Dental management of patients receiving anticoagulation or antiplatelet treatment

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

Bleeding After Dental Extraction in Patients Undergoing Percutaneous Coronary Intervention During Uninterrupted Single and Dual Antiplatelet Therapy

Purpose

This study aimed to assess bleeding risk after exodontia in patients with recent percutaneous coronary intervention during uninterrupted single or dual antiplatelet therapy.

Study design

A total of 100 patients who had a history of percutaneous stent insertion during the past year candidate for extraction of teeth were included in the study. Fifty patients took aspirin 100mg (monotherapy group), and 50 patients took a combination of aspirin 100mg and clopidogrel 75mg (dual therapy group). After exodontia, the bleeding status was categorized as "complete hemostasis," "persistent bleeding," and "delayed bleeding." Personal data, underlying diseases, number of teeth and roots extracted, and type of procedure required for exodontia were statistically analyzed.

Results

No significant difference was observed in the status of bleeding between the two groups regarding sex, age, underlying diseases, number of teeth and roots extracted, and type of procedure (p > 0.05). 39/50 (78%) of monotherapy patients and 32/50 (64%) of dual therapy patients achieved complete hemostasis. Persistent bleeding was noted in 11/50 (22%) of monotherapy participants, and 14/50 (28%) of dual therapy patients. Only 4/50 (8%) of dual therapy patients experienced delayed bleeding. However, these differences were not significant (p = 0.08). All persistent and delayed bleeding was easily controlled via local measures.

Conclusion

Simple or complicated extraction of multiple teeth can be performed safely during the first year after percutaneous coronary intervention without interruption of antiplatelet therapy.

Suppression of subgingival bacteria by antimicrobial photodynamic therapy using transgingival irradiation: A randomized clinical trial

BACKGROUND

Antimicrobial photodynamic therapy (aPDT) is an effective method for eradicating bacteria in periodontal therapy. Standard aPDT requires the insertion of a laser tip into a periodontal pocket, in which the direction of irradiation is limited. Therefore, we devised an aPDT method that uses a transgingival near-infrared wavelength and indocyanine green-encapsulated and chitosan-coated nanoparticles as a photosensitizer.

METHODS

Forty patients undergoing supportive periodontal therapy, who had a single root tooth with a pocket of 5 mm or deeper, were used as subjects. In the test group, aPDT was performed by laser irradiation from outside the gingiva using photosensitizer nanoparticles. In the control group, pseudo aPDT without photosensitizer was performed by transgingival irradiation. Subgingival plaque was sampled from inside the pocket before, immediately after, and 1 week after treatment, and evaluated by colony counting and real-time polymerase chain reaction.

RESULTS

There were no significant differences in age, sex, periodontal pocket depth, and bleeding on probing between the test and control groups. Compared with the colony count before treatment, the count in the test group was significantly reduced immediately after treatment. The number of patients with colony reduction to ≤50% and ≤10% was significantly higher in the test group than in the control group. None of the participants reported pain, although one participant reported discomfort.

CONCLUSION

As a bacterial control method for residual pockets in patients undergoing supportive periodontal therapy, transgingival aPDT is a promising treatment strategy that is not generally accompanied by pain or discomfort.

Knowledge and Practice of Dentists Managing Patients on Antithrombotic Medications: A Cross-Sectional Survey

OBJECTIVES

 In this article, we explored the level of knowledge and practice of licensed dentists in the United Arab Emirates regarding managing patients on antithrombotic medications. Moreover, to assess the need for educational intervention in this area is one of the objectives.

MATERIALS AND METHODS

 A total of 502 dentists answered 22 close-ended questionnaires. The sample size was determined based on the registry of the Ministry of Health.

RESULTS

 Only 5.6 and 5.9% showed satisfactory overall awareness about aspirin and plavix, respectively, as drugs may hamper hemostasis. A substantial proportion of dentists consider aspirin (63.1%) and clopidogrel (52.2%) discontinuation before treatment. More than one-third of the participants shall not consider extracting teeth before physician approval, and one-quarter to one-third of them refer patients on such medications to oral surgeons to perform tooth extraction. Most respondents did not adequately answer the questions about the additional hemostatic measures and postoperative analgesia. A significantly high number of participants (n = 440, 87.6%) want to attend updated courses on the dental management of such patients.

CONCLUSIONS

 The dentists demonstrate a contrasting diversity of knowledge and practice approaches to patient management on antiplatelet agents. There is an apparent demand to raise understanding of the evidence-based management of a patient on such medications. It is vital to keep formalized training sessions and provide the necessary expertise to students and dentists to prevent unwanted complications.

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

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

When do we need more than local compression to control intraoral haemorrhage?

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.

Management of anticoagulated patients in dentoalveolar surgery: a clinical comparative study

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.

Advances in Antiplatelet Therapy for Dentofacial Surgery Patients: Focus on Past and Present Strategies

BACKGROUND

Nowadays, patients involved in antiplatelet therapy required special attention during oral surgery procedures, due to the antiplatelet drugs assumption. The motivations of the assumption may be different and related to the patient's different systemic condition. For this reason, accordingly to the current international guidelines, different protocols can be followed. The aim of this work is to analyze how the dentist's approach to these patients has changed from the past to the present, evaluating the risk exposure for the patients.

METHODS

This review paper considered different published papers in literature through quoted scientific channels, going in search of "ancient" works in such a way as to highlight the differences in the protocols undertaken. The analyzed manuscripts are in the English language, taking into consideration reviews, case reports, and case series in such a way as to extrapolate a sufficient amount of data and for evaluating the past therapeutic approaches compared to those of today.

RESULTS

Colleagues in the past preferred to subject patients to substitution therapy with low molecular weight anticoagulants, by suspending antiplatelet agents to treatment patients, often for an arbitrary number of days. The new guidelines clarify everything, without highlighting an increased risk of bleeding during simple oral surgery in patients undergoing antiplatelet therapy.

CONCLUSION

Either patients take these medications for different reasons, because of cardiovascular pathologies, recent cardiovascular events, or even for simple prevention, although the latest research shows that there is no decrease of cardiovascular accidents in patients who carry out preventive therapy. Surely, it will be at the expense of the doctor to assess the patient's situation and risk according to the guidelines. For simple oral surgery, it is not necessary to stop therapy with antiplatelet agents because the risk of bleeding has not increased, and is localized to a post-extraction alveolus or to an implant preparation, compared to patients who do not carry out this therapy. From an analysis of the results it emerges that the substitutive therapy should no longer be performed and that it is possible to perform oral surgery safely in patients who take antiplatelet drugs, after a thorough medical history. Furthermore, by suspending therapy, we expose our patients to more serious risks, concerning their main pathology, where present.

Antiplatelet therapy in patients undergoing oral surgery: A systematic review and meta-analysis

Background

The number of patients under antiplatelet therapy (APT) continues to raise as current recommendations foster this practice. Although some recommendations to manage this treatment during oral surgery procedures exist, these have methodological shortcomings that preclude them from being conclusive.

Material and Methods

A systematic review and meta-analysis of the best current evidence was carried out; The Cochrane Library, EMBASE and MEDLINE databases were searched for Randomized Controlled Trials (RCT) concerning patients undergoing oral surgery with APT, other relevant sources were searched manually.

Results

5 RCTs met the Inclusion criteria. No clear tendency was observed (RR= 0.97 CI 95%: 0,41–2,34; p=0,09; I2= 51%), moreover, they weren’t clinically significant.

Conclusions

According to these findings and as bleeding is a manageable complication it seems unreasonable to undermine the APT, putting the patient in danger of a thrombotic event and its high inherent morbidity, which isn’t comparable in severity and manageability to the former.”

Key words:Antiplatelet therapy, aspirin, oral surgery, platelet aggregation inhibitors, oral surgical procedures, systematic reviews.

Dental management of patient with dual antiplatelet therapy: a meta-analysis

BACKGROUND

It is more common to need dual antiplatelet therapy (DAPT) for patients who had recently inserted coronary artery stent. However, the postoperative bleeding risk of patients in DAPT could significantly increase. The dental management of patients with antithrombotic therapy has always been a controversial problem. Focusing on this issue, this review discussed the available evidence to provide optimal strategy for patients taking dual antiplatelet agents in the dental setting.

METHODS

We searched the PubMed, Embase, ScienceDirect, Web of Science (WOS), Cochrane Library, and China National Knowledge Infrastructure (CNKI) which was performed in May 2018. Relevant articles were included according to our inclusion and exclusion criteria. Meta-analysis was conducted with fixed effects models. Subgroup analysis was used due to different dental surgeries.

RESULTS

Our meta-analysis included ten studies (continue DAPT vs. placebo, 535 patients vs.2907 patients). The quantitative results indicated that the risk of postoperative bleeding with continuing DAPT experienced significantly increase (RR = 1.95 95% CI [1.07, 3.54]; p = 0.03). There was no statistically significant difference between the postoperative bleeding rate and different dental surgeries (p = 0.72).

CONCLUSION

On the current studies, postoperative hemorrhage is exacerbated with DAPT, but it could be controlled by enhancing hemostasis methods. We recommend continuing long-term DAPT before tooth extraction.

CLINICAL RELEVANCE

In this work, we systematically evaluated and summarized the results of small clinical trials after reviewing the present literatures on this topic, so that we could propose more objective and more accurate evidence-based recommendations on dental management for patient with dual antiplatelet therapy.

Drug discontinuation before contrast procedures and the effect on acute kidney injury and other clinical outcomes: a systematic review protocol

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI) is defined as worsening of renal function after the administration of iodinated contrast material. In patients with cardiovascular disease, kidney disease, and/or diabetes, renin-angiotensin system blockers, non-steroidal anti-inflammatory drugs, diuretics, and metformin can increase the risk of CI-AKI when undergoing contrast imaging. Despite CI-AKI being the leading iatrogenic cause of acute kidney injury, there is a lack of sufficient scientific evidence supporting which drugs should be stopped, when they should be stopped, and when they should be resumed. The purpose of this systematic review is to assess (1) the effect of withholding medication before contrast procedures on the risk of CI-AKI and other clinical outcomes and (2) the incidence of adverse events occurring after withholding these drugs prior to contrast procedures. This protocol has been registered with PROSPERO, https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016033178 .

METHODS

An information specialist will assist in searching MEDLINE, Embase, and the Cochrane Library databases to identify randomized controlled trials, observational studies, case reports, and case series. Relevant abstracts from professional society meetings and web-based registries of clinical trials will also be included. Studies included will compare patients aged ≥ 18 years instructed to continue taking the drugs of interest and those advised to stop taking them before undergoing contrast procedures. If these drugs are not withheld prior to contrast procedures, the studies must compare patients who are administered these drugs and those who are not before undergoing contrast procedures. Two reviewers will independently screen the titles and abstracts of the studies obtained from the search using pre-defined inclusion criteria and will then extract data from the full texts of selected studies. The quality of the studies will be assessed by two independent reviewers using the Cochrane Risk of Bias 2.0 tool for randomized trials and the Newcastle-Ottawa Scale for observational studies.

DISCUSSION

This systematic review will provide a synthesis of current evidence on the discontinuation of drugs prior to contrast procedures and its effect on CI-AKI and other clinical outcomes. These findings will provide clinicians with guidelines and serve as a strong research base for future studies in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033178.

Endodontics in Systemically Compromised Patients

A substantial number of people in today’s world are elderly and as the incidence of a number of pathologies increases with age, it is predicted to produce millions of individuals with systemic medical conditions that can affect oral health and subsequent dental treatment. The dental management of these medically compromised patients can be sometimes problematic in terms of oral complications, dental therapy, and emergency care. One of the challenges faced by dental specialists today is the assessment and management of these patients. As mentioned in detail in Chap. 12, geriatric patients are much more likely to be at least partially dentulous having a complex medical history and the use of multiple medications.

Post-operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-analysis of Observational Studies

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.

Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy

As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.

Management of anticoagulated patients in implant therapy: a clinical comparative study

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.

Postoperative bleeding risk for oral surgery under continued clopidogrel antiplatelet therapy

Object. To determine the incidence of postoperative bleeding for oral osteotomy carried out under continued monoantiplatelet therapy with clopidogrel and dual therapy with clopidogrel/aspirin. Design. Retrospective single center observatory study of two study groups and a control group. Methods. A total of 64 and 60 oral osteotomy procedures carried out under continued monoclopidogrel therapy and dual clopidogrel/aspirin therapy, respectively, were followed for two weeks for postoperative bleeding. Another 281 similar procedures were also followed as a control group. All oral osteotomy procedures were carried out on an outpatient basis. Results. We observed postoperative bleeding in 2/281 (0.7%) cases in the control group, in 1/64 (1.6%) cases in the clopidogrel group, and in 2/60 (3.3%) cases in the dual clopidogrel/aspirin group. The corresponding 95% confidence intervals are 0–1.7%, 0–4.7%, and 0–7.8%, respectively, and the incidences did not differ significantly among the three groups (P > 0.09). Postoperative hemorrhage was treated successfully in all cases with local measures. No changes of antiplatelet medication, transfusion, nor hospitalisation were necessary. No major cardiovascular events were recorded. Conclusions. Our results indicate that minor oral surgery can be performed safely under continued monoantiplatelet medication with clopidogrel or dual antiplatelet medication with clopidogrel/aspirin.

Evaluation of postextraction bleeding incidence to compare patients receiving and not receiving warfarin therapy: a cross-sectional, multicentre, observational study

OBJECTIVES

We investigated incidence and risk factors for postextraction bleeding in patients receiving warfarin and those not receiving anticoagulation therapy.

DESIGN

Cross-sectional, multicentre, observational study.

SETTING

26 hospitals where an oral surgeon is available.

PARTICIPANTS

Data on 2817 teeth (from 496 patients receiving warfarin, 2321 patients not receiving warfarin; mean age (SD): 62.2 (17.6)) extracted between 1 November 2008 and 31 March 2010, were collected. Warfarin-receiving patients were eligible when prothrombin time-international normalised ratio (PT-INR) measured within 7 days prior to the extraction was less than 3.0.

INTERVENTIONS

Simple dental extraction was performed, and incidence of postextraction bleeding and comorbidities were recorded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Postextraction bleeding not controlled by basic haemostasis procedure was clinically significant.

RESULTS

Bleeding events were reported for 35 (7.1%) and 49 (2.1%) teeth, of which 18 (3.6%) and 9 (0.4%) teeth were considered clinically significant, in warfarin and non-warfarin groups, respectively, the difference between which was 3.24% (CI 1.58% to 4.90%). The incidence rates by patients were 2.77% and 0.39%, in warfarin and non-warfarin groups, respectively (incidence difference 2.38%, CI 0.65% to 4/10%). Univariate analyses showed that age (OR 0.197, p=0.001), PT-INR (OR 3.635, p=0.003), mandibular foramen conduction anaesthesia (OR 4.854, p=0.050) and formation of abnormal granulation tissue in extraction socket (OR 2.900, p=0.031) significantly correlate with bleeding incidence. Multivariate analysis revealed that age (OR 0.126, p=0.001), antiplatelet drugs (OR 0.100, p=0.049), PT-INR (OR 7.797, p=0.001) and history of acute inflammation at extraction site (OR 3.722, p=0.037) were significant risk factors for postextraction bleeding.

CONCLUSIONS

Our results suggest that there is slight but significant increase in the incidences of postextraction bleeding in patients receiving warfarin. Although absolute incidence was low in both groups, the bleeding risk is not negligible.

Consensus report of the XI Congress of the Spanish Society of Odontology for the handicapped and special patients

This article summarizes the findings of consensus of the XI congress of the SEOEME. All of these conclusions are referring to the review articles responsible to the general rapporteurs in order to bringing up to date knowledge with regard to the use of implants in patients medically compromised and with special needs and, in the dental management of autism and cerebral palsy, in the dental treatment of patients with genetic and adquired haematological disorders, the dental implications of cardiovascular disease and hospital dentistry.

New oral anticoagulants in practice: pharmacological and practical considerations

Although highly effective, warfarin use is complicated by its unpredictable narrow therapeutic window, genetic heterogeneity in pharmacokinetic response, numerous food and drug interactions, and the need for regular international normalized ratio (INR) monitoring. Currently, several novel oral anticoagulant (NOAC) drugs (dabigatran, rivaroxaban, apixaban) are available on the market as alternatives to warfarin. These agents all feature more predictable pharmacodynamic and pharmacokinetic properties than warfarin. Additionally, the NOACs do not require routine monitoring of coagulation parameters, and have a relatively lower potential for interactions with drug, herb, and dietary constituents, which enhances the convenience of management for both patients and health professionals alike. However, there are other considerations regarding the use of NOACs that must be taken into account during management of therapy. In contrast to warfarin, most NOACs need dosage adjustments in renal impairment and are contraindicated in severe liver impairment, and there are no specific antidotes for treating NOAC-related over-anticoagulation. The more frequent dosing needed for NOACs may reduce adherence, especially in elderly patients with polypharmacy. Furthermore, NOACs, especially dabigatran, are not as well tolerated as warfarin in patients with gastrointestinal diseases. Overall, the availability of the NOACs has expanded the treatment armamentarium, but they are not without risk. Given the limited experience with the NOACs, their limited range of indications, and their cost, the characteristics of each anticoagulant must be carefully considered to carefully select the agent that will provide the optimal risk/benefit profile in the individual patient.

Dental management of patients receiving anticoagulant and/or antiplatelet treatment

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.

Recovery time of platelet function after aspirin withdrawal

Introduction

Inappropriate antiplatelet therapy discontinuation increases the risk of thrombotic complications and bleeding after dental procedures. To determine the platelet reactivity recovery time after aspirin withdrawal in vivo, our study was conducted in patients with low-risk cardiovascular disease who can stop aspirin administration following the guidelines stipulated by the American College of Chest Physicians. The time it takes for platelet activity to normalize and the diagnostic accuracy of testing methods were assessed for a residual antiplatelet activity with multiple electrode aggregometry. Our study included patients with clinically indicated hypertension preparing for a dental extraction procedure.

Materials and methods

A total of 212 patients not taking aspirin (control group) and 248 patients with hypertension receiving long-time aspirin treatment at a 100-mg daily dose were prospectively included in the study, which involved stopping aspirin intake before dental extraction. The residual platelet activity and dental bleeding in patients who stopped aspirin intake were analyzed and compared with those of the control group. In addition, platelet reactivity recovery time and bleeding risk in patients who stopped taking aspirin every 24 hours for 0 to 5 days (0–143 hours) before dental extraction was also assessed.

Results

Platelet reactivity normalized 96 hours after aspirin withdrawal. The cut-off value of 49 arbitrary units in the arachidonic acid platelet aggregation test excluded the effect of aspirin with 91% sensitivity and 66% specificity. AUC showed 0.86 (P < 0.001) diagnostic accuracy. The immediate bleeding complications in all treatment groups were similar to those seen in the control group and were successfully managed with local hemostatic measures.

Conclusions

The antiplatelet effects of aspirin disappeared 96 hours after aspirin withdrawal in our study, and dental extractions may be safely performed in this period when appropriate local hemostatic measures are taken. Based on these results, a shorter aspirin intake cessation period may be allowable in complex dental procedures and surgery for which a longer aspirin intake cessation period (7–10 days) is recommended based on the American College of Chest Physicians guidelines.

Clinical diseases with thrombotic risk and their pharmacologycal treatment: how they change the therapeutic attitude in dental treatments

The new antiplatelets and anticoagulant drugs have been recently introduced in the daily medical practices for the control of thromboembolism associated with different diseases. The dental assistance of these patients forces us to know these drugs, understand their action mechanisms and try to decrease the risks that entail ours actions in these patients, making a thorough analysis of the risk of bleeding that is going to be related to our medical intervention, as well as the use of all the control measures of the hemorrhage from our knowledge with these patients, and to be prudent. The communication with the medical specialist that supervises these patients must be maxim, being necessary to make clinic trials for establishing protocols or guides of the handling with these patients during the odontological treatment.

Key words:Antiplatelet drugs, anticoagulants drugs, new/classic, thrombotic risk, hemorrhagic risk, dental treatment, caution.

Should aspirin be stopped before carpal tunnel surgery? A prospective study

AIM: To determine whether patients taking aspirin during carpal tunnel release had an increase of complications.

METHODS: Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery.

RESULTS: There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm²) was observed in 8 patients. A minor haematoma (score < 20 cm²) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy.

CONCLUSION: Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.

Is stopping of anticoagulant therapy really required in a minor dental surgery? - How about in an endodontic microsurgery?

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.

Inherited platelet disorders and oral health

Platelets play a key role in thrombosis and hemostasis. Accumulation of platelets at the site of vascular injury is the first step in the formation of hemostatic plugs, which play a pivotal role in preventing blood loss after injury. Platelet adhesion at sites of injury results in spreading, secretion, recruitment of additional platelets, and formation of platelet aggregates. Inherited platelet disorders are rare causes of bleeding syndromes, ranging from mild bruising to severe hemorrhage. The defects can reflect deficiency or dysfunction of platelet surface glycoproteins, granule contents, cytoskeletal proteins, platelet pro-coagulant function, and signaling pathways. For instance, Bernard-Soulier syndrome and Glanzmann thrombasthenia are attributed to deficiencies of glycoprotein Ib/IX/V and GPIIb/IIIa, respectively, and are rare but severe platelet disorders. Inherited defects that impair platelet secretion and/or signal transduction are among the most common forms of mild platelet disorders and include gray platelet syndrome, Hermansky-Pudlak syndrome, and Chediak-Higashi syndrome. When necessary, desmopressin, antifibrinolytic agents, and transfusion of platelets remain the most common treatment of inherited platelet disorders. Alternative therapies such as recombinant activated factor VII are also available for a limited number of situations. In this review, we will discuss the management of patients with inherited platelet disorders in various clinical situations related to dental cares, including surgical intervention.

Safety of dental extractions in coronary drug-eluting stenting patients without stopping multiple antiplatelet agents

BACKGROUND

The risk of excessive bleeding prompts physicians to stop multiple antiplatelet agents before minor surgery, which puts coronary stenting patients at risk for adverse thrombotic events.

HYPOTHESIS

We hypothesized that most dental extractions can be carried out safely without stopping multiple antiplatelet agents.

METHODS

All dental extraction patients who had undergone coronary stenting and who were also on oral multiple antiplatelet agents therapy were enrolled. One hundred patients underwent dental procedures without stopping antiplatelet agents. All wounds were sutured and followed up at 24 hours, 1 week, and 1 month after the procedure. There were 2233 patients who had not taken oral antiplatelet agents from a health promotion center and had teeth extracted by the same method. After performing propensity-score matching for the entire population, a total of 100 matched pairs of patients were created. The primary outcome was a composite of excessive intraextraction blood loss, transfusion, and rehospitalization for bleeding, and the secondary outcome was a composite of death, nonfatal myocardial infarction, target lesion revascularization, and stent thrombosis within 1 month after the procedure.

RESULTS

There were 2 excessive intraextraction bleeding cases that continued at the extraction site for 4 and 5 hours, respectively, in the coronary stenting patients, and 1 excessive intraextraction bleeding case that continued for 3 hours in the control patients. There were no cases of transfusion, rehospitalization for bleeding, or major cardiovascular events for the 2 propensity-matched groups.

CONCLUSIONS

We found that most dental extractions in coronary stenting patients can be carried out safely without stopping multiple antiplatelet agents.

Safety of dental extractions during uninterrupted single or dual antiplatelet treatment

Optimal dental management in patients on long-term antiplatelet treatment is not clearly defined. Antiplatelet discontinuation increases the risk of thrombotic complications, whereas uninterrupted antiplatelet therapy, which is the currently recommended approach, is assumed to increase the bleeding hazard after dental procedures. We sought to prospectively compare the risk of immediate and late postextraction bleeding in patients receiving uninterrupted single or dual antiplatelet therapy. We recruited 643 consecutive patients referred for dental extractions. In total 111 (17.3%) were on clinically indicated antiplatelet therapy: aspirin (n = 42), clopidogrel (n = 36), and aspirin and clopidogrel (n = 33). Controls (n = 532, 82.7%) were not on antiplatelet treatment. Immediate and late bleeding complications were recorded. Compared to controls the risk of prolonged immediate bleeding was higher in patients on dual antiplatelet therapy (relative risk [RR] 177.3, 95% confidence interval [CI] 43.5 to 722, p <0.001) but not in patients on aspirin alone (RR = 6.3, 95% CI 0.6 to 68.4, p = 0.2) or clopidogrel alone (RR = 7.4, 95% CI 0.7 to 79.5, p = 0.18); however, all immediate bleeding complications in all treatment groups were successfully managed with local hemostatic measures. No patient developed any late hemorrhage. In conclusion, dental extractions may be safely performed in patients receiving single or dual antiplatelet therapy when appropriate local hemostatic measures are taken, thus averting thrombotic risk of temporary antiplatelet discontinuation.

Bleeding evaluation during single tooth extraction in patients with coronary artery disease and acetylsalicylic acid therapy suspension: a prospective, double-blinded, and randomized study

PURPOSE

Acetylsalicylic acid (ASA) has been used for the primary and secondary prevention of cardiovascular events. To reduce bleeding, the administration of ASA has traditionally been suspended before dental procedures; however, this suspension potentially increases the risk of thromboembolic events. The effect of ASA on the amount of bleeding that occurs during tooth extraction procedures is controversial, and perioperative guidelines recommend that ASA administration should not be altered for such procedures. The aim of this study was to evaluate the amount of bleeding that occurs during the intraoperative period of tooth extraction procedures in patients with coronary artery disease who are either undergoing acetylsalicylic acid (ASA) therapy or who have been instructed to suspend their ASA use.

PATIENTS AND METHODS

Sixty-three patients with coronary artery disease who required tooth extraction were enrolled in this study. All patients were receiving 100 mg/d of ASA at the time of enrollment and were randomly placed into 2 groups: group S, which was comprised of patients whose ASA therapy was suspended 7 days before tooth extraction, and group NS, comprised of patients whose ASA therapy was unaltered. A platelet aggregation test was carried out on the day of the operation, and the amount of bleeding was measured during the intraoperative period by means of aspirated blood collection. All the extractions were performed by the same surgeon, who was unaware of whether the patient's ASA therapy had been suspended.

RESULTS

The mean (± SD) volume of bleeding was 12.10 ± 9.37 mL for patients who underwent ASA therapy suspension and 16.38 ± 13.54 mL for those patients whose treatments were unaltered (P = .151). Local hemostatic methods were sufficient to control bleeding, and there were no reported episodes of hemorrhaging during the intra- and postoperative periods. The platelet reactivity index values exhibited statistically significant differences between the 2 investigated groups (P = .004). The platelet reactivity index values for group S and group NS were 242.58 ± 71.26 and 192.09 ± 60.54, respectively.

CONCLUSION

There was no difference in the amount of bleeding that occurred during tooth extraction between patients who continued ASA therapy versus patients who suspended their ASA therapy. The platelet reactivity test demonstrated a reduction in platelet aggregation in the ASA therapy group (group NS), but this reduction was without clinical consequence.

Is anti-platelet therapy interruption a real clinical issue? Its implications in dentistry and particularly in periodontics

The use of anti-platelet therapy has reduced the mortality and morbidity of cardiovascular disease remarkably. A considerable number of patients presenting before a dentist or periodontist give a history of anti-platelet therapy. A clinical dilemma whether to discontinue the anti-platelet therapy or continue the same always confronts the practitioner. Diverse opinions exist regarding the management of such patients. While one group of researchers advise continuation of anti-platelet therapy rather than invite remote, but possible, thromboembolic events, another group encourages discontinuation for variable periods. This study aims at reviewing the current rationale of anti-platelet therapy and the various options available to a clinician, with regard to the management of a patient under anti-platelet therapy. Current recommendations and consensus favour no discontinuation of anti-platelet therapy. This recommendation, however, comes with a rider to use caution and consider other mitigating factors as well. With a large number of patients giving a history of anti-platelet therapy, the topic is of interest and helps a clinician to arrive at a decision.

The dental patient on oral anticoagulant medication: a literature review

Specific diseases and medications may considerably influence the delivery of oral care and the course of dental therapy. The purpose of this literature review is to examine the relationship between oral anticoagulant medication and dental treatment. Electronic and manual searches were conducted for clinical studies in the English literature for the years 1988-2010. The review process provided a total of 110 pertinent literature references, out of which 38 studies dealt with oral anticoagulants and dental treatment. Different treatment strategies relative to dental periprocedural anticoagulation regimens have been identified, and their accompanying thromboembolic and bleeding risks are being presented and discussed. Regarding to what extent a safe and successful dental treatment in patients on anticoagulant medication is feasible, the level of evidence is lacking. Until high-level data are provided, an individualised treatment approach after consultation with the physician of the patient is highly recommended.

[Conditions causing copious bleeding important for dental medicine practice]

<Zakljucak> Dobro poznavanje mogucih uzoraka prekomernog krvarenja, kao i stomatoloskih postupaka u toku oralnohirurskih intervencija kod obolelih od trombocitopenije, hemofilije, u slucaju snizene koncentracije faktora zavisnih od vitamina K i predozirane antitrombotske terapije, omogucava adekvatnu i blagovremenu oralnohirursku hemostazu u skladu sa predvidjenim protokolom lecenja. Ukoliko je, medjutim, oralnohirurska intervencija propracena produzenim krvarenjem u trajanju od nekoliko sati ili dana, bez pouzdanih anamnestickih podataka i pismene medicinske dokumentacije, problem postaje veliki. U takvim situacijama, podsecanje na stanja koja izazivaju prekomerno krvarenje, kao i na stomatoloske postupke u toku oralnohirurskih intervencija kod takvih bolesnika, moze biti dragocen doprinos dobroj stomatoloskoj praksi.

[Prevalence of abnormal coagulation tests in patients who undergo transrectal biopsy of the prostate]

PURPOSE

To determine the prevalence of abnormal coagulation tests in patients who undergo transrectal prostate biopsy.

MATERIAL AND METHODS

A cross-sectional study was performed at Hospital Universitario del Valle (HUV) between 1 June and 31 December 2008. Variables collected included age, PSA value, PT (prothrombin time), PTT (partial thromboplastin time) and INR (international normalized ratio) values and the presence of abnormalities in each of the haematological variables. There are no real normal or maximum acceptable values in clinical practice; however, the values described by some authors and different clinical practice protocols serve as a guide.

RESULTS

The average age was 70 years, the median PSA was 28, the partial thromboplastin time was altered in 2.3% of patients, and INR was abnormal in 3.4% of patients (cut-off point 1.5). There were no changes in PT or INR values (cut-off point 2.0).

CONCLUSIONS

The prevalence of abnormal coagulation tests is low even when there are no clear cut-off points in worldwide literature that would determine abnormality.

The effect of aspirin on bleeding after extraction of teeth

Acetylsalicylic acid (ASA) generically known as aspirin is used clinically as an analgesic, antipyretic, anti-inflammatory and as a medication to prevent platelet aggregation. Many studies have investigated bleeding associated with ASA.

OBJECTIVE

The aim of this study was to determine if ASA was associated with bleeding after dental extraction.

PATIENTS AND METHODS

One hundred and eighty-nine subjects were divided into four groups. Group 1A subjects who received ASA, underwent simple extraction. Group 1B subjects who received ASA, underwent surgical extraction. Group 2A subjects who did not receive ASA, underwent simple extraction which served as control group. Group 2B subjects who did not receive ASA, underwent surgical extraction which also served as control group.

RESULTS

The results showed that Group 1B was the only group which showed bleeding after 24 h. All groups had similar results after 48 h and 5 days post-operatively.

CONCLUSION

The study concluded that subjects who received 81 mg ASA daily could undergo dental extraction without bleeding risks.