Postextraction bleeding in a patient taking antithrombotics: report of a case.

Antithrombotic medications, including antiplatelets and anticoagulants, are used by millions of patients to prevent stroke or heart attack. When these patients present for dental surgery, a decision must be made whether to continue the antithrombotic medication and risk a bleeding problem or to interrupt the medication and risk an embolic complication such as a stroke or heart attack. In patients taking antithrombotic medications, a small risk of postoperative bleeding after dental extractions must be weighed against a small risk of stroke or heart attack when these medications are interrupted. This case report discusses an episode of minor postextraction bleeding in a patient taking combination anticoagulant and antiplatelet therapy. Antithrombotic therapy generally should not be interrupted for dental procedures, as the prognosis of potential postextraction bleeding that could result from antithrombotic continuation is almost always better than the prognosis of a potential stroke or heart attack that could follow antithrombotic interruption.

Critical appraisal: dental amalgam update--part II: biological effects.

Dental amalgam restorations have been controversial for over 150 years. In Part I of this Critical Appraisal, the clinical efficacy of dental amalgam was updated. Here in Part II, the biological effects of dental amalgam are addressed.

Critical appraisal: dental amalgam update­part I: clinical efficacy.

Dental amalgam use has been controversial ever since the Crawcour brothers of France introduced amalgam to the United States in 1833. It has been criticized for its alleged clinical shortcomings and biologic effects. As a result, we thought that it would be useful to provide an update on dental amalgam in two parts. Part I, presented here, focuses on the clinical aspects of dental amalgam, whereas Part II will focus on dental amalgam's biologic effects.

Dentistry's wonder drugs: local anesthetics and vasoconstrictors.

This article reviews recent developments concerning local anesthetics, including the amount of pain resulting from injection, which drugs achieve anesthesia most effectively, proper dosing for anesthetizing children and adults, the maximum recommended doses of lidocaine 2% with epinephrine for cardiac patients, and which drugs can be used for patients taking monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, or nonselective beta blockers. Dentists should be familiar with all aspects of local anesthetics, especially anesthetic toxicity and maximum recommended doses.

Dental implant surgery and risk of bleeding in patients on antithrombotic medications: A review of the literature.

OBJECTIVES: This literature review was performed to assess the risk of bleeding in dental implantation procedures in patients taking antiplatelet drugs (APs), oral anticoagulants (OACs) and direct oral anticoagulants (DOACs). STUDY DESIGN: MEDLINE and SCOPUS databases were searched for English language publications through October 2019, using the keywords "dental implants," "dental implantation," "anticoagulants," "platelet aggregation inhibitors," and "hemorrhage." Reference lists of relevant articles were also hand searched. Collected data regarding dental implantation procedures, type of medications (APs, OACs and DOAC), and postoperative bleeding episodes were analyzed. RESULTS: Nine studies were included in the review. Postoperative bleeding occurred in 10 (2.2%) of 456 of cases involving dental implant placements; in all of those cases, bleeding was controlled with the use of local hemostatic agents. The bleeding incidence in patients on antiplatelet medications was 0.4% (range 1 of 253 to 1 of 261). Among those taking oral anticoagulants, the bleeding incidence was 5.7% (range 6 of 105 to 6 of 113), and among those on direct oral anticoagulants, the bleeding incidence was 3.3% (3 of 90). The numbers of more extensive surgical procedures (i.e., sinus lift and bone augmentation procedures) were small, and additional information regarding the surgery, the specific antithrombotic used, or bleeding was often not provided, so further analysis was not possible. CONCLUSIONS: Evidence supports continuing OACs, DOACs, or APs during dental implant surgery.

Not all instability training devices enhance muscle activation in highly resistance-trained individuals.

The objective of this study was to measure the electromyographic (EMG) activity of the soleus, bicep femoris, rectus femoris, lower abdominal, and lumbosacral erector spinae (LSES) muscles with a variety of (a) instability devices, (b) stable and unstable (Dyna Disc) exercises, and (c) a fatiguing exercise in 16 highly conditioned individuals. The device protocol had participants assume standing and squatting postures while balancing on a variety of unstable platforms (Dyna Disc, BOSU ball, wobble board, and a Swiss ball) and a stable floor. The exercise protocol had subjects performing, static front lunges, static side lunges, 1-leg hip extensions, 1-leg reaches, and calf raises on a floor or an unstable Dyna Disc. For the fatigue experiment, a wall sit position was undertaken under stable and unstable (BOSU ball) conditions. Results for the device experiment demonstrated increased activity for all muscles when standing on a Swiss ball and all muscles other than the rectus femoris when standing on a wobble board. Only lower abdominals and soleus EMG activity increased while squatting on a Swiss ball and wobble board. Devices such as the Dyna Disc and BOSU ball did not exhibit significant differences in muscle activation under any conditions, except the LSES in the standing Dyna Disc conditions. During the exercise protocol, there were no significant changes in muscle activity between stable and unstable (Dyna Disc) conditions. With the fatigue protocol, soleus EMG activity was 51% greater with a stable base. These results indicate that the use of moderately unstable training devices (i.e., Dyna Disc, BOSU ball) did not provide sufficient challenges to the neuromuscular system in highly resistance-trained individuals. Since highly trained individuals may already possess enhanced stability from the use of dynamic free weights, a greater degree of instability may be necessary.

The mythology of anticoagulation therapy interruption for dental surgery.

BACKGROUND: Continuous anticoagulation therapy is used to prevent heart attacks, strokes, and other embolic complications. When patients receiving anticoagulation therapy undergo dental surgery, a decision must be made about whether to continue anticoagulation therapy and risk bleeding complications or briefly interrupt anticoagulation therapy and increase the risk of developing embolic complications. Results from decades of studies of thousands of dental patients receiving anticoagulation therapy reveal that bleeding complications requiring more than local measures for hemostasis have been rare and never fatal. However, embolic complications (some of which were fatal and others possibly permanently debilitating) sometimes have occurred in patients whose anticoagulation therapy was interrupted for dental procedures. PRACTICAL IMPLICATIONS AND CONCLUSIONS: Although there is now virtually universal consensus among national medical and dental groups and other experts that anticoagulation therapy should not be interrupted for most dental surgery, there are still some arguments made supporting anticoagulation therapy interruption. An analysis of these arguments shows them to be based on a collection of myths and half-truths rather than on logical scientific conclusions. The time has come to stop anticoagulation therapy interruption for dental procedures.

Size doesn't matter: needle gauge and injection pain.

Many dentists prefer using smaller gauge (27- or 30-gauge) needles for anesthesia injection, believing that needles with a smaller diameter result in less injection pain than wider diameter needles. For this study, three dentists in a general practice administered 930 injections to 810 adult patients using 25- and 27-gauge needles for mandibular inferior alveolar block injections and 25-, 27-, and 30-gauge needles for maxillary buccal infiltration or palatal injections. Patients, who were blinded as to the needle gauge, were asked afterward to rate the injection pain on an 11-point scale (0-10). There was no statistically significant difference in perceived injection pain based on needle gauge when analyzed for injection location (mandibular, maxillary posterior, maxillary anterior, and palatal), injection side, patient gender, treating dentist, or overall. These results indicate that when it comes to injection pain and needle gauge, size does not matter.

Osteoradionecrosis prevention myths.

PURPOSE: To critically analyze controversial osteoradionecrosis (ORN) prevention techniques, including preradiation extractions of healthy or restorable teeth and the use of prophylactic antibiotics or hyperbaric oxygen (HBO) treatments for preradiation and postradiation extractions. METHODS: The author reviewed ORN studies found on PubMed and in other article references, including studies on overall ORN incidence and pre- and postradiation incidence, with and without prophylactic HBO or antibiotics. RESULTS: Owing in part to more efficient radiation techniques, the incidence of ORN has been declining in radiation patients over the last 2 decades, but the prevention of ORN remains controversial. A review of the available literature does not support the preradiation extraction of restorable or healthy teeth. There is also insufficient evidence to support the use of prophylactic HBO treatments or prophylactic antibiotics before extractions or other oral surgical procedures in radiation patients. CONCLUSIONS: To prevent ORN, irradiated dental patients should maintain a high level of oral health. A preradiation referral for a dental evaluation and close collaboration by a multidisciplinary team can be invaluable for radiation patients. As with most other dental patients, restorable and healthy teeth should be retained in irradiated patients. The use of prophylactic HBO or antibiotics should be reconsidered for preradiation and postradiation extractions.

Injection pain of prilocaine plain, mepivacaine plain, articaine with epinephrine, and lidocaine with epinephrine.

In a double-blind study design, 1,391 consecutive patients in a general dental practice received one of four different local anesthetics (articaine with epinephrine, lidocaine with epinephrine, mepivacaine plain, or prilocaine plain) via a maxillary buccal infiltration, palatal infiltration, or inferior alveolar block injection. The anesthetics were administered under clinical conditions by one of two dentists. Immediately after receiving the injection, patients rated the pain from each injection on a ten-point scale. The pain response was analyzed according to the dentist administering the injection, the location of injection, the patient's gender, and the type of anesthetic administered. Injection of prilocaine plain produced significantly lower pain scores than lidocaine with epinephrine, mepivacaine plain, or articaine with epinephrine.

Dental surgery in anticoagulated patients--stop the interruption.

In a literature review, the incidence and morbidity of bleeding complications after dental surgery in anticoagulated patients was compared with embolic complications when anticoagulation was interrupted. Over 99% of anticoagulated patients had no postoperative bleeding that required more than local hemostatic measures. Of more than 5431 patients undergoing more than 11,381 surgical procedures, with many patients at higher than present therapeutic intenational normalized ratio (INR) levels, only 31 (∼0.6% of patients) required more than local hemostasis to control the hemorrhage; none died due to hemorrhage. Among at least 2673 patients whose warfarin dose was reduced or withdrawn for at least 2775 visits for dental procedures, there were 22 embolic complications (0.8% of cessations), including 6 fatal events (0.2% of cessations). The embolic morbidity risk in patients whose anticoagulation is interrupted for dental surgery exceeds that of significant bleeding complications in patients whose anticoagulation is continued, even when surgery is extensive. Warfarin anticoagulation, therefore, should not be interrupted for most dental surgery.

Injection pain of bupivacaine with epinephrine vs. prilocaine plain.

BACKGROUND: Prilocaine plain has been described in the literature as causing less pain on injection than bupivacaine with epinephrine, possibly because of the higher pH of the prilocaine anesthetic solution. METHODS: In a double-blind study design, 681 consecutive patients in a general dental practice received maxillary buccal infiltration, posterior palatal infiltration or inferior alveolar block injections, administered under clinical conditions by one of two dentists. Immediately after injection, patients rated the pain from each injection on a six-point scale. The pain response was analyzed according to treating dentist, location of injection, patient's sex and anesthetic administered. RESULTS: The reported pain on injection of bupivacaine with epinephrine was significantly greater than that of prilocaine plain. Patients reported no significant difference in pain at different injection locations, except that palatal injections caused significantly more reported pain than did anterior maxillary infiltration, posterior maxillary infiltration or inferior alveolar block injections. CONCLUSIONS: Under clinical conditions, the injection of bupivacaine with epinephrine causes significantly more perceived pain than does the injection of prilocaine plain. Clinical Implications. Bupivacaine with epinephrine and prilocaine plain have certain advantages and disadvantages that should be considered before choosing an anesthetic for a dental procedure. A disadvantage of bupivacaine with epinephrine is that it produces more perceived pain than does prilocaine plain.

Prevalence of cusp fractures in teeth restored with amalgam and with resin-based composite.

BACKGROUND: Complete cusp fracture in restored teeth is a common problem observed in general dental practice. Many dentists believe that teeth restored with amalgam are more likely to be associated with cusp fractures than are those restored with resin-based composite. METHODS. The authors noted the condition of 10,869 posterior teeth with amalgam or resin-based composite restorations with at least one cusp present, unrestored or missing in 1,902 consecutively seen adult patients in a private general dental practice. For each patient, the authors recorded age, type of restorations, number of surfaces of each restoration, and presence or absence of a complete cusp fracture and of caries. RESULTS: There was a lower percentage of cusp fractures in younger subjects than in older subjects and in teeth with a single restored surface than in those with more than one restored surface. There was no significant difference in the prevalence of cusp fracture rates in amalgam-restored teeth versus composite-restored teeth in subjects aged 18 through 54 years. In subjects aged 55 through 96 years, there was a marginally significantly greater cusp fracture rate in composite-restored teeth than in those restored with amalgam. Overall, there was no significant difference in the prevalence of cusp fracture in teeth restored with amalgam (1.88 percent) versus composite-restored teeth (2.29 percent). CONCLUSIONS: The prevalence of cusp fractures in amalgam-restored teeth and resin-based composite-restored teeth is not significantly different. Teeth with more than one surface restored with either resin-based composite or amalgam and teeth in older subjects were more likely to suffer a cusp fracture. CLINICAL IMPLICATIONS: Teeth restored with amalgam and with resin-based composite exhibited equally low cusp fracture prevalence. When choosing between amalgam and resin-based composite in consideration of the likelihood of a future cusp fracture, either restorative material is acceptable.

Are there acceptable alternatives to amalgam?

Amalgam has been the material of choice for restoring posterior teeth for more than 100 years. The past 25 years have witnessed significant advances in restorative materials themselves and in the bonding systems for retaining a restoration in the prepared tooth. As a result, there has been a shift toward resin composite materials during this same period because of concerns about the esthetics and biocompatibility of dental amalgam. In addition, other materials such as glass ionomer cements, ceramic inlays and onlays, and gold alloys have been used as alternatives to amalgam. This article will review recent studies on the longevity and biocompatibility of these alternatives to dental amalgam.

A resin alternative for posterior teeth: questions and answers on dental amalgam.

Amalgam has been used to restore cavities in posterior teeth for over 100 years, but formulations used today are different from those used a century ago. Amalgam restorations have been blamed for a number of problems, such as cusp fracture and higher rates of secondary caries. This article discusses these issues, along with possible toxic effects, in the light of current literature.

Dental surgery and antiplatelet agents: bleed or die.

In patients taking antiplatelet medications who are undergoing dental surgery, physicians and dentists must weigh the bleeding risks in continuing antiplatelet medications versus the thrombotic risks in interrupting antiplatelet medications. Bleeding complications requiring more than local measures for hemostasis are rare after dental surgery in patients taking antiplatelet medications. Conversely, the risk for thrombotic complications after interruption of antiplatelet therapy for dental procedures apparently is significant, although small. When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to "bleed or die." That is, there is a remote chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus a small but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is simple: It is time to stop interrupting antiplatelet therapy for dental surgery.