The management of patients on anticoagulation therapy is challenging, teeth extractions and coumadin. The objective of this study was to conduct a systematic review to establish the effectiveness of hemostatic interventions to prevent postoperative bleeding following dental extractions among patients taking warfarin.
Identified studies were screened independently by 2 reviewers using the following selection criteria: Six articles were included in the final review, teeth extractions and coumadin, all evaluating different interventions. Oral or local hemostatic agents were compared in 4 studies where patients continued taking warfarin before and after the procedure; in 3 studies, there were no differences between the agents in preventing postoperative bleeding and, in teeth extractions and coumadin, Histoacryl glue was superior to a gelatin sponge.
Two studies compared warfarin continuation with temporary discontinuation and found that continuation did not increase the risk of bleeding in patients who had an international normalized ratio INR within the therapeutic range. Patients with an INR within the therapeutic range teeth extractions and coumadin safely continue taking the regular dose of warfarin before dental extractions. There is no evidence to support or reject the superiority of local hemostatic agents over warfarin discontinuation.
Current management of dental extractions in patients on anticoagulation therapy is still a challenging and controversial area for dental professionals. The perceived risk of bleeding among these patients is usually weighed annual learning plan for teachers the risk of thromboembolic events, both of which could have severe consequences, teeth extractions and coumadin.
Warfarin, a vitamin K antagonist, remains the most commonly prescribed oral anticoagulant for the prevention and treatment of thromboembolic events, teeth extractions and coumadin. A systematic review and meta-analysis of 5 randomized controlled trials RCTs concluded that continuing the regular dose of warfarin does not increase the risk of bleeding during minor dental procedures compared with altering or discontinuing the dose.
In contrast, the latest guideline from the American College of Chest Physicians recommended, teeth extractions and coumadin, for patients undergoing minor dental procedures, teeth extractions and coumadin, "continuing VKAs [vitamin K antagonists] with coadministration of an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies," a weak recommendation based on low- or very low-quality evidence grade 2C.
In dental patients, a variety of oral and local hemostatic agents, such as tranexamic acid oral rinse, cellulose and gelatin foams, applied locally, have been used as physical matrices to aid clotting initiation.
Considering the evolving clinical recommendations and the existing gap in the literature, the objective of this study was to conduct such a review to establish the effectiveness of hemostatic interventions in preventing postoperative bleeding following dental extractions among patients taking warfarin.
We conducted a systematic review of the literature to determine which hemostatic interventions considering both the use of hemostatic agents and warfarin discontinuation are effective in preventing postoperative bleeding in patients taking warfarin, who are undergoing dental extractions.
Patients taking warfarin and undergoing tooth extraction s. Studies of patients taking forms of anticoagulant medication other than or in addition to warfarin, undergoing oral surgical procedures other than extractions or having an increased bleeding tendency because of chronic liver or renal disease or genetic bleeding disorders were excluded. Discontinuation of warfarin, any hemostatic agent including but not limited to tranexamic acid mouthwash, Histoacryl glue, gelatin sponges, resorbable cellulose meshes, resorbable sutures, autologous fibrin glue and commercial fibrin adhesives.
Postoperative bleeding following tooth extraction and outcomes of bleeding events. This was done with the help of a University of Toronto research librarian. Articles were retrieved by combining database-specific search terms for warfarin, bleeding or hemorrhage, specific hemostatic agents and hemostatic agents in general and tooth extraction.
The search was then limited to RCTs and human studies. At all stages — review of title, review of abstract, full-text review, assessment of quality and data abstraction — each study was assessed independently by 2 reviewers 4 reviewers in total: When deemed necessary, the team contacted the corresponding authors of the published articles.
We assessed the quality of the trials included in the final review using the Cochrane Risk of Bias Tool. Then, we teeth extractions and coumadin a judgement of the risk of bias high, low or unclear to each domain.
Information retrieved from each selected study included sample size, demographic data age and genderINR values at baseline, number of teeth extracted per patient, description of the hemostatic interventions, outcomes data and conclusions. The plan was to conduct a meta-analysis to evaluate the effectiveness of hemostasis if any of the studies compared similar hemostatic agents. After removing duplicates, our search identified 95 potentially relevant studies Fig.
A review of titles and abstracts eliminated 85 studies, resulting in 10 articles for a full-text review. Four additional studies were excluded at this stage. The third 16 teeth extractions and coumadin not specify which type of anticoagulant treatment patients were taking.
Hence, 6 studies were included in this research synthesis. We identified 2 potentially relevant systematic reviews closely related to the topic. In this review, the hemostatic agents were not the main focus and were described as "co-interventions.
Patients were using warfarin exclusively in only 3 of these studies, 24 2 of which were also identified in our search and were included in our systematic review. Blinding was the single domain where all studies had a high risk of bias Table 2. A low risk of bias was assigned to domains that evaluated completeness of outcome data, selective reporting and other sources of bias. Compared interventions and study outcomes are summarized in Table 3.
Oral or local agents were compared in 4 studies ,23 where patients continued taking warfarin before and after the procedure. Two studies 17,22 compared warfarin continuation with temporary discontinuation. In general, all 6 studies compared different interventions.
This heterogeneity in treatment modalities precluded us from conducting a meaningful meta-analysis. The study by Al-Belasy and Amer enrolled patients in experimental, control and negative control i. The authors concluded that patients taking warfarin can safely undergo dental extractions without any change of regimen if an effective local hemostatic agent, such as Histoacryl glue, teeth extractions and coumadin, is used. Studies by Carter and Goss 20 and Carter et al. The first study 20 randomly assigned patients to a 5-day or a 2-day regimen of 4.
Minor bleeding was observed in only 3 patients and there were no significant differences between the groups. The second study 21 compared a 7-day regimen of 4. Minor bleeds were observed in only 2 patients in the autologous fibrin glue group, with no significant differences among the groups. Both studies concluded that the compared interventions were similarly effective, teeth extractions and coumadin. After extraction, sockets were dressed with 1 of the hemostatic agents and then sutured with softgut.
Bleeding was observed in 3 patients in total: The low bleeding rate did not allow statistical testing of the difference. The authors concluded that both treatments were equally effective in preventing bleeding after dental extractions. The study by Evans et al. Two patients in the warfarin continuation group required a hospital visit to stop the bleeding. The study by Al-Mubarak et al. The observed bleeding rate on the first postoperative day was slightly but not significantly higher in the 2 groups that continued warfarin compared with the groups that discontinued warfarin treatment.
Bleeding rates significantly diminished ultrasound and throat cancer day 7 with no significant differences among the groups on any of the postoperative days.
Suturing did not play any role, and wound healing was similar across the groups. All bleeding events were described as "of the mild transient type. Optimal management strategies for patients taking oral anticoagulants and undergoing dental procedures have been discussed extensively in the past.
Although these studies rated highly in terms of quality of evidence, we identified some risks of bias. The most significant source of potential bias was the lack of blinding. The role of patient blinding was crucial in these studies, as bleeding was first reported by patients and then reviewed by treating doctors, if necessary. Although blinding patients to duration of tranexamic acid mouthwash use or to discontinuation of warfarin may seem to be impractical, it is still possible to achieve adequate blinding by using a placebo treatment.
Only 1 study reported blinding of outcome assessors, 17 and 1 reported partial blinding of personnel, teeth extractions and coumadin. Regular INR monitoring is part of the standard care for patients taking warfarin. INR was also actively monitored postoperatively.
Therefore, our findings are applicable only to patients whose INR is within the therapeutic range before dental extraction. This is in agreement with past clinical care pathways in oral surgery that have recommended measuring Teeth extractions and coumadin before the intervention and making a decision about continuation or discontinuation of the anticoagulant or the use of bridging therapy only afterwards.
The average number of dental extractions per patient varied from 1. However, past studies have not found an association between risk of bleeding and number of extracted teeth among patients on antithrombotic therapy. For example, teeth extractions and coumadin, extracting molars is generally more traumatic than extracting incisors and may lead to an increased risk of bleeding.
Similarly, complex extractions involving the raising of gingival flaps and bone removal may be associated with an increase in bleeding compared with simple extractions, teeth extractions and coumadin. Unfortunately, none of the reviewed studies reported this level of detail. The hemostatic agents teeth extractions and coumadin considering sutures compared in the studies were Histoacryl glue, 19 gelatin sponge, 19 4.
In only 1 study was a significant difference in postoperative bleeding observed: Histoacryl glue was found to be more effective than gelatin sponge. The availability and applicability of all these agents in Canada must be further considered. Similarly, tranexamic acid mouthwash is not readily available, is relatively expensive and largely relies on patient compliance as multiple mouth rinses are required.
Histoacryl glue is only effective for wounds in which the edges can be approximated, its use is technique sensitive an exothermic reaction may occur during polymerization and it may pose an occupational hazard for dental stress and skin cancer. Whether to discontinue warfarin therapy is a teeth extractions and coumadin of balancing the risk of thromboembolism associated with stopping warfarin with the risk of bleeding associated with continuing warfarin.
The perceived risk of bleeding has caused many clinicians, including dentists, to interrupt warfarin therapy before surgical interventions. In the reviewed studies, most bleeding occurred within 1 week of dental extraction, was minor in nature and teeth extractions and coumadin successfully treated with local measures.
In addition, no thromboembolic teeth extractions and coumadin was vitamin c and gum disease in any of the included studies.
Fatal or non-fatal thromboembolic events after a short-term withdrawal of warfarin have been reported in several past studies; the incidence of such events varied from 0. We acknowledge the limitations of our study.
The literature teeth extractions and coumadin was limited to 3 major medical databases and peer-reviewed publications. There could be a publication bias, where studies with negative results were not published. Considering that dental procedures, materials and accessibility may differ vastly in different parts of the world, a North American study would have added value to this review.
Finally, teeth extractions and coumadin, this review is limited to teeth extractions and coumadin who were taking warfarin only and does not consider the new generation of oral anticoagulants e. With the increasing global burden of atrial fibrillation 40 and stroke, 41 future research should address the management of patients undergoing tooth extraction whose INR values are above the therapeutic range.
In addition, teeth extractions and coumadin, future trials should compare the addition of a hemostatic agent to the current anticoagulant regimen with its discontinuation. Currently, warfarin is still the most widely used medication in patients who need continuous anticoagulation therapy. However, as the new oral anticoagulants are increasingly becoming part of the recommended standards of care, teeth extractions and coumadin, 37,42,43 new clinical trials should evaluate their impact on dental patient outcomes and their optimal management.
In conclusion, the results of our systematic review indicate that a patient whose INR is within the therapeutic range can safely continue taking the regular dose of warfarin.