patients on oral anticoagulants & antiplatelet therapy requiring oral surgery how to manage according to literature and latest recommendations

1. GUIDELINES FOR THE MANAGEMENT
OF PATIENTS ON ORAL
ANTICOAGULANTS & ANTIPLATELET
THERAPY REQUIRING ORAL SURGERY
MURAJA ALDOORI
OMFS
12/11/15

2.  The risks of bleeding associated with oral surgery in
individuals not receiving oral anticoagulants is
approximately 1%

3. WAHL MJ. MYTHS OF DENTAL SURGERY IN PATIENTS RECEIVING ANTICOAGULANT
THERAPY. J AM DENT ASSOC 2000; 131(1):77–81.
 Wahl reviewed 26 papers- meta analysis
 2014 oral surgery procedures ( single extraction, full
mouth clearance, alveoloplasties)
 771 patients, INR up to 4.0, some had INR over 4
 Continued warfarin
 98% no serious bleeding using local measures
 12 (1.3%) had uncontrolled bleeding
 4/12 their INR was above 4 at surgery time
 8/2014- 3 had INR above therapeutic after surgery
 2 had placebo rinse many times post surgery
 3 unexplained
 No deaths

4. 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(2):107-11.
 randomized 65 patients, 133 dental extractions
 G1: stop warfarin 2-3 days prior to surgery (INR
dropped from 2.6 to 1.6)
 G2: continue anticoagulants (INR 2.2 to 3.9)
 All patients received ‘Surgicel’ packing and sutures
 Results:
 None had immediate bleeding
 1 from each G had delayed bleeding that was
controlled by local measures

5. AL-MUBARAK S, RASS MA, ALSUWYED A, ALABDULAALY A, CIANCIO S.
THROMBOEMBOLIC RISK AND BLEEDING IN PATIENTS MAINTAINING OR STOPPING ORAL
ANTICOAGULANT THERAPY DURING DENTAL EXTRACTION. J THROMB HAEMOST
2006;4(3):689-91.
 Randomised 168 patients on warfarin
 four groups: no socket suturing with or without
discontinuation of warfarin (INR 1.8)
 socket suturing with or without discontinuation of
warfarin (INR 2.6)
 Results:
 12 % bled in 3rd group who had suturing
 36 % bled in 4th group who didn’t have sutures
 Clinically the difference was not significant and no
surgical management was done

6. SACCO R, SACCO M, CARPENEDO M, MOIA M. ORAL SURGERY IN PATIENTS ON ORAL
ANTICOAGULANT THERAPY: A RANDOMIZED COMPARISON OF DIFFERENT INR TARGETS.
J THROMB HAEMOST 2006;4(3):688-9.
 Randomized 131 patients on anticoagulants
 551 extractions, each patient had 4 extractions
 G1 Reduce their warfarin dose 72 hours (INR mean 1.7)
 G2 Continue anticoagulants with no alteration but using
hemostatic measures (INR mean 2.9), surgicel and TA
 All had sutures
 10 pt in G1 bled
 6 pt in G2 bled
 Summ: it is not necessary to reduce OAT in oral surgery,
and local hemostatic measures is sufficient

7. 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(1):27-30.
 Prospective study 515 patients undergoing oral surgery
 250 pt receives OAT (INR 1.8 to 5), local hemostasis:
surgicel, sutures, TA
 265 pt not receiving OAT (control group)
 G1 had 4 pt bleeding
 G2 had 3 pt bleeding
 When anticoagulated group was stratified according to
INR (1.8-2, 2-3 and 3-5) bleeding were seen in 1.2%,
1.3% and 4.8% of patients respectively
 This difference was not significantly different

8. BRITISH COMMITTEE FOR STANDARDS IN HAEMATOLOGY
BCSH (2011)
 Recommendations:
 The risk of significant bleeding in patients on oral
anticoagulants and with a stable INR in the
therapeutic range 2-4, is low. The risk of thrombosis
if anticoagulants are discontinued may be
increased. Oral anticoagulants should not be
discontinued in the majority of patients requiring
out-patient oral surgery. An appreciation of the
surgical skills particularly when INR levels approach
4, is also important when assessing the risk of
bleeding. Individuals, in whom the INR is unstable,
should be discussed with their anticoagulant
management team

9.  Recommendations:
 For patients stably anticoagulated on warfarin
(INR 2-4) and who are prescribed a single dose
of antibiotics as prophylaxis against
endocarditis, there is no necessity to alter their
anticoagulant regimen

10. RECOMMENDATIONS
 The risk of bleeding may be minimised by:
 a. The use of oxidised cellulose (Surgicel) or
collagen sponges and sutures
 b. 5% tranexamic acid mouthwashes used four
times a day for 2 days.
 For patients who are stably anticoagulated on
warfarin, a check INR is recommended 72 hours
prior to oral surgery
 5. Patients taking warfarin should not be
prescribed non-selective NSAIDs and COX-2
inhibitors as analgesia following surgery

11. THE AMERICAN COLLEGE OF CHEST PHYSICIANS
(2013)
 continuing warfarin with co-administration of an oral
prohemostatic agent or stopping warfarin 2 to 3
days before the procedure.
 Four prospective studies were cited, In each of the four
studies cited, oral surgery in patients who were taking
anticoagulants was compared with patients whos
anticoagulation was reduced or interrupted. Although
there were no embolic complications in any of these
patients, there were also no bleeding complications
requiring more than local measures for hemostasis. The
incidence of bleeding was the same in both the
anticoagulation continuation and interruption groups in
each study, and the authors of each of the four studies
concluded that anticoagulation should not be interrupted
for oral surgery.

12.  Campbell JH , Alvarado F , Murray RA . Anticoagulation and minor oral surgery:
should the anticoagulation regimen be altered? J Oral Maxillofac Surg . 2000 ;
58 ( 2 ): 131 - 135 .
 Devani P , Lavery KM , Howell CJT . Dental extractions in patients on warfarin:
is alteration of anticoagulant regime necessary? Br J Oral Maxillofac Surg .
1998 ; 36 (2): 107 - 111 .
 Gaspar R , Brenner B , Ardekian L , Peled M , Laufer D . Use of tranexamic
acid mouthwash to prevent postoperative bleeding in oral surgery patients on
oral anticoagulant medication . Quintessence Int . 1997 ; 28 ( 6 ): 375 - 379 .
 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 ( 6
): 518 - 521 .

13.  In summary, local hemostatic measures are almost
always sufficient for oral surgery in patients on
warfarin, with no long-term sequelae. In contrast,
thromboembolic events occurring in patients with
warfarin interruption are much more likely to result
in permanent disability or death.
 We, therefore, respectfully suggest that the option
for alteration of warfarin therapy should be
eliminated for minor oral surgery and reserved only
for the most invasive oral surgical procedures in
which a significant amount of blood loss is
anticipated (eg, orthognathic surgery).

14.  Antiplatelet therapy

15.  Some physicians assume there is little or no risk of
serious thrombotic complications in patients whose
antiplatelet therapy is interrupted for dental
procedures, but in large case-control studies of
patients on low-dose aspirin, strokes or myocardial
infarctions were significantly more likely to occur in
those whose antiplatelet therapy was interrupted for
any reason
 Garcia Rodríguez LA, Cea Soriano L, Hill C, Johansson S. Increased risk of stroke after
discontinuation of acetylsalicylic acid: a UK primary care study. Neurology
2011;76(8):740-6.
 Garcia Rodríguez LA, Cea-Soriano L, Hill C, Martin-Merino E, Johansson S.
Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in
UK primary care. Brit Med J 2011;343:d4094.

16. MEDEIROS FB, DEANDRADE AC, ANGELIS GA ET AL. BLEEDING EVALUATION DURING
SINGLE TOOTH EXTRACTION IN PATIENTS WITH CORONARY ARTERY DISEASE AND
ACETYLSALICYLIC ACID THERAPY SUSPENSION: A PROSPECTIVE, DOUBLE-BLINDED AND
RANDOMIZED STUDY. J ORAL MAXILLOFAC SURG 2011;69(12):2949-55.
 63 patients with CAD on ASA therapy, 100mg/day
 Group S, ASA suspended 7days prior
 Group NS, ASA continued
 Same surgeon and unaware
 The mean volume of bleeding was 12.10 ± 9.37 mL
in Gs
 16.38 ± 13.54 mL in Gns
 Sum: There was no difference in the amount of
bleeding that occurred during tooth extraction
between patients who continued ASA therapy versus
patients who suspended their ASA therapy

17. NAPENAS 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 ANTI-PLATELET THERAPY. J AM DENT ASSOC.
2009;140(6):690-5.
 retrospective study 43 pts (single or dual
antiplatelet)
 Invasive surgical procedures
 concluded that there is negligible risk of bleeding
complications after invasive surgical procedures in
patients taking single or dual anti-platelet therapy

18. CANIGRAL A, SILVESTRE FJ, CANIGRAL G, ALOS M, GARCIA-HERRAIZ A,
PLAZA A. EVALUATION OF BLEEDING RISK AND MEASUREMENT METHODS IN
DENTAL PATIENTS. MED ORAL PATHOL ORAL CIR BUCAL. 2010;15(6):E863-
E868.
 simple and complex (surgical and multiple teeth
extractions)
 aspirin or clopidogrel or aspirin + clopidogrel or non-
steroidal anti-inflammatory drugs (NSAIDs) or low
molecular weight heparin (LMWH) therapy
 (92%), bleeding was mild which subside within 10
minutes with the help of gauze pressure
 8% cases of bleeding, it was described as moderate,
which was easily controlled by local hemostatic measures
 Sum: safety of oral surgery in patients on continued anti-
thrombotic therapy

19. HEMELIK M, WAHL G, KESSLER B. TOOTH EXTRACTION UNDER MEDICATION
WITH ACETYLSALICYLIC ACID. MUND KIEFER GESICHTSCHIR. 2006;10(1):3-
6.
 151 tooth extractions in 65 patients , 100 mg/day
aspirin
 postoperative bleeding was 1.54%
 bleeding episodes were handled easily
 concluded that there is no need to stop 100 mg/day
aspirin prior to dental extractions.

20. MADAN GA, MADAN SG, MADAN G, MADAN AD. MINOR ORAL SURGERY
WITHOUT STOOPING DAILY LOW-DOSE ASPIRIN THERAPY: A STUDY OF 51
PATIENTS. J ORAL MAXILLOFAC SURG. 2005;63(9):1262-5.
- simple & surgical extractions and implant
placement
- 51 Patients on Aspirin 75- 100 mg/day
- Suturing and pressure pack for 30 minute was used
as hemostatic measure in all the cases
- 1 pt showed excessive bleeding intra-operatively
which was easily managed by pressure pack
soaked in 1% ferracrylum solution
- no postoperative bleeding in any case
- authors concluded that most oral surgical
procedures can be carried out safely without
interrupting long term low-dose aspirin therapy

21. M.-W. PARK, S.-H. HER, J. B. KWON ET AL., “SAFETY OF DENTAL
EXTRACTIONS IN CORONARY DRUG-ELUTING STENTING PATIENTS WITHOUT
STOPPING MULTIPLE ANTIPLATELET AGENTS,” CLINICAL CARDIOLOGY, VOL.
35, NO. 4, PP. 225–230, 2012.
 prospective clinical study
 59 patients were on dual aspirin (100 or 200 mg/day) +
clopidogrel 75 mg/day
 41 patients were on triple antiplatelet therapy (aspirin
100 or 200 mg/day plus clopidogrel 75 mg/day plus
cilostazol 100 mg/day).
 100 patients not taking any antiplatelet agents served as
control group.
 Only 3 pts exhibited post-operative bleeding (1 on dual,
1 on triple anti-platelet therapy and 1 not taking any anti-
platelet drug).
 All the episodes of bleeding were easily controlled by
pressure application by patients themselves. The
authors concluded that dental extractions can be
performed safely in patients on multiple antiplatelet
agents

22. GAURAV V ET AL. ASPIRIN THERAPY AND EXODONTIA: REVIEW OF
LITERATURE . ANNALS OF DENTAL RESEARCH . 2014
 Based on the review of literature, it can be
concluded that current recommendations and
consensus are in favor of continuing anti-platelet
dose of aspirin prior to tooth extraction. The safety
of dental extractions in such patients is supported
by studies reported in literature. It must be
emphasized that appropriate use of local
hemostatic measures should always be considered
whenever indicated. There is no justification to
predispose the patient to the risk of
thromboembolism at the expense of minor bleeding
which can be easily controlled

23. C. L. GRINES, R. O. BONOW, D. E. CASEY JR. ET AL., “PREVENTION OF PREMATURE
DISCONTINUATION OF DUAL ANTIPLATELET THERAPY IN PATIENTS WITH CORONARY ARTERY STENTS: A
SCIENCE ADVISORY FROM THE AMERICAN HEART ASSOCIATION, AMERICAN COLLEGE OF
CARDIOLOGY, SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS, AMERICAN
COLLEGE OF SURGEONS, AND AMERICAN DENTAL ASSOCIATION, WITH REPRESENTATION FROM THE
AMERICAN COLLEGE OF PHYSICIANS,” CIRCULATION, VOL. 115, NO. 6, PP. 813–818, 2007
 A consensus opinion from the American Heart
Association, American College of Cardiology, Society
for Cardiovascular Angiography and Interventions,
American College of Surgeons, and American Dental
Association
 recommended either continuing aspirin and
clopidogrel therapy for minor oral surgical
procedures in patients who have coronary artery
stents or delaying treatment until prescribed regimen
will be completed

24. ORAL MEDICINE AND ORAL SURGERY FRANCOPHONE SOCIETY. MANAGEMENT OF
PATIENTS UNDER ANTI-PLATELET AGENTS’ TREATMENT IN ODONTOSTOMATOLOGY. (11
JUNE 2007).
 Oral Medicine and Oral Surgery Francophone
Society conducted a literature review and gave
recommendations for management of patients on
antiplatelet therapy based on the agreement among
professionals in the field. The society stated that
interruption of antiplatelet therapy prior to dental
procedures is unnecessary. The risk of bleeding is
very low and local hemostatic measures are usually
successful

25.  The American Dental association Division of Legal
Affairs has stated that “the oral surgeon who blindly
follows the physician’s recommendation, even
though it conflicts with the oral surgeon professional
judgment, will not be able to defend himself or
herself by claiming ‘the devil made me do it’ if the
patient sues. The courts recognize that each
independent professional is ultimately responsible
for his or her own treatment decisions

26.  There have been at least four separate cases of embolic
complications (two fatal) after physician consultation and
anticoagulation interruption.45 In other words, the
surgeon consulted the physician, who recommended
interruption of warfarin before the oral surgery. The
patients in each of these cases suffered strokes, and
two died. A lawsuit was filed in each case. In these
cases, there was no reason to interrupt therapeutic
levels of anticoagulation for dental extractions and
certainly no reason for the surgeon to ask the patient’s
physician to consider such an interruption (although
there may have been a reason to consult with the
physician to determine the patient’s INR levels).

27. THANK YOU