Post-extraction bleeding complications in patients on uninterrupted dual antiplatelet therapy-a prospective study

The quantified method for blood clot detection in the extraction socket

Background

Currently, there is no objective and quantified measurement for detecting blood clots during extraction socket hemostasis. It has relied solely on clinical observation, even when conducting clinical research by using extraction sockets as samples. This study aimed to assess the in vitro reliability and clinical-relevant validity of a new objective measurement providing quantified data called blood clot detection (BCD) using a standard capillary tube.

Methods

The in vitro part of the study was conducted using surplus blood samples from ten healthy participants. Two identical sets of blood samples in simulation reservoirs mimicking bleeding sockets were prepared for reliability tests. Then, the capillary tubes were concurrently placed in the reservoirs. The blood-filled distances were measured. The part of clinical-relevant validity study was conducted in sixteen extraction sockets from each healthy participant. Clinical observation and BCD measurement were evaluated by two calibrated assessors. The total duration of the assessment was a 30-minute.

Results

The distances of the blood-filled capillary tube were decreased by time. Test and retest reliability analysis of the BCD measurement showed an excellent intraclass correlation coefficient of 0.980 (0.968 to 0.988). The medians of blood-filled distance categorized by clinical observation into active bleeding, sluggish oozing, and clot formation were 13.0 mm (Q1 = 11.7, Q3 = 13.8), 5.6 mm (Q1 = 4.3, Q3 = 7.0), and 0.9 mm (Q1 = 0.5, Q3 = 1.3), respectively. The blood-filled distance of the clot formation group was significantly less than the active bleeding and sluggish oozing (p<0.001). Therefore, the BCD measurement also significantly indicated the completion of extraction socket hemostasis.

Conclusions

A distance of blood-filled in capillary tube of 0.9 mm from the BCD measurement significantly ensured complete clot formation. The BCD measurement proved to be a quantified tool for objectively measuring hemostasis of bleeding socket.

Management of antithrombotic therapy in patients undergoing dental procedures

A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.

Evaluation of Bleeding Time after Dental Extractions during Uninterrupted Single or Dual Antiplatelet Treatment - A Comparative Study

Introduction

This study aimed to assess the duration of bleeding after dental extractions amongst subjects with uninterrupted single antiplatelet therapy and dual antiplatelet therapy (DAPT) and to compare the bleeding time after dental extractions amongst those subjects undergoing various antiplatelet therapies.

Materials and Methods

Post-extraction bleeding time was categorised as within 30 min, within 1 h and within 24 h. The bleeding time in different categories was compared and analysed using Chi-square. The antiplatelet agents assessed were aspirin, clopidogrel, ticagrelor and a combination of aspirin with clopidogrel and ticagrelor.

Results

Bleeding time was significantly higher in patients under DAPT, compared to those under single antiplatelet therapy, and with an increase in the number of teeth extracted, there was an increase in bleeding time. All cases with prolonged bleeding could be managed with local haemostatic measures.

Discussion

Simple extraction can be undertaken safely in patients under single antiplatelet therapy, considering that local haemostatic measures are available for use in the setup to control bleeding if necessary. Patients under DAPT are better managed if the therapy is altered, as there was a definite increase in bleeding time in patients under DAPT after extraction.

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.

Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications

PURPOSE

The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists.

METHODS

The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control.

RESULTS

The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period.

CONCLUSION

Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.

Risk of postoperative bleeding after dental extraction in patients on antiplatelet therapy: systematic review and meta-analysis

OBJECTIVE

To determine the risk of bleeding after minor extraction in patients on different antiplatelet therapy (APT) regimens.

STUDY DESIGN

A search was conducted using PubMed and Google Scholar. Thirty-five papers were included in the systematic review, of which 23 papers provided the requisite information for meta-analysis. Subgroups were created based on the controls, as follows: (1) no control, (2) healthy control, and (3) interrupted APT control. In a meta-analysis, the studies were further subdivided into immediate and delayed bleeding.

RESULTS

No immediate or delayed bleeding risk was found in patients treated with aspirin vs healthy controls (relative risk [RR] = 1.26; P = .5 and RR = 2.17; P = .09, respectively). A higher immediate bleeding was recorded for patients on single nonaspirin APT vs those in the healthy population (RR = 3.72; P = .0009). A high risk of bleeding was recorded in patients receiving dual APT compared with healthy controls for immediate (RR = 10.3; P < .0001) and delayed (RR = 7.72; P = .001) bleeding. Dual APT continuation showed a higher risk of immediate bleeding (RR = 2.13) than interrupted APT, but the difference was insignificant (P = .07).

CONCLUSIONS

Dental extraction can be performed safely in patients on aspirin monotherapy. In contrast, patients receiving dual APT should be considered at risk for immediate and continued bleeding.

Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis

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.

Assessment of immediate clotting after flapless extraction using piezosurgery or turbine handpiece in patients receiving dual antiplatelet therapy

PURPOSE

This study aimed to investigate the efficacy of piezosurgery (PI) in promoting immediate clotting after flapless extraction in patients undergoing dual antiplatelet therapy (DAPT).

METHODS

In this randomized controlled trial, 80 DAPT patients were equally divided into the PI and turbine handpiece (TH) groups. Accordingly, flapless extraction of a single tooth using PI or TH was performed on each patient, and the immediate clotting status was evaluated. The results of the preoperative hematological examinations, surgery-related variables and postoperative complications were recorded for analysis.

RESULTS

Both groups presented with low platelet aggregation and similar coagulation functions. The PI group exhibited a higher proportion of patients with normal intra-alveolar clotting (≤30 min) (70% vs. 40%, P = 0.007) and fewer intraoperative complications (25% vs. 47.5%, P = 0.036) than that in the TH group. Logistic regression analysis indicated that the applied instrument was an independent risk factor for prolonged immediate bleeding (odds ratio = 3.10, 95% confidence interval: 1.20-8.00, P = 0.019). Intergroup differences were insignificant in terms of the other surgery-related variables and postoperative complications, except for the longer surgical duration in the PI group.

CONCLUSION

The application of PI may contribute to better immediate clotting in DAPT patients after flapless extraction compared with the use of TH.

Bleeding disorders in implant dentistry: a narrative review and a treatment guide

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.