Management of dental extraction in patients undergoing anticoagulant treatmentResults from a large, multicentre, prospective, case-control study
24 February 2010
Accepted after major revision: 02 July 2010
24 November 2017 (online)
Following favourable results from a previous study, a large, multicentre, prospective, case-control study was performed to further assess the incidence of bleeding complications after dental extraction in patients taking oral anticoagulant therapy (OAT). Four hundred fifty-one patients being treated with warfarin who required dental extraction were compared with a control group of 449 non-anticoagulated subjects undergoing the same procedure. In the warfarin-treated group, the oral anticoagulant regimen was maintained unchanged, such that the patients had an International Normalised Ratio ranging between 1.8 and 4, and local haemostatic measures (i.e. fibrin sponges, silk sutures and gauzes saturated with tranexamic acid) were adopted. All the procedures were performed in an outpatient setting. Seven bleeding complications occurred in the OAT group and four in the control group; the difference in the number of bleeding events between the two groups was not statistically significant (OR=1.754; 95% CI 0.510 – 6.034; p=0.3727). No post-operative late bleeds requiring hospitalisation and/or blood transfusions were recorded, and the adjunctive local haemostatic measures were adequate to stop the bleeding. The results of our protocol applied in this large, multicenter study show that dental extractions can be performed easily and safely in anticoagulated out-patients without any modification of the ongoing anticoagulant therapy, thus minimising costs and reducing discomfort for patients.
- 1 Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. J Am Dent Assoc 2000; 131: 77-81.
- 2 Pavek V, Bigl P. Stomatological treatment of patients with artificial heart valves: coagulation control and antibiotic cover. Int Dent J 1993; 43: 59-61.
- 3 Mulligan R, Weitzel KG. Pretreatment management of the patients receiving anticoagulation drugs. J Am Dent Assoc 1988; 117: 479-483.
- 4 Troulis MJ, Head TW, Lecter JR. Dental extraction in patients on oral anticoagulant: a survey of practices in north America. J Oral Maxillofac Surg 1998; 56: 914-917.
- 5 DeClerck D, Vinkier F, Vermylen J. The influence of anticoagulation on blood loss following dental extraction. J Dent Res 1992; 71: 387-390.
- 6 Gaspar R, Brenner B, Ardekian L. et al. Use of tranexamic acid mouthwash to prevent postoperative bleeding in oral surgery patients on oral anticoagulant medication. Quintessence Int 1997; 28: 375-379.
- 7 Devani P, Lavery KM, Howell CJ. Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?. Br J Oral Maxillofac Surg 1998; 36: 107-111.
- 8 Bailey BMW, Fordyce AM. Complications of dental extraction in patients receiving warfarin anticoagulant therapy: a controlled clinical trial. Br Dent J 1983; 155: 308-310.
- 9 Ramstrom G, Sindet-Pedersen S, Hall G. et al. Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 1993; 51: 1211-1216.
- 10 Sindet-Pedersen S, Ramstrom G, Bernvil S. et al. Hemostatic effect of tranexamic acid mouthwash in anticoagulant-treated patients undergoing oral surgery. N Engl J Med 1989; 320: 840-843.
- 11 Wahl MJ. Dental surgery in anticoagulated patients. Arch Int Med 1998; 158: 1610-1616.
- 12 McIntyre H. Management, during dental surgery, of patients on anticoagulants. Lancet 1966; 02: 99-100.
- 13 Nematullah A, Alabousi A, Blanas N. et al. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis. J Can Dent Assoc 2009; 75: 41.
- 14 Brewer AK. Continuing warfarin therapy does not increased risk of bleeding for patients undergoing minor dental procedures. Evid Based Dent 2009; 10: 52.
- 15 Prisco D, Baudo F, Moia M. et al. Terapia anticoagulante orale, chirurgia e manovre invasive. Raccomandazioni della fcsa per la task force della fcsa su Anti-coagulazione, Chirurgia e manovre invasive. November 2005. Available at: http://www.fcsa.it/sito2008/raccomandazioni/FCSAchirurgiaDefinitiva.pdf Available at: Accessed June 30, 2010.
- 16 Perry DJ, Nokes TJC, Heliwell PS. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. British Committee for Standards in Haematology. September 2007. http://www.bcshguidelines.com/pdf/WarfarinandOralSurgery26407.pdf Accessed June 30, 2010.
- 17 Linnebur SA, Ellis SL, Astroth JD. Educational practices regarding anticoagulation and dental procedures in U.S. dental schools. J Dent Educ 2007; 71: 296-303.
- 18 Perry DJ, Noakes TJ, Helliwell PS. British Dental Society.. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Dent J 2007; 203: 389-393.
- 19 Salam S, Yusuf H, Milosevic A. Bleeding after dental extractions in patients taking warfarin.
- 20 Br J Oral Maxillofac Surg 2007; 45: 463-466.
- 21 Zanon E, Martinelli F, Bacci C. et al. Safety of dental extraction among consecutive patients on oral anticoagulant treatment managed using a specific dental management protocol. Blood Coagul Fibrinolysis 2003; 14: 27-30.
- 22 Borea G, Montebugnoli L, Capuzzi P. et al. Tranexamic acid as a mouthwash in anticoagulant-treated patients undergoing oral surgery. Oral Surg Oral Pathol Oral Med 1993; 75: 29-31.
- 23 Halfpenny W, Fraser JS, Adlam DM. Comparison of 2 hemostatic agents for the prevention of postextraction haemorrhage in patients on anticoagulants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92: 257-259.
- 24 Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M. et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association Circulation 2007; 116: 1736–1754. Erratum in: Circulation 2007; 116: e376-377.
- 25 Ferrieri GB, Castiglioni S, Carmagnola D. et al. Oral surgery in patients on anticoagulant treatment without therapy interruption. J Oral Maxillofac Surg 2007; 65: 1149-1154.
- 26 Benoliel R, Leviner E, Katz J, Tzukert A. Dental treatment for patients on anticoagulant therapy: prothrombin time value. Oral Surg Oral Med Oral Pathol 1986; 62: 149-152.
- 27 Al-Mubarak S, Al-Ali N, Abou-Rass M, Al-Sohail A, Robert A, Al-Zoman K. et al. Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy. Br Dent J 2007; 203: E15 discussion 410-411.
- 28 Scully C, Wolff A. Oral surgery in patients on anticoagulant therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94: 57-64.