Anticoagulation Use prior to Common Dental Procedures: A Systematic Review

Johnny Chahine,Samer Nasr,Marwan N Khoudary

doi:10.1155/2019/9308631

Abstract

Currently, the number of patients on oral anticoagulation is increasing. There is a paucity of data regarding maintaining oral anticoagulation (especially novel oral anticoagulants) around the time of specific dental procedures. A dentist has three options: either to stop anticoagulation, to continue it, or to bridge with heparin. A systematic review of 10 clinical trials was conducted to address this issue. It was found that continuing anticoagulation during dental procedures did not increase the risk of bleeding in most trials. Although none of the studies reported a thromboembolic event after interruption of anticoagulation, the follow-up periods were short and inconsistent, and the heightened thromboembolic risk when stopping anticoagulation is well known in the literature. Heparin bridging was associated with an increased bleeding incidence. We recommend maintaining oral anticoagulation with vitamin K antagonists and novel oral anticoagulants for the vast majority of dental procedures along with the use of local hemostatic agents.

Highlights

In the case of a surgical procedure, three possibilities are available: first to maintain warfarin, second to interrupt it, and third to withhold it and to do heparin bridging before the procedure
Concerning novel oral anticoagulants (NOACs), a four-year cross-sectional study showed no significant bleeding when continuing anticoagulation with dental procedures, regardless of the invasiveness of the procedure [7]. e analysis of the RE-LY trial revealed that no significant differences in bleeding and thromboembolic complications exist between dabigatran and warfarin [8]
Most studies consisted of two groups: the first had oral anticoagulation continued during the dental procedure, the other had it stopped a few days before, with or without bridging with heparin

Summary

Introduction

In the case of a surgical procedure, three possibilities are available: first to maintain warfarin, second to interrupt it, and third to withhold it and to do heparin bridging before the procedure. Concerning NOACs, a four-year cross-sectional study showed no significant bleeding when continuing anticoagulation with dental procedures, regardless of the invasiveness of the procedure [7]. Because there is not enough data available regarding NOACs, the American Dental Association suggests continuing anticoagulation for the vast majority of dental procedures unless the patient is at a very high risk of bleeding, when a physician referral might be appropriate before the procedure [13]. While maintaining anticoagulation with VKAs during dental interventions, the postoperative bleeding risk might be reduced by adopting local hemostatic measures. The data on VKAs are quite extensive and knowing that the bleeding risk in patients on NOACs might be higher, we are attempting a review of the literature of both VKAs and NOACs in the setting of a dental procedure. Rather than dividing the dental procedures largely into mild, moderate, and high risk of bleeding, we will attempt the evaluation of the risk of bleeding periprocedurally with specific dental procedures

Methods

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Discussion

Conclusion