Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: A prospective randomized study

doi:10.1016/S0278-2391(96)90297-9

Journal of Oral and Maxillofacial Surgery

Volume 54, Issue 1, January 1996, Pages 27-32

https://doi.org/10.1016/S0278-2391(96)90297-9 Get rights and content

Abstract

Purpose:This study assessed the risk associated with several schedules of perioperative treatment with coumadin in anticoagulated patients who underwent oral surgery.

$Patients and Methods:$ A prospective, randomized study compared bleeding complications with six perioperative schedules in 92 patients chronically treated with acenocoumarol. In three of the perioperative schedules, the dose was reduced before surgery and calcium heparin was added. In the other three, oral anticoagulation was not modified and heparin was not used. The groups also differed regarding the antifibrinolytic agents used and the postoperative measures applied.

$Results:$ Those schedules in which the oral anticoagulation was not modified preoperatively and an antifibrinolytic agent was applied locally both during and after surgery were not associated with a significantly higher odds ratio of bleeding complications than those in whom oral anticoagulation was reduced and calcium heparin was added preoperatively.

$Conclusions:$ In orally anticoagulated patients who undergo oral surgery, schedules that maintain the oral anticoagulant regimen and use local tranexamic acid as an antifibrinolytic agent postoperatively for 2 days are safe, simple, and less troublesome.

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Cited by (139)

Risk of bleeding in anticoagulated patients undergoing dental extraction treated with topical tranexamic acid compared to collagen-gelatin sponge: Randomized clinical trial
2023, Journal of Cranio-Maxillofacial Surgery
This two-arm, parallel-group, double-blind, randomized clinical trial design evaluated the risk of postoperative bleeding in anticoagulated patients undergoing dental extraction treated with topical TXA in comparison to collagen-gelatin sponge. Forty patients were randomly included in one of the study groups: (1) topical use of 4.8% TXA solution; and (2) resorbable hydrolyzed collagen-gelatin sponge applied to the surgical alveolus. Primary outcomes were postoperative bleeding episodes and secondary outcomes were thromboembolic events and postoperative INR values. The relative risk (RR), the absolute risk reduction (RAR) and the number needed to treat (NNT) were used as effect estimates and calculated from the counting of bleeding episodes observed during the first postoperative week. The bleeding rate under the TXA treatment was 22.2%, while in the collagen-gelatin sponge group it was 45.7%, resulting in a RR of 0.49 (95% CI 0.24–099; p = 0.046), RAR 23.5% and NNT 4.3. TXA was more effective in reducing bleeding in surgical sites located in the mandible (RR = 0.10; 95% CI 0.01–0.71; p = 0.021) and the posterior region (RR = 0.39; 95% CI 0.18–0.84; p = 0.016). Within the limitations of the study it seems that topical TXA is more effective in controlling bleeding after tooth extractions in anticoagulated patients than collagen-gelatin sponge.
RBR-83qw93.
Effectiveness of local hemostatic to prevent bleeding in dental patients on anticoagulation: A systematic review and network meta-analysis
2021, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
The study by Ramström et al. (1993) evaluated tooth extraction and surgically treated teeth, while Giuffrè et al. (2006) investigated tooth extraction and cystectomies. In the other studies, only surgeries for tooth extractions were reported (Souto et al., 1996; Blinder et al., 1999; Halfpenny et al., 2001; Al-Belasy and Amer, 2003; G Carter and Goss, 2003; Glen Carter et al., 2003; Al-Mubarak et al., 2007; Çakarer et al., 2013; Bajkin et al., 2014; Okamoto et al., 2014; Ripollés-de Ramón et al., 2014; Scarano et al., 2014; Soares et al., 2014; Pippi et al., 2015; Kumar et al., 2016; da Silva et al., 2018; Queiroz et al., 2018; Baldoni and Lauritano, 2019). The most used hemostatic type was TXA, followed by the gelatin sponge and fibrin hemostatic.
This study aimed to determine the effectiveness of hemostatic protocols to prevent bleeding in dental procedures among individuals undergoing oral anticoagulation therapy. A systematic review and network meta-analysis were accomplished. Searches of literature and grey literature were performed in different electronic databases. Clinical trials were considered as part of the inclusion criteria. Data extraction and assessment of the risk of bias of the included articles were performed. Assessment of the certainty of evidence was also performed. As results we find that the N-butyl-2-cyanoacrylate [RR -35.00 (95% CI - 107.12, −5.78)], calcium sulfate (CaSO₄) [RR -5.62 (95% CI -11.41, −1.03)], and tranexamic acid (TXA) [RR -3.46 (95% CI -7.63, −0.77)] showed beneficial effects compared to placebo. However, only TXA presented beneficial effects with moderate certainty evidence. N-butyl-2-cyanoacrylate and CaSO₄ presented very low certainty evidence. In the comparisons between the hemostatic agents, no differences were observed. For the mean bleeding time, no significant difference in the comparisons was observed as well. Concluding, bleeding events in individuals on oral anticoagulation decreased with the use of TXA compared to placebo. N-butyl-2-cyanoacrylate and CaSO₄ were also superior to placebo, but the certainty of evidence was low. For the mean bleeding time, no significant difference in hemostatic agents was observed.
Intra-alveolar epsilon-aminocaproic acid for the control of post-extraction bleeding in anticoagulated patients: randomized clinical trial
2018, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The aim of the present study was to assess the local efficacy of EACA in the control of bleeding after tooth extraction in warfarin-treated patients, without interference in anticoagulation. Only one study has assessed the use of EACA mouthwash in these patients; hence, the review presented herein focuses on articles in which TXA was used for the same purpose14. As just one immediate bleeding episode (1.4%) was observed in the intervention group, it was not possible to make a statistical comparison of this outcome with the control group.
The aim of this study was to compare the effectiveness of the intra-alveolar administration of epsilon-aminocaproic acid (EACA) and daily gentle rinsing with EACA mouthwash with that of routine postoperative procedures for the control of bleeding after tooth extraction in anticoagulated patients. A randomized clinical trial was conducted involving 52 patients submitted to 140 tooth extractions, assigned randomly to two groups. The intervention group was treated with intra-alveolar administration of EACA immediately after surgery and gentle rinsing with EACA mouthwash during the postoperative period. The control group received routine postoperative recommendations. A single episode of immediate bleeding occurred in the intervention group. Late bleeding episodes occurred in 23 procedures (16.4%): 11 (15.7%) in the intervention group and 12 (17.1%) in the control group. Among the patients with late bleeding, 18 (78.3%) events were classified as moderate and were controlled by the patient applying pressure to a gauze pack placed over the extraction socket. The remaining five cases (21.7%) required re-intervention. No statistically significant difference in the frequency of postoperative bleeding was observed between the groups. Thus, routine measures were as effective for the control of bleeding after simple tooth extractions in anticoagulated patients as the topical administration of EACA.
Supportive topical tranexamic acid application for hemostasis in oral bleeding events – Retrospective cohort study of 542 patients
2018, Journal of Cranio-Maxillofacial Surgery
Tranexamic acid (TXA) is widely used in the prevention of postsurgical oral bleeding. Tranexamic acid in addition to further surgical measures is widely utilized in prevention of post-surgical oral bleeding. The aim of the present study was to investigate: Can oral hemostasis be achieved by merely compression and topical application of tranexamic acid in different anticoagulant regimes among patients attending a general emergency department? Where are the limits to this procedure? Which has the greater impact on surgeons' choice for an invasive hemostatic approach—bleeding quality or oral anticoagulant therapy?
A retrospective cohort study of 542 patients who consecutively received treatment for oral bleeding was performed. We surveyed the values of the diverse hemostatic approaches. Special attention was granted to patient anticoagulant regimen and quality of the oral bleeding event.
A total of 199 of 542 (36.7%) oral bleeding events were stopped by compression with a gauze or gauze soaked with TXA (4.8%). Stopping an oral bleeding event with wound compression can be improved by factor 1.6 if the gauze is soaked with tranexamic acid (4.8%), p ≤ 0.05. LMWH presented significantly more moderate bleeding than bloody oozing of the wound, p < 0.05. The quality of bleeding had a strong influence on oral surgeons' decisions to apply further surgical means. Sutures and native collagen fleeces were the favored methods to stop moderate and severe bleeding (p < 0.05).
Topical application of TXA aids as a useful supportive tool to stop mild bleeding events such as the bloody oozing of an oral wound. The quality of an oral bleeding episode should be considered in the choice of hemostatic measure. Hemostatic approaches should begin with the least invasive procedure. TXA is a helpful tool.
Topical application of tranexamic acid in anticoagulated patients undergoing minor oral surgery: A systematic review and meta-analysis of randomized clinical trials
2017, Journal of Cranio-Maxillofacial Surgery
To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) investigating the efficacy and safety of topical tranexamic acid (TXA) to prevent postoperative bleeding in anticoagulated patients undergoing minor oral surgery.
We analyzed RCTs comparing the use of topical TXA versus other topical hemostatic agents or placebo solutions for minor oral surgeries. We assessed the risk of bias and strength of evidence according to the Cochrane guidelines and GRADE rating system, respectively. The pooled relative risk (RR) was calculated for the effect of topical application of TXA on postsurgical bleeding.
Five RCTs were included in the study. The combined RR for the number of patients receiving TXA in comparison to the control group was 0.13 (95% CI 0.05–0.36; P = 0.01), indicating a protective effect of topical TXA on bleeding after minor oral surgeries. Subgroup analysis revealed that topical TXA was effective in preventing postsurgical bleeding compared to placebo and epsilon-aminocaproic acid. No cases of thromboembolic events were reported.
Currently available evidence suggests that surgical site irrigation with TXA followed by mouthwash during the first postoperative week is safe and may reduce the risk of bleeding after minor oral surgeries in anticoagulated patients.
Is alteration of warfarin regimen necessary before dental extractions in Taiwanese patients? Results of a retrospective cohort study
2015, Journal of Dental Sciences
Most Western studies do not recommend interrupting warfarin therapy or replacing it with heparin prior to tooth extraction if the international normalized ratio (INR) levels are maintained. However, this issue remains controversial in Taiwan. The aim of this study was to investigate whether Taiwanese patients who had an INR within the therapeutic range required cessation of warfarin prior to dental extractions.
A total of 60 patients on warfarin with INR <4.0 who underwent 207 dental extractions in 70 occasions were divided into two groups. Thirty-two patients were allocated to the control group (warfarin stopped and switched to heparin under hospitalization) with average preoperative INR (range) from 2.30 (1.32–3.12) brought down to 1.14 (1.04–1.32), and 28 patients were allocated to the study group (warfarin continued) with an average preoperative INR of 1.95 (1.06–3.08).
The incidence of postoperative bleeding in the study group was higher (3/33, 9.1%) than in the control group (3/37, 8.1%), but this difference was not significant. Local hemostasis with Gelfoam sponge was sufficient in most patients. Postoperative hemorrhage can be successfully managed by repacking with Gelfoam impregnated with tranexamic acid powder in five patients and resuturing in one patient.
The study proved that dental extractions can be performed without interruption or alteration of warfarin regimen in Taiwanese patients, provided the INR is below 4.0. A sufficient hemostasis can be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin.

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Clinical articleOral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: A prospective randomized study

Abstract

Chest

Chest

Anticoagulation is necessary in all patients with mechanical prosthesis in sinus rhythm

Z Kardiol

Warfarin versus dipyridamol—aspirin and pentoxifylline—aspirine for the prevention of rosthetic heart valve thromboembolism: A prospective clinical trial

Circulation

Oral anticoagulant drugs

N Engl J Med

Bleeding associated with antithrombotic therapy

Influence of anticoagulation on blood loss following dental extraction

J Dent Res

Clinical reports on dental extraction from patients undergoing oral anticoagulant therapy

Bull Tokyo Dent Coll

Control of gingival emorrhage in hemophilic patients by inhibition of fibrinolysis with tranexamic acid

J Periodont Res

Clinical article
Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: A prospective randomized study