Dental management of patients receiving anticoagulant and/or antiplatelet treatment

Abstract

Introduction: 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. Objectives: 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. Material and Methods: 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. Results and Conclusions: 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.

Dental implant surgery in patients in treatment with the anticoagulant oral rivaroxaban

“…Nevertheless, it can be assumed that rivaroxaban patients who are to undergo surgery or other invasive procedures are subject to higher risks of hemorrhage (Mingarro‐de‐León et al. ). For this reason, surgical interventions may require temporary interruption of rivaroxaban administration, assessing the risk of thromboembolic phenomena that suspending anticoagulant treatment might occasion.…”

Anticoagulant therapy and its impact on dental patients: a review

“…3,10,28 Minor bleeding following a procedure may be managed with local measures, such as mechanical pressure, haemostatic agents and suturing. 3,10,28,29 If bleeding continues and does not respond to local measures, or if there is spontaneous bleeding, urgent medical attention is required, with consideration of referral to a tertiary centre for bleeding control. 10,36 Due to the evolving management guidelines associated with dealing with major haemorrhage, a specialized service (e.g.…”

“…Haemostasis may be achieved with local measures such as mechanical pressure, haemostatic agents (such as Gelfoam TM or Surgicel TM ), suturing and tranexamic acid mouthwash. 3,10,[28][29][30] Procedures which are associated with an increased risk of bleeding, such as surgical extractions, multiple extractions, more complex oral surgery, or head and neck cancer surgery, require a multidisciplinary approach preoperatively, and may require cessation of anticoagulant medications before surgery. 5,28 The time period of cessation of NOAC therapy is dependent on each patient's renal function, but there remains significant variability between authors.…”

“…27 Cessation of anticoagulant therapy is not usually advised, as the risk of catastrophic embolism after anticoagulant suspension far outweighs the risk of increased bleeding from extraction wounds. 5,10,[28][29][30] Warfarin has an established management protocol, where the only indication to delay treatment is if the INR is more than 4.0. 31 The recent introduction of the NOACs means that there have been limited randomized control trials at this point in time, and only generalized management protocols have been established.…”

Medical Management of Patients Undergoing Dentoalveolar Surgery

“…12 During surgical procedures involving high bleeding risk (multiple extractions, operations lasting>45 minutes, head and neck cancer surgery), the recommendation is to suspend the medication 2 to 3 days before the operation and consider bridging or switching to subcutaneous heparin or Lovenox. 13 Medication should be reintroduced after 24 hours, provided good hemostasis has been achieved. 14 The current idea for patients taking rivaroxaban (Xarelto), and apixaban (Eliquis) is to discontinue these medications, in the case of high surgical bleeding risk, 2 to 3 days before the procedure.…”