aggregation inhibitors, antiplatelet drugs, anticoagulants, warfarin, acenocoumarol.
Results and Conclusions: Many management protocols have been developed, though in all cases a full clinical history is required, together with complementary hemostatic tests to minimize any risks derived from dental treatment. Many authors consider that patient medication indicated for the treatment of background disease should not be altered or suspended unless so indicated by the prescribing physician. Local hemostatic measures have been shown to suffice for controlling possible bleeding problems resulting from dental treatment.
Key words:Tooth extraction, oral surgery, hemostasis, platelet aggregation inhibitors, antiplatelet drugs, anticoagulants, warfarin, acenocoumarol.
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Affiliation(s)
- Ana Mingarro-de-León
- Degree in Dental Surgery. Master in Oral Medicine and Surgery. Valencia University Medical and Dental School. Valencia, Spain
| | - Begonya Chaveli-López
- Degree in Dental Surgery. Master in Oral Medicine and Surgery. Valencia University Medical and Dental School. Valencia, Spain
| | - Carmen Gavaldá-Esteve
- Associate Professor of Oral Medicine. Valencia University Medical and Dental School. Valencia, Spain
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Abstract
When preparing for oral surgery, patients taking anticoagulants usually should not discontinue their medication because of the risk of a thromboembolic event. The therapeutic effect of many anticoagulants is not readily measured, so preoperatively, the surgeon cannot know the true risk for postoperative hemorrhage. The risk of a thromboembolic event usually outweighs the concerns of controlling postoperative hemorrhage. Hemophilia patients are also at risk for postoperative bleeding. Single extractions probably do not pose a serious risk for postoperative hemorrhage. However, when a mucogingival flap is raised in these patients, there may be prolonged bleeding. Surgical sponges saturated with aqueous tranexamic acid solution and compressed onto the bleeding site with biting pressure may stop bleeding. Bleeding was stopped in the case example presented here after three 10-minute compressions over 30 minutes in a patient taking aspirin and clopidogrel for a previous thromboembolic event and a metal coronary stent. The clot formed is very fragile and is prone to bleeding, so it should not be disturbed. This technique needs to be studied for efficacy.
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Cho YW, Kim E. Is stopping of anticoagulant therapy really required in a minor dental surgery? - How about in an endodontic microsurgery? Restor Dent Endod 2013; 38:113-8. [PMID: 24010076 PMCID: PMC3761118 DOI: 10.5395/rde.2013.38.3.113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/10/2013] [Accepted: 06/17/2013] [Indexed: 11/11/2022] Open
Abstract
Nowadays, oral anticoagulants are commonly prescribed to numerous patients for preventing cardiovascular accident such as thromboembolism. An important side effect of anticoagulant is anti-hemostasis. In a major surgery, the oral anticoagulant therapy (OAT) regimen must be changed before the surgery for proper post-operative bleeding control. However, in a minor dental surgery and endodontic surgery, the necessity for changing or discontinuing the OAT is open to debate. In this study, risks of the consequences were weighed and analyzed. In patients who stop the OAT, the occurrence of thromboembolic complication is rare but the result is fatal. In patients who continuing the OAT, post-operative bleeding can be controlled well with the local hemostatic measures. In the endodontic surgery, there are almost no studies about this issue. The intra-operative bleeding control is particularly important in the endodontic surgery because of its delicate and sensitive procedures such as inspection of resected root surface using dental microscope and retrograde filling. Further studies are necessary about this issue in the viewpoint of endodontic surgery.
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Affiliation(s)
- Yong-Wook Cho
- Department of Conservative Dentistry, Yonsei University College of Dentistry, Seoul, Korea
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