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Zhang YQ, Zhao YJ, Jiang JD, Cheng QT, Yang ZC, Lu MM. Assessment of immediate clotting after flapless extraction using piezosurgery or turbine handpiece in patients receiving dual antiplatelet therapy. J Oral Sci 2022; 64:294-299. [PMID: 36089374 DOI: 10.2334/josnusd.22-0187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Ya-Qiong Zhang
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital, Fudan University.,Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University
| | - Yi-Jie Zhao
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital, Fudan University.,Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University
| | - Ji-Dang Jiang
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital, Fudan University.,Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University
| | - Qing-Tao Cheng
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital, Fudan University.,Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University
| | - Zhi-Cheng Yang
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital, Fudan University.,Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University
| | - Meng-Meng Lu
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital, Fudan University.,Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University
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Combined aspirin and clopidogrel therapy in phacoemulsification cataract surgery: a risk factor for ocular hemorrhage? Int Ophthalmol 2020; 40:2023-2029. [PMID: 32342255 DOI: 10.1007/s10792-020-01378-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the safety of phacoemulsification cataract surgery in the patients undergoing dual antiplatelet therapy with aspirin and clopidogrel. METHODS Consecutive patients undergoing phacoemulsification cataract surgery with a clear corneal incision under topical anesthesia were eligible for inclusion in the study. Thirty-eight eyes from 38 patients on combined aspirin and clopidogrel therapy who continued the treatment were classified into the maintenance group, a matched group of 38 eyes from 38 patients on no antiplatelet/anticoagulant therapy as the control group. The best-corrected visual acuity (BCVA) and incidences of complications were compared between the two groups. RESULTS There was no significant difference in final BCVA between the maintenance group and the control group (p = 0.178). No significant difference existed in the incidences of hemorrhagic or non-hemorrhagic complications between the two groups (p = 0.529 and p = 0.589, respectively). Moreover, no surgery was postponed or cancelled due to hemorrhagic complications in either group, and no cardiovascular events occurred during the follow-up. There was no case of anterior chamber hemorrhage, vitreous hemorrhage, or suprachoroidal hemorrhage. CONCLUSIONS Our outcomes indicated that phacoemulsification cataract surgery using a clear corneal incision with topical anesthesia could be safely done without stopping dual antiplatelet therapy with aspirin and clopidogrel.
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Doganay O, Atalay B, Karadag E, Aga U, Tugrul M. Bleeding frequency of patients taking ticagrelor, aspirin, clopidogrel, and dual antiplatelet therapy after tooth extraction and minor oral surgery. J Am Dent Assoc 2019; 149:132-138. [PMID: 29389336 DOI: 10.1016/j.adaj.2017.09.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Perioperative bleeding complications of ticagrelor, a newer oral antiplatelet, has not been studied in dentistry. Studies about bleeding status after oral surgical procedures in patients receiving continued antiplatelet therapy are also limited. We investigated the effects of continuing aspirin, clopidogrel, ticagrelor, or dual antiplatelet therapy on the frequency of bleeding events in patients undergoing tooth extractions or minor oral surgery. METHODS In this retrospective study, patient demographic characteristics, medical history, type of antiplatelet therapy, dental procedures, and perioperative bleeding associated with tooth extraction or other minor oral surgical procedures were obtained from the dental records of 222 patients. Bleeding was classified as normal, mild, moderate, or severe. RESULTS One hundred sixty-eight patients (75.7%) had 1 or more teeth extracted, and 54 patients (24.3%) underwent other minor oral surgical procedures. The most common single antiplatelet regimen was aspirin (n = 123; 55.4%), followed by clopidogrel (n = 22; 9.9%) and ticagrelor (n = 17; 7.7%). Sixty patients (27%) received dual antiplatelet therapy. The overall frequency of postoperative bleeding was 4.9% (11 of 222). The frequencies of postoperative bleeding in the aspirin, clopidogrel, ticagrelor, and dual antiplatelet therapy groups were 3.2%, 4.5%, 5.9%, and 8.3%, respectively (P ≥ .5). None of the patients experienced prolonged bleeding. CONCLUSIONS Patients taking aspirin, clopidogrel, ticagrelor, and dual antiplatelet therapy experienced acceptable rates of controllable postoperative bleeding after tooth extraction or minor oral surgical procedures. PRACTICAL IMPLICATIONS In accordance with recommendations from published studies and guidelines, antiplatelet medications, including dual antiplatelet therapy, should not be interrupted for tooth extractions or minor oral surgery.
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Rubino RT, Dawson DR, Kryscio RJ, Al-Sabbagh M, Miller CS. Postoperative bleeding associated with antiplatelet and anticoagulant drugs: A retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:243-249. [DOI: 10.1016/j.oooo.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/21/2019] [Accepted: 04/08/2019] [Indexed: 12/22/2022]
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Ockerman A, Bornstein MM, Leung YY, Li SKY, Politis C, Jacobs R. Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2019; 49:90-98. [PMID: 31248706 DOI: 10.1016/j.ijom.2019.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/24/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Abstract
Bleeding is a feared complication of minor oral surgery in patients on treatment with antiplatelet agents and there is no agreed strategy regarding the cessation or not of antiplatelet treatment. The aim of this systematic review was to evaluate bleeding with minor oral surgery in patients on dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), or no antiplatelet therapy (no APT). The PubMed, Embase, Web of Science, and Cochrane Library databases were screened. Sixteen studies were included. DAPT was continued in all studies. The perioperative bleeding risk was significantly higher for DAPT than for SAPT (risk ratio (RR) 10.16, P= 0.010; risk difference (RD) 0.35, P= 0.269), but not higher compared to no APT (RR 6.50, P= 0.057; RD 0.19, P= 0.060). The postoperative bleeding risk was significantly elevated for DAPT compared to SAPT (RR 2.61, P= 0.010) and no APT (RR 3.63, P= 0.035), but only by 1% (RD 0.01, P= 0.103) and 1% (RD 0.01, P= 0.421), respectively. Clinically, this may be considered quite similar. Additionally, local haemostatic measures could control all reported bleeding and no lethal events occurred. Therefore, DAPT interruption is not advised before minor oral surgery.
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Affiliation(s)
- A Ockerman
- Oral and Maxillofacial Surgery - Imaging and Pathology Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Department of Oral and Maxillofacial Surgery, University of Leuven, Leuven, Belgium.
| | - M M Bornstein
- Applied Oral Sciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - Y Y Leung
- Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - S K Y Li
- Centralized Research Laboratory, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
| | - C Politis
- Oral and Maxillofacial Surgery - Imaging and Pathology Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Department of Oral and Maxillofacial Surgery, University of Leuven, Leuven, Belgium
| | - R Jacobs
- Oral and Maxillofacial Surgery - Imaging and Pathology Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven and Department of Oral and Maxillofacial Surgery, University of Leuven, Leuven, Belgium; Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Gottlieb M, DeMott JM, Peksa GD. Topical Tranexamic Acid for the Treatment of Acute Epistaxis: A Systematic Review and Meta-analysis. Ann Pharmacother 2018; 53:652-657. [DOI: 10.1177/1060028018820625] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: To compare topical tranexamic acid (TXA) with control groups for the treatment of acute epistaxis assessing bleeding cessation, discharge within 2 hours, rebleeding rates, complication rates, and patient satisfaction. Data Sources: PubMed, CINAHL, LILACS, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched from inception to November 2018. Study Selection and Data Extraction: All randomized controlled trials comparing topical TXA with control groups for the treatment of acute epistaxis in humans were included. There were no age, language, or date restrictions. Data were double extracted into a predefined worksheet, and quality analysis was performed using the Cochrane Risk of Bias tool. Data Synthesis: Three studies (n = 408 patients) were identified. Topical TXA was not associated with a statistically significant difference in cessation of bleeding within 30 minutes. However, more patients were discharged within 2 hours of arrival, there were fewer episodes of rebleeding within both the first 24 hours and at 1 week, and there was higher patient satisfaction in the TXA group. There was no difference identified in complication rates. Relevance to Patient Care and Clinical Practice: This review compares topical TXA with control groups for epistaxis and discusses the risks and benefits of adding this therapy to usual care. Conclusions: Topical TXA appears to be a reasonable option for the treatment of acute epistaxis, with reduced rebleeding rates, shorter discharge times, and minimal risk of complications. Topical TXA may be considered as part of the treatment of acute epistaxis.
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Tang M, Yu C, Hu P, Wang C, Sheng J, Ma S. Risk factors for bleeding after dental extractions in patients over 60 years of age who are taking antiplatelet drugs. Br J Oral Maxillofac Surg 2018; 56:854-858. [DOI: 10.1016/j.bjoms.2018.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 09/17/2018] [Indexed: 12/18/2022]
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Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2018; 25:261-266. [PMID: 29125679 DOI: 10.1111/acem.13345] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/02/2017] [Accepted: 11/05/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We evaluated the efficacy of topical application of the injectable form of tranexamic acid (TXA) compared with anterior nasal packing (ANP) for the treatment of epistaxis in patients taking antiplatelet drugs (aspirin, clopidogrel, or both) who presented to the emergency department (ED). METHODS A randomized, parallel-group clinical trial was conducted at two EDs. A total of 124 participants were randomized to receive topical TXA (500 mg in 5 mL) or ANP, 62 patients per group. The primary outcome was the proportion of patients in each group whose bleeding had stopped at 10 minutes. Secondary outcomes were the rebleeding rate at 24 hours and 1 week, ED length of stay (LOS), and patient satisfaction. RESULTS Within 10 minutes of treatment, bleeding was stopped in 73% of the patients in the TXA group, compared with 29% in the ANP group (difference = 44%, 95% confidence interval, 26% to 57%; p < 0.001). Additionally, rebleeding was reported in 5 and 10% of patients during the first 24 hours in the TXA and the ANP groups, respectively. At 1 week, 5% of patients in the TXA group and 21% of patients in the ANP group had experienced recurrent bleeding (p = 0.007). Patients in the TXA group reported higher satisfaction scores (median [interquartile range {IQR}], 9 [8-9.25]) compared with the ANP group (median [IQR] = 4 [3-5]; p < 0.001). Discharge from the ED in <2 hours was achieved in 97% of patients in the TXA group versus 13% in the ANP group (p < 0.001). There were no adverse events reported in either group. CONCLUSIONS In our study population, epistaxis treatment with topical application of TXA resulted in faster bleeding cessation, less rebleeding at 1 week, shorter ED LOS, and higher patient satisfaction compared with ANP.
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Affiliation(s)
- Reza Zahed
- Department of Emergency Medicine Imam Khomeini Hospital Complex Faculty of Medicine Tehran University of Medical Sciences TehranIran
| | | | - Asieh Naderi
- Eye Research Center Farabi Eye Hospital Tehran University of Medical Sciences Tehran Iran
| | - Zeinab Naderpour
- Department of Internal Medicine Tehran University of Medical Sciences TehranIran
| | - Morteza Saeedi
- Emergency Medicine Research Center Department of Emergency Medicine Shariati Hospital Faculty of Medicine Tehran University of Medical Sciences TehranIran
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Lanau N, Mareque J, Giner L, Zabalza M. Direct oral anticoagulants and its implications in dentistry. A review of literature. J Clin Exp Dent 2017; 9:e1346-e1354. [PMID: 29302288 PMCID: PMC5741849 DOI: 10.4317/jced.54004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/05/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Four novel direct oral anticoagulants (DOACs) named dabigatran, rivaroxaban, edoxaban and apixaban have been recently introduced to overcome some of the drawbacks of existing anticoagulants. They have less interactions and do not require routine monitoring. However, there is not enough scientific data about the protocol to apply in these patients on DOACs undergoing dental treatment. Thus is necessary to evaluate the potential bleeding risk of these drugs, the possibility of thromboembolic events occurring if they are withdrawn or the need to change to heparin previously. MATERIAL AND METHODS A comprehensive search of the PubMed, Scopus and ISI Web of Science databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The quality of the reported information was assessed following the PRISMA statement. RESULTS Eleven studies that met the inclusion criteria were included in the review: 2 randomized clinical trials, 3 prospective studies, 3 retrospective studies, 2 case series and 1 case report. CONCLUSIONS DOACs are safe drugs in terms of bleeding. The possible postoperative bleeding complications are manageable with conventional haemostasis measurements. The bridging approach with heparin does not seem to be recommended. Consensus among the professionals involved in the management of the patient is fundamental in invasive dental treatments and in complex patients. Key words:Oral anticoagulants, DOAC, NOAC, dabigatran, rivaroxaban, apixaban, edoxaban, bleeding, oral surgery.
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Affiliation(s)
- Neus Lanau
- DDS, PhD Student. Faculty of Dentistry. Universitat Internacional de Catalunya, Spain
| | - Javier Mareque
- MD, DDS, PhD. Vice-dean for Research. Faculty of Dentistry. Universitat Internacional de Catalunya, Spain
| | - Lluis Giner
- MD, DDS, PhD. Dean of the Faculty of Dentistry. Universitat Internacional de Catalunya, Spain
| | - Michel Zabalza
- MD, PhD. Faculty of Medicine and Dentistry. Universitat Internacional de Catalunya, Spain
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Yanamoto S, Hasegawa T, Rokutanda S, Komori S, Tachibana A, Kojima Y, Koyama Y, Shibuya Y, Kurita H, Komori T, Umeda M. Multicenter Retrospective Study of the Risk Factors of Hemorrhage After Tooth Extraction in Patients Receiving Antiplatelet Therapy. J Oral Maxillofac Surg 2017; 75:1338-1343. [DOI: 10.1016/j.joms.2017.02.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/27/2016] [Accepted: 02/20/2017] [Indexed: 11/26/2022]
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López-Lacomba D, Roa-López A, González-Jaranay M, Gómez-Moreno G, Moreu G. Periodontal and biochemical bone metabolism assessment on a chronic oral anticoagulation population treated with dicoumarins. Med Oral Patol Oral Cir Bucal 2017; 22:e258-e263. [PMID: 28160591 PMCID: PMC5359708 DOI: 10.4317/medoral.21567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 12/30/2016] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The aim is to evaluate periodontal alteration and biochemical markers associated with bone turnover in chronic oral with dicoumarins anticoagulant treatment patients. MATERIAL AND METHODS 80 patients treated with oral anticoagulants were divided into 2 cohort: Group A (n=36) 6 month to 1 year with anticoagulant treatment and Group B (n=44) > 2 years with anticoagulant treatment. Clinical evaluation included: Clinical attachment level (CAL), plaque index (PI) and gingival index (GI). Analytically biochemical parameters of bone remodeling (calcium and phosphorus), formation (total acid phosphatase, alkaline phosphatase and osteocalcin) and resorption (tartrate-resistant acid phosphatase and beta-crosslaps) were evaluated. RESULTS High values of PI (67-100%) especially in men and in Group B were observed. Men with anticoagulation treatment length showed an increased GI (49.167 vs 78.083) while Group B women showed a decreased GI in comparison with Group A (59.389 vs 42.120). Women presented a greater average CAL than men as well as Group B vs Group A but without statistical significance. All biochemical markers were decreased respect to values of general population. Osteocalcin in GroupB women showed a statistically significant outcome vs GroupA (p=0.004). Acid phosphatase (total and tartrate-resistant) has a slight increase in Group B women versus Group A, and Beta-crosslap showed lower values in Group A men than Group B and slightly lower in Group A women versus Group B, without statistical significance. CONCLUSIONS Patients showed a slight to moderate degree of periodontal affectation, especially gingivitis related to bacterial plaque. Periodontal disorders tended to be more severe in Group B. While bone remodeling showed an overall decrease with greater affectation of bone neoformation phenomena, bone destruction tended to recover and normalize in time.
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Affiliation(s)
- D López-Lacomba
- Departamento de Estomatología, Unidad Docente de Periodoncia, Facultad de Odontología, Campus de Cartuja S/N, Universidad de Granada, E-18071, Granada, Spain,
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Gualandro DM, Yu PC, Caramelli B, Marques AC, Calderaro D, Fornari LS, Pinho C, Feitosa ACR, Polanczyk CA, Rochitte CE, Jardim C, Vieira CLZ, Nakamura DYM, Iezzi D, Schreen D, Adam EL, D'Amico EA, Lima EQD, Burdmann EDA, Mateo EIP, Braga FGM, Machado FS, Paula FJD, Carmo GALD, Feitosa-Filho GS, Prado GF, Lopes HF, Fernandes JRC, Lima JJGD, Sacilotto L, Drager LF, Vacanti LJ, Rohde LEP, Prada LFL, Gowdak LHW, Vieira MLC, Monachini MC, Macatrão-Costa MF, Paixão MR, Oliveira MTD, Cury P, Villaça PR, Farsky PS, Siciliano RF, Heinisch RH, Souza R, Gualandro SFM, Accorsi TAD, Mathias W. 3rd Guideline for Perioperative Cardiovascular Evaluation of the Brazilian Society of Cardiology. Arq Bras Cardiol 2017; 109:1-104. [PMID: 29044300 PMCID: PMC5629911 DOI: 10.5935/abc.20170140] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gómez-Moreno G, Fernández-Cejas E, Aguilar-Salvatierra A, de Carlos F, Delgado-Ruiz RA, Calvo-Guirado JL. Dental implant surgery in patients in treatment by dabigatran. Clin Oral Implants Res 2016; 29:644-648. [DOI: 10.1111/clr.12785] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gerardo Gómez-Moreno
- Department of Special Care in Dentistry; Pharmacological Research in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Esther Fernández-Cejas
- International Research Cathedra in Dentistry; San Antonio Catholic University of Murcia; UCAM; Murcia Spain
| | - Antonio Aguilar-Salvatierra
- Department of Pharmacological Research in Dentistry; Faculty of Dentistry; University of Granada; Granada Spain
| | - Félix de Carlos
- Department of Surgery and Medical-Surgical Specialities; Area of Orthodontics; Faculty of Medicine; University of Oviedo; Oviedo Spain
| | | | - José Luis Calvo-Guirado
- International Research Cathedra in Dentistry; San Antonio Catholic University of Murcia; UCAM; Murcia Spain
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