Tooth extraction in patients on chronic anticoagulant treatment – preliminary results of a clinical prospective study

Patients under anticoagulant treatment which needs dental extractions have a significant high risk of postoperative bleeding, in consequence they need either hospitalization or ambulatory postextractional monitoring. The objective of this study was while using Surgicel® as a socket local hemostat for extractions at patients under anticoagulants to prove his efficacy during a clinical prospective experimental study. We followed three groups of patients under anticoagulant treatment with single or multiple dental extractions: one group under oral anticoagulants (warfarin) and socket meshing with Surgicel®, one group under i.v. anticoagulants (heparin) and one control group under antithrombotics. Many parameters were observed and studied with special focus on postextractional hemorrhage. Results were statistically analyzed and they were compared with the latest findings on international literature. The study conclusions suggest using Surgicel® as viable intraalveolar hemostat which can reduce many postoperative bleeding accidents and avoid thrombotic risks associated with suppression of oral anticoagulant or heparin treatment.

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THE THROMBOTIC COMPLICATIONS OF TWO GROUPS OF PATIENTS WITH DIFFERENT INR THERAPEUTIC RANGES. THE NECESSITY OF INTENSE ORAL ANTICOAGULANT TREATMENT

10.1055/s-0038-1643263 ◽

1987 ◽

Author(s):

Ir Kontopoulou-Griva ◽

J Spiliotopoulou ◽

L Digenopoulou ◽

J Georgopoulos

Keyword(s):

High Risk ◽

Oral Anticoagulant ◽

Heart Valves ◽

Oral Anticoagulants ◽

Anticoagulant Treatment ◽

Oral Anticoagulant Treatment ◽

Daily Dose ◽

Group A ◽

Thrombotic Complications ◽

Group B

One of the reasons why oral anticoagulants fell into disrepute is the absence of internationally acceptable standarised procedures for controlling the level of anticoagulation. This deplorable situation resulted in over and under coagulation and uncertainty in the therapeutic range. The International Normalised Ratio (INR) can safely be applied in patients on oral anticoagulants.We present two Groups of patients under long term anti coagulation, mainly because of prosthetic heart valves that have recently been added to our outpatients clinic. These patients were till then attended by two cardiologists with different attitudes on the intensity of the anticoagulant treatment. The thromboplastin reagent used is that of ox origin and the results are expressed on INR.The Group A with 32 patients had at the time that we started attending them an INR x = 1,80 ± 0,48 and a daily dose of acenocoumarol x = 1,65 ± 0,51.The Group B with 49 patients had an INR x = 2,75 ± 0,51 and a daily dose of acenocoumarol x = 2,52 ± 1,53.Seven patients of the Group A referred thrombotic complications, while three patients of the Group B referred transiant thrombotic complications.The statistical analysis with the t-test of the INR between the two Groups is p<0,001 while that of the thrombotic complication with the x2 is p<0,05.The introduction of the INR and the acceptance by the medical people of the necessity of the intense oral anticoagulant treatment especially on high risk patients with mechanical heart valves as is the majority of the presented patients, will minimize the thromboembolic complications without high risk of bleeding.

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PROSPECTIVE STUDY OF ASPIRIN FOR THROMBOEMBOLISM PROPHYLAXIS IN TOTAL HIP ARTHROPLASTY

Acta Ortopédica Brasileira ◽

10.1590/1413-785220182602187265 ◽

2018 ◽

Vol 26 (2) ◽

pp. 86-90

Author(s):

RAUL CARNEIRO LINS ◽

EPITÁCIO LEITE ROLIM FILHO ◽

FERNANDO DE SANTA CRUZ OLIVEIRA ◽

SAULO MONTEIRO DOS SANTOS ◽

TALE LUCAS VIEIRA ROLIM ◽

...

Keyword(s):

Venous Thromboembolism ◽

High Risk ◽

Total Hip Arthroplasty ◽

Prospective Study ◽

Hip Arthroplasty ◽

Postoperative Bleeding ◽

Thromboembolism Prophylaxis ◽

Level Of Evidence ◽

Total Hip ◽

Post Procedure

ABSTRACT Objectives: To evaluate the effectiveness of aspirin as prophylaxis for deep venous thrombosis (DVT) in patients undergoing total hip arthroplasty (THA), and to analyze the incidence of bleeding during the post-operative period. Methods: This prospective study carried out in 2017 consisted of 37 patients indicated for THA with high risk for DVT. Immediately after the procedure, aspirin, elastic compression socks and early deambulation were initiated. Doppler ultrasound was performed in the legs 6 days and 6 weeks post-procedure to rule out venous thromboembolism. Hematometric variables and clinical criteria were used to detect bleeding. Results: The incidence of VTE (venous thromboembolism) 6 days post-procedure was 21.6%. By 6 weeks post-procedure, it dropped to 8.1%, (p = 0.102). Only 2.7% were diagnosed with VTE, 6 days and also 6 weeks post-procedure. Within the immediate postoperative period, hemoglobin was lower (p < 0.001), in contrast to 6 weeks after surgery, when it returned to baseline levels. Conclusion: Aspirin was an effective chemical prophylaxis for venous thromboembolism in high-risk patients who underwent THA. There was no clinical record of postoperative bleeding and hematometric levels suggested that there was no chronic bleeding. Level of Evidence II; Prospective study.

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Sa1078 Prospective Study to Reduce the Postoperative Bleeding After Gastric Endoscopic Submucosal Dissection in Patients With High-Risk for Bleeding

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2017.03.397 ◽

2017 ◽

Vol 85 (5) ◽

pp. AB182

Author(s):

Daisuke Maruoka ◽

Shingo Kasamatsu ◽

Hideaki Ishigami ◽

Kenichiro Okimoto ◽

Tomoaki Matsumura ◽

...

Keyword(s):

High Risk ◽

Prospective Study ◽

Endoscopic Submucosal Dissection ◽

Postoperative Bleeding ◽

Submucosal Dissection ◽

Risk For Bleeding

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Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing bridging with heparin versus unpaused vitamin K antagonist medication

BMC Oral Health ◽

10.1186/s12903-021-01464-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Mayte Buchbender ◽

Felix Rößler ◽

Marco R. Kesting ◽

Gesche Frohwitter ◽

Werner Adler ◽

...

Keyword(s):

Retrospective Study ◽

Prothrombin Time ◽

Vitamin K ◽

Tooth Extraction ◽

Postoperative Bleeding ◽

Vitamin K Antagonist ◽

Control Group ◽

Risk For Bleeding ◽

Tooth Removal ◽

Anticoagulated Patients

Abstract Background The aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin. Methods A retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/osteotomy/combined extraction and osteotomy) and the prothrombin time. Results In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG versus VG p = 0.004; CG versus BG p < 0.001, BG versus VG p < 0.001. A significant correlation of number of the extracted teeth in the BG (p = 0.014) and no significance in VG (p = 0.298) and CG (p = 0.210) and in the BG versus VG and CG with p < 0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time. Conclusions Bridging with heparin increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well-coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences.

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A Systematic Review and Meta- Analysis of Randomized Controlled Trials on Primary Ambulatory Thromboprophylaxis (PATP) in Patients with Gastrointestinal Cancers Receiving Chemotherapy

Blood ◽

10.1182/blood-2019-126732 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3679-3679

Author(s):

Kyaw Zin Thein ◽

Donald P. Quick ◽

Thein Hlaing Oo

Keyword(s):

Systematic Review ◽

High Risk ◽

Cancer Patients ◽

Fixed Effects ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Control Group ◽

Number Needed To Treat ◽

Solid Cancer ◽

Gastrointestinal Cancers

Introduction: PATP in solid cancer patients remains uncertain and is not routinely recommended although thrombosis is shown to be the second leading cause of death in cancer patients. Many studies failed to demonstrate in solid cancer outpatients improvement in overall survival despite decreasing venous thromboembolism (VTE) rates by PATP. We conducted a systematic review and meta-analysis of RCTs to determine the benefit and risk of PATP with low-molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) in patients with gastrointestinal cancers receiving chemotherapy. Methods: We performed a comprehensive literature search using MEDLINE and EMBASE databases through June 30, 2019. The references of all potential studies were also reviewed for any additional relevant studies. The RCTs with reduction in VTE as a primary or secondary endpoint and the major bleeding (MB) as a safety outcome were incorporated in the analysis. The primary meta- analytic approach was a fixed effects model using the Mantel-Haenszel (MH) method. It was used to calculate the estimated pooled risk ratio (RR), and risk difference (RD) with 95% confidence interval (CI). Heterogeneity was assessed with Cochran's Q- statistic. Results: A total of 1,932 patients with gastric, gastroesophageal junctional (GEJ) and colorectal cancers from a subgroup of three RCTs were included in our meta-analysis. The prophylactic doses of LMWHs and DOAC (rivaroxaban) were used in the studies. The duration of LMWH and DOAC ranged from 3 to 6 months. The randomization ratio was 2 to 1 in PROTECHT study and 1 to 1 in all other studies. The I2 statistic for heterogeneity was 0, suggesting homogeneity among RCTs. The VTE incidence was 13 (1.26%) in PATP group and 23 (2.55%) in control group with a RR of 0.49 (95% CI: 0.25 to 0.96, P = 0.04). The absolute RD in VTE was -0.01 (95% CI: -0.03 to -0.00, P 0.04) with an estimate of the number needed to treat (NNT) of 78 to prevent one VTE event. In a subset of patients with gastric and GEJ cancers (n=587), the VTE incidence was 4 (1.37%) in PATP group and 10 (3.40%) in control group with a RR of 0.40 (95% CI: 0.13 to 1.24, P = 0.11). Conclusions: In our study, the relative risk reduction is 48% with a NNT of 78 to prevent one VTE in ambulatory patients with gastrointestinal cancers. Nevertheless, there is no statistically significant reduction in VTE events in a subset of gastric and GEJ cancers which are considered high risk in Khorana score. Based on the findings, PATP is not recommended in patients with gastrointestinal cancers on chemotherapy at this time. Further studies are necessary to define high risk subsets of gastrointestinal cancer patients receiving chemotherapy who may benefit from PATP. Disclosures Oo: Medical Education Speakers Network: Honoraria; Janssen and Janssen: Other: site co-investigator.

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Are Direct Oral Anticoagulants Plasma Concentrations Associated with the Risk of Postoperative Bleeding? Results from the Real Life Cohort

Blood ◽

10.1182/blood.v128.22.3819.3819 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3819-3819

Author(s):

Pável Olivera ◽

Vicente Cortina ◽

Verónica Pons ◽

Tania Canals ◽

Erik Johansson ◽

...

Keyword(s):

High Risk ◽

Major Bleeding ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Postoperative Bleeding ◽

Plasma Concentrations ◽

Thrombin Inhibitor ◽

Bleeding Events ◽

Risk Of Bleeding ◽

Increased Risk

Abstract Background The perioperative management (PM) of direct oral anticoagulants (DOACs) is controversial. The role of assessing DOAC plasma levels in order to ensure a safe use of these anticoagulants is still unknown. Aims To examine the association between DOACs plasma concentrations obtained before surgery and the risk of postoperative bleeding in the perioperative setting. Methods From June 2014 to December 2015 we have consecutively included 99 patients treated with DOACs and referred to our Unit for PM. Management was performed following the PM recommendations from the Catalan Thrombosis Working Group (Tromboc@t) . Bleeding events were classified following the ISTH criteria. Plasma concentrations were measured in the day of invasive procedure using the Technoclone anti-Xa assay from Technoclone (Vienna-Austria) for Rivaroxaban and Apixaban, and the Direct Thrombin Inhibitor Assay from IL (Bedford-MA-USA) for Dabigatran; in each case, specific calibrators were used. Patients were systematically followed 30 days after the surgical procedure. Results A total of 99 patients were recruited. Median age was 76 years (range: 61-94) and 51 (51.5%) were female. Among them, 23 patients received dabigatran, 40 rivaroxaban and 36 apixaban. As per the risk scores, 66.7% of the patients had a CHA2DS2-VASc score >3, 57.6% had a HAS-BLED score >3, and 51 (51.5%) were considered high-risk procedures. Total bleeding events occurred in 23 patients (47.8% minor, 30.4% non-major clinically relevant, and 21.7% major bleeding). The median plasma NOACs concentration was 38.3 ng/ml (0.8-226 ng/ml), with 32 patients having levels >30 ng/mL. HASBLED score > 3 was associated with an increased risk of bleeding events within 30 days (hazard ratio (HR)= 3.9, 95% CI= 1.14-13.4, P=0.03). Plasma DOAC levels > 30 ng/ml were not significantly associated with an increased risk of bleeding events (HR=2.17, 95% CI=0.862-6.67, P=0.10). Major bleeding (n=5) was probably associated with the risk of the procedure than to the DOAC plasma concentrations. Conclusion In our cohort we found significant association between the individual bleeding risk before surgery with the risk of postoperative bleeding. In spite of that, this study will continue to reevaluate PM in high-risk procedures according to plasma DOAC levels. Disclosures No relevant conflicts of interest to declare.

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Updated Meta-Analysis of Randomized Controlled Trials on Primary Ambulatory Thromboprophylaxis (PATP) in Patients with Advanced Pancreatic Cancer (APC) Receiving Chemotherapy

Blood ◽

10.1182/blood-2019-128674 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3469-3469 ◽

Cited By ~ 1

Author(s):

Kyaw Zin Thein ◽

Donald P. Quick ◽

Thein H. Oo

Keyword(s):

Relative Risk ◽

High Risk ◽

Cancer Patients ◽

Fixed Effects ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Advanced Pancreatic Cancer ◽

Control Group ◽

Number Needed To Treat ◽

Solid Cancer

Introduction: Thrombosis is the second leading cause of death in cancer patients and patients with APC are categorized as high-risk of developing venous thromboembolism (VTE). Many trials had failed to demonstrate improvement in survival with PATP. Despite decreasing VTE events, PATP in solid cancer patients is not routinely recommended. We conducted an updated meta- analysis of RCTs to determine the benefit and risk of PATP with low-molecular weight heparins (LMWH) and direct oral anticoagulants (DOAC) in patients with APC receiving chemotherapy. Methods: We performed a comprehensive literature search using MEDLINE and EMBASE databases through June 30, 2019. The references of all potential studies were also reviewed for any additional relevant studies. The RCTs with reduction in VTE as a primary or secondary endpoint and the major bleeding (MB) as a safety outcome were incorporated in the analysis. The primary meta- analytic approach was a random effects model using the Mantel-Haenszel (MH) method. It was used to calculate the estimated pooled risk ratio (RR), and risk difference (RD) with 95% confidence interval (CI). Heterogeneity was assessed with Cochran's Q- statistic. Results: A total of 1,013 patients with APC from two RCTs and a subgroup of another three RCTs were included in our meta-analysis. The prophylactic, intermediate and therapeutic doses of LMWH and prophylactic dose of DOAC (rivaroxaban) were used in the studies. The duration of LMWH and DOAC ranged from 3 to 6 months. The randomization ratio was 2 to 1 in PROTECHT study and 1 to 1 in all other studies. The I2statistic for heterogeneity was 60, suggesting some heterogeneity among RCTs. The VTE incidence was 28 (5.43%) in PATP group and 60 (12.07%) in control group with a RR of 0.44 (95% CI: 0.20 to 0.99, P = 0.05) and RD of -0.06 (95% CI: -0.11 to -0.01, P = 0.01). In fixed effects model, the pooled RR was 0.45 (95% CI: 0.29 to 0.70, P = 0.0003) and the absolute RD in VTE was -0.07 (95% CI: -0.10 to -0.03, P = 0.0002) with an estimate of the number needed to treat (NNT) of 15 to prevent one VTE event. MB events were reported in 9 (4.11%) patients in PATP group compared to 7 (3.27%) in control group according to an analysis of 2 RCTs. The pooled relative risk for MB was statistically non-significant at 1.25 (95% CI: 0.47 to 3.31, P = 0.65). Conclusions: In our study, PATP in APC may statistically significantly decrease VTE events, approximately with relative risk reduction of 55% and a NNT of 15, without increasing MB events. Proper selection of patients who are high risk for VTE in outpatient setting is important. More RCTs are required to further define high risk subsets of APC patients receiving chemotherapy who may benefit from PATP. Disclosures Oo: Medical Education Speakers Network: Honoraria; Janssen and Janssen: Other: Research: site co-investigator .

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Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing Bridging with heparin versus unpaused vitamin K antagonist medication.

10.21203/rs.3.rs-55563/v2 ◽

2021 ◽

Author(s):

Mayte Buchbender ◽

F Rößler ◽

Marco Kesting ◽

Gesche Frohwitter ◽

Werner Adler ◽

...

Keyword(s):

Retrospective Study ◽

Prothrombin Time ◽

Vitamin K ◽

Tooth Extraction ◽

Postoperative Bleeding ◽

Vitamin K Antagonist ◽

Control Group ◽

Risk For Bleeding ◽

Tooth Removal ◽

Anticoagulated Patients

Abstract Background: The aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin. Methods: A retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/ osteotomy/ combined extraction and osteotomy) and the prothrombin time. Results: In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG vs.VG p=0.004; CG vs. BG p<0.001, BG vs.VG p<0.001. A significant correlation of number of the extracted teeth in the BG (p=0.014) and no significance in VG (p=0.298) and CG (p=0.210) and in the BG vs. VG and CG with p<0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time. Conclusion: Bridging with heparin increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well- coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences. Key words:

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Microscopic examination of the effect of bromelain on the healing of tooth extraction sockets in an animal model

Journal of Birjand University of Medical Sciences ◽

10.32592/jbirjandunivmedsci.2021.28.2.104 ◽

2020 ◽

pp. 139-146

Keyword(s):

Experimental Study ◽

Animal Model ◽

Granulation Tissue ◽

Tooth Extraction ◽

Bone Cells ◽

Male Rats ◽

Control Group ◽

Analgesic Effects ◽

Maxillary Molar ◽

Minimal Damage

Background and Aims: Bromelain is a substance derived from pineapple and has antioxidant, anti-inflammatory, and analgesic effects. This study aimed to investigate the effect of bromelain on the healing of tooth extraction sockets in an animal model. Materials and Methods: This experimental study was performed on 24 male rats. After anesthesia, the first maxillary molar tooth was extracted with minimal damage using a hemostat. The rats were randomly divided into two groups, namely control and bromelain. In the bromelain group, the rats were orally administered by gavage with a 500 mg dose of bromelain that was dissolved in water twice a day for 2 days, while the control group received no medications. On the 3rd and 10th days after the surgery, 6 rats were killed per group each day. Afterward, the maxillae of rats were removed and slides were prepared from their dental sockets. The slides were examined by light microscope for histopathological variables (mean of macrophages, fibroblasts, lymphocytes, neutrophils; granulation tissue extent and angiogenesis and bone cells). Results: The results showed that the angiogenesis and granulation tissue extent increased significantly in the bromelain group, compared to the control group, on the 3rd day (P<0.05). Also, bromelain administration significantly increase the the number of fibroblasts (P<0.01), granulation tissue extent (P<0.05) and angiogenesis (P<0.05) in 3rd day of the experiment in comparison with the 10th day. Conclusion: The results of the present study showed that bromelain accelerates the process of wound healing after tooth extraction.

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Management of Anticoagulated Patients in Dentoalveolar Surgery: A Retrospective Study Comparing Bridging Versus Unpaused Vitamin K Antagonist Medication.

10.21203/rs.3.rs-55563/v1 ◽

2020 ◽

Author(s):

Mayte Buchbender ◽

F Rößler ◽

Marco Kesting ◽

Gesche Frohwitter ◽

Werner Adler ◽

...

Keyword(s):

Retrospective Study ◽

Prothrombin Time ◽

Vitamin K ◽

Tooth Extraction ◽

Postoperative Bleeding ◽

Vitamin K Antagonist ◽

Control Group ◽

Risk For Bleeding ◽

Tooth Removal ◽

Anticoagulated Patients

Abstract Objectives: The aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin. Study design: A retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/ osteotomy/ combined extraction and osteotomy) and the prothrombin time.Results: In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG vs.VG p=0.004; CG vs. BG p<0.001, BG vs.VG p<0.001. A significant correlation of number of the extracted teeth in the BG (p=0.014) and no significance in VG (p=0.298) and CG (p=0.210) and in the BG vs. VG and CG with p<0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time.Conclusion: Bridging increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well- coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences.

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