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Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review

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Abstract

Objective

The interruption of antithrombotics prior to tooth removal because of the fear of bleeding or following postoperative bleeding increases the risk of thromboembolic events. The aim of this systematic review was to investigate which local haemostatic measures can effectively prevent postoperative bleeding in patients continuing oral antithrombotics.

Methods

A systematic review was conducted by running a search in PubMed, Embase, Web of Science and Cochrane Library. Clinical randomised trials investigating bleeding and haemostatics after tooth removal in patients on antithrombotics were identified.

Results

In total, 15 articles were included. The investigated haemostatics included gauze pressure, tranexamic acid-soaked gauze, sponges, glue, calcium sulfate, plant extract Ankaferd Blood Stopper, epsilon-aminocaproic acid and tranexamic acid. In patients treated with vitamin K antagonists, tranexamic acid mouthwash significantly reduced bleeding compared to placebo. Further, histoacryl glue was proven better than gelatin sponges. Other studies failed to show significant differences between haemostatics, but bleeding events were low.

Conclusions

Tranexamic acid seems to effectively reduce bleeding, although its superiority to other haemostatics was not proven. In view of the rapidly changing landscape of antithrombotics and the lack of standardization of bleeding outcome, adequately powered clinical studies are required to optimise postoperative management in patients on antithrombotics.

Clinical relevance

In order to optimise postoperative management, the best haemostatics over different patient groups have to be identified and implemented in guidelines.

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References

  1. Baron TH, Kamath PS, McBane RD (2013) Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 368:2113–2124. https://doi.org/10.1056/NEJMra1206531

    Article  Google Scholar 

  2. Wahl MJ, Pinto A, Kilham J, Lalla RV (2015) Dental surgery in anticoagulated patients--stop the interruption. Oral Surg Oral Med Oral Pathol Oral Radiol 119:136–157. https://doi.org/10.1016/j.oooo.2014.10.011

    Article  PubMed  Google Scholar 

  3. Wahl MJ (1998) Dental surgery in anticoagulated patients. Arch Intern Med 158:1610–1616. https://doi.org/10.1001/archinte.158.15.1610

    Article  PubMed  Google Scholar 

  4. Carter G, Goss AN, Lloyd J, Tocchetti R (2003a) Current concepts of the management of dental extractions for patients taking warfarin. Aust Dent J 48:89–96

    Article  PubMed  Google Scholar 

  5. Santhosh K (2016) Local hemostatic agents in the management of bleeding in oral surgery. Asian J Pharm Clin Res 9:35–41

    Article  Google Scholar 

  6. Queiroz SIML, Alves HS, de Assis GM, Conceicao TS, Germano AR, da Silva JSP et al (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 11:230–240. https://doi.org/10.2174/1574884711666161003163217

    Article  PubMed  Google Scholar 

  7. Gurgel Costa FW, Rodrigues RR, de Sousa LH, Rodrigues Carvalho FS, Chaves FN, Fernandes CP et al (2013) Local hemostatic measures in anticoagulated patients undergoing oral surgery. A systematized literature review. Acta Cir Bras 28:78–83. https://doi.org/10.1590/S0102-86502013000100013

    Article  Google Scholar 

  8. Miclotte I, Vanhaverbeke M, Agbaje JO, Legrand P, Vanassche T, Verhamme P, Politis C (2017) Pragmatic approach to manage new oral anticoagulants in patients undergoing dental extractions: a prospective case-control study. Clin Oral Investig 21:2183–2188. https://doi.org/10.1007/s00784-016-2010-1

    Article  PubMed  Google Scholar 

  9. Higgings J, Altman D, Gotsche P, Jüni P, Moher D, Oxamn A (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ Open 343:d5928. https://doi.org/10.1136/bmj.d5928

    Article  Google Scholar 

  10. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. https://doi.org/10.1186/2046-4053-4-1 Accessed 2 februari 2018

  11. Viswanathan M, Ansari M, Berkman N (2012) Assessing the risk of bias of individual studies in systematic reviews of health care interventions. In: Methods guide for effectiveness and comparative effectiveness reviews. Rockville (MD): Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK91433/. Accessed 2 Feb 2018

  12. Sammartino G, Marenzi G, Miro A, Ungaro F, Nappi A, Sammartino JC, Quaglia F, Mortellaro C (2012) Local delivery of the hemostatic agent tranexamic acid in chronically anticoagulated patients. J Craniofac Surg 23:e648–e652. https://doi.org/10.1097/SCS.0b013e318271055dS

    Article  PubMed  Google Scholar 

  13. Cakarer S, Eyupoglu E, Gunes CO, Kuseoglu BG, Berberoglu HK, Keskin C (2013) Evaluation of the hemostatic effects of Ankaferd blood stopper during dental extractions in patients on antithrombotic therapy. Clin Appl Thromb 19:96–99. https://doi.org/10.1177/1076029611435836

    Article  Google Scholar 

  14. Al-Belasy FA, Amer MZ (2003) Hemostatic effect of n-butyl-2-cyanoacrylate (histoacryl) glue in warfarin-treated patients undergoing oral surgery. J Oral Maxillofac Surg 61:1405–1409. https://doi.org/10.1016/j.joms.2002.12.001

    Article  PubMed  Google Scholar 

  15. 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:E1–E5. https://doi.org/10.1038/bdj.2007.725

    Article  Google Scholar 

  16. Bajkin BV, Vujkov SBSB, Milekic BR, Vuckovic BA (2015) Risk factors for bleeding after oral surgery in patients who continued using oral anticoagulant therapy. J Am Dent Assoc 146:375–381. https://doi.org/10.1016/j.adaj.2015.01.017

    Article  PubMed  Google Scholar 

  17. Halfpenny W, Fraser JS, Adlam DM (2001) Comparison of 2 hemostatic agents for the prevention of postextraction hemorrhage in patients on anticoagulants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 92:257–259. https://doi.org/10.1067/moe.2001.115463

    Article  PubMed  Google Scholar 

  18. Scarano A, Sinjari B, Murmura G, Mijiritsky E, Iaculli F, Mortellaro C, Tetè S (2014) Hemostasis control in dental extractions in patients receiving oral anticoagulant therapy: an approach with calcium sulfate. J Craniofac Surg 25:843–846. https://doi.org/10.1097/SCS.0000000000000824

    Article  PubMed  Google Scholar 

  19. Souto JC, Oliver A, Zuazu-Jausoro I, Vives A, Fontcuberta J (1996) Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: a prospective randomized study. J Oral Maxillofac Surg 54:27–32. https://doi.org/10.1016/S0278-2391(96)90297-9

    Article  PubMed  Google Scholar 

  20. Bajkin BV, Selakovic SD, Mirkovic SM, Sarcev IN, Tadic AJ, Milekic BR et al (2014) Comparison of efficacy of local hemostatic modalities in anticoagulated patients undergoing tooth extractions. Vojnosanit Pregl 71:1097–1101. https://doi.org/10.2298/VSP1412097B

    Article  PubMed  Google Scholar 

  21. Blinder D, Manor Y, Martinowitz U, Taicher S, Hashomer T (1999) Dental extractions in patients maintained on continued oral anticoagulant: comparison of local hemostatic modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:137–140. https://doi.org/10.1016/S1079-2104(99)70106-X

    Article  PubMed  Google Scholar 

  22. Bajkin BV, Popovic SL, Selakovic SDJ (2009) Randomized, prospective trial comparing bridging therapy using low-molecular-weight heparin with maintenance of oral anticoagulation during extraction of teeth. J Oral Maxillofac Surg 67:990–995. https://doi.org/10.1016/j.joms.2008.12.027

    Article  PubMed  Google Scholar 

  23. Ramström G, Sindet-Pedersen S, Hall G, Blombäck M, Alander U (1993) Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 51:1211–1216

    Article  PubMed  Google Scholar 

  24. Carter G, Goss A (2003) Tranexamic acid mouthwash—a prospective randomized study of a 2-day regimen vs 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions. Int J Oral Maxillofac Surg 32:504–507. https://doi.org/10.1054/ijom.2002.0414

    Article  PubMed  Google Scholar 

  25. Carter G, Goss A, Lloyd J, Tocchetti R (2003b) Tranexamic acid mouthwash versus autologous fibrin glue in patients taking warfarin undergoing dental extractions: a randomized prospective clinical study. J Oral Maxillofac Surg 61:1432–1435. https://doi.org/10.1016/j.joms.2003.01.001

    Article  PubMed  Google Scholar 

  26. Soares ECS, Costa FWG, Bezerra TP, Nogueira CBP, de Barros Silva PG, Batista SHB, Sousa FB, Sá Roriz Fonteles C (2015) Postoperative hemostatic efficacy of gauze soaked in tranexamic acid, fibrin sponge, and dry gauze compression following dental extractions in anticoagulated patients with cardiovascular disease: a prospective, randomized study. Oral Maxillofac Surg 19:209–216. https://doi.org/10.1007/s10006-014-0479-9

    Article  PubMed  Google Scholar 

  27. Borea G, Montebugnoli L, Capuzzi P, Magelli C (1993) Tranexamic acid as a mouthwash in anticoagulant-treated patients undergoing oral surgery. An alternative method to discontinuing anticoagulant therapy. Oral Surg Oral Med Oral Pathol 75:29–31. https://doi.org/10.1016/0030-4220(93)90401-O

    Article  PubMed  Google Scholar 

  28. Gaspar R, Brenner B, Ardekian L, Peled M, Laufer D (1997) Use of tranexamic acid mouthwash to prevent postoperative bleeding in oral surgery patients on oral anticoagulant medication. Quintessence Int 28:375–379

    PubMed  Google Scholar 

  29. Ker K, Beecher D, Roberts I (2013) Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev 7:1–71. https://doi.org/10.1002/14651858.CD010562.pub2

    Article  Google Scholar 

  30. Sindet-Pedersen S (1987) Distribution of tranexamic acid to plasma and saliva after oral administration and mouth rinsing: a pharmacokinetic study. J Clin Pharmacol 27:1005–1008

    Article  PubMed  Google Scholar 

  31. Nematullah A, Alabousi A, Blanas N, Douketis J, Sutherland S (2009) Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis. J Can Dent Assoc 75:41–41i

    PubMed  Google Scholar 

  32. Yagyuu T, Kawakami M, Ueyama Y, Imada M, Kurihara M, Matsusue Y, Imai Y, Yamamoto K, Kirita T (2017) Risks of postextraction bleeding after receiving direct oral anticoagulants or warfarin: a retrospective cohort study. BMJ Open 7:e015952. https://doi.org/10.1136/bmjopen-2017-015952

    Article  PubMed  PubMed Central  Google Scholar 

  33. Jensen S (1974) Hemorrhage after oral surgery. Oral Surg 37:2–16

    Article  PubMed  Google Scholar 

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Funding

The work was supported by the Department of Oral and Maxillofacial Surgery, Imaging & Pathology, University of Leuven, Belgium.

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Authors and Affiliations

  1. OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000, Leuven, Belgium

    Anna Ockerman, Laura-Lien Poortmans, Constantinus Politis & Reinhilde Jacobs

  2. Department of Oral & Maxillofacial Surgery, University of Leuven, Leuven, Belgium

    Anna Ockerman & Isabel Miclotte

  3. Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium

    Maarten Vanhaverbeke, Peter Verhamme & Thomas Vanassche

  4. Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden

    Reinhilde Jacobs

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  1. Anna Ockerman
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Correspondence to Reinhilde Jacobs.

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The authors declare that they have no conflict of interest.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Appendix 1: Search strategies conducted in the different databases

Appendix 1: Search strategies conducted in the different databases

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Ockerman, A., Miclotte, I., Vanhaverbeke, M. et al. Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review. Clin Oral Invest 23, 1695–1708 (2019). https://doi.org/10.1007/s00784-018-2576-x

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