GUIDELINES FOR THE MANAGEMENT OF PATIENTS ON ORAL ANTICOAGULANTS & ANTIPLATELET THERAPY REQUIRING ORAL SURGERY

MURAJA ALDOORIOMFS

12/11/15

The risks of bleeding associated with oral surgery in individuals not receiving oral anticoagulants is approximately 1%

WAHL MJ. MYTHS OF DENTAL SURGERY IN PATIENTS RECEIVING ANTICOAGULANT THERAPY. J AM DENT ASSOC 2000; 131(1):77–81.

Wahl reviewed 26 papers- meta analysis 2014 oral surgery procedures ( single extraction,

full mouth clearance, alveoloplasties) 771 patients, INR up to 4.0, some had INR over 4 Continued warfarin 98% no serious bleeding using local measures 12 (1.3%) had uncontrolled bleeding 4/12 their INR was above 4 at surgery time

8/2014- 3 had INR above therapeutic after surgery 2 had placebo rinse many times post surgery 3 unexplained No deaths

DEVANI P, LAVERY KM, HOWELL CJ. DENTAL EXTRACTIONS IN PATIENTS ON WARFARIN: ISALTERATION OF ANTICOAGULANT REGIME NECESSARY? BR J ORAL MAXILLOFAC SURG1998;36(2):107-11.

randomized 65 patients, 133 dental extractions

G1: stop warfarin 2-3 days prior to surgery (INR dropped from 2.6 to 1.6)

G2: continue anticoagulants (INR 2.2 to 3.9) All patients received ‘Surgicel’ packing and

sutures Results: None had immediate bleeding 1 from each G had delayed bleeding that was

controlled by local measures

AL-MUBARAK S, RASS MA, ALSUWYED A, ALABDULAALY A, CIANCIO S.THROMBOEMBOLIC RISK AND BLEEDING IN PATIENTS MAINTAINING OR STOPPING ORAL ANTICOAGULANT THERAPY DURING DENTAL EXTRACTION. J THROMB HAEMOST 2006;4(3):689-91.

Randomised 168 patients on warfarin four groups: no socket suturing with or

without discontinuation of warfarin (INR 1.8) socket suturing with or without

discontinuation of warfarin (INR 2.6) Results: 12 % bled in 3rd group who had suturing 36 % bled in 4th group who didn’t have

sutures Clinically the difference was not significant

and no surgical management was done

SACCO R, SACCO M, CARPENEDO M, MOIA M. ORAL SURGERY IN PATIENTS ON ORAL ANTICOAGULANT THERAPY: A RANDOMIZED COMPARISON OF DIFFERENT INR TARGETS. J THROMB HAEMOST 2006;4(3):688-9.

Randomized 131 patients on anticoagulants 551 extractions, each patient had 4 extractions G1 Reduce their warfarin dose 72 hours (INR mean

1.7) G2 Continue anticoagulants with no alteration but

using hemostatic measures (INR mean 2.9), surgicel and TA

All had sutures 10 pt in G1 bled 6 pt in G2 bled Summ: it is not necessary to reduce OAT in oral

surgery, and local hemostatic measures is sufficient

ZANON E, MARTINELLI F, BACCI C, CORDIOLI G, GIROLAMI A. SAFETY OF DENTALEXTRACTION AMONG CONSECUTIVE PATIENTS ON ORAL ANTICOAGULANT TREATMENT MANAGED USING A SPECIFIC DENTAL MANAGEMENT PROTOCOL. BLOOD COAGUL FIBRINOLYSIS 2003;14(1):27-30.

Prospective study 515 patients undergoing oral surgery

250 pt receives OAT (INR 1.8 to 5), local hemostasis: surgicel, sutures, TA

265 pt not receiving OAT (control group) G1 had 4 pt bleeding G2 had 3 pt bleeding When anticoagulated group was stratified according

to INR (1.8-2, 2-3 and 3-5) bleeding were seen in 1.2%, 1.3% and 4.8% of patients respectively

This difference was not significantly different

BRITISH COMMITTEE FOR STANDARDS IN HAEMATOLOGY BCSH (2011)

Recommendations:

The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4, is low. The risk of thrombosis if anticoagulants are discontinued may be increased. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient oral surgery. An appreciation of the surgical skills particularly when INR levels approach 4, is also important when assessing the risk of bleeding. Individuals, in whom the INR is unstable, should be discussed with their anticoagulant management team

Recommendations:

For patients stably anticoagulated on warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their anticoagulant regimen

RECOMMENDATIONS The risk of bleeding may be minimised by: a. The use of oxidised cellulose (Surgicel) or

collagen sponges and sutures b. 5% tranexamic acid mouthwashes used

four times a day for 2 days. For patients who are stably anticoagulated

on warfarin, a check INR is recommended 72 hours prior to oral surgery

5. Patients taking warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesia following surgery

THE AMERICAN COLLEGE OF CHEST PHYSICIANS (2013) continuing warfarin with co-administration of an

oral prohemostatic agent or stopping warfarin 2 to 3 days before the procedure.

Four prospective studies were cited, In each of the four studies cited, oral surgery in patients who were taking anticoagulants was compared with patients whos anticoagulation was reduced or interrupted. Although there were no embolic complications in any of these patients, there were also no bleeding complications requiring more than local measures for hemostasis. The incidence of bleeding was the same in both the anticoagulation continuation and interruption groups in each study, and the authors of each of the four studies concluded that anticoagulation should not be interrupted for oral surgery.

Campbell JH , Alvarado F , Murray RA . Anticoagulation and minor oral surgery: should the anticoagulation regimen be altered? J Oral Maxillofac Surg . 2000 ; 58 ( 2 ): 131 - 135 .

Devani P , Lavery KM , Howell CJT . Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary? Br J Oral Maxillofac Surg . 1998 ; 36 (2): 107 - 111 .

Gaspar R , Brenner B , Ardekian L , Peled M , Laufer D . Use of tranexamic acid mouthwash to prevent postoperative bleeding in oral surgery patients on oral anticoagulant medication . Quintessence Int . 1997 ; 28 ( 6 ): 375 - 379 .

Blinder D , Manor Y , Martinowitz U , Taicher S . Dental extractions in patients maintained on oral anticoagulant therapy: comparison of INR value with occurrence of postoperative bleeding . Int J Oral Maxillofac Surg . 2001 ; 30 ( 6 ): 518 - 521 .

In summary, local hemostatic measures are almost always sufficient for oral surgery in patients on warfarin, with no long-term sequelae. In contrast, thromboembolic events occurring in patients with warfarin interruption are much more likely to result in permanent disability or death.

We, therefore, respectfully suggest that the option for alteration of warfarin therapy should be eliminated for minor oral surgery and reserved only for the most invasive oral surgical procedures in which a significant amount of blood loss is anticipated (eg, orthognathic surgery).

Antiplatelet therapy

Some physicians assume there is little or no risk of serious thrombotic complications in patients whose antiplatelet therapy is interrupted for dental procedures, but in large case-control studies of patients on low-dose aspirin, strokes or myocardial infarctions were significantly more likely to occur in those whose antiplatelet therapy was interrupted for any reason

Garcia Rodríguez LA, Cea Soriano L, Hill C, Johansson S. Increased risk of stroke after discontinuation of acetylsalicylic acid: a UK primary care study. Neurology 2011;76(8):740-6.

Garcia Rodríguez LA, Cea-Soriano L, Hill C, Martin-Merino E, Johansson S. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. Brit Med J 2011;343:d4094.

MEDEIROS FB, DEANDRADE AC, ANGELIS GA ET AL. 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 2011;69(12):2949-55.

63 patients with CAD on ASA therapy, 100mg/day Group S, ASA suspended 7days prior Group NS, ASA continued Same surgeon and unaware The mean volume of bleeding was 12.10 ± 9.37

mL in Gs 16.38 ± 13.54 mL in Gns Sum: There was no difference in the amount of

bleeding that occurred during tooth extraction between patients who continued ASA therapy versus patients who suspended their ASA therapy

NAPENAS JJ, HONG CH, BRENNAN MT, FURNEY SL, FOX PC, LOCKHART PB. THE FREQUENCY OF BLEEDING COMPLICATIONS AFTER INVASIVE DENTAL TREATMENT IN PATIENTS RECEIVING SINGLE AND DUAL ANTI-PLATELET THERAPY. J AM DENT ASSOC. 2009;140(6):690-5.

retrospective study 43 pts (single or dual antiplatelet)

Invasive surgical procedures concluded that there is negligible risk of

bleeding complications after invasive surgical procedures in patients taking single or dual anti-platelet therapy

CANIGRAL A, SILVESTRE FJ, CANIGRAL G, ALOS M, GARCIA-HERRAIZ A, PLAZA A. EVALUATION OF BLEEDING RISK AND MEASUREMENT METHODS IN DENTAL PATIENTS. MED ORAL PATHOL ORAL CIR BUCAL. 2010;15(6):E863-E868.

simple and complex (surgical and multiple teeth extractions)

aspirin or clopidogrel or aspirin + clopidogrel or non-steroidal anti-inflammatory drugs (NSAIDs) or low molecular weight heparin (LMWH) therapy

(92%), bleeding was mild which subside within 10 minutes with the help of gauze pressure

8% cases of bleeding, it was described as moderate, which was easily controlled by local hemostatic measures

Sum: safety of oral surgery in patients on continued anti-thrombotic therapy

HEMELIK M, WAHL G, KESSLER B. TOOTH EXTRACTION UNDER MEDICATION WITH ACETYLSALICYLIC ACID. MUND KIEFER GESICHTSCHIR. 2006;10(1):3-6.

151 tooth extractions in 65 patients , 100 mg/day aspirin

postoperative bleeding was 1.54% bleeding episodes were handled easily concluded that there is no need to stop 100

mg/day aspirin prior to dental extractions.

MADAN GA, MADAN SG, MADAN G, MADAN AD. MINOR ORAL SURGERY WITHOUT STOOPING DAILY LOW-DOSE ASPIRIN THERAPY: A STUDY OF 51 PATIENTS. J ORAL MAXILLOFAC SURG. 2005;63(9):1262-5.

- simple & surgical extractions and implant placement- 51 Patients on Aspirin 75- 100 mg/day

- Suturing and pressure pack for 30 minute was used as hemostatic measure in all the cases

- 1 pt showed excessive bleeding intra-operatively which was easily managed by pressure pack soaked in 1% ferracrylum solution

- no postoperative bleeding in any case - authors concluded that most oral surgical

procedures can be carried out safely without interrupting long term low-dose aspirin therapy

M.-W. PARK, S.-H. HER, J. B. KWON ET AL., “SAFETY OF DENTAL EXTRACTIONS IN CORONARY DRUG-ELUTING STENTING PATIENTS WITHOUT STOPPING MULTIPLE ANTIPLATELET AGENTS,” CLINICAL CARDIOLOGY, VOL. 35, NO. 4, PP. 225–230, 2012.

prospective clinical study 59 patients were on dual aspirin (100 or 200 mg/day) +

clopidogrel 75 mg/day 41 patients were on triple antiplatelet therapy (aspirin

100 or 200 mg/day plus clopidogrel 75 mg/day plus cilostazol 100 mg/day).

100 patients not taking any antiplatelet agents served as control group.

Only 3 pts exhibited post-operative bleeding (1 on dual, 1 on triple anti-platelet therapy and 1 not taking any anti-platelet drug).

All the episodes of bleeding were easily controlled by pressure application by patients themselves. The authors concluded that dental extractions can be performed safely in patients on multiple antiplatelet agents

GAURAV V ET AL. ASPIRIN THERAPY AND EXODONTIA: REVIEW OF LITERATURE . ANNALS OF DENTAL RESEARCH . 2014

Based on the review of literature, it can be concluded that current recommendations and consensus are in favor of continuing anti-platelet dose of aspirin prior to tooth extraction. The safety of dental extractions in such patients is supported by studies reported in literature. It must be emphasized that appropriate use of local hemostatic measures should always be considered whenever indicated. There is no justification to predispose the patient to the risk of thromboembolism at the expense of minor bleeding which can be easily controlled

C. L. GRINES, R. O. BONOW, D. E. CASEY JR. ET AL., “PREVENTION OF PREMATURE DISCONTINUATION OF DUAL ANTIPLATELET THERAPY IN PATIENTS WITH CORONARY ARTERY STENTS: A SCIENCE ADVISORY FROM THE AMERICAN HEART ASSOCIATION, AMERICAN COLLEGE OF CARDIOLOGY, SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS, AMERICAN COLLEGE OF SURGEONS, AND AMERICAN DENTAL ASSOCIATION, WITH REPRESENTATION FROM THE AMERICAN COLLEGE OF PHYSICIANS,” CIRCULATION, VOL. 115, NO. 6, PP. 813–818, 2007

A consensus opinion from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association

recommended either continuing aspirin and clopidogrel therapy for minor oral surgical procedures in patients who have coronary artery stents or delaying treatment until prescribed regimen will be completed

ORAL MEDICINE AND ORAL SURGERY FRANCOPHONE SOCIETY. MANAGEMENT OF PATIENTS UNDER ANTI-PLATELET AGENTS’ TREATMENT IN ODONTOSTOMATOLOGY. (11 JUNE 2007).

Oral Medicine and Oral Surgery Francophone Society conducted a literature review and gave recommendations for management of patients on antiplatelet therapy based on the agreement among professionals in the field. The society stated that interruption of antiplatelet therapy prior to dental procedures is unnecessary. The risk of bleeding is very low and local hemostatic measures are usually successful

The American Dental association Division of Legal Affairs has stated that “the oral surgeon who blindly follows the physician’s recommendation, even though it conflicts with the oral surgeon professional judgment, will not be able to defend himself or herself by claiming ‘the devil made me do it’ if the patient sues. The courts recognize that each independent professional is ultimately responsible for his or her own treatment decisions

There have been at least four separate cases of embolic complications (two fatal) after physician consultation and anticoagulation interruption.45 In other words, the surgeon consulted the physician, who recommended interruption of warfarin before the oral surgery. The patients in each of these cases suffered strokes, and two died. A lawsuit was filed in each case. In these cases, there was no reason to interrupt therapeutic levels of anticoagulation for dental extractions and certainly no reason for the surgeon to ask the patient’s physician to consider such an interruption (although there may have been a reason to consult with the physician to determine the patient’s INR levels).

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