Local Hemostatic Measures Research Articles

Perioperative Dental Management of Patients in The Background of Antithrombotic Use

Objectives: Treatment and perioperative dental management in patients on antithrombotic medications poses a serious challenge to dental professionals due to perceived risk of bleeding complications. This article aims to study the anticoagulant / antiplatelet drugs currently available on the market, review contemporary oral anti-thrombotic treatment and offer management guidelines in such situations based on the review of pertinent literature. Material and Methods: Science Direct and Ovid databases, PubMed, Scopus and product literature were accessed to review relevant literature with respect to current anti-thrombotic drugs, indications for their use in medical conditions, complications related to their use and drug interactions. The search covered studies published in medical and dental journals in English with a relevant impact factor over a period of 10 years. Meta analyses, systematic reviews, randomized trials, cohort based and case-control studies and society-based guidelines were considered. Key words utilized in the search criteria included Warfarin, Coumarin, Aspirin, P2Y12 inhibitors, Prasugrel, Clopidogrel, Ticagrelor, Hemorrhage, Anti-thrombin, Platelet aggregation inhibitors and International Normalized Ratio (INR) and were validated by the MeSH dictionaries. Results: Dental practitioners today, are faced with the challenge of conducting surgical procedures on patients who are on anti-thrombotic medications for a variety of medical/ surgical co-morbid conditions. Although there is consensus amongst various studies regarding continuation of warfarin in therapeutic ranges for dento-alveolar surgery, there is insufficient evidence to reach a consensus in those groups who are at intermediate or high risk of bleeding. However, most studies and published literature do agree that there is no real increased risk of bleeding complications during conduct of these procedures if the patient’s INR is less than 3.5 along with adequate haemostatic measures. Conclusion: Regardless of the procedure to be performed, every case needs to be titrated on its individual merit based on both patient and surgical factors. Further, it is recommended that INR values should be established at least 72 hours prior to the surgery, which admits a margin of safety for dose modification if necessary. A meticulous case history with complementary hemostatic tests and adoption of adequate local hemostatic measures hold the key to not having the necessity to modify the antiplatelet or anticoagulation treatment in most cases. Additionally, the advent of newer anticoagulants and antiplatelets have raised the requirement of dedicated Randomized Clinical Trials to answer the specific clinical questions of bleeding risk versus thrombo-embolic complications in the perioperative management of such patients.

Local haemostatic measures after tooth removal in patients on antithrombotic therapy: a systematic review.

The interruption of antithrombotics prior to tooth removal because of the fear of bleeding or following postoperative bleeding increases the risk of thromboembolic events. The aim of this systematic review was to investigate which local haemostatic measures can effectively prevent postoperative bleeding in patients continuing oral antithrombotics. A systematic review was conducted by running a search in PubMed, Embase, Web of Science and Cochrane Library. Clinical randomised trials investigating bleeding and haemostatics after tooth removal in patients on antithrombotics were identified. In total, 15 articles were included. The investigated haemostatics included gauze pressure, tranexamic acid-soaked gauze, sponges, glue, calcium sulfate, plant extract Ankaferd Blood Stopper, epsilon-aminocaproic acid and tranexamic acid. In patients treated with vitamin K antagonists, tranexamic acid mouthwash significantly reduced bleeding compared to placebo. Further, histoacryl glue was proven better than gelatin sponges. Other studies failed to show significant differences between haemostatics, but bleeding events were low. Tranexamic acid seems to effectively reduce bleeding, although its superiority to other haemostatics was not proven. In view of the rapidly changing landscape of antithrombotics and the lack of standardization of bleeding outcome, adequately powered clinical studies are required to optimise postoperative management in patients on antithrombotics. In order to optimise postoperative management, the best haemostatics over different patient groups have to be identified and implemented in guidelines.

Assessing an oral surgery specific protocol for patients on direct oral anticoagulants: a retrospective controlled cohort study

Chronic therapy with the new direct oral anticoagulants (DOACs) poses new challenges for dental practitioners assessing the risk versus benefit of cessation versus non-cessation of anticoagulant therapy for dentoalveolar procedures. A retrospective controlled cohort study was designed to evaluate a non-cessation protocol for patients taking DOACs in the setting of dental extractions. A records review covering the period 1 January 2016 to 31 December 2016 identified 43 patients on DOAC therapy; 53 dentoalveolar procedures were performed under local anaesthesia, of which 15 included varying degrees of peri-procedural cessation. A control group of 50 patients on uninterrupted warfarin therapy undergoing 59 dentoalveolar procedures was identified. The incidence, severity, and timing of bleeding events were recorded for each group. Four (10.5%) minor bleeding events were recorded in the non-cessation DOAC group and nine (15.3%) minor bleeding events in the warfarin group. No bleeding events were recorded in the DOAC cessation group. Comparison of the incidence of bleeding events between the non-cessation DOAC group and the warfarin group showed no statistically significant difference (odds ratio 0.65, P=0.56). Within the limitations of this study, dental extractions in the context of continuing DOAC therapy can be performed safely provided extra local haemostatic measures are applied.

A Systematic Review of the Hemorrhage Risk for Patients on Antithrombotic Medication after Dental Procedures

ABSTRACT Aim Antithrombotic medication represents a challenge for any dental practitioner due to the possible hemorrhage complications that can be associated with an important morbidity/mortality risk. The objective of the present literature review is to establish which dental procedures have a risk to increase the incidence of hemorrhage in patients on antithrombotic therapy. Materials and methods A systematic review of the literature was conducted using MEDLINE, PubMed, and DiscoverEd databases. The inclusion criteria used were as follows: Current antithrombotic therapy, invasive dental procedures, and postoperative incidence of bleeding follow-up. Results A total of 14 clinical studies and 5 literature reviews were selected after the initial screening. The incidence of hemorrhage was assessed for dental implant placements, dental extractions, simple dental procedures, and periodontal treatment. Conclusion A well-coagulated patient can safely have invasive dental procedures in a hospital environment or nonhospital setting without having their antithrombotic therapy altered. Local hemostatic measures can offer a proper hemorrhage control. How to cite this article Pirlog CD, Pirlog AM, Maghiar T. A Systematic Review of the Hemorrhage Risk for Patients on Antithrombotic Medication after Dental Procedures. World J Dent 2018;9(1):59-67.

Clinical Evaluation of Role of Dual Antiplatelet Therapy on Bleeding after Dental Extraction.

Aims and Objectives:Altered platelet function and increased bleeding time (BT) can occur with antiplatelet therapy. This study was conducted to evaluate the need for stoppage of dual antiplatelet therapy in patients undergoing dental extractions.Materials and Methods:One hundred and fifty patients indicated for dental extraction were grouped as Group I: Consisted of 75 patients on dual antiplatelet therapy and Group II: Consisted of 75 patients who have discontinued antiplatelet therapy 1 week before dental extraction. BT of all the participants was recorded before extraction procedures. Under local anesthesia, single molar tooth indicated for simple extraction was done in both the groups. Suturing along with pressure pack was done after extraction. BT after extraction was statistically checked between the groups after 1 h and 24 h using Chi-square test with P < 0.05.Results:Postoperatively, none of the patients in both the groups showed active bleeding 1 h and 24 h. No bleeding was seen in 73 patients in Group I and 78 patients in Group II after 24 h.Conclusion:This study concluded that there is no significant difference in BT in both the groups. Antiplatelet monotherapy or even antiplatelet dual therapy needs no alteration or stopped before minor oral surgical procedures. Most of the postoperative bleeding can be easily controlled by local hemostatic measures.

Effect of Low-Dose Aspirin on Bleeding Following Exodontia: A Prospective Clinical Study

This research aims to study the effects of low-dose aspirin on bleeding after exodontia and to compare statistically and analyze perioperative blood loss during exodontia in patients on aspirin therapy and healthy patients and also to discuss the various measures if required necessary for controlling postoperative bleeding in simple and uncomplicated exodontia. The study included 100 patients, ranging in age from 30 to 60years. The patients were divided into two groups, a test group consisting of 50 patients who were on a daily dose of 75-150mg of aspirin and a control group consisting of 50 patients not on any antiplatelet therapy. All extraction procedures were performed on outpatient basis. Patients were operated under local anesthesia. Post-extraction sockets were checked for bleeding immediately (30min) and followed up at 24, 48, and 72h, and 1week, after the procedure. Amount of intraoperative blood loss was similar in both test and control groups, and there was no excessive postoperative bleeding in any case. Out of 100 patients, only three patients of test group and two patients of control group required level II hemostatic measures and two patients of test group needed level III measures. We could reach a conclusion and recommend that patients on long-term low-dose aspirin (75-150mg) need not to discontinue their aspirin dose prior to routine exodontia and can be carried out safely with enhanced local hemostatic measures, if required.

Quantification of bleeding during dental extraction in patients on dual antiplatelet therapy

In spite of the possibility of triggering thromboembolic events, many professionals indicate the suspension of antiplatelet agents before dental surgical procedures. The aim of this study was to perform a quantitative assessment of intraoperative bleeding in patients on dual antiplatelet therapy. A case–control study was conducted in patients on dual antiplatelet therapy (APT group) and in patients who did not use these medications (control group). The following examinations were requested: complete blood cell count, blood coagulation tests, and platelet aggregation. The quantity of bleeding was measured intraoperatively by collection of aspirated blood. The mean volume of blood lost during the surgical procedure was 6.10ml in the control group and 16.07ml in the APT group (P=0.002). The mean volume of blood lost per minute was 0.60ml/min in the control group and 1ml/min in the APT group (P=0.001), with local haemostatic methods being sufficient to control the bleeding. There was no postoperative bleeding complication in any case. Patients on dual antiplatelet therapy presented a larger volume of bleeding, but this could be controlled by means of local haemostatic measures. Therefore, there is no need to stop either of the two dual antiplatelet therapy medications before dental extractions.

Perioperative anticoagulation with NOAC using the example of rivaroxaban

Recent findings require an update of earlier recommendations on the perioperative management of non Vitamin K antagonist oral anticoagulants (NOAC). The present position paper summarises the outcomes of an expert panel discussion. Based on the pharmacokinetic profile of rivaroxaban, a preoperative interruption of 24-72 hours is recommended depending on the patient's renal function, as well as individual and surgery-related bleeding risks. Similar NOAC-free intervals are recommended for patients with epidural catheters. Elective surgery should be delayed accordingly. A low molecular weight heparin (LMWH) "bridging" (in fact "switching") should be avoided because of an increased bleeding risk. Six to 8 hours after the intervention rivaroxaban can be re-initiated or, in case of more extensive interventions or an increased bleeding risk, after 24-72 hours; if necessary this interval could by bridged with LMWH, e. g. if the thromboembolic risk is considered high. In case of emergency surgery with a rivaroxaban pause of less than 9 hours, one should be prepared for a bleeding management including the use of prothrombin concentrate (PCC). Coagulation tests have no value for predicting perioperative bleeding, in contrast to a standardised bleeding history. As an overall estimate, the PT (Quick) can be determined with a suitable reagent. Currently, rivaroxaban-specific measurements of anti Xa levels are available at few specialised centres only. Moderate to severe haemorrhages can usually be managed by temporary interruption of rivaroxaban in conjunction with local and general haemostatic measures. Life-threatening bleeding events require a specific haemostasis management including the administration of PCC; these events are rare and usually have a favourable prognosis, except for intracranial haemorrhages.

Dental management in patients with antiplatelet therapy: A systematic review.

IntroductionCardiovascular diseases are the most frequent cause of death in the Western world. Its treatment frequently needs therapy with antiplatelet agents, which increases the haemorrhage risk after oral surgical procedures. The aim of this study is to present a review on the dental management of the patients under antiplatelet treatment.Material and MethodsA systematic review was carried out following PRISMA recommendations including studies searched in Pubmed-Medline, Embase and Cochrane databases.ResultsThe current trend is to maintain the treatment during the surgical procedure, assuring a good control of the haemorrhage with local haemostatic measures. However, new antiplatelet drugs protocols are not firmly established.ConclusionsIn spite of the existing recommendations, it is always advisable to consult with the internist or cardiologist of every patient before any intervention. Key words:Antiplatelet, Oral Surgery, Exodontia, Dental Management.

An Evaluation of the Efficacy of Local Hemostatic Measures in Dental Patients Taking Oral Anticoagulants: A Critical Review of the Literature Over the Past Two Decades.

The increased risk of bleeding observed in patients on oral anticoagulant therapy (OAT) undergoing outpatient oral surgical procedures has been reported in the literature and remains a major concern in the care of these patients. This is still of great concern to dental surgeons that discontinuing OAT medication increases the risk of thromboembolism, while maintaining the therapeutic dose increases the risk of hemorrhage. Several local hemostatic measures have been used to control bleeding in patients on OAT. However, the effectiveness of these measures has not been thoroughly investigated. The aim of this study is to evaluate the efficacy of local hemostatic measures in patients taking oral anticoagulants. Various databases were searched using the key terms. Selection criteria included publications in English, Spanish, or Portuguese within the last 20 years. The titles and abstracts of papers were initially screened, and reports of 18 clinical trials were selected for a critical review and scored according to CONSORT 2010 guidelines. The data extracted from these trials represented 1821 patients receiving OAT, 4116 tooth extractions, and 144 cases of postoperative bleeding. In most studies, there were no differences in the effectiveness of various local hemostatic measures, and only tranexamic acid was proven effective as compared with a placebo group. The reported INR values varied widely among studies; the lowest INR value was 0.9 and the highest was 5.0. All local hemostatic methods showed low rates of bleeding; and when bleeding occurred, the use of these methods was essential for controlling postoperative bleeding. While local hemostatic measures appear to be effective in controlling postoperative bleeding, additional controlled randomized clinical trials are needed to assess the true effectiveness of these measures in patients taking OAT.

Managing reversal of direct oral anticoagulants in emergency situations. Anticoagulation Education Task Force White Paper.

Anticoagulation is the cornerstone of prevention and treatment of venous thromboembolism (VTE) and stroke prevention in patients with atrial fibrillation (AF). However, the mechanisms by which anticoagulants confer therapeutic benefit also increase the risk of bleeding. As such, reversal strategies are critical. Until recently, the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban, and edoxaban lacked a specific reversal agent. This report is based on findings from the Anticoagulation Education Task Force, which brought together patient groups and professionals representing different medical specialties with an interest in patient safety and expertise in AF, VTE, stroke, anticoagulation, and reversal agents, to discuss the current status of anticoagulation reversal and fundamental changes in management of bleeding associated with DOACs occasioned by the approval of idarucizumab, a specific reversal agent for dabigatran, as well as recent clinical data on specific reversal agents for factor Xa inhibitors. Recommendations are given for when there is a definite need for a reversal agent (e.g. in cases of life-threatening bleeding, bleeding into a closed space or organ, persistent bleeding despite local haemostatic measures, and need for urgent interventions and/or interventions that carry a high risk for bleeding), when reversal agents may be helpful, and when a reversal agent is generally not needed. Key stakeholders who require 24-7/around-the-clock access to these agents vary among hospitals; however, from a practical perspective the emergency department is recommended as an appropriate location for these agents. Clearly, the advent of new agents requires standardised protocols for treating bleeding on an institutional level.

Dental and oral surgical treatment of medication-induced bleeding patients: Audit of the national guideline in Hungary

In 2015 a new Hungarian guideline was published regarding dental treatment and management of anticoagulated patients in agreement of the Hungarian Association of Oral and Maxillofacial Surgeons and the Dental Implantology Association of Hungarian Dentists. The aim of the authors was to evaluate the efficiency and safety of local hemostatic measures recommended by the guideline in anticoagulated patients. In these patients, postoperative bleeding episodes were examined after dental and oral surgical treatments, retrospectively. Overall 263 bleeding risk cases were treated; 138 patients with vitamin K antagonists, 97 patients with antiplatelet therapy and 6 patients with novel oral anticoagulants. Six patients (2.3%) had minor postoperative bleeding after the "one hour control", while one patient needed a night duty support (0.5%). In contrast, 86 patients who were treated in rural practices neglecting the guideline attended the night duty with postoperative bleeding (3 patients treated with vitamin K antagonists, 24 patients taking low molecular weight heparin, 30 patients receiving antiplatelet therapy and one patient on novel oral anticoagulant therapy. The Hungarian guideline can be applied safely, without increasing the risk of postoperative bleeding, however, rural dental practices are frequently unprepared for these treatments. Orv. hetil., 2016, 157(43), 1722-1728.

Management of dental extraction in patients undergoing anticoagulant oral direct treatment: a pilot study

The main goal of this study was to compare the incidence of postoperative bleeding events after dental extractions between patients treated with direct oral anticoagulants (DOACs) and those treated with vitamin K antagonists (VKAs) without withdrawal of oral anticoagulant therapy (OAT). Our second objective was to evaluate the risk factors affecting postoperative hemorrhage after tooth extraction in patients taking DOACs. This prospective observational study included 51 patients who were being treated with oral anticoagulants and required dental extractions. They were divided into two groups: 31 patients receiving a DOAC and 20 control patients taking VKA with an international normalized ratio between 2.0 and 3.0. In both groups, extractions were performed under continued OAT, and the same local hemostatic measures were applied. All procedures were performed in an outpatient facility. A bleeding event was defined as persistent oozing or marked hemorrhage over 20minutes after tooth extraction despite local hemostasis procedures or all bleeding episode occurring during the first postoperative week. Five patients taking DOACs had seven bleeding episodes, and four patients receiving VKAs had five bleeding episodes during the postoperative follow-up period. The difference in the number of bleeding events between the two groups was not statistically significant (adjusted odds ratio=0.77; 95% confidence interval 0.19-3.19; P=.723). Eleven (91.67%) bleeding events were mild and controlled by mechanical compression with gauzes, and one (8.33 %) was managed with a revision of the wound, application of fibrin glue, and resuturing. No bleeding required hospitalization or blood transfusion. All bleeding episodes occurred during the first 3 postoperative days. According to our preliminary outcome data, dental extractions can be performed safely in an outpatient facility in patients treated with DOAC by applying local hemostatic measures, without interrupting or modifying OAT.

An Assessment of the Incidence of Prolonged Postoperative Bleeding After Dental Extraction Among Patients on Uninterrupted Low Dose Aspirin Therapy and to Evaluate the Need to Stop Such Medication Prior to Dental Extractions.

To propose that low dose aspirin therapy need not be withdrawn for routine dental extraction procedure. This study was designed to evaluate the post operative bleeding in patients on low dose aspirin therapy by dividing them into two groups: one with withdrawing and the other without withdrawing the regime before dental extraction. This study included 80 patients on low dose aspirin therapy. They were divided into two groups of 40 patients each; Group I (control group) included patients on who were asked to stop the medication 5days prior to dental extraction; Group II (test group) included patients who were asked not to stop the medication prior to dental extraction. Strict atraumatic extractions were performed by a single surgeon. Data were analyzed using the independent "t" test @ 80% power. The mean pre-operative bleeding time in the control group was 87.75s and the test group was 95.75s which was statistically significant (p<0.05). The mean pre-operative clotting time in the control group was 228.63s and the test group was 246.25s which was also statistically significant (p<0.05). No patients in either group had any episode of prolonged postoperative bleeding following extraction from the surgical site and no local haemostatic measures had to be used except for one patient in Group II. Authors conclude from this study that dental extraction procedures in patients on low-dose therapy can be safely carried out without stopping the antiplatelet therapy.

Exodontia in dual antiplatelet therapy: the evidence.

Haemostasis is crucial for the success of oral surgical treatment as bleeding problems can cause complications both pre- and post-operatively. Patients on antiplatelet drugs present a challenge due to their increased risk of bleeding. To identify a protocol for the management of oral surgery patients on dual antiplatelet therapy (aspirin and clopidogrel). A literature review was conducted in January 2016 of free-text and MESH searches (keywords: aspirin, clopidogrel and dental extractions) in the Cochrane Library, PubMed and CINAHL. Trial registers, professional bodies for guidelines and OpenGrey for unpublished literature were also searched. Studies were selected for appraisal after limits were applied (adult, human and English only studies) and inclusion/exclusion criteria imposed. Eight studies were identified for critical appraisal using the CASP tools. These were a combination of retrospective, prospective, cohort and case control studies. Napenas et al. and Park et al. found no statistically significant risk of postoperative bleeding complications in patients on dual antiplatelet therapy. Girotra et al., Lillis et al., Omar et al. and Olmos-Carrasco et al., however, found statistically significant risk of postoperative bleeding in this group of patients, all of which can be controlled with local measures. Patients on dual antiplatelet therapy - although at an increased risk of postoperative bleeding complications - can be managed safely with local haemostatic measures and without the need to discontinue antiplatelet therapy.

Oral surgery in liver transplant candidates: a retrospective study on delayed bleeding and other complications

Untreated dental infections pose a threat for immunocompromised liver transplant (LT) recipients. Therefore, pretransplant dental evaluations are recommended. However, risk of bleeding should be considered among patients with end-stage liver disease, and prophylactic blood transfusions may be used to prevent bleeding. We performed a retrospective study of the incidence of and risk factors for oral surgery-related bleeding in candidates for LT and hypothesized that complications may occur despite preoperative and perioperative hemostatic actions. One hundred thirty-four patients who had tooth extractions performed by oral and maxillofacial surgeons before LT were studied. The primary endpoint was bleeding between 24 hours and 2 weeks after extraction. Bleeding risk was analyzed by preoperative platelet (PLT) count and international normalized ratio (INR). Invasiveness of procedures, severity of liver disease, PLT, INR, prophylactic transfusions of PLT, fresh frozen plasma, and tranexamic acid (TA) were included in univariate and multivariate logistic regression analyses to further assess risk. Twelve patients exhibited minor bleeding; four despite PLT >100 × 10(9)/L and INR <1.5. Increased bleeding associated with INR and prophylactic transfusions by univariate analysis; by multivariate analyses, prophylactic TA (odds ratio [OR] = 8.0; 95% confidence interval [CI] 1.7-37.0), and PLT (OR = 8.3; 95% CI 1.1-62.7) remained significant. Most extractions were safe, but prophylactic transfusions did not ensure adequate hemostasis. Local hemostatic measures and close follow-up are warranted.

Dental implant surgery in patients in treatment by dabigatran.

The aim of this study was to evaluate the incidence of bleeding complications after dental implant placement in patients in treatment by the oral anticoagulant dabigatran following a specific protocol. Seventy-one patients were divided into two groups: 29 had been taking dabigatran for over 6months (150mg orally every 12h) before implant surgery (dabigatran group) and a control group consisting of 42 healthy subjects. Patients were treated in an outpatient setting. All subjects received dental implants in different positions, dabigatran group patients 12h after the last dose of dabigatran. Nonabsorbable sutures were used and patients were given gauzes impregnated with tranexamic acid 5% to bite on for 30-60min. Dabigatran patients resumed medication 8h after the procedure, resuming usual dosage (every 12h) the day after surgery. Two dabigatran patients and two control patients presented slight bleeding the day after surgery. Bleeding was managed with gauzes impregnated with tranexamic acid. No statistically significant differences (P=0.542) were found in relation to bleeding episodes between the groups, with a relative risk of 0.675 based on the pooled groups and a 95% confidence interval of 0.090-5.088. Dental implant surgery in patients taking dabigatran can be performed safely providing 12h have passed since the last dose and local hemostatic measures are applied. Normal dosage can be resumed 8h after implant surgery.

Total Extraction as a Treatment for Anaemia in a Patient of Glanzmann's Thrombasthenia with Chronic Gingival Bleed: Case Report

Glanzmann's Thrombasthenia (GT) is a rare autosomal recessive bleeding disorder affecting the megakaryocyte lineage and is characterized by lack of platelet aggregation on stimulation. The molecular basis is linked to quantitative and qualitative abnormalities of αIIbβ3 integrin. Most of the patients with severe Glanzmann's thrombasthenia have spontaneous gum bleeding and persistent low haemoglobin levels. Often these patients are addressed with local haemostatic measures and platelet coverage. We report a case of a severe Glanzmann's thrombasthenia with chronic gingivitis and associated spontaneous gum bleed with chronic low haemoglobin levels, managed subsequently with total dental extraction under appropriate platelet and recombinant factor VIIa coverage. Further follow up of the patient substantiated the treatment protocol with increased and stable haemoglobin levels, thus emphasizing the need for total dental extraction in patients with severe Glanzmann's with chronic spontaneous gum bleed, as a definitive treatment option, which has not been reported so far in the literature.

Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions.

Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease. The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date. The primary objective was to assess the efficacy of local or systemic use of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures. Secondary objectives were to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or Von Willebrand disease and to further establish the effects of these agents on bleeding in oral or dental procedures for each of these populations. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and The Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2015. Randomised and quasi-randomised controlled trials in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. While there were no eligible trials in people with Von Willebrand disease identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of epsilon aminocaproic acid published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference of -0.64 (95% confidence interval -0.93 to - 0.36) and the EACA trial a risk difference of -0.50 (95% confidence interval 0.77 to -0.22). The combined risk difference of both trials was -0.57 (95% confidence interval -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping epsilon aminocaproic acid (combined risk difference of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the epsilon aminocaproic acid trial, but overall the risk of bias appeared to be low for both trials. Despite the discovery of a beneficial effect of systemically administered tranexamic acid and epsilon aminocaproic acid in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with Von Willebrand disease.

Antiplatelet therapy and exodontia

BackgroundThis is a review of the management considerations regarding exodontia for patients taking antithrombotic medications that affect platelet function or aggregation. MethodsThe authors reviewed the literature, focusing on the indications and mechanisms of antiplatelet therapy and the perioperative management of patients taking these agents who require exodontia or other dentoalveolar surgery. ResultsDentists making management decisions regarding patients taking antiplatelet therapy should consider the patient’s risk of experiencing perioperative hemorrhage against the risk of experiencing complications associated with thromboembolic events. The risk of perioperative bleeding complications is low for patients taking single or dual antiplatelet therapy. Intraoperative and postoperative bleeding can be controlled with local hemostatic measures. ConclusionFor patients taking antiplatelet medication, bleeding risk for exodontia is generally lower than the risk of experiencing thromboembolic events owing to cessation of therapy. Practical ImplicationsDentists can safely complete exodontia in patients who continue taking antiplatelet therapy. The dentist should consult the patient’s prescribing physician before considering altering the patient’s antiplatelet therapy regimen.