Ralph Rosenblum Jr. DDS, MHA
Patients taking oral anticoagulant therapy [OAT] did not experience a higher risk of post-operative bleeding compared to patients not on OAT or OAT patients who discontinue therapy following simple oral surgical procedures.
The findings suggest that it is not necessary to discontinue OAT for simple oral surgical procedures.
Would there be any increased risk of bleeding events in patients undergoing implant therapy and/or simple oral surgical procedures if OAT was not discontinued?
The authors searched four databases for English-language articles published between 1966 and 2008. The inclusion criteria were clinical trials, prospective and retrospective studies of patients on OAT undergoing simple oral surgery and reporting bleeding complications and/or thromboembolic events in the case of OAT modification. The exclusion criteria were case reports, studies on antiplatelet medications, and single expert recommendations.
Nineteen studies were included that reported outcomes after simple oral surgery procedures. Most procedures were dental extractions in patients on OAT and with an International Normalized Ratio [INR] of 2-4. Five studies were randomized controlled trials [RCTs], eleven were controlled clinical trials [CCTs], and three were prospective case series. Studies examined bleeding outcomes for patients on OAT, patients for whom OAT was temporarily discontinued and patients who had never used OAT. All of the tested postoperative hemostatic strategies [application of tranexamic acid mouthwashes, gelatine sponges and cellulose gauzes] in the three groups were effective in controlling any post-operative bleeding that did occur. The resulting heterogeneity prevented any possible data aggregation and synthesis, allowing only a descriptive analysis of the selected studies.
There is good evidence that simple oral surgical procedures can be performed in a patient population taking OAT without discontinuing the OAT. Local hemostatic measures appear to be adequate.
Source of Funding:
Importance and Context:
Dentists frequently encounter patients taking OAT who require simple oral surgical procedures. It is unclear whether the risk of difficult to control postoperative bleeding is great enough to contemplate temporary discontinuation of OAT therapy with the attendant increased risk of thromboemboli. This information can provide clinical guidance in that decision process. Another recently published SR has arrived at the same conclusions: Nematullah A, Alabousi A, Blanas N, Douketis J, Sutherland S. Dental surgery for patients on anticoagulant therapy with warfarin: a systemic review and meta-analysis JCDA 2009; 75: 41-41i.
Strengths and Weaknesses of the Systematic Review:
The search strategy and methods were appropriate and the analysis focused on clinically relevant outcomes of the studies, principally differences in postoperative bleeding rates and the control of any bleeding that did occur. Although the title implies that the systematic review dealt with the influence of OAT on oral implant therapy, all data provided relate only to simple oral surgical procedures. The authors recommended that drugs that may increase bleeding tendencies, aspirin and other NSAIDs, and antibiotics that can potentiate the anticoagulant effect of OAT be avoided prior to these procedures.
Strengths and Weaknesses of the Evidence:
There were five studies that were RCTs, 11 that were CCTs, and three that were prospective case series. Because the study designs were heterogeneous the results could not be combined through a meta-analysis. The results of the studies, however, all supported the main conclusion that there is not a higher occurrence of peri-and postoperative bleeding following simple oral surgical procedures in patients on OAT when the appropriate hemostatic measures are implemented.
Implications for Dental Practice:
Dentists with patients needing simple oral surgical procedures who are taking OAT may not need to discontinue the OAT for successful hemostatic outcomes.