Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Clinical Oral Investigations
Published in: Clinical Oral Investigations 6/2021

01-06-2021 | Tooth Extraction | Review

Is alteration in single drug anticoagulant/antiplatelet regimen necessary in patients who need minor oral surgery? A systematic review with meta-analysis

Authors: Thayanne Barbosa Brasil Calcia, Harry Juan Rivera Oballe, Alice Maria de Oliveira Silva, Stephanie Anagnostopoulos Friedrich, Francisco Wilker Mustafa Gomes Muniz

Published in: Clinical Oral Investigations | Issue 6/2021

Login to get access

Abstract

Objective

This study aimed to systematically review literature about the effect of alteration of the pharmacological regimen in adult patients using anticoagulants or antiplatelets who need minor oral surgery.

Material and methods

A search strategy was performed in three databases—PubMed-Medline, Scopus, and Embase—and included randomized clinical trials (either parallel or crossover), involving individuals under anticoagulant or antiplatelet therapy who underwent oral surgeries. Studies comprised two groups: those who stopped their medication prior to the dental procedure (control) or those who did not (test). Meta-analyses were conducted for the pooled risk ratio (RR) between the groups. Subgroup analyses were performed for anticoagulant and antiplatelet therapies.

Results

Thirteen studies were included. It was found that patients who did not stop therapy had 157% higher intraoperative bleeding occurrences (95%CI: 1.40–4.71). In the subgroup analysis, warfarinazed patients showed significantly higher occurrences of intraoperative bleeding when compared with the control (RR: 1.79; 95%CI: 1.00–3.21). Conversely, there was no statistically significant difference in postoperative bleeding between the groups (RR: 0.81; 95%CI: 0.54–1.22; p = 0.42).

Conclusion

Minor oral surgeries can be safely performed in patients under antiplatelets or anticoagulants without drug regimen modification. Because these patients tend to bleed more during procedures, use of local hemostatic measures is strongly advised.

Clinical relevance

Management of patients under antiplatelet or anticoagulant drugs is still challenging in clinical practice. However, clinicians may perform minor oral surgeries safely without changing the pharmacological regimen. Use of local hemostatic measures is strongly advised during these procedures.
Literature
1.
Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L (2018) 2018 Focused update of the Canadian Cardiovascular Society Guidelines for the management of atrial fibrillation. Can J Cardiol 34:1371–1392PubMedCrossRef
2.
Bajkin BV, Vujkov SB, Milekic BR, Vuckovic BA (2015) Risk factors for bleeding after oral surgery in patients who continued using oral anticoagulant therapy. J Am Dent Assoc 146:375–381PubMedCrossRef
3.
4.
Andras A, Sala Tenna A, Stewart M (2017) Vitamin K antagonists versus low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism. Cochrane Database Syst Rev 7:CD002001PubMed
5.
Akin M, Schäfer A, Akin I, Widder J, Brehm M (2015) Use of new oral anticoagulants in the treatment of venous thromboembolism and thrombotic prophylaxis. Cardiovasc Hematol Disord Drug Targets 15:92–96PubMedCrossRef
6.
Shi Q, Xu J, Zhang T, Zhang B, Liu H (2017) Post-operative bleeding risk in dental surgery for patients on oral anticoagulant therapy: a meta-analysis of observational studies. Front Pharmacol 8:58PubMedPubMedCentralCrossRef
7.
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R (2012) Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e326S–e350SPubMedPubMedCentralCrossRef
8.
Bacci C, Maglione M, Favero L, Perini A, Di Lenarda R, Berengo M et al (2010) Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicentre, prospective, case-control study. Thromb Haemost 104:972–975PubMedCrossRef
9.
Medeiros FB, de Andrade AC, Angelis GA, Conrado VC, Timerman L, Farsky P et al (2011) Bleeding evaluation during single tooth extraction in patients with coronary artery disease and acetylsalicylic acid therapy suspension: a prospective, double-blinded, and randomized study. J Oral Maxillofac Surg 69:2949–2955PubMedCrossRef
10.
Engelen ET, Schutgens RE, Mauser-Bunschoten EP, van Es RJ, van Galen KP (2018) Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions. Cochrane Database Syst Rev 7:CD012293PubMed
11.
Jimson S, Amaldhas J, Kannan I, Parthiban J (2015) Assessment of bleeding during minor oral surgical procedures and extraction in patients on anticoagulant therapy. J Pharm Bioallied Sci 7(Suppl 1):S134–S137PubMedPubMedCentral
12.
Clark NP, Douketis JD, Hasselblad V, Schulman S, Kindzelski AL, Ortel TL, BRIDGE Investigators (2018) Predictors of perioperative major bleeding in patients who interrupt warfarin for an elective surgery or procedure: analysis of the BRIDGE trial. Am Heart J 195:108–114PubMedCrossRef
13.
Davis C, Robertson C, Shivakumar S, Lee M (2013) Implications of Dabigatran, a direct thrombin inhibitor, for oral surgery practice. J Can Dent Assoc 79:d74PubMed
14.
Della Valle A, Sammartino G, Marenzi G, Tia M, Espedito di Lauro A, Ferrari F et al (2003) Prevention of postoperative bleeding in anticoagulated patients undergoing oral surgery: use of platelet-rich plasma gel. J Oral Maxillofac Surg 61:1275–1278PubMedCrossRef
15.
Wahl MJ (2000) Myths of dental surgery in patients receiving anticoagulant therapy. J Am Dent Assoc 131:77–81PubMedCrossRef
16.
Ardekian L, Gaspar R, Peled M, Brener B, Laufer D (2000) Does low-dose aspirin therapy complicate oral surgical procedures? J Am Dent Assoc 131:331–335PubMedCrossRef
17.
Weltman NJ, Al-Attar Y, Cheung J, Duncan DP, Katchky A, Azarpazhooh A et al (2015) Management of dental extractions in patients taking warfarin as anticoagulant treatment: a systematic review. J Can Dent Assoc 81:f20PubMed
18.
Chinnaswami R, Bagadia RK, Mohan A, Kandaswamy E, Chandrasekaran D (2017) Dentists’ knowledge, attitude and practice in treating patients taking oral antithrombotic medications - a survey. J Clin Diagn Res 11:ZC88–ZC91PubMedPubMedCentral
19.
Lombardi N, Varoni EM, Sorrentino D, Lodi G (2020) International normalized ratio (INR) values in patients receiving oral vitamin K antagonists and undergoing oral surgery: a clinical audit. Spec Care Dentist 40:374–381PubMedCrossRef
20.
Hatzis GP (2013) Protocol for the management of oral surgery patients on warfarin utilizing a Point-of-Care In-Office international normalized ratio monitoring device. Open J Stomatol 3:35013
21.
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898PubMedCrossRef
22.
Duygu G, Ozcakir-Tomruk C, Guler N, Sencift K (2010) Assessment of effects of antiplatelet drugs on bleeding risk after teeth extractions. Biotechnol Biotechnol Equip 24:2040–2043CrossRef
23.
Shah KA, Patel MA, Tatu R, Patel V (2013) Relationship between use of aspirin and post-extraction bleeding time: a single blind study. Adv Hum Biol 3:28
24.
Varghese KG, Manoharan S, Sadhanandan M (2015) Evaluation of bleeding following dental extraction in patients on long-term antiplatelet therapy: a clinical trial. Indian J Dent Res 26:252–255PubMedCrossRef
25.
Eapen BV, Baig MF, Avinash S (2017) An assessment of the incidence of prolonged postoperative bleeding after dental extraction among patients on uninterrupted low dose aspirin therapy and to evaluate the need to stop such medication prior to dental extractions. J Maxillofac Oral Surg 16:48–52PubMedCrossRef
26.
27.
Devani P, Lavery KM, Howell CJ (1998) Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary? Br J Oral Maxillofac Surg 36:107–111PubMedCrossRef
28.
Campbell JH, Alvarado F, Murray RA (2000) Anticoagulation and minor oral surgery: should the anticoagulation regimen be altered? J Oral Maxillofac Surg 58:131–135 discussion 5-6PubMedCrossRef
29.
Al-Mubarak S, Al-Ali N, Abou-Rass M, Al-Sohail A, Robert A, Al-Zoman K et al (2007) Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy. Br Dent J 203:E15 discussion 410-1PubMedCrossRef
30.
Evans IL, Sayers MS, Gibbons AJ, Price G, Snooks H, Sugar AW (2002) Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg 40:248–252PubMedCrossRef
31.
Ahmed I, Younis M, Shah AA (2019) Extraction in patients on oral anticoagulant therapy with and without stopping the drug: a comparative study. J Maxillofac Oral Surg 18:555–558PubMedPubMedCentralCrossRef
32.
Dinkova A, Daskalov H (2020) Safety of teeth extractions in patients on Acenocoumarol therapy. J of IMAB 26:3039–3044
33.
Aldous JA, Olson CJ (2001) Managing patients on warfarin therapy: a case report. Spec Care Dentist 21:109–112PubMedCrossRef
34.
Caliskan M, Tükel HC, Benlidayi ME, Deniz A (2017) Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants? Med Oral Patol Oral Cir Bucal 22:e767–e773PubMedPubMedCentral
35.
Doganay O, Atalay B, Karadag E, Aga U, Tugrul M (2018) Bleeding frequency of patients taking ticagrelor, aspirin, clopidogrel, and dual antiplatelet therapy after tooth extraction and minor oral surgery. J Am Dent Assoc 149:132–138PubMedCrossRef
36.
Cervino G, Fiorillo L, Monte IP, De Stefano R, Laino L, Crimi S et al (2019) Advances in antiplatelet therapy for dentofacial surgery patients: focus on past and present strategies. Materials (Basel) 12(9):1524CrossRef
37.
Wahl MJ (2018) The mythology of anticoagulation therapy interruption for dental surgery. J Am Dent Assoc 149:e1–e10PubMedCrossRef
38.
Queiroz SI, Alves HS, de Assis GM, Conceicao TS, Germano AR, da Silva JS (2016) An evaluation of the efficacy of local hemostatic measures in dental patients taking oral anticoagulants: a critical review of the literature over the past two decades. Curr Clin Pharmacol 11:230–240PubMedCrossRef
39.
Tello-Montoliu A, Jover E, Rivera J, Valdés M, Angiolillo DJ, Marín F (2012) New perspectives in antiplatelet therapy. Curr Med Chem 19:406–427PubMedCrossRef
40.
Lu SY, Lin LH, Hsue SS (2018) Management of dental extractions in patients on warfarin and antiplatelet therapy. J Formos Med Assoc 117:979–986PubMedCrossRef
41.
Amer MZ, Mourad SI, Salem AS, Abdelfadil E (2014) Correlation between International Normalized Ratio values and sufficiency of two different local hemostatic measures in anticoagulated patients. Eur J Dent 8:475–480PubMedPubMedCentralCrossRef
42.
Aframian DJ, Lalla RV, Peterson DE (2007) Management of dental patients taking common hemostasis-altering medications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103 Suppl:S45.e1–S45.11
43.
Kataoka T, Hoshi K, Ando T (2016) Is the HAS-BLED score useful in predicting post-extraction bleeding in patients taking warfarin? A retrospective cohort study. BMJ Open 6:e010471PubMedPubMedCentralCrossRef
44.
Douketis JD (2011) Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood 117:5044–5049PubMedCrossRef
Metadata
Title
Is alteration in single drug anticoagulant/antiplatelet regimen necessary in patients who need minor oral surgery? A systematic review with meta-analysis
Authors
Thayanne Barbosa Brasil Calcia
Harry Juan Rivera Oballe
Alice Maria de Oliveira Silva
Stephanie Anagnostopoulos Friedrich
Francisco Wilker Mustafa Gomes Muniz
Publication date
01-06-2021
Publisher
Springer Berlin Heidelberg
Published in
Clinical Oral Investigations / Issue 6/2021
Print ISSN: 1432-6981
Electronic ISSN: 1436-3771
DOI
https://doi.org/10.1007/s00784-021-03882-z

Other articles of this Issue 6/2021

Clinical Oral Investigations 6/2021 Go to the issue

Original Article

Influence of different endodontic sealers on bond strength of fiber posts to weakened roots after resin restoration

Original Article

Objective assessment of simulated non-carious cervical lesion by tridimensional digital scanning

Review

The influence of zirconia veneer thickness on the degree of conversion of resin-matrix cements: an integrative review

Original Article

Compressive force strengthened the pro-inflammatory effect of zoledronic acid on il-1ß stimulated human periodontal fibroblasts

Original Article

Clinical, radiographic, and histological evaluation of three different pulp-capping materials in indirect pulp treatment of primary teeth: a randomized clinical trial

Original Article

Alteration of the oral microbiota may be a responsible factor, along with estrogen deficiency, by the development of larger periapical lesions