A prospective comparative study to assess the risk of postoperative bleeding after dental surgery while on medication with direct oral anticoagulants, antiplatelet agents, or vitamin K antagonists

Influence of antiplatelet medication and anticoagulation therapy after dental extractions on hospitalization: a retrospective 10-year study

BACKGROUND

The aim of this retrospective study was to identify high-risk dental extraction patients and the timing of postoperative hemorrhage to evaluate whether preventive hospitalization should be considered in patients on antiplatelet medication (AP) or anticoagulants.

METHODS

Our study included 1595 procedures; 1319 were conducted under monotherapy (Group I: AP; Group II: indirect oral anticoagulant [IAC]; Group III: direct oral anticoagulant [DOAC]) and 276 under dual therapy (Group IV: double AP; Group V: AP and IAC; Group VI: AP and DOAC). We evaluated the incidence, frequency and timing of hemorrhage, hospitalization rate, and treatment of bleeding incidents.

RESULTS

The incidence of hemorrhagic events was significantly higher in the dual therapy groups compared to the monotherapy groups (p < 0.001). Comparing the procedures under monotherapy, those on DOAC (Group III) had a significantly higher risk of postoperative bleeding than Groups I and II (p < 0.001) and a higher rate of repeated bleeding episodes (p = 0.035). Regarding bleeding incidents, 44% (dual therapy) vs. 51.1% (monotherapy) occurred on the day of surgery.

CONCLUSIONS

The bleeding risk after dental extractions is overall low and patients were often hospitalized preventively due to their comorbidities rather than actual bleeding risk. Patients should be instructed about local compression, and surgeries should be completed in the morning to avoid emergency visits. However, patients with cardiovascular diseases and dual therapy had a higher risk of postoperative hemorrhage. Thus, hospitalization is to be considered in these cases.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the Medical Faculty of RWTH Aachen (Decision Number 24-136). This was a retrospective clinical study designed to analyze postoperative bleeding and hospitalization rates after dental extractions in patients on AP or anticoagulation therapy.

Impacted third molar surgery in older patients-Is patient´s age really a risk factor for complications?

OBJECTIVES

The aim of this study was to analyze the influence of patients´ age on perioperative complications in impacted third molar surgery and how established risk factors are affected by age.

MATERIALS AND METHODS

The clinical findings, digital panoramic radiographs and perioperative data of 200 patients (554 impacted third molars) that had been subjected to tooth extraction, from July 2023 until July 2024, were analyzed. Perioperative complications (Inferior alveolar nerve (IAN) hypesthesia, oroantral communication (OAC), lingual nerve (LN) hypesthesia, postoperative bleeding, postoperative infection) as well as impaction patterns and risk factors (angulation type, bone coverage, depth- and risk scores) were analyzed by age (cut-off 30 years).

RESULTS

The population was divided into two groups by age (Group A =  ≥ 30 years (n = 52) vs. Group B =  < 30 years (n = 148)). Upper third molars showed significantly deeper bone coverage, higher depth scores, higher risk scores and different angulation types in patients aged < 30 years. Mandibular third molars showed significantly deeper bone coverage, higher depth scores, higher risk scores according and different angulation types in patients aged ≥ 30 years. However, IAN hypesthesia, LN hypesthesia, postoperative bleeding and postoperative infection did not show any significant differences regarding patients' age.

CONCLUSION

The current findings suggest that age (cut-off 30 years) does not statistically correlate with a higher risk for postoperative complications in impacted third molar surgery in contrast to recent publications.

CLINICAL RELEVANCE

In contrast to recent publications, the present study falsified a positive correlation between patients' age and the occurrence of postoperative complications in impacted third molar surgery. Therefore, other risk factors should be investigated in order to minimize these procedure specific complications.

Post-extraction bleeding in patients on direct oral anticoagulants

Objectives

This study aimed to evaluate the association between use of direct oral anticoagulants (DOACs) and post-extraction bleeding and to quantify bleeding risk in patients receiving DOACs.

Materials and Methods

The study included 293 patients who were taking DOACs and underwent tooth extraction (414 teeth). The patients were divided into those who had the extraction while taking DOACs and those who discontinued DOACs before the extraction. Bleeding complications were recorded and compared between the patient groups and types of DOACs.

Results

Of the 293 patients, 12 patients (6.9%) had post-extraction bleeding. Post-extraction bleeding occurred in 12 of the 414 tooth extraction sites. Among the 246 patients who underwent dental extraction while continuing DOAC therapy, 12 patients (8.5%) had post-extraction bleeding. Among the 47 patients who underwent dental extraction after discontinuing the administration of DOACs, none reported post-extraction bleeding. There was no significant difference in the number of patients with post-extraction bleeding between the two groups (P=0.122).

Conclusion

Continuing DOAC therapy during dental extraction does not increase post-extraction bleeding tendency. These results are consistent with those of previous studies.

Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures

In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.

Effect of direct oral anticoagulant dabigatran on early bone healing: An experimental study in rats

Background

Dabigatran belongs to the new generation of direct oral anticoagulants (DOACs). Its advantages are oral administration and no need for international normalized ratio (INR) monitoring. Although its use has increased, its potential side effects on bone healing and remodeling have not been fully investigated. The present study aimed to evaluate the possible effects of dabigatran on early bone healing.

Methods

Sixteen male Wistar rats were divided into two groups; in group A, 20-mg/kg dabigatran dose was administered orally daily for 15 days, while group B served as a control. Two circular bone defects (d=6 mm) were created on either side of the parietal bones. Two weeks after surgery and euthanasia of the animals, tissue samples (parietal bones that contained the defects) were harvested for histological and histomorphometric analysis. Statistical analysis was performed with a significance level of α=0.5.

Results

No statistically significant differences were found between the two groups regarding the regenerated bone (21.9% vs. 16.3%, P=0.172) or the percentage of bone bridging (63.3% vs. 53.5%, P=0.401).

Conclusion

Dabigatran did not affect bone regeneration, suggesting that it might be a safer drug compared to older anticoagulants known to lead to bone healing delay.

Bleeding Disorders and Dental Implants: Review and Clinical Indications

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Association of vitamin K, fibre intake and progression of periodontal attachment loss in American adults

BACKGROUND

Periodontitis-related attachment loss is accompanied by mucosal bleeding and inflammatory lesions. Dietary vitamin K and fibre intake are known to be correlation factors of haemostasis and anti-inflammation, respectively.

OBJECTIVE

To explore the association between severe periodontal attachment loss and vitamin K or fibre intake in American adults.

METHODS

A cross-sectional analysis was conducted including 2747 males and 2218 females in the National Health and Nutrition Examination Surveys (NHANES) from 2009 to 2014. The number of teeth with severe periodontal attachment loss (above 5 mm attachment loss) was used as the dependent variable. The main independent variables included the intake of vitamin K and dietary fibre. The association among variables was examined using multivariable linear regression models, hierarchical regression, fitted smoothing curves, and generalized additive models.

RESULTS

Based on the indicators of 4965 subjects, we found that severe attachment loss tended to occur in elderly individuals or males and was accompanied by less intake of vitamin K or dietary fibre, as well as lower educational qualification. Vitamin K intake was stably negatively associated with attachment loss progression in each multivariable linear regression model. In subgroup analyses, a negative association between fibre intake and attachment loss progression was identified in all races except blacks (β = 0.0005, 95% CI: -0.0005 to 0.0016). The relationship between fibre intake and attachment loss progression was a broad U-shaped curve (inflection point: 753.4 mg), which especially manifested in males (inflection point: 967.5 mg).

CONCLUSION

There was an inverse association between vitamin K intake and the progression of periodontal attachment loss in American adults, while dietary fibre should be moderate in intake (below 753.4 mg), especially in males (below 967.5 mg).

Dental Management Considerations for Patients with Cardiovascular Disease-A Narrative Review

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.