Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants

doi:10.1016/j.oooo.2013.07.026

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Volume 116, Issue 6, December 2013, Pages 709-716

https://doi.org/10.1016/j.oooo.2013.07.026 Get rights and content

Objective

The aims were (1) to search the scientific literature from 2007 to 2012 for guidelines and new studies on the dental management of patients using oral antithrombotic medication; (2) to summarize the articles' evidence and recommendations; and (3) to propose an updated clinical practice guideline for general dentists.

Study Design

A systematic literature search in MEDLINE, Embase, and the Guideline websites, from October 2007 to October 2012, produced articles that were critically evaluated.

Results

The systematic literature search for guidelines yielded 74 citations (MEDLINE, 45; Embase, 22; and the Guideline websites, 7). Of these, only 2 guideline publications and 2 systematic reviews met the inclusion criteria. They yielded 32 recommendations.

Conclusions

The evidence and subsequent recommendations from published guidelines all point in the same direction: do not interrupt oral antithrombotic medication, not even dual antiplatelet therapy, in simple dental procedures.

Section snippets

Methods

We used the search strategies from our previous systematic search for guidelines on invasive dental treatment in patients using OAM (as described and published in 2009¹⁷) to obtain additional guidelines, systematic reviews, and randomized controlled trials (RCTs) published between October 2007 and October 2012 (Tables I and II). We searched MEDLINE, Embase, and the Guideline websites (the National Guideline Clearinghouse [www.guidelines.gov], the Scottish Intercollegiate Guidelines Network [//www.sign.ac.uk

Results

The systematic literature search for guidelines from October 2007 to October 2012 yielded 74 citations (MEDLINE, 45; Embase, 22; and the Guideline websites, 7) (see Tables I and II). Of these, only 2 guideline publications met the inclusion criteria.20, 21 Furthermore, one systematic review and meta-analysis was published in 2009 on dental procedures in patients using warfarin, which reviewed all studies that appeared until June 2008.²² Napenas et al.²³ performed a systematic review on dental

Discussion and Conclusions

Since the publication in 2007 of 2 evidence-based guidelines in the United Kingdom and the United States,18, 19 some additional evidence has emerged from 2 guideline publications, one systematic review on antiplatelet therapy and dental procedures,²³ and one meta-analysis on procedures in patients using VKAs.²² Both systematic reviews conclude in concordance with the earlier published guidelines, stating that “continuing the regular dose of warfarin therapy does not seem to confer an increased

References (35)

M.J. Wahl
Myths of dental surgery in patients receiving anticoagulant therapy
J Am Dent Assoc
(2000)
M.T. Brennan et al.
Aspirin and bleeding in dentistry: an update and recommendations
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2007)
C. Scully et al.
Oral surgery in patients on anticoagulant therapy
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2002)
D.E. van Diermen et al.
Dental management of patients using antithrombotic drugs: critical appraisal of existing guidelines
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2009)
D.J. Aframian et al.
Management of dental patients taking common hemostasis-altering medications
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2007)
J.D. Douketis et al.
Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012)
J.J. Napenas et al.
Review of postoperative bleeding risk in dental patients on antiplatelet therapy
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2013)
D.E. van Diermen et al.
Treating dental patients who use oral antithrombotic medication: a survey of dentists in the Netherlands
J Am Dent Assoc
(2011)
D.E. van Diermen et al.
Survey response of oral and maxillofacial surgeons on invasive procedures in patients using antithrombotic medication
Int J Oral Maxillofac Surg
(2013)
F.J. Firriolo et al.
Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients
Oral Surg Oral Med Oral Pathol Oral Radiol
(2012)

J.W. Little

New oral anticoagulants: will they replace warfarin?

Oral Surg Oral Med Oral Pathol Oral Radiol

(2012)

S.R.K. Seshasai et al.

Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials

Arch Intern Med

(2012)

K.L. Furie et al.

Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

Stroke

(2010)

C. Baigent et al.

Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials

Lancet

(2009)

F. Dentali et al.

Combined aspirin-oral anticoagulant therapy compared with oral anticoagulant therapy alone among patients at risk for cardiovascular disease: a meta-analysis of randomized trials

Arch Intern Med

(2007)

M.J. Wahl

Dental surgery in anticoagulated patients

Arch Intern Med

(1998)

G. Piersma-Wichers

[Coagulation disorders: risk factors for bleeding at dental procedures]

Ned Tijdschr Tandheelkd

(1998)

Cited by (70)

Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications
2024, Journal of Oral and Maxillofacial Surgery
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.
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.
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.
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 dentoalveolar surgery postoperative bleeding in patients taking direct oral anticoagulants and vitamin K antagonists: A prospective observational study
2024, Journal of Cranio-Maxillofacial Surgery
The aim of this study was to evaluate whether direct oral anticoagulants (DOAC) and vitamin K antagonists (VKA) increase the risk of postoperative bleeding after dentoalveolar surgery. Patients were classified into two groups: one taking DOAC and the other taking VKA with a therapeutic INR range. The control group comprised non-anticoagulated subjects. Participants were matched regarding dentoalveolar procedure. The primary predictor was anticoagulant status. The primary outcome was postoperative bleeding. The DOAC group comprised 77 patients, while the VKA group and control group each consisted of 103 participants. In each group, 103 dentoalveolar surgical procedures were conducted. Postoperative bleeding was recorded in 3/103 (2.9%), 5/103 (4.8%), and 1/103 (0.97%) occasions in the DOAC, VKA, and control groups, respectively, without significant difference (χ²; p = 0.54). The fully adjusted odds ratio for postoperative bleeding was 0.14 (CI 0.01–1.61; p = 0.05) for patients taking DOAC and 0.19 (CI 0.02–1.65; p = 0.285) for those taking VKA compared with non-anticoagulated controls. In conclusion, there was no increase in risk for clinically significant postoperative bleeding after dentoalveolar surgery in patients taking DOAC or VKA compared with non-anticoagulated subjects. Dentoalveolar surgery in patients taking DOAC and VKA can be performed safely without therapy cessation.
The study was registered at Clinicaltrials.gov (NCT04505475).
Society of Defence Anaesthesiologists review and recommendations for the provision of anaesthesia for elective dental procedures in various echelons of dental care
2024, Medical Journal Armed Forces India
Oral diseases are a burden for developing countries such as India where owing to socioeconomic conditions cost is a factor in selecting the type of treatment. Dental care in India is provided at various levels of care including standalone clinics run by individual dental surgeons, multi-speciality dental centres providing specialist care under one roof including paediatric, prosthodontics, and so on and dental centres affiliated with hospitals having facilities for provision of operation theatre and anaesthesia services. Most dental procedures are performed as day-care procedures requiring local anaesthetics, oral, or moderate intravenous sedation and anxiolytics while maxillofacial procedures are carried out in a controlled operation theatre setting. Dental procedures are fraught with risks due to shared oral surgical space and airway leading to reduced field of visibility to dentists especially with the usage of supplementary oxygenation devices, mouth props, and so on. Various dental societies have proposed minimum standards of care for provision of anaesthesia to various dental procedures; however, there are no extant guidelines in our country. The authors propose these guidelines for provision of minimal sedation (anxiolysis) and moderate sedation/analgesia for various day care dental procedures at various levels of care, keeping the aim that no patient’s life is endangered during provision of anaesthesia services at all dental locations.
Risk of postoperative bleeding following dental extractions in patients on antithrombotic treatment
2021, Saudi Dental Journal
The risk of bleeding after dental extractions in patients taking antithrombotic medication is not well known. This study aims to investigate the incidence of postoperative bleeding following dental extractions in adult patients taking antithrombotic medication in Saudi Arabia.
This retrospective study included 539 patients aged 18–93 years who attended 840 appointments for dental extractions from January 2012 to June 2016 at a tertiary care hospital in Saudi Arabia. Patients who returned with a complaint of bleeding were treated with local hemostatic measures as outpatients.
Results and Conclusion: Only 1.7% of extraction appointments were associated with postoperative bleeding. The highest risk of bleeding was noted in patients receiving warfarin (3.88%), whereas those on clopidogrel had no significant risk of bleeding. Women were found to have the highest rate of bleeding, particularly those on newer oral anticoagulant medications.
Dental extractions can be safely done in adults receiving antithrombotic treatment, provided established guidelines are followed; therefore, dental professionals must exercise caution when planning invasive dental treatment for patients on continued antithrombotic therapy.
The Dentoalveolar Surgical Patient: Perioperative Principles Based on Contemporary Controversies
2020, Oral and Maxillofacial Surgery Clinics of North America
Citation Excerpt :
Van Diermen and colleagues26 recommend discussion with the patient’s physician if the INR is greater than 3.5 and complicated oral surgery is planned. Other studies did not confirm the association of increased risk of bleeding and a high INR.26 Bajkin and colleagues27 studied 54 patients with INR values between 3.5 and 4.2 who had up to 3 teeth extracted and recorded postoperative bleeding at 3.7% (2/54).
Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature
2020, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
This literature review was performed to assess the risk of bleeding in dental implantation procedures in patients taking antiplatelet drugs (APs), oral anticoagulants (OACs) and direct oral anticoagulants (DOACs).
MEDLINE and SCOPUS databases were searched for English language publications through October 2019, using the keywords “dental implants,” “dental implantation,” “anticoagulants,” “platelet aggregation inhibitors,” and “hemorrhage.” Reference lists of relevant articles were also hand searched. Collected data regarding dental implantation procedures, type of medications (APs, OACs and DOAC), and postoperative bleeding episodes were analyzed.
Nine studies were included in the review. Postoperative bleeding occurred in 10 (2.2%) of 456 of cases involving dental implant placements; in all of those cases, bleeding was controlled with the use of local hemostatic agents. The bleeding incidence in patients on antiplatelet medications was 0.4% (range 1 of 253 to 1 of 261). Among those taking oral anticoagulants, the bleeding incidence was 5.7% (range 6 of 105 to 6 of 113), and among those on direct oral anticoagulants, the bleeding incidence was 3.3% (3 of 90). The numbers of more extensive surgical procedures (i.e., sinus lift and bone augmentation procedures) were small, and additional information regarding the surgery, the specific antithrombotic used, or bleeding was often not provided, so further analysis was not possible.
Evidence supports continuing OACs, DOACs, or APs during dental implant surgery.

View all citing articles on Scopus

View full text

Oral medicineManagement recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants

Objective

Study Design

Results

Conclusions

Section snippets

Methods

Results

Discussion and Conclusions

J Am Dent Assoc

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Chest

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Am Dent Assoc

Int J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol

Oral Surg Oral Med Oral Pathol Oral Radiol

Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials

Arch Intern Med

Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

Stroke

Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials

Lancet

Combined aspirin-oral anticoagulant therapy compared with oral anticoagulant therapy alone among patients at risk for cardiovascular disease: a meta-analysis of randomized trials

Arch Intern Med

Dental surgery in anticoagulated patients

Arch Intern Med

[Coagulation disorders: risk factors for bleeding at dental procedures]

Ned Tijdschr Tandheelkd

Oral medicine
Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants