Oral surgery for patients on anticoagulant therapy: current thoughts on patient management

Management of Patients Receiving Anticoagulation Therapy in Dental Practice: A Systematic Review

BACKGROUND

Anticoagulant drugs are a valuable tool for minimizing thrombotic risks in at-risk patients. The purpose of this study is to conduct a literature review highlighting the management of these drugs during daily clinical dental practice.

MATERIALS AND METHODS

We limited our search to English-language papers published between 1 January 1989, and 7 March 2024, in PubMed, Scopus and Web of Science that were relevant to our topic. In the search approach, the Boolean keywords "anticoagulant AND dentistry" were used.

RESULTS

Twenty-five clinical trials were included for final review from 623 articles obtained from the databases Web of Science (83), PubMed (382), and Scopus (158), eliminating duplicates and 79 off-topic items, resulting in 419 articles after removing 315 entries and confirming eligibility. Overall, these studies support the use of local hemostatic measures to manage the risk of bleeding in patients on anticoagulant therapy undergoing dental procedures and highlight the importance of greater education and collaboration among healthcare professionals.

CONCLUSIONS

Research and clinical investigation have improved understanding and management of dental procedures in patients undergoing anticoagulant or antiplatelet therapy. Hemostatic agents, clinical protocols, risk factors, and continuous education are essential for navigating the complexities of anticoagulant therapy, ensuring optimal outcomes and enhancing patient well-being.

A "Tie-Over" Hemostatic Approach in Emergency Department: An Alternative Option for Recurrent Episodes of Postoperative Intraoral Hemorrhage

Objective

This case series aimed to describe a hemostatic technique that has been applied in patients admitted to emergency department (ED) of a tertiary hospital due to recurrent episodes of intraoral hemorrhage (IOH) after various dentoalveolar operations. The "tie-over" approach involved the intraoral use of Xeroform® gauze (as compressive bolster dressing) and the oral rinsing with a liquid mixture of hemostatic agents.

Materials and Methods

Between February 1, 2014, and July 31, 2017, we retrospectively reviewed the medical data and records of patients in ED who chiefly complained about IOH. The inclusion criteria were cases secondary to dentoalveolar surgeries that have been exclusively treated by tie-over bolster approach. Data such as frequency and severity of hemorrhage episodes, pain, and discomfort were assessed pre- and postoperatively.

Results

The presented technique was applied in 23 patients, but 20 of them complied with follow-up evaluation. The mean age of those patients was 60.57 years (15-82 years) with a mean follow-up time of 5.05 days. Eighteen patients were taking antithrombotic medications, either per os (oral antiplatelets and anticoagulants-OAA group) or subcutaneously (heparin group). One patient from OAA group and 2 from heparin group experienced in total 4 bleeding events postoperatively. Three of those events were recorded as minimal (oozing) and did not last over 20 min. All the patients declared satisfaction about the non-bleeding oral status.

Conclusions

In addition to its compelling outcomes, we advocate that this approach conferred physiological benefits on patients who visited ED with symptoms of anxiety and malaise, secondary to multiple, lasting, or uncontrolled episodes of IOH related to extensive surgical trauma. The presence of the gauze intraorally was short-term and created minimal discomfort.

Controversies in Stoppage of Antiplatelet and Anticoagulant Medications Prior to Oral Surgery

Dental procedures can pose a risk of bleeding, and it is not uncommon for dentists to consult prescribing physicians regarding a mutual patient's antiplatelet and anticoagulant medication to prevent excessive bleeding during or after an upcoming procedure. However, there has been a growing controversy in the dental community surrounding the stoppage of these medications prior to dental procedures. Some believe that stopping these medications prior to dental procedures is necessary to reduce the risk of bleeding complications, while others argue that stopping them can increase the risk of stroke or other thromboembolic events. The debate has left many dentists and specialists unsure about the best course of action when it comes to managing bleeding risk during dental procedures.In this article, we will review the antithrombotic medications, indications, mechanism of action, and its effects on the coagulation pathway, laboratory testing and reversal agents. Also, we will explore the controversy surrounding the stoppage of novel anitplatelets (eg,: prasurgrel and ticagrelor), dual-antiplatelets, triple-antiplatelet, vitamin K antagonists (eg,: wafarin, coumadin), and direct oral anticoagulants (eg,: dabigatran, rivaroxaban, xarelto and endoxaban) in dentistry and examine the current evidence and guidelines for managing dental patients undergoing oral surgery.

Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing bridging with heparin versus unpaused vitamin K antagonist medication

Background

The aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin.

Methods

A retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/osteotomy/combined extraction and osteotomy) and the prothrombin time.

Results

In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG versus VG p = 0.004; CG versus BG p < 0.001, BG versus VG p < 0.001. A significant correlation of number of the extracted teeth in the BG (p = 0.014) and no significance in VG (p = 0.298) and CG (p = 0.210) and in the BG versus VG and CG with p < 0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time.

Conclusions

Bridging with heparin increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well-coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences.

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.

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.

The effect of the new hemostatic agent Ostene® on bone healing: An experimental study in rabbits

Introduction: Ostene® is a water-soluble wax-like alkylene oxide copolymer preparation for use as a mechanical hemostatic agent. This study aims to evaluate the effects of Ostene® on bone healing. Materials and Methods: Twenty albino rabbits were divided into four groups according to post-treatment follow-up (24 hr, 3 days, 7 days, 14 days) with five rabbits in each group. Each rabbit in all groups was treated with two study materials (Ostene® and Gelfoam®). Three holes were made in the mandibular bone of each rabbit using 5mm surgical bur; two holes were made on right side: one for testing Ostene® and another for Gelfoam®. A third hole, on the left side of mandible, was not treated, and was used as a control. Finally, the incision was closed. The specimens were collected at different days post-treatment and examined by histopathology. Result and Discussion: This study showed that there is a significant difference (p-value≤ 0.05) between the Ostene® group and the other groups (Gelfoam® and control). At 24 hr post intervention, there is a significant difference in osteoblast cell formation (p-value=0.03), and osteoclast cell formation (p-value=0.05). New blood vessel formation, osteoblast and osteoclast cell formation for Ostene® group at 3 days post-intervention were also significantly different (p-values = 0.05, 0.03, 0.04, respectively). At 7 days post-intervention p-values were 0.05 for osteoblast formation and 0.04 for osteoclast formation, respectively. After 14 days of healing p-value for osteoblast cell formation in the Ostene® group was 0.05 and 0.04 for osteoclast cell formation. Conclusions: The bone hemostatic agent Ostene® is an effective at enhancing osteogenesis by initiating proliferation of osteoblast and osteoclast cells.

Distribution of medical status and medications in elderly patients treated with dental implant surgery covered by national healthcare insurance in Korea

Background

The purpose of this study was to investigate the distribution of systemic diseases and medications in patients older than 65 years of age who visited the hospital for implant treatment, as well as to investigate basic information about surgical complications that may occur after insured implant treatment.

Methods

A total of 126 patients over 65 years of age were treated for implant surgery from October 1, 2013 to October 30, 2016. Electronic chart review was conducted to obtain medical records, which included sex, age, systemic diseases, medication(s) being taken, and control of the medications. Five patients were excluded due to lack of medical records giving information about systemic disease.

Results

Of the 126 patients, 112 (88.9%) were taking medication due to systemic disease and 9 patients (7.1%) were not. The sex distribution was 71 women and 55 men and the highest proportion of patients were between 65 and 69 years old. The most common diseases were, from most to least frequent, hypertension, cardiovascular disease, diabetes, and osteoporosis. The drug groups that can cause major complications after dental treatment were classified as hemorrhagic, osteoporotic, and immunosuppressive agents, and were taken by 45 (35.7%), 22 (17.5%) and 4 (3.2%) patients, respectively.

Conclusion

Given that 88.9% of the elderly patients who were eligible for insurance implant treatment had systemic disease, it is necessary to carefully evaluate patients' medical histories and their general conditions in order to prevent emergencies during implant surgery.

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.

Oral surgery during therapy with anticoagulants-a systematic review

OBJECTIVES

Oral anticoagulation therapy (OAT) with vitamin K inhibitors protects the patients from thromboembolic events. It may however lead to excessive hemorrhage during and after an oral surgery procedure. The aim of this systematic review was to evaluate the justifications to reduce, withdraw, or alter OATs prior to minor oral surgery procedures to manage bleeding events.

MATERIALS AND METHODS

A systematic MEDLINE search was conducted for clinical studies in English or German language from 1994 to 2014 comparing patients treated with OAT, without OAT, as well as patients with altered OAT for oral surgery purposes. Relevant outcome parameters were: postoperative local hemostasis, bleeding episodes, occurrence of thromboembolic events, and other complications due to the anticoagulation medication. A hand search for references cited in the identified publications completed the review.

RESULTS

After screening of 1755 abstracts, 16 clinical studies were identified according to the selection criteria. Due to the heterogeneity of the obtained data, aggregation and synthesis were not possible. There was no significant difference in bleeding events comparing patients under continued OAT to those with reduced, altered, and/or discontinued OAT medications. Minor bleeding events in the test and control groups were successfully stopped with local measures. However, no superiority of a single hemostatic measure could be identified. Neither the international normalized ratio (INR), within the therapeutic range (2-4), nor the extent of the minor oral surgery procedure had an influence on postoperative bleeding episodes.

DISCUSSION

There is strong evidence that OAT patients undergoing minor oral surgery should not discontinue their medication in order to prevent thromboembolic complications.

CLINICAL RELEVANCE

Nonetheless, INR should be less than 4, local hemostatic measures are of high importance and patients need to be instructed and closely monitored as minor bleedings might occur more often in OAT patients.