Management of dental patients taking common hemostasis-altering

Salivary Gland Clinic and Residency Program, The Hebrew University, Hadassah School of Dental Medicine, Jerusalem, Israel.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology (Impact Factor: 1.46). 04/2007; 103 Suppl(Suppl):S45.e1-11. DOI: 10.1016/j.tripleo.2006.11.011
Source: PubMed


Millions of patients worldwide are taking medications that alter hemostasis and decrease the risk for thromboembolic events. This systematic review is intended to provide recommendations regarding optimal management of such patients undergoing invasive dental procedures. The primary focus of this report is on warfarin therapy, although issues related to heparin and aspirin are briefly discussed because of the frequency with which they are encountered in dental practice.
The review of literature and development of recommendations was based on the Reference Manual for Management Recommendations for the World Workshop in Oral Medicine IV (WWOM IV). A total of 64 publications were identified for initial review. From these publications, the following types of articles were critically analyzed using WWOM standard forms: randomized controlled trials (RCT), non-RCT studies that assess effects of interventions, and studies that assess modifiable risk factors. Development of recommendations was based on the findings of these reviews as well as expert opinion.
The following evidence-based recommendations were developed: (1) For patients within the therapeutic range of International Normalized Ratio (INR) below or equal to 3.5, warfarin therapy need not be modified or discontinued for simple dental extractions. Nevertheless, the clinician's judgment, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision. Patients with INR greater than 3.5 should be referred to their physician for consideration for possible dose adjustment for significantly invasive procedures. (2) A 2-day regimen of postoperative 4.8% tranexamic acid mouthwash is beneficial after oral surgical procedures in patients on warfarin. (3) It is not necessary to interrupt low-dose aspirin therapy (100 mg/day or less) for simple dental extractions.
For most patients undergoing simple single dental extractions, the morbidity of potential thromboembolic events if anticoagulant therapy is discontinued clearly outweighs the risk of prolonged bleeding if anticoagulant therapy is continued.

    • "Warfarin and acenocoumarol are among this type of oral anticoagulants (Bauersachs, 2012). The mechanism of action of these types of drugs is based on the inhibition of the vitamin K conversion cycle (Aframian et al., 2007; Cervera and Chamorro, 2010; Hirsh et al., 2001). On the other hand, glucosamine sulfate is a slow acting drug for the symptoms of osteoarthritis, and therefore is one of the most commonly used drugs for rheumatic diseases due to its antiinflammatory effects. "
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    ABSTRACT: Chronic diseases are the major contributors to the global burden of disease and involve prodigious consumption of various drugs that usually affect platelet function. The autologous technology of plasma rich in growth factors (PRGF) provides a biological approach using autologous platelets as a reservoir and local delivery of proteins to promote tissue healing. The purpose of this study was to evaluate the effect of the consumption of acetylsalicylic acid, acenocumarol and glucosamine sulfate on the preparation as well as on the biological properties of the PRGF technology. Clotting time and platelet activation of PRGF was evaluated. The latter was performed by flow cytometry. PRGF growth factor content and the release of various biomolecules by gingival fibroblasts were quantified by enzyme-linked immunosorbent assay. Cell proliferation was evaluated by means of a fluorescence-based method and cell migration was performed on culture inserts. None of the parameters evaluated was modified by the consumption of any of the three drugs tested; only the plasma of patients who had consumed acetylsalicylic acid and acenocumarol expressed greater gingival fibroblast migration compared to plasma control. The intake of acetylsalicylic acid, acenocumarol and glucosamine sulfate does not alter the preparation and biological properties of the autologous technology of PRGF.
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    • "Warfarin, which acts by antagonizing the effect of vitamin K, is one of the most commonly used oral anticoagulants. The drug can be absorbed completely and reaches its peak in 1 hour after ingestion.1 Albumin is bound to circulating warfarin, and the half-life of warfarin is approximately 36 hours.2 "
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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.
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    • "They further stated that the benefit of continued aspirin therapy to prevent thromboembolic event clearly outweighs the risk of increased bleeding episode. This is a Class-I recommendation based on Level of Evidence B [68]. "
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    ABSTRACT: Cardiac patients on aspirin therapy may require extractions for their diseased teeth. It is a common practice among physicians and treating surgeons to stop aspirin prior to tooth extraction because of fear of bleeding complications. This practice often predisposes the patient to adverse thromboembolic events. This practice is based on theoretical risk of bleeding and on isolated case reports of excessive bleeding with aspirin therapy. The current consensus and recommendations are in favor of continuing aspirin therapy during simple tooth extraction as the bleeding complication incidence is very less and if it occurs can be controlled efficiently with local hemostasis measures.
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