Oral surgery in patients taking anticoagulant therapy

Abstract

To the Editor:—In his letter to the editor in the September issue of the Journal of Oral and Maxillofacial Surgery (J Oral Maxillofac Surg 61:1117, 2003), Dr Todd draws attention to the debate on oral surgery in patients who are taking oral anticoagulant therapy and to literature in support of reducing or stopping anticoagulant therapy. However, most opinions in the literature on this subject are based on retrospective studies, case reports, or anecdotal experience that, as Dr Todd demonstrates, can easily be challenged. Research that complies with evidence-based standards leads to safe and effective treatment and the randomized controlled trial remains the gold standard of clinical investigation.1Landray M.J Whitlock G Evaluating treatment effects reliability.BMJ. 2002; 325: 1372Crossref PubMed Scopus (6) Google Scholar National guidelines on anticoagulants and oral surgery procedures are available in the UK.2Randal C.J Surgical management of the primary care dental patient on warfarin. 2004Google Scholar These recommend that warfarin does not need to be stopped before dental surgical procedures providing the international normalized ratio of the patient is below 4. To assess if warfarin can be continued during dental extractions, we carried out a randomized controlled trial at Morriston Hospital in Swansea.3Evans I.L Sayers M.S Gibbons A.J et al.Can warfarin be continued during dental extractions? Results of a randomised controlled trial.Br J Oral Maxillofac Surg. 2002; 40: 248Abstract Full Text PDF PubMed Scopus (152) Google Scholar The control group who stopped their warfarin 2 days before extractions had a lower incidence of bleeding complications compared with the intervention group who continued their warfarin. However, this difference was not statistically significant. In addition, all but 2 patients controlled their minor postoperative bleeding by biting on gauze squares at home. For the 2 patients who remained in the hospital, the bleeding was stopped by local treatment of the extraction socket. Our study supports the view that in selected patients, anticoagulant therapy can be continued during oral surgical procedures. Nevertheless, further evidence is required to establish more precise recommendations and we would encourage other groups to publish their research.4Randal C.J Wars on warfarin.Br Dent J. 2002; 193: 608Crossref Scopus (1) Google Scholar