Dental Extractions In Patients Research Articles

Dental Extraction in the Neutropenic Patient

To identify risks of dental extraction in patients with mild, moderate, and severe neutropenia. The authors undertook an observational study of 116 patients diagnosed with neutropenia and undergoing dental extractions in the Mayo Clinic Division of Oral and Maxillofacial Surgery. Absolute neutrophil count (ANC) was no higher than 1,500/μL. Predictors were ANC, age, diagnosis, number of teeth removed, type and location of extraction, length of antibiotic use, presence and type of bacteremia at the time of consultation or extraction, reason for consultation, indication for extraction, and use of any granulocyte colony-stimulating factor (GCSF). Primary outcomes were total complications, surgical site infections, delayed healing, and prolonged postoperative pain. Descriptive and bivariate analyses were undertaken, with statistical significance set at a P value less than or equal to .05. One hundred sixteen patients underwent extraction while neutropenic. The overall complication rate was 8.6% (n=10). All were minor complications requiring simple interventions, if any. Complications were delayed healing, surgical site infection, and prolonged postoperative pain. Delayed healing was not associated with ANC. GCSF and related medications did not appear to affect outcomes in these patients. The results of this preliminary study suggest that extraction of teeth in patients at all stages of neutropenia can be conducted safely. Complications of extraction were few and should be easily controlled. Further studies are required to clarify and stratify risk for future patients.

Management of dental extraction in patients with Haemophilia A and B: A report of 58 extractions

Objectives: Patients with inherited bleeding disorders are at high risk of bleeding following oral surgery and present challenges to the oral surgeons. Aim of this study was to report our experience in dental extraction in patients exhibiting Haemophilia A and B between 2007 and 2012. Patient and Methods: 58 dental extractions in 15 patients during 19 interventions were performed. Replacement therapy with recombinant and plasma-derived factor VIII and IX was applied systematically in combination with antifibrinolytic treatment and local haemostatic measures. The following data were recorded: type of surgery, applied local haemostatic measures, general substitution, systemic antifibrinolytic agents and occurrence of postoperative bleeding complications. Results: Two patients presented postoperative bleeding. One had secondary bleeding requiring additional injection of factor concentrates. The other one presented epistaxis which was managed conservatively with a nasal tamponade. Conclusions: Excellent haemostasis is achievable after dental extractions in patients with Haemophilia A and B by following a protocol using defined pre- and postoperative doses of factor concentrates in combination with haemostatic measures. Key words:Antifibrinolytic treatment, dental extraction, Haemophilia, inherited bleeding disorders, local haemostatic measures.

Effectiveness of Hemcon Dental Dressing Versus Conventional Method of Haemostasis in 40 Patients on Oral Antiplatelet Drugs

The purpose of the study was to evaluate the effectiveness of the HemCon Dental Dressing (HDD) in controlling post extraction bleeding and to ascertain its role in healing of extraction wounds, as compared to control. The 40 participants in the study were all receiving oral antiplatelet therapy (OAT). A total of 80 extractions were conducted without altering the patients' drug therapy. The extraction sites were divided into 2 groups: one group received a HDD, and the control group where the conventional method of pressure pack with sterile gauze under biting pressure (followed by suturing if required) was used to achieve haemostasis. All HemCon treated sites achieved haemostasis sooner (mean = 53 seconds) than the control sites (mean = 918 seconds) which was statistically significant (P <0.001). Postoperative pain in the HDD group (1.74) was also significantly lower than in the control group (5.26) (P <0.001). Approximately 72.5% of HDD-treated sites showed significantly better postoperative healing when compared to the control site (P <0.001). HDD proved to be an excellent haemostatic agent that significantly shortened the bleeding time following dental extraction in patients on OAT. Additionally, HDD offered significantly improved post-operative healing of the extraction socket and less postoperative pain.

Dental Extraction in a Hemophilia Patient Without Factor Replacement Therapy: A Case Report

Hemophilia is a congenital bleeding disorder caused by the deficiency of coagulation factor VIII (hemophilia A) or IX (hemophilia B). According to the degree of factor deficiency, hemophilia is classified as severe ( 1 IU/dL), moderate (2-5 IU/dL), or mild (6-40 IU/dL). In patients with hemophilia, every oral surgical procedure poses the risk of prolonged and excessive bleeding, and up to now, there has been no consensus about dental extractions in patients with hemophilia. Factor VIII replacement therapy in hemophilia A patients or factor IX replacement therapy in hemophilia B patients is usually recommended before surgical treatment. Because this hematologic treatment poses certain risks, such as development of inhibitors, efficient local hemostasis measures are applied to minimize the use of clotting factor support. We present a case report of dental extraction in a hemophilia A patient without factor replacement therapy. Application of a fibrin sealant and suturing were used for local hemostatic treatment.

Tooth extraction in patients on zoledronic acid therapy

Surgical management of patients following zoledronic acid therapy is particularly difficult, since the dental extraction is the main cause of BRONJ. A case-control study was conducted on 176 patients treated with intravenous (IV) bisphosphonates for oncologic pathologies who also underwent dental extractions. The study was divided randomly into two groups: 91 were treated with Plasma Rich in Growth Factor Plasma (PRGF) (study group) and the other 85 were not treated with the growth factor preparation (control group). Panoramic X-ray and computed tomography were performed both before and 60 months after surgery. By clinical and radiological diagnosis, BRONJ was diagnosed in only 5 patients in the control group at an average of 91, 6 days after tooth extraction. We hypothesize that Plasma Rich in Growth Factor (PRGF) is important for the successful treatment of patients on bisphosphonates to restore the osteoblast/osteoclast homeostatic cycles via autologous cytokines. Moreover, this protocol reduces the risk of BRONJ when it is necessary to perform dental extractions in patients undergoing IV bisphosphonate treatment.

Evaluation of the Hemostatic Effects of Ankaferd Blood Stopper During Dental Extractions in Patients on Antithrombotic Therapy

This study evaluated the early hemostatic effects of a novel hemostatic agent (Ankaferd blood stopper [ABS]) during dental extractions in patients on antithrombotic therapy, without interruption or diminution of the medication. In total, 25 patients, who are on antithrombotic therapy and in need of simple dental extractions, were randomized into 2 groups. In group I (control group), which consisted of 10 patients, local hemostasis was achieved with direct packing with gauze. In group II, which consisted of 15 patients, local hemostasis was achieved by the local application of ABS on the extraction sockets. The bleeding time was compared between 2 groups following the tooth extraction. The bleeding time in the dental sockets treated with ABS was statistically lower compared to the sockets of the control group (p = 0.0001). It is concluded that the dental extractions could be performed without interruption of the medication in patients on antithrombotic therapy. The ABS appears to be sufficient as an alternative hemostatic agent.

Bisphosphonate-related osteonecrosis of the jaws

The purpose of this article is to review a new pathologic entity named bisphosphonate-related osteonecrosis of the jaws (BRONJ). BRONJ was observed and first reported in 2001-2002 when clinicians noticed cases of refractory osteomyelitis after simple dental procedures such as dental extractions in patients who had received bisphosphonate therapy. The condition was initially seen in patients who received i.v. bisphosphonates for malignancies such as multiple myeloma and metastatic breast cancer. However, with the use of bisphosphonate therapy for osteoporosis, BRONJ is seen in patients without a cancer diagnosis. The incidence of BRONJ remains unclear. Treatment recommendations based on sound scientific data are sparse. The management of BRONJ remains a difficult and controversial situation that continues to challenge the clinician.

Comparison of the Effects of Warfarin and Heparin on Bleeding Caused by Dental Extraction: A Clinical Study

Replacement of warfarin with heparin for dental extractions in patients on long-term warfarin therapy is associated with wasted time, consumed labor, and increased treatment expenses. The aim of this study was to evaluate the safety of dental extraction without altering the warfarin regimen in patients with an international normalized ratio from 1 to 4. Forty patients who underwent tooth extraction were divided into 4 groups: continuation of warfarin without interruption (group 1), warfarin bridged with low-molecular-weight heparin (group 2), warfarin bridged with unfractionated heparin (group 3), and a control group of healthy individuals (group 4). Total amount of bleeding (milligrams) was measured for 20 minutes after tooth extraction. International normalized ratio values on the operative day and number of extra gauze swabs used for bleeding control in the first 48 hours were recorded for each patient. Results were statistically analyzed by analysis of variance, Fisher least-significant difference post hoc test, Pearson correlation, χ(2) test, and Student t test. Mean amounts of bleeding were 2,486 ± 1,408; 999 ± 425; 1,288 ± 982; and 1,736 ± 876 mg for groups 1, 2, 3, and 4, respectively. There was no severe postoperative bleeding in any patient and the number of used extra gauze swabs did not differ significantly among groups. With the aid of local hemostatic agents, dental extraction in patients receiving warfarin who have an international normalized ratio from 1 to 4 could be carried out without a significant risk of bleeding and without altering the anticoagulant regimen.

Complicanze postoperatorie in seguito a estrazioni dentarie chirurgiche

ObjectivesThe aim of this study was to compare the incidence of postoperative complications after surgical dental extractions in patients with systemic diseases versus healthy patients. Materials and methodsFrom January 2007 to December 2009, a total of 220 patients underwent surgical dental extractions (single or multiple: total no. of teeth 388) at the MDO of the University of Ferrara's Sant’Anna Hospital. Patients were divided into two groups: 95 healthy patients, who served as controls, and a study group of 125 patients with one or more systemic diseases (including concomitant diseases). ResultsTo prevent postoperative complications, antibiotic therapy was administered to every patient. During the 3-year study period, there were 4 complications: 3 cases of late bleeding related to ineffective clotting and 1 case of delayed wound healing. ConclusionsThe results indicate that complications are more frequent in patients taking warfarin. The risk of postoperative infection can be eliminated with appropriate antibiotic therapy (systemic and local) irrespective of the patient's general health status.

A brain abscess following dental extractions in a patient with hereditary hemorrhagic telangiectasia

Oral and maxillofacial surgeons must be aware of the potentially life-threatening complications of dental extractions in patients with hereditary haemorrhagic telangiectasia because of their high prevalence of pulmonary arteriovenous fistulas. Despite the lack of evidence-based guidelines, antibiotic cover should be given to patients with HHT who require oral surgery according to the same rules as those used for patients at high risk of bacterial endocarditis.

Behaviour and attitudes among Spanish general dentists towards the anticoagulated patient: a pilot study

To determine the attitude of Spanish general dentists in relation to dental extraction in patients with heart valve prostheses subjected to acenocoumarol anticoagulation. A telephone survey was made of Spanish general dentists, asking about the indicated approach in the case of performing dental extractions in patients with heart valve prostheses subjected to acenocoumarol (Sintrom) anticoagulation. Of the 271 dentists answered, 175 were male (64.6%) and 96 were female (35.4%), with a mean professional experience of 20.17 +/- 9.3 years. A total of 228 dentists (84.1%) indicated the need to refer the patient to a specialist for establishing the required approach, while 43 dentists (15.9%) did not consider such a measure to be necessary. Among this latter group of 43 dentists, 26 (60.5%) considered that acenocoumarol should be withdrawn or replaced by low-molecular weight heparin, while 17 (39.5%) were of the opinion that the anticoagulation regimen should not be modified. In relation to the international normalized ratio, 36 (83.7%) did not consider it necessary to request this parameter. As regards the prevention of endocarditis, 11 (25.6%) specified the need for prophylaxis, although only eight (72.7%) did so correctly. There were no statistically significant differences in behaviour in relation to either gender or years of professional experience. This study identifies a lack of knowledge on the part of the dentists regarding the approach to dental extraction in patients with heart valve prostheses subjected to anticoagulation. Due educational measures therefore should be reinforced among these professionals.

Management of dental extraction in patients undergoing anticoagulant treatment

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 outpatients without any modification of the ongoing anticoagulant therapy, thus minimising costs and reducing discomfort for patients.

160 Factors arising bleeding risk in dental surgery in patients treated with antivitamin K

In dental surgery, to take charge of heart disease patients treated with antivitamin K remains a common practice problem. To research the factors which increase bleeding after dental extractions in patients treated by acenocoumarol. Cohort study in which dental extractions are realized in heart disease patients treated by acenocoumarol, with an International Normalized Ratio (INR1) the day before the act between 2.00 and 4.50, using in all cases the local hemostatic measures : oxycellulose mesh (surgicel*) + sutures + compression gutter. The day of extraction, a pre-operative INR control (INR2) was systematic. The degree of dental traumatism corresponded to the extracted root number / session. The results are expressed with confidence intervals at 95%. 229 extraction sessions are realized in 135 patients, 50.32 + 2.12 years old with a 1.25 sex ratio, an extractions number / subject / session of 1.96 + 0.23 teeth and a degree of dental traumatism of 2.89 + 0.24. The INR1 and INR2 were respectively of 3.30 + 1.10 and 3.40 + 1.59. Bleeding complicated 9 extraction sessions (3.93%) and occurred after the 48 th hour in 4 cases (44.44%). In the bleeding group, INR2 was 3.33 + 7.02 against 3.40 + 1.64 in absence of haemorrhage, p = 0.86. The degree of dental traumatism was 4.89 + 3.11 in cases of bleeding against 2.80 + 0.22, p = 0.02. In heart disease patients treated by acenocoumarol, it's the degree of dental traumatism which was the hemorrhagic factor, not the INR pre-operative value.

Intractable Bimaxillary Osteomyelitis in Osteopetrosis: Review of the Literature and Current Therapy

Osteopetrosis (OP), also known as Albers-Schönberg disease, is a rare metabolic bone disease caused by a congenital defect in the development or function of the osteoclasts resulting in generalized increase in skeletal mass. Osteomyelitis is a recognized complication, and prevention of dental infections can be difficult. The locations of osteomyelitis in the jawbones have been either in the mandible or maxilla. In this article, a case of OP complicated with osteomyelitis of the mandible and the maxilla is presented, and types of OP and treatment options are discussed with a literature review. The 18-year-old blind female patient had been diagnosed with OP in the past. She had a purulent discharge at the medial canthus of the left eye, in addition to another discharge of pus in the infraorbital and upper left molar region, and multiple malformed and partially impacted teeth, and there were sequestrum formations in the maxilla and mandible. For the treatment of osteomyelitis, systemic combined antibiotics of sultamicillin 750 mg and ornidazole 500 mg twice daily, were given orally for 5 weeks followed by surgical removal of small sequestra in the jaws. Persistent osteomyelitic bones were removed by saucerization in the mandibular anterior and right premolar region and the left posterior maxilla under the same antibiotic regimen. After wound healing was completely achieved in both jaws, the oroantral opening in the left posterior maxilla was successfully closed with a buccal flap under antibiotic coverage. The purulent discharge at the medial canthus of her left eye subsided and she had no recurrent infections during the long-term follow-up of 2 years. The case reported shows that osteomyelitis is difficult to treat in subjects suffering from OP. Therefore, it is necessary to be very cautious against infections in even minor surgical interventions such as simple dental extractions in patients with OP, regardless of the location of the teeth. When considering removal of impacted teeth in the posterior maxilla, resultant oroantral communication from osteomyelitis of the extraction site should be regarded as a potential complication.

Acupuncture Anesthesia for Complicated Dental Extractions in Patients with Lidocaine Allergy

Clinical presentation of the soft tissue abscess and periodontitis of the buccal gingiva of the upper right first molar after the metal crown was removed.

What influence do anticoagulants have on oral implant therapy? A systematic review

This systematic review aims to assess the risks (both thromboembolic and bleeding) of an oral anticoagulation therapy (OAT) patient undergoing implant therapy and to provide a management protocol to patients under OAT undergoing implant therapy. Medline, Cochrane Data Base of Systematic Reviews, the Cochrane Central Register of Controlled Trials and EMBASE (from 1980 to December 2008) were searched for English-language articles published between 1966 and 2008. This search was completed by a hand research accessing the references cited in all identified publications. Nineteen studies were identified reporting outcomes after oral surgery procedures (mostly dental extractions in patients on OAT following different management protocols and haemostatic therapies). Five studies were randomized-controlled trials (RCTs), 11 were controlled clinical trials (CCTs) and three were prospective case series. The OAT management strategies as well as the protocols during and after surgery were different. This heterogeneity prevented any possible data aggregation and synthesis. The results from these studies are very homogeneous, reporting minor bleeding in very few patients, without a significant difference between the OAT patients who continue with the vitamin K antagonists vs. the patients who stopped this medication before surgery. These post-operative bleeding events were controlled only with local haemostatic measures: tranexamic acid mouthwashes, gelatine sponges and cellulose gauzes's application were effective. Post-operative bleeding did not correlate with the international normalised ratio (INR) status. In none of the studies was a thromboembolic event reported. OAT patients (INR 2-4) who do not discontinue the AC medication do not have a significantly higher risk of post-operative bleeding than non-OAT patients and they also do not have a higher risk of post-operative bleeding than OAT patients who discontinue the medication. In patients with OAT (INR 2-4) without discontinuation, topical haemostatic agents were effective in preventing post-operative bleeding. OAT discontinuation is not recommended for minor oral surgery, such as single tooth extraction or implant placement, provided that this does not involve autogenous bone grafts, extensive flaps or osteotomy preparations extending outside the bony envelope. Evidence does not support that dental implant placement in patients on OAT is contraindicated.

Dental extractions in patients on antiplatelet therapy. A study conducted by the Oral Health Department of the Navarre Health Service (Spain)

Antiplatelet drugs are used to treat and prevent a wide range of cardiovascular pathologies and/or cerebrovascular accidents. Although the use of anticoagulants in dental extractions is highly protocolized, a clear control method has not yet been established for antiplatelet drugs. This study is directed at evaluating the clinical consequences of extractions in patients on antiplatelet therapy. The Oral Health Department of the Navarre Health Service-Osasunbidea conducted a trial on 155 patients who underwent dental extractions and were receiving antiplatelet therapy. The patients were not requested to interrupt the medication and local measures were taken to control potential haemorrhage. No major haemorrhages were reported. One patient had a moderate haemorrhage that required emergency care. In the remaining patients the bleeding was controlled with local measures. With regard to subsequent bleeding, no differences were observed between the various antiplatelet drugs used. The only statistically significant relationship found was between bleeding and the number of teeth extracted. It can be concluded that no more than 3 teeth should be removed at any one time, and for multiple extractions, the teeth should be adjacent to each other.

Successful Use of Recombinant Factor VIIa (rVIIa, NovoSeven) in Two Patients with Bernard Soulier Syndrome and Dental Extraction

Background: Bernard Soulier syndrome (BSS) is a platelet function disorder that results from partial to complete deficiency or dysfunction of the GP Ib-IX-V receptor. Specific treatment of bleeding episodes or prophylaxis for the prevention of bleeding during surgical procedures is platelet transfusion. Alloimmunization by HLA antigens and antibody formation to the GPIb-IX-V complex frequently occur and, thus limit future responses to platelet transfusions. Recent patient studies have suggested that rVIIa may be an effective therapy for treatment of bleeding in BSS.Case Reports: We report on our experience with rFVIIa in two patients with BSS and dental extraction. Patient 1 is a 21-year-old woman (extraction of 2 wisdom teeth). In 2000, after a first extraction of one wisdom tooth, which was covered by administration of DDAVP and platelet transfusion, a bleeding episode occurred, requiring resurgery. Patient 2 is a 14 year old boy (extraction of 4 wisdom teeth). rFVIIa was used as first line therapy. An initial dose of rFVIIa (100 μg/kg/bw) was administered 15 min prior to surgery, followed by three doses of 90 μg/kg/bw at 120 min intervals and three doses at 8 hour intervals postoperatively. In the first three days after surgery, 90μg/kg/bw rFVIIa were administered every 12 hours. Tranexamic acid (CyklokapronÒ 3 × 1 g/d) was started postoperatively and continued for 10 days. There were no postoperative bleeding episodes and no platelet transfusion was required.In conclusion, rFVIIa in combination with tranexamic acid appears to be an effective and safe therapeutic alternative for prophylaxis of bleeding episodes in dental extraction in patients with BSS.

O.291 Dental extractions in patients on anticoagulant therapy

Postoperative hemorrhage is one of the few serious complications that can occur as a result of dental procedures. We report a case of an elderly patient with postextraction bleeding caused by dengue hemorrhagic fever (DHF). Although a major sequel of DHF is bleeding secondary to thrombocytopenia, prolonged hemorrhage as a result of extraction of tooth has not been reported.In the current scenario of emerging and reemerging infections worldwide, dengue is gaining global prominence. This case documents the course and progression of this disease from a dental perspective and highlights the as yet unreported capacity of causing oral complications after dental treatment.

Poster 020: Management of Dental Extractions in Patients Receiving IV Bisphosphonate Therapy

Poster 020: Management of Dental Extractions in Patients Receiving IV Bisphosphonate Therapy