Dental surgery for patients on anticoagulant therapy with warfarin: A systematic review and meta-analysis

Faculty of Dentistry, University of Toronto, Toronto, Ontario.
Texas dental journal 12/2009; 126(12):1183-93.
Source: PubMed


To evaluate the effect of continuing warfarin therapy on the bleeding risk of patients undergoing elective dental surgical procedures.
Data sources were the MEDLINE and EMBASE databases, the Cochrane Central Register of Controlled Trials, a manual citation review of the relevant literature, content experts and relevant abstracts from the proceedings of the International Association for Dental Research. Study selection was carried out independently by two reviewers, as was quality assessment. Data extraction was done by three reviewers. Differences were resolved by consensus. Eligible studies were randomized controlled trials that compared the effects of continuing the regular dose of warfarin therapy with the effects of discontinuing or modifying the dose on the incidence of bleeding in patients undergoing dental procedures.
Five trials (a total of 553 patients) met the inclusion criteria. Compared with interrupting warfarin therapy (either partial or complete), perioperative continuation of warfarin with patients' usual dose was not associated with an increased risk for clinically significant nonmajor bleeding (relative risk [RR], 0.71; 95 percent confidence interval [CI]: 0.39-1.28; p = 0.65; 12 = 0%) or an increased risk for minor bleeding (RR, 1.19; 95% CI: 0.90-1.58; p = 0.22; 12 = 0%).
Continuing the regular dose of warfarin therapy does not seem to confer an increased risk of bleeding compared with discontinuing or modifying the warfarin dose for patients undergoing minor dental procedures.

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Available from: Abdullah Alabousi, Mar 05, 2015
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    • "Heparin is used in anticoagulation bridge therapy, as it has a faster onset and offset action compared with warfarin.12 Many reports stated that patients requiring a minor dental procedure and having an INR of up to 4.0 are able to continue warfarin without any dose adjustment.3,14,15 It has, however, been debated whether stopping warfarin can increase the risk of cerebrovascular accidents (CVA). "
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    ABSTRACT: Background Warfarin is one of the most common oral anticoagulants used to prevent thromboembolic episodes. The benefits of discontinuation of this drug before simple surgical procedures are not clear and this approach could be associated with complications. The aim of this study was to evaluate the risk of bleeding in a series of 35 patients (in cases where the international normalized ratio [INR] is less than 4) following simple tooth extraction without modification of the warfarin dose given to patients. Methods Thirty-five patients taking warfarin who had been referred to the Oral and Maxillofacial Department, College of Dentistry, King Saud University, for dental extractions were included in the study. Exclusion criteria included patients with an INR of ≥4 or with a history of liver disease or coagulopathies. No alteration was made in warfarin dose, and the CoaguChek System was used to identify the INR on the same day of dental extraction. Bleeding from the extraction site was evaluated and recorded immediately after extraction until the second day. Results A total of 35 patients (16 women and 19 men) aged between 38 and 57 years (mean =48.7) were included in the present study. All patients underwent simple one-tooth extraction while undergoing warfarin treatment. Oozing, considered mild bleeding and which did not need intervention was seen in 88.6% of patients. Moderate bleeding occurred in 11.4% of all cases. The INR of the patients ranged from 2.00 to 3.50, with 77.2% of patients having INR between 2.0 and 2.5 on the day of extraction. No severe bleeding which needed hospital management was encountered after any of the extractions. The patients who suffered moderate bleeding were returned to the clinic where they received local treatment measures to control bleeding. Moderate bleeding occurred only in four patients, where three had INR between 3.1 and 3.5, and one with INR less than 3. Conclusion In the present study, we have shown that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.
    Full-text · Article · Aug 2014 · Clinical
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    • "With respect to dental procedures or surgeries, optimal management varies considerably for patients at high risk of thromboembolism receiving long-term OAC.4,5,6 Periprocedural anticoagulation therapy is especially important in patients with MHV receiving long-term OAC, since they have the highest annualized risk of thromboembolic complications in the absence of anticoagulation therapy.2 A previous meta-analysis study reported that maintaining a regular dose of warfarin may not confer an increased bleeding risk as opposed to interrupting or modifying the warfarin dose for patients who undergo minor dental procedures.12 The American College of Chest Physicians guidelines also recommended continuing warfarin around the time of dental procedures in patients receiving long-term OAC.13 "
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    ABSTRACT: Purpose Bridge anticoagulation therapy is mostly utilized in patients with mechanical heart valves (MHV) receiving warfarin therapy during invasive dental procedures because of the risk of excessive bleeding related to highly vascular supporting dental structures. Bridge therapy using low molecular weight heparin may be an attractive option for invasive dental procedures; however, its safety and cost-effectiveness compared with unfractionated heparin (UFH) is uncertain. Materials and Methods This study investigated the safety and cost-effectiveness of enoxaparin in comparison to UFH for bridge therapy in 165 consecutive patients (57±11 years, 35% men) with MHV who underwent invasive dental procedures. Results This study included 75 patients treated with UFH-based bridge therapy (45%) and 90 patients treated with enoxaparin-based bridge therapy (55%). The bleeding risk of dental procedures and the incidence of clinical adverse outcomes were not significantly different between the UFH group and the enoxaparin group. However, total medical costs were significantly lower in the enoxaparin group than in the UFH group (p<0.001). After multivariate adjustment, old age (≥65 years) was significantly associated with an increased risk of total bleeding independent of bridging methods (odds ratio, 2.51; 95% confidence interval, 1.15-5.48; p=0.022). Enoxaparin-based bridge therapy (β=-0.694, p<0.001) and major bleeding (β=0.296, p=0.045) were significantly associated with the medical costs within 30 days after dental procedures. Conclusion Considering the benefit of enoxaparin in cost-effectiveness, enoxaparin may be more efficient than UFH for bridge therapy in patients with MHV who required invasive dental procedures.
    Full-text · Article · Jul 2014 · Yonsei Medical Journal
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    • "In contrast, other investigators prefer non-reabsorbable silk sutures, since they retain much less plaque and therefore greatly lessen the risk of bacterial penetration into the bloodstream (23). This in turn reduces the risk of postoperative complications such as thromboembolic phenomena or infections (13-15). "
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    ABSTRACT: 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. 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. 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. 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.
    Full-text · Article · Apr 2014 · Journal of Clinical and Experimental Dentistry
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