Relación entre la presión arterial y el control de la hemorragia post-exodoncia en pacientes bajo tratamiento con warfarina / Relationship between blood pressure and hemorrhage control post exodontia in patients under warfarin treatment

Objetivo: Determinar la relación entre el nivel de pre- sión arterial (PA) y la hemorragia post-exodoncia aplicando medidas de hemostasia local en pacientes bajo tratamiento con warfarina. Materiales y métodos: Este estudio se realizó sobre 30 pacientes (15 hombres y 15 mujeres) bajo tratamiento anti- coagulante oral (TACO) con warfarina. Los pacientes concu- rrían al programa de TACO del Hospital y Centro de Referen- cia de Salud El Pino (HEP y CRS). Se les realizaron una o dos extracciones dentales (n=38) sin suspensión del anticoagulan- te oral a pacientes que tuvieran un coeficiente internacional normalizado (INR) del día menor o igual a 3. Se aplicaron medidas de hemostasia local con gasa compresiva y/o sutura en 30 de las extracciones dentales. Los procedimientos quirúr- gicos fueron llevados a cabo en el Servicio Dental del CRS y HEP. Se registraron las siguientes variables: 1) PA previa a la exodoncia, 2) PA a los 30 minutos, 3) Presencia o ausencia de hemorragia a los 30 minutos post-exodoncia y 4) PA y presen- cia o ausencia de hemorragia a las 24 horas post-exodoncia. Se estudió la relación entre el nivel de PA y la hemorragia post-exodoncia. Resultados: De todos los pacientes evaluados, ninguno presentó hemorragia post-exodoncia en los distintos momen- tos de evaluación, independientemente de cuál fuera su PA. No se encontraron efectos de la variable PA ­considerando valores de PA sistólica (PAS) por debajo de 140 mmHg y de PA diastólica (PAD) menores a 90 mmHg- en relación con la hemorragia post-exodoncia. Conclusión: De acuerdo con los resultados obtenidos en este estudio, la presión arterial con PAS <140 mmHg y PAD <90 mmHg no es un factor que influya en el sangrado post-exodoncia en pacientes bajo tratamiento con warfarina con ≤3 (AU)

Aim: To establish the relationship between blood pres- sure (BP) level and post-exodontic hemorrhage by applying local hemostasis measures in patients under warfarin treat- ment. Materials and methods: This study was conducted in 30 patients (15 men and 15 women) under oral anticoagu- lant (OAC) treatment with warfarin. The patients attended the TACO program of the "Hospital y Centro de Referencia de Salud el Pino (HEP y CRS)". One or two dental extractions (n=38) were performed in the patients that had an INR low- er or equal to 3, without suspending the oral anticoagulant treatment, applying local hemostasis measures with compres- sive gauze and/or suture in 30 of the extractions. The surgical procedure was carried out in the Dental Department of the CRS and HEP. The following variables were registered: 1) BP prior to extraction, 2) BP after 30 minutes, 3) presence or absence of hemorrhage after 30 minutes post-exodontia and 4) BP and presence or absence of hemorrhage 24 hours post-exodontia. The relation between BP level and post-exo- dontic bleeding was studied. Results: Considering all the examined patients, none of them presented post-exodontic hemorrhage at any of the dif- ferent moments of evaluation, regardless of their BP level. No effect of the BP variable ­considering a range of systolic BP SBP) below 140 mmHg and a diastolic BP (DBP) under 90 mmHg- was found in relation to post-exodontic hemorrhage. Conclusion: According to the results obtained in this study, blood pressure with SBP <140 mmHg and DBP <90 mmHg is not an influential factor in post-exodontic bleeding in patients under warfarin treatment with ≤3 (AU)

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

BACKGROUND: 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 (VWD). 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. This is an update of a previously published Cochrane Review. OBJECTIVES: Primarily, we aim to assess the efficacy of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or VWD undergoing oral or dental procedures.Secondary objectives are to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or VWD and to establish the effects of these agents on bleeding in oral or dental procedures for each of these patient populations. SEARCH METHODS: 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, Cinahl 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: 01 March 2019. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials in people with haemophilia or VWD undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid (EACA)) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS: 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 standardised forms. MAIN RESULTS: While there were no eligible trials in people with VWD 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 EACA 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 (RD) of -0.64 (95% confidence interval (CI) -0.93 to - 0.36) and the EACA trial a RD of -0.50 (95% CI 0.77 to -0.22). The combined RD of both trials was -0.57 (95% CI -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 EACA (combined RD 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 EACA trial, but overall the risk of bias appeared to be low for both trials. AUTHORS' CONCLUSIONS: Despite the discovery of a beneficial effect of systemically administered tranexamic acid and EACA 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 VWD.

U.K. hemophilia treaters' knowledge of risk assessment for prolonged bleeding associated with dental procedures.

INTRODUCTION: Optimal delivery of dental care for adults with congenital bleeding disorders (CBD) requires close collaboration between hemophilia treaters and dentists. AIM: To explore U.K. hemophilia treaters' knowledge of dental procedures and associated hemostatic management in adults with CBD. METHOD: Staff (N = 180) from N = 60 hemophilia facilities in the United Kingdom were invited to participate in a questionnaire-based study using a web-based tool. The questionnaire assessed participants' knowledge, adherence and appropriateness of application of U.K. guidance on hemostatic management of common dental procedures. RESULTS: The response rate was 23% of treaters (n = 41) from 62% (n = 32) hemophilia facilities. Individual participants (87%; n = 34) reported they adhered to guidelines, though knowledge of guidance was poor with only 36% (n = 15) applying guidance appropriately in 3 common dental scenarios. There was a tendency for participants to assign the use of systemic hemostatic measures independent of the agreed bleeding risk associated with the proposed dental procedure. CONCLUSION AND RECOMMENDATIONS: While hemophilia treaters were aware of current guidelines, their knowledge of the guidelines and ability to risk assess dental procedures was poor. There was a tendency to overprescribe systemic hemostatic measures for dental procedures. Education initiatives to aid decision making are needed.

Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions.

BACKGROUND: Individuals on continuous treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) are at increased risk of bleeding complications during and after oral or dental procedures. Anticoagulant treatment is preferably continued at the same dose, since dose reduction or discontinuation of treatment is associated with an increased risk of thromboembolism. The use of haemostatic measures during or after the procedure (or both) could enable continuation of the oral anticoagulant treatment. OBJECTIVES: We aimed to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and the Cochrane Library. Additional searches were performed using ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), the CINAHL database of nursing and allied health services, the open access ProQuest dissertation database, papers and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences.Date of last search: 04 January 2018. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials in people on continuous treatment with VKAs or DOACs undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid (TXA) or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS: Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained from potentially relevant abstracts and two authors independently assessed these for inclusion based of the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. The quality of the evidence was assessed using GRADE. MAIN RESULTS: No eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures were identified.Three randomised trials and one quasi-randomised trial (follow-up in all was seven days) in people on continuous treatment with VKAs were included with a total of 253 participants (mean age 60 years). Two trials published in 1989 and 1993 compared the antifibrinolytic agent TXA with placebo in people using VKAs. Two other trials were published in 1999 and 2015 and compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively. In all included trials, those who were treated with VKAs had international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically.The two trials from 1989 and 1993 comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of -0.25 (95% confidence interval (CI) -0.36 to -0.14) (128 participants) (moderate-quality evidence). For the two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression, there was no difference between the TXA and the standard care group, RD 0.02 (95% CI -0.07 to 0.11) (125 participants) (moderate-quality evidence). The combined RD of all included trials was -0.13 (95% CI -0.30 to 0.05) (moderate-quality evidence). There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate-quality evidence). Despite heterogeneity between trials with respect to the different haemostatic measures used in the control groups, the trials were comparable regarding design and baseline participant characteristics.Overall, we considered the risk of bias to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures. AUTHORS' CONCLUSIONS: Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population.We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs.

The use of platelet-rich fibrin as a hemostatic material in oral soft tissues.

The control of postoperative bleeding represents one of the main intercurrent events associated with soft tissue surgical procedures in the oral cavity. In this context, platelet-rich fibrin (PRF) membranes are materials with great potential for optimizing soft tissue healing and induction of hemostasis. This interventional case series describes the treatment of 10 patients with excisional biopsy of benign oral cavity lesions, following a screening sequence at the surgery clinic of a Brazilian dental school between the years of 2015 and 2017. After treatment with PRF, patients presented mean time for postoperative hemostasis of 10.3 ± 2.5 s, requiring the average use of three membranes to cover the surgical area. The results suggest that the use of platelet-rich fibrin membranes may represent a feasible alternative hemostatic material for the treatment of oral lesions.

Supportive topical tranexamic acid application for hemostasis in oral bleeding events - Retrospective cohort study of 542 patients.

PURPOSE: Tranexamic acid (TXA) is widely used in the prevention of postsurgical oral bleeding. Tranexamic acid in addition to further surgical measures is widely utilized in prevention of post-surgical oral bleeding. The aim of the present study was to investigate: Can oral hemostasis be achieved by merely compression and topical application of tranexamic acid in different anticoagulant regimes among patients attending a general emergency department? Where are the limits to this procedure? Which has the greater impact on surgeons' choice for an invasive hemostatic approach-bleeding quality or oral anticoagulant therapy? MATERIALS AND METHODS: A retrospective cohort study of 542 patients who consecutively received treatment for oral bleeding was performed. We surveyed the values of the diverse hemostatic approaches. Special attention was granted to patient anticoagulant regimen and quality of the oral bleeding event. RESULTS: A total of 199 of 542 (36.7%) oral bleeding events were stopped by compression with a gauze or gauze soaked with TXA (4.8%). Stopping an oral bleeding event with wound compression can be improved by factor 1.6 if the gauze is soaked with tranexamic acid (4.8%), p ≤ 0.05. LMWH presented significantly more moderate bleeding than bloody oozing of the wound, p < 0.05. The quality of bleeding had a strong influence on oral surgeons' decisions to apply further surgical means. Sutures and native collagen fleeces were the favored methods to stop moderate and severe bleeding (p < 0.05). CONCLUSION: Topical application of TXA aids as a useful supportive tool to stop mild bleeding events such as the bloody oozing of an oral wound. The quality of an oral bleeding episode should be considered in the choice of hemostatic measure. Hemostatic approaches should begin with the least invasive procedure. TXA is a helpful tool.

Preoperative Detailed Coagulation Tests Are Required in Patients With Noonan Syndrome.

PURPOSE: Patients with Noonan syndrome often require surgery at young ages. They are at high risk of perioperative bleeding from coagulation defects that might not have been detected by routine screening. These risks are rarely described in the oral and maxillofacial surgery (OMS) literature. The aim of this study was to evaluate the perioperative bleeding risks associated with Noonan syndrome and to propose preoperative guidelines. MATERIALS AND METHODS: This report describes a retrospective case series of patients with Noonan syndrome who underwent OMS procedures during a continuous observational period (2013 through 2016) in the authors' center. Clinical data, blood screening test results, and perioperative bleeding were analyzed. RESULTS: Five patients (age, 4 to 20 yr) with Noonan syndrome who underwent OMS procedures were included in this study. One patient presented a spontaneous bleeding tendency (epistaxis requiring cauterization). Blood screening showed clotting defects in 3 patients. One patient presented abnormal perioperative bleeding owing to a mild defect in factor XI. CONCLUSION: Patients with Noonan syndrome must be referred to a hematologist for specific preoperative investigations and for adapted perioperative management.

Tranexamic acid as a local hemostasis method after dental extraction in patients on warfarin: a randomized controlled clinical study.

OBJECTIVES: The present work is a controlled, blinded, and randomized clinical trial comparing hemostatic measures for the control of post-tooth extraction hemorrhage in patients on anticoagulation therapy with warfarin. MATERIALS AND METHODS: The sample consisted of 37 patients (37.8% male and 62.2% female) with a mean age of 45.5 years. After randomization, 20 patients were allocated to the control group (conventional hemostasis measures) and 17 to the study group (addition of local tranexamic acid). All variables that could influence the outcome were similar between the groups and no significant difference was seen (p > 0.05). RESULTS: In the assessment of immediate hemostasis, for the control group, the time to achieve cessation of bleeding was 9.1 (± 3.6) minutes. For the study group this was much lower, and this difference (6.018 / confidence interval of 95%, 4.677 to 7.359) was statistically significant (p < 0.001). In evaluating the control of intermediate hemorrhage, the use of tranexamic acid was more significantly associated with the absence of bleeding, especially in the first 24 h. CONCLUSIONS AND CLINICAL RELEVANCE: Thus, this measure of local hemostasis in topical form with gauze compression and irrigation was shown to be more effective in reducing the time to attain immediate hemostasis, and in preventing intermediate hemorrhage.

Dental treatment in the era of new anti-thrombotic agents.

BACKGROUND: In recent years, there have been dramatic changes in anti-thrombotic treatment as a result of new anti-thrombotic agents, as well as changes in the indications for their use. As a consequence, dentists are encountering larger numbers of patients who are undergoing anti-thrombotic treatment and who have increased risk for bleeding. The current paper aims to review the literature regarding up-to-date anti-thrombotic treatment and provide information regarding their implications on dentistry. METHODS: An online search was performed of the literature published between 2000 and 2016. Articles dealing with evidence-based clinical guidelines for anti-thrombotic treatments, as well as literature reporting the use of anti-thrombotic medications were included. The manuscripts were screened according to their relevance to dentistry as well as their treatment protocol guidelines. RESULTS: In total, 5,539 publications were identified: 56 of 554 evidence-based clinical guidelines were found that dealt with treatment protocols with anti-thrombotic agents; and 132 of 5,539 articles describe direct anti-thrombotic medications. CLINICAL IMPLICATIONS: Dental treatment includes a risk for bleeding. As a result of the increasing number of patients taking new-generation anti-thrombotic drugs, dentists must be up to date regarding the implications of such drugs on dental treatment as well as the practical means to achieve haemostasis.

Management of Patients With Left Ventricular Assist Devices Requiring Teeth Extraction: Is Halting Anticoagulation Appropriate?

PURPOSE: An increasing number of patients with end-stage heart failure are supported with left ventricular assist device (LVAD) implantation and must be maintained on a consistent anticoagulation regimen. Pre-emptive extraction of carious teeth in these patients is necessary to prevent seeding of the implanted device and endocarditis. Thus, the objective of this study was to evaluate bleeding complications after minor oral surgery, specifically teeth extractions, in this unique patient population requiring long-term anticoagulation. MATERIALS AND METHODS: This study was a retrospective single-center review. Adult patients supported on an implanted continuous-flow LVAD from January 1, 2007 to December 31, 2016 were included. Baseline characteristics were collected by retrospective chart review and the institutional LVAD registry. All extractions were performed in the operating room under local anesthesia with moderate sedation or general anesthesia with nasal intubation, and LVAD settings were monitored by a trained perfusionist. Preoperative and postoperative hematology laboratory values, such as hemoglobin and international normalized ratio (INR), were collected by chart review. Continuous variables were presented as mean ± standard deviation and compared using the Student t test. Categorical variables were presented as proportion and percentage and compared using the χ2 test or Fisher exact test as appropriate. Statistical significance was established at a P value less than .05. RESULTS: After screening 798 patients, 32 (4%) were found to have undergone dental extractions after LVAD implantation. The sample was composed of 32 patients with a mean age of 60.13 years and 81.25% were men. The average time from LVAD implantation to extraction was 445.19 ± 1,108.53 days. Average preoperative INR was 1.76 ± 0.47. Preoperative fresh frozen plasma was not administered to any patients. Twenty-eight patients (87.5%) were on Coumadin (warfarin) preoperatively. In 11 of these 28 patients (39.3%), Coumadin was held preoperatively. The average postoperative change in hemoglobin level was -0.79 ± 1.45. Only 1 patient (3%) required postoperative blood transfusion for a hemoglobin level of 7.6 that responded appropriately. There were no reoperations for bleeding. CONCLUSIONS: Minor oral surgical procedures can be performed safely for patients being supported on LVAD therapy. With primary closure of the gingiva at the site of extraction, dental extractions can be performed without the full reversal of anticoagulation.

Avaliação do diâmetro do ramo intraósseo da artéria alveolar superior posterior e sua relação com a cirurgia de levantamento do seio maxilar ­ estudo transversal / Evaluation of intra-osseous branch of posterior superior alveolar artery diameter and its relation with the maxillary sinus

Objetivo: descrever a anatomia do ramo intraósseo da artéria alveolar superior posterior (riAASP) na parede lateral do seio maxilar. Material e métodos: 31 pacientes se encaixaram nos critérios de inclusão para a pesquisa. Avaliou-se a presença ou não do riAASP, sua distância até o assoalho do seio maxilar e até a crista alveolar, e seu diâmetro nas regiões dentais posteriores bilateralmente em maxila, comparando regiões dentadas com edentadas através de TCFCs. Resultados: o riAASP foi identificado em 21 pacientes (67,7%), sendo mais visualizado na região de primeiro molar. Foram avaliadas 248 regiões dentais de 31 pacientes, onde o riAASP foi visualizado e mensurado em 153 regiões (61,7%). Quanto mais posterior era a região, maior era o diâmetro do vaso, tanto para regiões dentadas quanto para as edentadas, e o diâmetro médio encontrado foi de 1,2 mm. A distância do riAASP até o assoalho do seio maxilar nas regiões dentadas não apresentou diferença estatisticamente significante nas diferentes regiões dentais. Já nas regiões edentadas, quanto mais posterior foi a região, menor foi esta distância. Em relação à distância da artéria até a crista alveolar, quanto mais anterior era a região dental, mais distante da crista o riAASP se posicionou. Conclusão: o conhecimento anatômico, a solicitação de exames de tomografi a computadorizada, a interpretação no planejamento pré-operatório e a habilidade do cirurgião poderão eliminar ou diminuir os acidentes relacionados à hemorragia do riAASP durante a cirurgia de levantamento do seio maxilar.

Objective: to define the anatomy of the intraosseous branch of the posterior superior alveolar artery (ioPSAA) in the lateral wall of the maxillary sinus. Material and methods: 31 patients meet the inclusion criteria for the study. The presence or absence of ioAASP, its distance to the floor of the maxillary sinus, to the alveolar crest and its diameter, were evaluated in the posterior dental regions bilaterally in the maxilla, comparing edentulos and dentate regions through CBCTs. Results: the ioPSAA was identifi ed in 21 patients (67.7%), being more visualized in the 1st molar region. A total of 248 dental regions of 31 patients were evaluated, where ioAASP was visualized and measured in 153 regions (61.7%). The diameter of the artery increases as it runs posteriorly in the maxilla, for both toothed and edentate regions. The mean diameter found was 1.2 mm. The distance from the ioPSAA to the maxillary sinus fl oor in the dentate regions did not present a statistically significant difference in the different dental regions. In the edentate regions, the more posterior the region, the smaller the distance to the sinus floor. Regarding the distance from the artery to the alveolar crest, the more anteror the dental anterior, the greater the distance of ioPSAA from the alveolar crest. Conclusion: anatomical knowledge, the need for CT scans, its interpretation in the preoperative planning, and the surgeon's ability, may eliminate or reduce the accidents related to riAASP hemorrhage during maxillary sinus surgery.

Manejo y tratamiento dental quirúrgico de pacientes en terapia con antiagregantes plaquetarios: revisión de la literatura / Management and dental surgical treatment of patients under antiplatelet therapy: a review of the literature

El temor a desarrollar un sangrado excesivo lleva a los especialistas a suspender el tratamiento con antiagregantes plaquetarios -de rutina en pacientes con patología cardíaca isquémica, fibrilación atrial y stents coronarios, entre otros- antes de un procedimiento quirúrgico. La interrupción pone en riesgo la vida del paciente, pues estas terapias se utilizan para la prevención de accidentes trombóticos. Este trabajo se propuso realizar una revisión bibliográfica de los pacientes en terapia con antiagregantes plaquetarios sometidos a procedimientos quirúrgicos odontológicos. Labúsqueda se efectuó por medio del portal PubMed a partir de palabras clave como exodontia, aspirin, antiplatelet therapy y clopidogrel. Se incluyeron aquellos artículos que hacen referencia a la indicación y el manejo de la terapia con antiagregantes plaquetarios –en monoterapia o terapia dual– antes deuna cirugía dentoalveolar. El riesgo de sangrado intraoperatorio es ciertamente mayoren los pacientes en terapia con antiagregantes plaquetarios. Sin embargo, el sangrado posoperatorio no lo es, puespuede ser controlado satisfactoriamente con medidas locales. Además, la prevención del peligro de sangrado no compensael riesgo de tromboembolismo que implica la suspensión dela terapia.Los procedimientos quirúrgicos en pacientes con antiagregantes plaquetarios pueden llevarse a cabo de forma segura,sin alteración o modificación de la terapia, siempre y cuando se tomen las medidas pertinentes de hemostasia, y mientras sean realizados por un profesional con la experiencia necesaria. De todas formas, se aconseja consultar al médico especialista antes de interrumpir cualquier terapia.

The fear of developing an excessive bleeding leads thespecialists to discontinue the treatment with antiplatelet drugsbefore a surgical procedure increasing the risk of thromboembolicevents in patients. These therapies are used routinely forthe prevention of thrombotic events in patients with ischemicheart disease, atrial fibrillation and coronary stents, amongothers.The aim was to review the literature about the case ofpatients under antiplatelet therapy in need of surgical dentalprocedures. The following search terms were used in PubMed:exodontia, aspirin, antiplatelet therapy, clopidogrel. Articlesthat made a reference to the indication and management ofboth mono and dual antiplatelet therapy in patients who areundergoing dentoalveolar surgery were included.The risk of intraoperative bleeding is certainly greater forpatients on therapy with antiplatelet agents. However this isnot due to postoperative bleeding that can be satisfactorilycontrolled with local measures and this increased risk is notworth the risk of thromboembolism which the interruption ofthe therapy involves.Surgical procedures in patients receiving antiplateletagents can be safely carried out without alteration or modification of the therapy. It is important to implementappropriate hemostasis measures and the procedures haveto be conducted by a dentist with adequate experience inthis type of cases. Similarly, it is advisable to consult aphysician to decide if therapy discontinuation is appropriate.

The Use of a Chitosan-Derived Hemostatic Agent for Postextraction Bleeding Control in Patients on Antiplatelet Treatment.

PURPOSE: The current approach for tooth extraction in patients receiving antiplatelet treatment requires the use of local hemostatic agents without previous thromboembolic treatment interruption. The aim of the present study was to evaluate the effectiveness of an extra-alveolar hemostatic agent, the HemCon Dental Dressing (HDD), in controlling postsurgical bleeding. MATERIALS AND METHODS: Routine, atraumatic tooth extractions were performed in a single session under local anesthesia without a vasoconstrictor and without interruption of antiplatelet therapy. All patients underwent extraction of 2 teeth in the same session, with each in a different dental hemi-arch, and the hemostatic method to be used was randomly chosen: in the test site, the HDD was applied, whereas in the control site, a common hemostatic sponge (CollaPlug, Zimmer Dental) was applied and stabilized in situ with a suture. For each surgery, 2 different times were measured: the time required for hemostatic agent application and the time required for hemostasis achievement. Postoperative pain and healing quality also were evaluated. RESULTS: Twenty outpatients were enrolled. The mean application time was considerably shorter in the test group than in the control group; the mean bleeding time in the control group was considerably shorter than in the test group; pain values were lower in the test group than in the control group, especially at suture removal; and postextraction socket healing was better in the test group than in the control group. CONCLUSION: HDD seems to be a valid and safe alternative in treating postextraction sockets in outpatients under single-drug antiplatelet treatment in the absence of surgical wound lacerations.

Pragmatic approach to manage new oral anticoagulants in patients undergoing dental extractions: a prospective case-control study.

OBJECTIVES: The aim of this study was to validate a standardized pragmatic approach to manage new oral anticoagulants (NOACs) in patients who undergo dental extractions. MATERIALS AND METHODS: This prospective case-control study in patients undergoing dental extraction included 26 patients (mean age 76 years, 57% male) treated with dabigatran, rivaroxaban, or apixaban and 26 matched controls. Regardless of timing of extraction, drug regimen, or renal function, patients were instructed to skip only the dose on the morning of the procedure. A procedural bleeding score was recorded and early and delayed bleeding was assessed at day 1 and day 7. Bleeding events were compared with a prospectively matched control group not taking any antithrombotic drug. RESULTS: There was no difference in the procedural bleeding score or in early bleeding events (5 in both groups). However, delayed bleeding occurred more frequently in anticoagulated compared to non-anticoagulated patients (7 versus none, p = 0.01). CONCLUSIONS: Skipping the morning dose of NOACs avoids excess bleeding during and early after the procedure. However, anticoagulated patients had an increased risk of delayed bleedings. Further study is needed to determine the optimal post-procedural management. CLINICAL RELEVANCE: This is the first prospective study for the management of patients on NOACs undergoing dental extraction. Our pragmatic approach, omitting only a single morning dose, can guide clinical practice. Both patients and physicians should be aware of the increased delayed bleeding risk.

Haemostatic agents in apical surgery. A systematic review.

BACKGROUND: Blood presence in apical surgery can prevent the correct vision of the surgical field, change the physical properties of filling materials and reduce their sealing ability. OBJECTIVES: To describe which are the most effective and safest haemostatic agents to control bleeding in patients undergoing apical surgery. MATERIAL AND METHODS: We carried out a systematic review, using Medline and Cochrane Library databases, of human clinical studies published in the last 10 years. RESULTS: The agents that proved more effective in bleeding control were calcium sulphate (100%) and collagen plus epinephrine (92.9%) followed by ferric sulphate (60%), gauze packing (30%) and collagen (16.7%). When using aluminium chloride (Expasyl®), over 90% of the apical lesions improved, but this agent seemed to increase swelling. Epinephrine with collagen did not significantly raise either blood pressure or heart rate. CONCLUSIONS: Despite the use of several haemostatic materials in apical surgery, there is little evidence on their effectiveness and safety. The most effective haemostatic agents were calcium sulphate and epinephrine plus collagen. Epinephrine plus collagen did not seem to significantly raise blood pressure or heart rate during surgery. Aluminium chloride did not increase postoperative pain but could slightly increase postoperative swelling. Randomized clinical trials are needed to assess the haemostatic effectiveness and adverse effects of haemostatic materials in apical surgery.

Prevention of post-operative bleeding in hemostatic compromised patients using native porcine collagen fleeces-retrospective study of a consecutive case series.

INTRODUCTION: Various anticoagulant therapy regimes bear the risk of postsurgical bleeding events after dental extractions. Local hemostyptic measures, e.g., collagen fleeces, are applied by surgeons to prevent such bleedings. No standard protocol in prevention of bleeding events has met general acceptance among surgeons yet. PURPOSE: The purpose of this retrospective study was to determine if post-operative bleeding can be prevented by suturing native collagen fleeces into extraction wounds immediately after teeth removal, regardless what anticoagulant regime is performed. METHODS: A total of 741 extraction units were removed from 200 consecutive in-ward patients with or without alternation of different anticoagulant therapy regimes. Anti-vitamin K agents were the most prescribed drugs (n = 104, 52 %), followed by Acetylsalicylate (ASS) (n = 78, 39 %). Nineteen (9.5 %) patients received a dual anti-platelet therapy. Out of 104 patients receiving an anti-vitamin K agent (phenprocoumon), 84 patients were bridged, 20 patients continued to their anticoagulant therapy without alterations. Following careful tooth extraction, extraction sockets were filled using a native type I and III porcine collagen sponge (Collacone, Botiss Biomaterials, Berlin), supported by single and mattress sutures for local hemostasis. Post-operative bleeding events were rated according to their clinical relevance. RESULTS: In the post-operative phase, 8 out of 200 consecutively treated patients experienced a post-operative bleeding event. All of them had been designated for a long-term anti-vitamin K therapy (p ≤ 0.05), and extractions were performed under a heparin bridging regime (n = 6) or an uninterrupted anti-vitamin K agent therapy (n = 2). No bleeding events occurred in patients with ASS 100 therapy or low-dose LMWH therapy (p ≤ 0.05), or in patients with dual anti-platelet therapy (0 out of 24). None of the bleeding events put patients' health at risk or required systemic intervention. CONCLUSION: Sufficiently performed local hemostyptic measures, like the application of collagen fleeces in combination with atraumatic surgery, bears a great potential for preventing heavy bleeding events in hemostatic compromised patients, regardless of their anticoagulant therapy.

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

OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSIONS: Most extractions were safe, but prophylactic transfusions did not ensure adequate hemostasis. Local hemostatic measures and close follow-up are warranted.

Overcoming the oral aspects of -self-mutilation: description of a method.

BACKGROUND/AIM: Self-injurious behavior (SIB) is a serious and chronic condition frequently seen in special needs populations, affecting 10% to 17% of individuals diagnosed with intellectual and/or developmental disabilities. A 2.5-year-old infant with SIB, whose presenting symptoms were severe tongue and lip lacerations accompanied by much hemorrhage, is presented here to illustrate the problem and to show how this may be prevented. MATERIALS AND METHODS: An appliance is described which effectively limits the damage caused by SIB and permits rapid healing of existing injuries. RESULTS: The method provides for a stable, retentive, and comfortable device on the infant's undererupted and largely nonretentive crowns of the deciduous teeth as well as for all permanent teeth in children, adolescents, and adults. CONCLUSIONS: The appliance has been successfully employed for the past 10 years in patients with SIB who have attended for treatment in the Special Needs Clinic in our Department.

Manejo odontológico en el paciente cirrótico / Dental management in patients with cirrhosis

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The present article provides a brief review of dental management in patients with cirrhosis. It focuses on problems related to infections, hemorrhagic events, and treatment with commonly used drugs in odontology

Anticoagulant therapy and its impact on dental patients: a review.

Several new oral anticoagulants have been studied in the past decade, and have now started to enter the market. These drugs are reported to be as effective as, or more effective than, warfarin. In Australia, the Therapeutic Goods Administration has approved dabigatran, rivaroxaban and apixaban. The use of these newer anticoagulants is likely to increase in time, and it is important for dentists to have a sound understanding of the mechanisms of action, reversal strategies, and management guidelines for patients taking oral anticoagulants. This article discusses the process of coagulation, available anticoagulants and their monitoring and reversal, and provides clinical advice on the management of patients on anticoagulants who require dental treatment.