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Kwon S, Lee SR, Choi EK, Lee KY, Choi J, Ahn HJ, Oh S, Lip GYH. Perioperative Management in Patients with Atrial Fibrillation Treated with Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Minor Bleeding Risk Procedure: Rationale and Protocol for the PERIXa Study. Vasc Health Risk Manag 2024; 20:231-244. [PMID: 38774425 PMCID: PMC11107937 DOI: 10.2147/vhrm.s455530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/20/2024] [Indexed: 05/24/2024] Open
Abstract
Background While treatment interruption of non-vitamin K antagonist oral anticoagulants (NOACs) for elective surgery or procedures among patients with atrial fibrillation (AF) is becoming more prevalent, there remains insufficient evidence regarding the optimal perioperative management of NOACs, particularly procedures with minor bleeding risks. Objective This study aims to evaluate the safety and effectiveness of a simplified, standardized protocol for perioperative management of direct factor Xa inhibitors in patients, with AF undergoing procedures associated with minor bleeding risk. Methods This multicenter, prospective single-arm registry study plans to enroll patients undergoing procedures with minor bleeding risk who were prescribed direct factor Xa inhibitors for AF. The procedures with minor bleeding risk will include gastrointestinal endoscopy for diagnostic purposes, selected dental procedures, and ocular surgery for cataracts or glaucoma. For apixaban, patients will withhold the last evening dose and resume either from the evening dose of the procedure day or the following morning, depending on the bleeding risk of the patient. For edoxaban or rivaroxaban, patients will withhold only a single dose on the procedure day. The primary outcome is the occurrence of major bleeding events within 30 days. Secondary outcomes include systemic thromboembolism, all-cause mortality, and a composite of major and clinically relevant non-major bleeding events. Conclusion This study has the potential to generate evidence regarding the safety of perioperative management for patients, with AF undergoing procedures associated with minor bleeding risk. Trial Registration Clinicaltrials.gov: NCT05801068.
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Affiliation(s)
- Soonil Kwon
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Yeon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - JungMin Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Yoke Hong Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Chest & Heart Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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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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Valenzuela-Mencia J, Serrera-Figallo MÁ, Torres-Lagares D, Machuca-Portillo G, Sánchez-Fernández E, Valmaseda-Castellón E, Peñarrocha-Diago M, Fernández-Mosteirín N, Somoza-Martin JM, Pérez-Jardón A, Chamorro-Petronacci CM, García-García A. Clinical practice guideline of the spanish society of oral surgery for oral surgery in patients with coagulation disorders. Med Oral Patol Oral Cir Bucal 2024; 29:e58-e66. [PMID: 37330959 PMCID: PMC10765342 DOI: 10.4317/medoral.26063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND The number of patients treated with coagulation disorders, and more specifically with anticoagulant therapy, has increased worldwide in recent years due to increased life expectancy in developed countries. The protocols for managing this type of patient in oral surgery has varied over recent years, especially after the appearance of new direct-acting oral anticoagulants (DOACs). The assessment of risk of bleeding in this type of patient when undergoing a surgical procedure continues to be a controversial issue for patients, dentists and general practitioners. The objective of this document is to offer recommendations, based on evidence, for decision making for patients with coagulopathies who require dental surgical intervention. MATERIAL AND METHODS Based on the indications of the "Preparation of Clinical Practice guidelines in the National Health System. Methodological manual", we gathered a group of experts who agreed on 15 PICO questions based on managing patients with coagulation disorders in dental surgical procedures, such as fitting of implants or dental extractions. RESULTS The 15 PICO questions were answered based on the available evidence, being limited in most cases due to the lack of a control group. Two of the PICO questions were answered by the experts with a grade C recommendation, while the rest were answered with grade D. CONCLUSIONS The results of this review highlight the need to undertake well designed clinical trials with control groups and with a representative sample size.
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Sandhu P, Mayor S, Sproat C, Kwok J, Beneng K, Patel V. The continuation of oral anticoagulation and antiplatelet therapy for dento-alveolar surgery: a service evaluation. Br Dent J 2023; 235:313-318. [PMID: 37684457 DOI: 10.1038/s41415-023-6227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/10/2023] [Indexed: 09/10/2023]
Abstract
Background Patients taking oral anticoagulants (OACs) and oral antiplatelets (OAPs) have a risk of post-operative bleeding when dental extractions are required. Guidance exists to assist dental practitioners on how best to clinically manage these patients, but this is based upon low-quality evidence. The current service evaluation provides real world clinical data when these drugs are not discontinued for oral surgery procedures.Materials and methods All OACs and OAPs were continued and patients requiring dental extractions had local haemostatic measures (local anaesthesia with adrenaline, socket packing with haemostat and resorbable sutures). All patients were offered a follow-up via a telephone clinic service after surgery to assess any post-operative bleeding.Results A total of 439 patients underwent 513 surgical episodes, equating to 1,001 dental extractions. Overall, 412 (95.9%) patients reported no post-operative bleeding complications. A total of 18 (4.1%) patients reported post-operative bleeding requiring further intervention. All but two patients were managed with local haemostatic measures, and no patient required hospital admission. For the single novel OAC cohort of patients, 8/185 (4.3%) procedures had post-operative bleeding.Conclusion This current service evaluation highlights that the risk of significant or life-threatening bleeding following dental extraction when OACs or OAPs are continued remains rare.
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Affiliation(s)
- Pradeep Sandhu
- Speciality Registrar, Oral Surgery, Oral and Maxillofacial Surgery Department, Salisbury District Hospital, United Kingdom
| | - Serena Mayor
- Speciality Dentist, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Christopher Sproat
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Jerry Kwok
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Kiran Beneng
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom
| | - Vinod Patel
- Consultant, Oral Surgery, Oral Surgery Department, Guy´s and St Thomas´ Hospital, United Kingdom.
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Boccatonda A, Frisone A, Lorusso F, Bugea C, Di Carmine M, Schiavone C, Cocco G, D’Ardes D, Scarano A, Guagnano MT. Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5293. [PMID: 37047909 PMCID: PMC10093975 DOI: 10.3390/ijerph20075293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The surgical dental treatment of subjects admitted for anticoagulants therapy represents a consistent risk for peri-operative bleeding. The aim of the present study was to investigate the clinical findings of dental surgery operative management of the patients under anticoagulants drugs protocol. METHODS The literature screening was performed using Pubmed/Medline, EMBASE and Cochrane library, considering only randomized clinical trials (RCTs) papers. No limitations about the publication's period, follow-up time or clinical parameters were considered. RESULTS A total of eight RCTs were included for the qualitative synthesis. No thromboembolic complications were reported in any studies. Several bleeding episodes associated with anticoagulant drugs in dental surgery were mild and generally happened on the first day after the treatment. CONCLUSIONS The use of local haemostatic measures is generally effective for bleeding control with no further pharmacological drug management or suspension.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, 40010 Bentivoglio, Italy
| | - Alessio Frisone
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Felice Lorusso
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Calogero Bugea
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Maristella Di Carmine
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
| | - Cosima Schiavone
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Giulio Cocco
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Damiano D’Ardes
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Antonio Scarano
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100 Chieti, Italy
- Department of Oral Implantology, Dental Research Division, College Ingà, UNINGÁ, Cachoeiro de Itapemirim 29312, ES, Brazil
| | - Maria Teresa Guagnano
- Department of Medicine and Science of Aging, “G. d’Annunzio” University, 66100 Chieti, Italy
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Johansson K, Götrick B, Holst J, Tranæus S, Naimi-Akbar A. Impact of direct oral anticoagulants on bleeding tendency and postoperative complications in oral surgery: a systematic review of controlled studies. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 135:333-346. [PMID: 36100547 DOI: 10.1016/j.oooo.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The recommendations for the management of direct oral anticoagulants (DOACs) in oral surgery are inconsistent. The present review evaluated whether DOACs increase the risk of bleeding during oral surgery and postoperative complications. STUDY DESIGN The patients undergoing oral surgery and receiving a DOAC were compared with the patients receiving a DOAC different from the exposure, a vitamin K antagonist (VKA), or no anticoagulant. Three electronic databases were searched for eligible clinical trials and systematic reviews. The risk of bias was assessed, data were extracted, a meta-analysis was done, and the Grading of Recommendations, Assessment, Development and Evaluations certainty-of-evidence ratings were determined. RESULTS Three clinical trials comparing patients receiving DOAC medication with patients on a VKA were eligible. A meta-analysis of bleeding 7 days postoperatively detected no significant differences between patients continuing DOAC or VKA medication during and after surgery. All of the point estimates favored uninterrupted DOAC over VKA therapy. Tranexamic acid was topically administered to some patients. CONCLUSIONS Based on an interpreted trend among 3 studies with mixed patient populations, the risk of bleeding during the first 7 postoperative days may be lower for patients on uninterrupted DOAC than VKA therapy (⨁⨁⭘⭘), but the effect size of the risk is unclear. 80 of 274 included patients experienced postoperative bleeding.
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Affiliation(s)
- Krister Johansson
- Department of Oral and Maxillofacial Surgery and Oral Medicine, Faculty of Odontology, Malmö University, Malmö, Sweden.
| | - Bengt Götrick
- Department of Oral Diagnostics, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Jan Holst
- Department of Vascular Diseases and HTA Syd, Skåne University Hospital, Malmö/Lund, Sweden
| | - Sofia Tranæus
- Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö, Sweden
| | - Aron Naimi-Akbar
- Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö, Sweden
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Statman BJ. Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2. Anesth Prog 2023; 70:37-48. [PMID: 36995961 PMCID: PMC10069535 DOI: 10.2344/anpr-70-01-06] [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: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/31/2023] Open
Abstract
Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
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8
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van Erk M, Lomme RMLM, Roozen EA, van Oirschot BAJA, van Goor H. A novel ex vivo perfusion-based mandibular pig model for dental product testing and training. BMC Oral Health 2023; 23:122. [PMID: 36823579 PMCID: PMC9948382 DOI: 10.1186/s12903-023-02794-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND A translational ex vivo perfusion-based mandibular pig model was developed as an alternative to animal experiments, for initial assessment of biomaterials in dental and maxillofacial surgery and training. This study aimed to assess the face and content validity of the novel perfusion-based model. METHODS Cadaveric porcine heads were connected to an organ assist perfusion device for blood circulation and tissue oxygenation. Dental professionals and dental trainees performed a surgical procedure on the mandibula resembling a submandibular extraoral incision to create bone defects. The bone defects were filled and covered with a commercial barrier membrane. All participants completed a questionnaire using a 5-point Likert scale to assess the face and content validity of the model. Validation data between the two groups of participants were compared with Mann-Whitney U test. RESULTS Ten dental professionals and seven trainees evaluated the model for face and content validity. Participants reported model realism, with a mean face validity score of 3.9 ± 1.0 and a content validity of 4.1 ± 0.8. No significant differences were found for overall face and content validity between experts and trainees. CONCLUSION We established face and content validity in a novel perfusion-based mandibular surgery model. This model can be used as an alternative for animal studies evaluating new biomaterials and related dental and maxillofacial surgical procedural training.
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Affiliation(s)
- Machteld van Erk
- Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Roger M. L. M. Lomme
- grid.10417.330000 0004 0444 9382Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Edwin A. Roozen
- grid.10417.330000 0004 0444 9382Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Bart A. J. A. van Oirschot
- grid.10417.330000 0004 0444 9382Department of Dentistry – Regenerative Biomaterials, Radboud University Medical Centre, Philips van Leydenlaan 25, 6525 EX Nijmegen, The Netherlands
| | - Harry van Goor
- grid.10417.330000 0004 0444 9382Department of Surgery (Route 618), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Zaib A, Shaheryar M, Shakil M, Sarfraz A, Sarfraz Z, Cherrez-Ojeda I. Local Tranexamic Acid for Preventing Hemorrhage in Anticoagulated Patients Undergoing Dental and Minor Oral Procedures: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10122523. [PMID: 36554047 PMCID: PMC9778130 DOI: 10.3390/healthcare10122523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Dental procedures have posed challenges in managing anticoagulated patients due to early reports of oral hemorrhage. This study aims to evaluate the risks of postoperative bleeding with the local application of tranexamic acid. A systematic search was conducted until 31 March 2022, with keywords including tranexamic acid, oral hemorrhage, dental, and/or coagulation. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane Library. Statistical analysis was conducted using Review Manager 5.4. In total, 430 patients were pooled in with the local application of tranexamic acid using mouthwash, irrigation, and compression with a gauze/gauze pad. The mean age was 61.8 years in the intervention group and 58.7 in the control group. Only 4 patients in the intervened group out of the 210 discontinued the trial due to non-drug-related adverse events. The risk difference was computed as -0.07 (p = 0.05), meaning that patients administered with local antifibrinolytic therapy for postoperative bleeding reduction for dental procedures were at a 7% less risk of oral bleeding. Current evidence on managing anticoagulated patients undergoing dental or oral procedures remains unclear. The present study presents favorable outcomes of postoperative bleeding with local tranexamic acid used in the postoperative period.
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Affiliation(s)
- Asma Zaib
- Department of Research, University Medical & Dental College Faisalabad, Faisalabad 38800, Pakistan
| | - Muhammad Shaheryar
- Department of Research, Rawal Institute of Health Sciences, Islamabad 45550, Pakistan
| | - Muhammad Shakil
- Department of Research, Frontier Medical & Dental College, Abbottabad 22030, Pakistan
| | - Azza Sarfraz
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi 74800, Pakistan
- Correspondence: (A.S.); (I.C.-O.)
| | - Zouina Sarfraz
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore 54000, Pakistan
| | - Ivan Cherrez-Ojeda
- Department of Allergy and Pulmonology, Universidad Espíritu Santo, Samborondón 092301, Ecuador
- Correspondence: (A.S.); (I.C.-O.)
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Gupta K, Kumar S, Anand Kukkamalla M, Taneja V, Syed GA, Pullishery F, Zarbah MA, Alqahtani SM, Alobaoid MA, Chaturvedi S. Dental Management Considerations for Patients with Cardiovascular Disease-A Narrative Review. Rev Cardiovasc Med 2022; 23:261. [PMID: 39076626 PMCID: PMC11266964 DOI: 10.31083/j.rcm2308261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 07/31/2024] Open
Abstract
Dental therapists encounter patients with various systemic diseases of which cardiovascular disease (CVD) patients form a significant segment. Relation between oral health and cardiac diseases has been well established. Common cardiac disorders encountered in a dental practice include arterial hypertension, heart failure, ischemic heart disease, cardiac arrhythmias, infective endocarditis, stroke, and cardiac pacemaker. Patients with CVDs pose a significant challenge to dental therapy. These patients need special considerations and an adequate understanding of the underlying cardiovascular condition to provide safe and effective dental treatment. Based on the cardiac condition, an appropriate modification in dental care is crucial. A multidisciplinary approach including the patient's cardiologist can potentially reduce complications and improve dental treatment results. This review aims at unfolding the risks associated with the dental management of a cardiac patient and outlines the measures to be undertaken for optimum dental treatment.
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Affiliation(s)
- Kanishk Gupta
- Department of Periodontology, Dentistry Program, Batterjee Medical College, 21442 Jeddah, Saudi Arabia
| | - Santhosh Kumar
- Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, 576104 Manipal, Karnataka, India
| | - Meena Anand Kukkamalla
- Department of Periodontology, Faculty of Dentistry, Manipal University College Malaysia (MUCM), 75150 Melaka, Malaysia
| | - Vani Taneja
- Department of Pediatric Dentistry, Dentistry Program, Batterjee Medical College, 21442 Jeddah, Saudi Arabia
| | - Gufaran Ali Syed
- Department of Endodontics, Dentistry Program, Batterjee Medical College, 21442 Jeddah, Saudi Arabia
| | - Fawaz Pullishery
- Division of Dental Public Health, Dentistry Program, Batterjee Medical College, 21442 Jeddah, Saudi Arabia
| | - Mohammad A Zarbah
- Department of Prosthetic Dental Science, College of Dentistry, King Khalid University, 62529 Abha, Saudi Arabia
| | - Saeed M. Alqahtani
- Department of Prosthetic Dentistry, College of Dentistry, King Khalid University, 62529 Abha, Saudi Arabia
| | - Mohammed A. Alobaoid
- Department of Restorative Dental Sciences and Department of Dental Education, King Khalid University College of Dentistry, 61471 Abha, Saudi Arabia
| | - Saurabh Chaturvedi
- Department of Prosthetic Dental Science, College of Dentistry, King Khalid University, 62529 Abha, Saudi Arabia
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11
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Römer P, Heimes D, Pabst A, Becker P, Thiem DGE, Kämmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. Int J Implant Dent 2022; 8:20. [PMID: 35429255 PMCID: PMC9013394 DOI: 10.1186/s40729-022-00418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 01/08/2023] Open
Abstract
Purpose Considering a high prevalence of congenital and especially acquired bleeding disorders, their heterogeneity and the multitude of possible treatments strategies, a review of the scientific data on this topic is needed to implement a treatment guide for healthcare professionals.
Methods A selective literature review was performed via PubMed for articles describing oral surgery / dental implant procedures in patients with congenital and acquired bleeding disorders. Out of the existing literature, potential treatment algorithms were extrapolated. Results In order to assess the susceptibility to bleeding, risk stratification can be used for both congenital and acquired coagulation disorders. This risk stratification, together with an appropriate therapeutic pathway, allows for an adequate and individualized therapy for each patient. A central point is the close interdisciplinary cooperation with specialists. In addition to the discontinuation or replacement of existing treatment modalities, local hemostyptic measures are of primary importance. If local measures are not sufficient, systemically administered substances such as desmopressin and blood products have to be used. Conclusions Despite the limited evidence, a treatment guide could be developed by means of this narrative review to improve safety for patients and practitioners. Prospective randomized controlled trials are needed to allow the implementation of official evidence-based guidelines.
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Manfredini M, Poli PP, Creminelli L, Porro A, Maiorana C, Beretta M. Comparative Risk of Bleeding of Anticoagulant Therapy with Vitamin K Antagonists (VKAs) and with Non-Vitamin K Antagonists in Patients Undergoing Dental Surgery. J Clin Med 2021; 10:5526. [PMID: 34884228 PMCID: PMC8658703 DOI: 10.3390/jcm10235526] [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: 10/24/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A wide variety of approaches have been proposed to manage anticoagulant drugs in patients undergoing dental surgery; vitamin K antagonists and novel direct oral anticoagulants have been used. The present study aims to explore the existing evidence concerning the management of patients in anticoagulant therapy undergoing oral surgery procedures and to give suggestions related to peri- and post-operative measures. MATERIALS AND METHODS A comprehensive search of databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The present scoping review was realized in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The publications varied from randomized controlled trials (RCT) to cohort trials. Only articles written in English language and published between 2000 to 2020 were screened. The studies were included if discussing the management of a patient in anticoagulant therapy (warfarin or direct oral anticoagulants) scheduled for tooth extraction. RESULTS 33 studies were selected and included in the qualitative review. Nineteen considered anticoagulant therapy with warfarin, six considered anticoagulant therapy with new oral anticoagulants and eight compared patients taking warfarin with patients taking direct oral anticoagulants. CONCLUSIONS No case of extractive surgery should alter the posology of the drug: thromboembolic risks derived from discontinuation are heavier than hemorrhagic risks. CLINICAL RELEVANCE direct oral anticoagulants are safer in terms of bleeding and manageability and bleeding episodes are manageable with local hemostatic measures.
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Affiliation(s)
| | | | | | - Alberto Porro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Implant Center for Edentulism and Jawbone Atrophies, Maxillofacial Surgery and Odontostomatology Unit, University of Milan, Via della Commenda 10, 20122 Milan, Italy; (M.M.); (P.P.P.); (L.C.); (C.M.); (M.B.)
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Foo M, See L, Lee J, Feng B, Kruger E. Current practices of Western Australian general dentists regarding management of patients on anticoagulant/antiplatelet therapy. Aust Dent J 2021; 66:385-390. [PMID: 34143428 DOI: 10.1111/adj.12863] [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: 05/13/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Currently, there are little to no published studies outlining general dentists' knowledge in the management of patients on anticoagulant/antiplatelet therapies in Australia. The aim of this study was to investigate the current practices of Western Australian (WA) general dentists with regards to dental management of patients taking anticoagulants/antiplatelets. MATERIALS AND METHODS WA dentists were invited to undertake a survey to investigate their knowledge on the management of patients taking anticoagulant/antiplatelet. The questionnaire provided to WA general dentists consisted of pre-extraction advice on patients (direct oral anticoagulants [DOACs], antiplatelets, warfarin, dual antiplatelets and antiplatelet/anticoagulant). Results were analysed using descriptive statistics as well as chi-square tests. RESULTS Of the 89 participants, 40.5% had <5 years of general dental experience. Most WA general dentists (64%-71%) responded with 'no change' when performing extractions on patients on DOACs, antiplatelet therapy, warfarin, dual antiplatelets and antiplatelets/anticoagulants (P = 0.00). Furthermore, dentists with 6-10 years of experience were more likely to cease antiplatelet for 24 h before extractions (P < 0.05). Dentists who extracted 10-30 teeth per month were likely to stop antiplatelets and DOACs for more than 48 h compared to other groups (P < 0.05). CONCLUSION Most WA dentists would not cease anticoagulant/antiplatelet therapy when undergoing dental extractions.
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Affiliation(s)
- M Foo
- UWA Dental School, The University of Western Australia, Nedlands, Western Australia, Australia
| | - L See
- UWA Dental School, The University of Western Australia, Nedlands, Western Australia, Australia
| | - J Lee
- International Research Collaborative - Oral Health and Equity, The University of Western Australia, Crawley, Western Australia, Australia
| | - B Feng
- International Research Collaborative - Oral Health and Equity, The University of Western Australia, Crawley, Western Australia, Australia
| | - E Kruger
- International Research Collaborative - Oral Health and Equity, The University of Western Australia, Crawley, Western Australia, Australia
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14
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Lin S, Hoffman R, Nabriski O, Moreinos D, Dummer PMH. Management of patients receiving novel antithrombotic treatment in endodontic practice: Review and clinical recommendations. Int Endod J 2021; 54:1754-1768. [PMID: 33894015 DOI: 10.1111/iej.13533] [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: 03/13/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Cardiovascular diseases are a major component of non-communicable diseases and death, with thrombosis constituting the most common underlying pathosis of the three major cardiovascular disorders: ischaemic heart disease (acute coronary syndrome), stroke and venous thromboembolism (VTE). The introduction of direct oral anticoagulants (DOACs) in recent years has necessitated a more complex approach to periprocedural and perioperative anticoagulation management and the need for revised management strategies and protocols. Currently, patients taking classic oral anticoagulants are advised to stop taking the drugs and have their INR values checked 72 h prior to dental surgery (e.g., apical surgery, tooth extraction, and periodontal surgery) and checked again 24 h prior to the procedure to ensure it is within the therapeutic range. However, the current incorporation of these novel DOACs in routine medical practice requires changes in the way patients are managed preoperatively in dentistry, and specifically in endodontic surgery. The methodology applied in this review included searching for relevant articles in the PubMed database using keywords listed in the Entree Terms databases. Articles published on human blood clotting mechanism, antithrombotic drugs, as well as treatment guidelines and recommendations for dentistry were retrieved. In addition, textbooks and guidelines that may not have surfaced in the online search were searched manually. The aim of this paper was to review the mechanisms of action of classic and novel antithrombotic medications and their impact on endodontic treatment and the management of local haemostasis in endodontics.
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Affiliation(s)
- Shaul Lin
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,The Israeli National Center for Trauma & Emergency Medicine Research, Gertner Institute, Tel Hashomer, Israel
| | - Ron Hoffman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Omri Nabriski
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel
| | - Daniel Moreinos
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Paul M H Dummer
- School of Dentistry, College of Biomedical Sciences and Life Sciences, Cardiff University, Cardiff, UK
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Vandeput AS, Brijs K, De Kock L, Janssens E, Peeters H, Verhamme P, Politis C. Maxillofacial and oral surgery in patients with thrombophilia: safe territory for the oral surgeon? A single-center retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:514-522. [PMID: 34030997 DOI: 10.1016/j.oooo.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/25/2021] [Accepted: 03/02/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to analyze patients with thrombophilia who underwent oral and/or maxillofacial surgery at our center. STUDY DESIGN We performed a retrospective analysis of patients with hereditary or acquired thrombophilia who had undergone oral/maxillofacial surgery between January 1, 2000 and December 31, 2019. Data regarding demographic and patient characteristics, surgical treatment modalities, antithrombotic therapies, and complications were analyzed. RESULTS A total of 76 eligible patients (26 male, 50 female) were included in this study, with a mean follow-up period of 3.8 months (range, 0-51 months). The mean age at time of surgery was 44.7 ± 19.4 years. Seven different hereditary and acquired thrombophilia were identified: factor V Leiden (n = 31; 40.8%), prothrombin G20210A mutation (n = 5; 6.6%), protein C deficiency (n = 4; 5.3%), protein S deficiency (n = 11; 14.5%), antiphospholipid syndrome (n = 10; 13.2%), hyperhomocysteinemia (n = 8; 10.5%), and elevated factor VIII (n = 2; 2.6%). Complications occurred in 9 patients (11.8%) and included postoperative infections (n = 6; 7.9%) and postoperative bleeding (n = 3; 3.9%). CONCLUSION Our data suggest that oral and/or maxillofacial surgery in patients with a confirmed diagnosis of thrombophilia is not associated with a burden of thrombosis or high complication rates. Furthermore, we formulated a guideline for preoperative antithrombotic therapy for patients with thrombophilia undergoing oral and/or maxillofacial surgery.
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Affiliation(s)
- An-Sofie Vandeput
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Katrien Brijs
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lisa De Kock
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Elien Janssens
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Hilde Peeters
- Centre for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Vascular Medicine and Haemostasis, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
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Lee JS, Kim MK, Kang SH. Effect of warfarin discontinuation on the incidence of postoperative bleeding in tooth extraction. J Korean Assoc Oral Maxillofac Surg 2020; 46:228-234. [PMID: 32855369 PMCID: PMC7469966 DOI: 10.5125/jkaoms.2020.46.4.228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 12/03/2022] Open
Abstract
Objectives The number of patients undergoing oral anticoagulant therapy for cardiovascular and cerebrovascular disease is increasing. However, the risk of bleeding after tooth extraction in patients receiving warfarin is unclear. Here, we assess the risk of bleeding after tooth extraction in patients on warfarin. Materials and Methods The study included 260 patients taking warfarin who underwent tooth extraction (694 teeth). The patients were divided into those whose teeth were extracted while they were taking warfarin, those who discontinued warfarin before extraction, and those who underwent extraction while receiving heparin bridging therapy. Bleeding complications in the two groups were compared. Results Of the 260 patients, 156 underwent extraction while taking warfarin, 70 stopped taking warfarin before extractions, and 34 received heparin bridging therapy and stopped taking either medication before extractions. Bleeding complications occurred in 9 patients (3.5%) and 9 tooth sites (1.3%). Among the 9 patients with bleeding complications, 6 underwent extraction while taking warfarin, 2 stopped warfarin before extraction, and 1 underwent extraction after receiving heparin bridging therapy. No significant difference was seen between patient groups regarding bleeding after extractions (P=0.917). Conclusion Warfarin use does not increase the risk of post-extraction bleeding and can therefore be continued during tooth extraction.
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Affiliation(s)
- Jung-Soo Lee
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Moon-Key Kim
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang-Hoon Kang
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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