|DENTAL SCIENCE - RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 5 | Page : 134-137
Assessment of bleeding during minor oral surgical procedures and extraction in patients on anticoagulant therapy
S Jimson1, Julius Amaldhas2, Sudha Jimson3, I Kannan4, J Parthiban5
1 Department of Oral and Maxillofacial Surgery, Bharath University, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Biochemistry, Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Oral and Maxillofacial Pathology, Bharath University, Sree Balaji Dental College and Hospital, Chennai, India
4 Department of Microbiology, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
5 Department of Oral and Maxillofacial Surgery, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||31-Oct-2014|
|Date of Decision||31-Oct-2014|
|Date of Acceptance||09-Nov-2014|
|Date of Web Publication||30-Apr-2015|
Dr. S Jimson
Department of Oral and Maxillofacial Surgery, Bharath University, Tagore Dental College and Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The risk of postoperative hemorrhage from oral surgical procedures has been a concern in the treatment of patients who are receiving long-term anticoagulation therapy. A study undertaken in our institution to address questions about the amount and severity of bleeding associated with minor outpatient oral surgery procedures by assessing bleeding in patients who did not alter their anticoagulant regimen. Subjects and Methods: Eighty-three patients receiving long-term anticoagulant therapy visited Department of Oral and Maxillofacial Surgery from May 2010 to October 2011 for extractions and minor oral surgical procedures. Each patient was required to undergo preoperative assessment of prothrombin time (PT) and measurement of the international normalized ratio. Fifty-six patients with preoperative PT values within the therapeutic range 3-4 were included in the study. The patients' age ranged between 30 and 75 years. Application of surgispon was done following the procedure. Extraction of teeth performed with minimal trauma to the surrounding tissues, the socket margins sutured, and sutures removed after 5 days. Results: There was no significant incidence of prolonged or excessive hemorrhage and wound infection and the healing process was normal.
Keywords: Anticoagulant, antiplatelet, extraction of teeth, oral surgery
|How to cite this article:|
Jimson S, Amaldhas J, Jimson S, Kannan I, Parthiban J. Assessment of bleeding during minor oral surgical procedures and extraction in patients on anticoagulant therapy. J Pharm Bioall Sci 2015;7, Suppl S1:134-7
|How to cite this URL:|
Jimson S, Amaldhas J, Jimson S, Kannan I, Parthiban J. Assessment of bleeding during minor oral surgical procedures and extraction in patients on anticoagulant therapy. J Pharm Bioall Sci [serial online] 2015 [cited 2019 Jul 23];7, Suppl S1:134-7. Available from: http://www.jpbsonline.org/text.asp?2015/7/5/134/155862
Minor oral surgical procedures (MOS) in patients under anticoagulation therapy is a top listed controversy among the oral and maxillofacial surgeons (OMFS) because of the high risk they might encounter later due to the postoperative bleeding, which can be fatal. Various protocols are being employed in order to avoid untoward effects during and after MOS procedures. Though different authors voice different opinions, majority of them recommend continuation of anticoagulation therapy on and after the procedure without any alteration in the regime. , Clinical trial based evidence suggests postoperative bleeding in patients under Anticoagulant and antiplatelet therapy can be effectively controlled by the usage of local hemostatic agents. 
| Subjects and Methods|| |
Ninety-one patients receiving long-term anticoagulant therapy visited our center from May 2010 to October 2011 for extractions and MOS. Each patient was required to undergo preoperative assessment of prothrombin time (PT) and measurement of the international normalized ratio (INR). , An initial check of PT and INR was done on the day of the visit, and another on the day of the procedure after 3 days. Eighty-three patients with preoperative INR between 3 and 4 obtained on the day of surgery were included in the study. Opinion and consent from their respective treating physician was sought before initiating the procedure. All the patients were informed about the study and consent obtained. Eight patients whose INR were not within the therapeutic range were excluded from the study. Patients with the other coagulopathy, within 6 months of MI, liver disease, birth control pills, hormone replacement therapy, infection at surgical site and patient on nonsteroidal antiinflammatory drugs were also excluded from the study. The patients' age ranged between 30 and 75 years. Blood pressure was recorded for all the patients prior to administration of anesthetic. About 2% lignocaine with 1:80000 adrenaline was used as a local anesthetic. Injection was administered slowly after aspiration was found to be negative. Procedures included dental extractions that were limited to 1-3 teeth in the same quadrant, surgical extraction, soft tissue biopsy and apicoectomy. Application of gelatin sponge with a dimension of 10 mm × 10 mm × 10 mm led to local hemostasis. Extraction of teeth performed with minimal trauma to the surrounding tissues, the socket margins sutured with 3.0 silk, and sutures removed after 5 days.
Patients were kept under observation for 1 h following the procedure before being sent home. Review appointments were scheduled at 24 h, 5 days. Postoperative antibiotics and analgesics were prescribed for all the patients.
The statistical test was performed by Statistical Package for the Social Sciences (SPSS) version 22 software,(IBM, International) The Chi-square test for association was performed to find if there is any association between the anticoagulants used and bleeding. The P value above will be taken as no association between these two.
| Results|| |
There were 54 males and 29 female patients with their age ranging between 30 and 75 [Table 1]. The frequency of medical history is tabulated in [Table 2].
[Table 3] indicates the percentage of patients on various anticoagulants and [Table 4] shows the bleeding characteristics of the patients. There were only four incidences of prolonged bleeding in our study.
|Table 4: Anti-coagulants *intraoperative bleeding cross tabulation count|
Click here to view
It was found that there is no association between the anticoagulant therapy and bleeding during MOS extraction of teeth using Chi-square analysis (P > 0.05) [Table 5].
| Discussion|| |
The most commonly used drug in anticoagulation therapy is warfarin. , Warfarin acts as Vitamin K antagonist and thus decreases the coagulation of blood by inhibiting the enzyme Vitamin K epoxide reductase. Usually, it takes 48-72 h for the anticoagulant effect of warfarin to come into existence in the circulation. Opinion varies among the OMFS regarding the perioperative and postoperative management of patients under warfarin therapy. ,
The most commonly and frequently used antiplatelet drug is aspirin.  Aspiring acts by irreversibly inhibiting the activity of cyclooxygenase-1 and modifying the enzymatic action of cyclooxygenase-2. Another commonly used antiplatelet drug is clopidogrel. It causes irreversible inhibition of adenosine diphosphate receptor, which plays a vital role in promoting platelet aggregation and cross-linking of platelets using fibrins. Other antiplatelet drugs used are ticlopidene, dipyridamole. He also says that bleeding complication is high for patients under combined drug therapy (aspirin and clopidogrel) than single dose therapy. ,
In patients with high risk of thromboembolism in whom warfarin therapy has to be ceased for few days, another alternative is sought in order to shorten the period of time that the patient will be not protected from thromboembolism. The alternative is bridging therapy with unfractionated heparin or low-molecular-weight heparin (LMWH). , Bridging therapy is opted because of the side effects that may occur due to the slow reversal of warfarin therapy.
Bridging therapy  is commonly used in patients under warfarin therapy when they need to undergo a minor or major oral surgical procedure in order to prevent thromboembolic events and other side effects that can occur due to the cessation of warfarin therapy. 
Low-molecular-weight heparin acts by binding itself to antithrombin III and inactivating the factor Xa and factor II. It is commonly used as a bridging therapy in patients under warfarin therapy. Catherine H suggests patients under combination therapy that is, warfarin  and LMWH  are more prone to the risk of bleeding after extractions. 
Most authors ,,, suggest MOS can be carried out confidently on patients under warfarin therapy or anticoagulation therapy relying on the INR value. Though they all believe on INR ratio, there are different schools of thought.
Ward and Smith  suggests that one of the few strategies followed by OMFS during extraction or any MOS is to decrease the INR to 1.5-2.0 instead of completely ceasing the usage of warfarin for few days. This might lead to untoward effect due to the hypercoagulability whereas Bakathir  says that if the INR value ≤3.5 in patients under warfarin therapy, MOS can be safely carried out without altering or ceasing the usage of warfarin and without the fear of postoperative bleeding. ,,
If warfarin efficacy decrease when the INR value falls below two,  whereas as Ansell et al. , says that if the patients has serious bleeding, INR should be reduced to 1.0 and in case of urgent surgeries, decrease the INR values to 1-1.5 by three different approaches. 
Though the majority of the authors rely on INR, few have differences of opinion. , They believe INR system lack reliability and accuracy when used with thromboplastins with high ISI values and few maxillofacial surgeons rely on PT.  Loss of accuracy is due to an error in automated clot detectors used in labs to calculate INR values. Blinder et al.  suggests irrespective of INR value, extractions can be carried out in patients under anticoagulation therapy without the fear of postoperative bleeding. 
In patients under anticoagulant therapy, local hemostatic agents play an important role in controlling postoperative bleeding effectively. Blinder et al.  recommends the use of gelatin sponge and suture for controlling the postoperative bleeding. He also says gelatin sponge plus the suture combination is more effective than gelatin sponge, Fibrin glue and Suture. Occurrence of hemostatic events can be prevented with the usage of local hemostatic agents like oxidized cellulose, gelatine sponge and fibrin glue, whereas in severe hemorrhagic events author suggests cauterization of soft tissue bleeding points by instructing the patient to bite on the gauze for 30 min which will help to control bleeding.  Another method  used to control postoperative bleeding is administration of HemCon dental dressing or HemCon bandage, HemCon Medical Technologies, Inc. Portland, Oregon, USA. which helps to achieve hemostasis within a minute and also fastens the wound healing. Mechanism behind HemCon dental dressing  is, electro positively charged HemCon dressing adheres to the negatively charged red blood cell and thus clot formation occurs immediately within 1 min of the application of the dressing to the surgical site. There is a suggestion , that it's better to imply the curettage technique at the site of extraction and then use either tranexamic acid, suture or gelatin sponge to control postoperative bleeding effectively. , Tranexamic acid mouthwash is not as effective as other local hemostatic agents.  Using various methods of local hemostatic agents we can observe control of bleeding in the operative site. 
Majority of the OMFS recommend continuation of anticoagulant therapy during the minor surgical procedure, and they highly recommend the use of local hemostatic agents. , Interruption or cessation of anticoagulation therapy can be dangerous at times and can cost the patient's life due to the high risk of thromboembolic events that can occur. Surgeons should also limit the usage of multi dose antibiotic therapy  to patients under warfarin therapy as they can interfere with the anticoagulation effect. Another school of thought  says individual approach is the best way to manage the patients under warfarin therapy as the medical conditions vary from patients to patients.
| References|| |
Beirne OR. Evidence to continue oral anticoagulant therapy for ambulatory oral surgery. J Oral Maxillofac Surg 2005;63:540-5.
Blinder D, Manor Y, Martinowitz U, Taicher S, Hashomer T. Dental extractions in patients maintained on continued oral anticoagulant: Comparison of local hemostatic modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:137-40.
Della Valle A, Sammartino G, Marenzi G, Tia M, Espedito di Lauro A, Ferrari F, et al.
Prevention of postoperative bleeding in anticoagulated patients undergoing oral surgery: Use of platelet-rich plasma gel. J Oral Maxillofac Surg 2003;61:1275-8.
Ansell J, Holden A, Knapic N. Patient self-management of oral anticoagulation guided by capillary (fingerstick) whole blood prothrombin times. Arch Intern Med 1989;149:2509-11.
Hirsh J, Poller L. The international normalized ratio. A guide to understanding and correcting its problems. Arch Intern Med 1994;154:282-8.
Aldridge E, Cunningham LL Jr. Current thoughts on treatment of patients receiving anticoagulation therapy. J Oral Maxillofac Surg 2010;68:2879-87.
Hirsh J, Dalen JE, Anderson DR, Poller L, Bussey H, Ansell J, et al
. Oral anticoagulants: Mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest 1998;114:445S-69.
Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: A systematic review. Arch Intern Med 2003;163:901-8.
Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med 1998;158:1610-6.
Madan GA, Madan SG, Madan G, Madan AD. Minor oral surgery without stopping daily low-dose aspirin therapy: A study of 51 patients. J Oral Maxillofac Surg 2005;63:1262-5.
Napeñas JJ, Hong CH, Brennan MT, Furney SL, Fox PC, Lockhart PB. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. J Am Dent Assoc 2009;140:690-5.
Payne DA, Hayes PD, Jones CI, Belham P, Naylor AR, Goodall AH. Combined therapy with clopidogrel and aspirin significantly increases the bleeding time through a synergistic antiplatelet action. J Vasc Surg 2002;35:1204-9.
Bajkin BV, Popovic SL, Selakovic SD. Randomized, prospective trial comparing bridging therapy using low-molecular-weight heparin with maintenance of oral anticoagulation during extraction of teeth. J Oral Maxillofac Surg 2009;67:990-5.
Pettinger TK, Owens CT. Use of low-molecular-weight heparin during dental extractions in a medicaid population. J Manag Care Pharm 2007;13:53-8.
Johnson-Leong C, Rada RE. The use of low-molecular-weight heparins in outpatient oral surgery for patients receiving anticoagulation therapy. J Am Dent Assoc 2002;133:1083-7.
Salam S, Yusuf H, Milosevic A. Bleeding after dental extractions in patients taking warfarin. Br J Oral Maxillofac Surg 2007;45:463-6.
Bloomer CR. Excessive hemorrhage after dental extractions using low-molecular-weight heparin (Lovenox) anticoagulation therapy. J Oral Maxillofac Surg 2004;62:101-3.
Hong CH, Napeñas JJ, Brennan MT, Furney SL, Lockhart PB. Frequency of bleeding following invasive dental procedures in patients on low-molecular-weight heparin therapy. J Oral Maxillofac Surg 2010;68:975-9.
Blinder D, Manor Y, Martinowitz U, Taicher S. Dental extractions in patients maintained on oral anticoagulant therapy: Comparison of INR value with occurrence of postoperative bleeding. Int J Oral Maxillofac Surg 2001;30:518-21.
Le DT, Weibert RT, Sevilla BK, Donnelly KJ, Rapaport SI. The international normalized ratio (INR) for monitoring warfarin therapy: Reliability and relation to other monitoring methods. Ann Intern Med 1994;120:552-8.
Evans IL, Sayers MS, Gibbons AJ, Price G, Snooks H, Sugar AW. Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg 2002;40:248-52.
Ward BB, Smith MH. Dentoalveolar procedures for the anticoagulated patient: Literature recommendations versus current practice. J Oral Maxillofac Surg 2007;65:1454-60.
Bakathir AA. Minor oral surgery procedures in patients taking warfarin: A 5-year retrospective study at Sultan Qaboos University Hospital, Sultanate of Oman. Sultan Qaboos Univ Med J 2009;9:279-86.
Campbell JH, Alvarado F, Murray RA. Anticoagulation and minor oral surgery: Should the anticoagulation regimen be altered? J Oral Maxillofac Surg 2000;58:131-5.
Devani P, Lavery KM, Howell CJ. Dental extractions in patients on warfarin: Is alteration of anticoagulant regime necessary? Br J Oral Maxillofac Surg 1998;36:107-11.
Souto JC, Oliver A, Zuazu-Jausoro I, Vives A, Fontcuberta J. Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: A prospective randomized study. J Oral Maxillofac Surg 1996;54:27-32.
Ginsberg JA, Crowther MA, White RH, Ortel TL. Anticoagulation therapy. Hematology Am Soc Hematol Educ Program 2001;339-57.
Ansell JE. The quality of anticoagulation management. Arch Intern Med 2000;160:895-6.
Ansell J, Hirsh J, Dalen J, Bussey H, Anderson D, Poller L, et al
. Managing oral anticoagulant therapy. Chest 2001;119:22S-38.
Albers GW. Atrial fibrillation and stroke. Three new studies, three remaining questions. Arch Intern Med 1994;154:1443-8.
Ferrieri GB, Castiglioni S, Carmagnola D, Cargnel M, Strohmenger L, Abati S. Oral surgery in patients on anticoagulant treatment without therapy interruption. J Oral Maxillofac Surg 2007;65:1149-54.
Morimoto Y, Niwa H, Hanatani A, Nakatani T. Hemostatic management during oral surgery in patients with a left-ventricular assist system undergoing high-level anticoagulant therapy: Efficacy of low molecular weight heparin. J Oral Maxillofac Surg 2008;66:568-71.
Malmquist JP, Clemens SC, Oien HJ, Wilson SL. Hemostasis of oral surgery wounds with the HemCon Dental Dressing. J Oral Maxillofac Surg 2008;66:1177-83.
Wedmore I, McManus JG, Pusateri AE, Holcomb JB. A special report on the chitosan-based hemostatic dressing: Experience in current combat operations. J Trauma 2006;60:655-8.
Carter G, Goss A. Tranexamic acid mouthwash - a prospective randomized study of a 2-day regimen vs 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions. Int J Oral Maxillofac Surg 2003;32:504-7.
Ramström G, Sindet-Pedersen S, Hall G, Blombäck M, Alander U. Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 1993;51:1211-6.
Carter G, Goss A, Lloyd J, Tocchetti R. Tranexamic acid mouthwash versus autologous fibrin glue in patients taking warfarin undergoing dental extractions: A randomized prospective clinical study. J Oral Maxillofac Surg 2003;61:1432-5.
Assael LA. Hemostasis is a shared responsibility. J Oral Maxillofac Surg 2003;61:1377-8.
Zanon E, Martinelli F, Bacci C, Cordioli G, Girolami A. 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.
Todd DW. Evidence to support an individualized approach to modification of oral anticoagulant therapy for ambulatory oral surgery. J Oral Maxillofac Surg 2005;63:536-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]