Comparison of uninterrupted warfarin and bridging therapy using low-molecular weight heparin with respect to the severity of bleeding after dental extractions in patients with prosthetic valves

Abstract

Objective:The management of anticoagulated patients with warfarin during dental extraction is an intricate issue. We carefully designed the current study so that the amount of bleeding was measured with objective methods and the data from the same patient in different dental extraction appointments could be compared, eliminating the bleeding diathesis differences of patients.Methods:This prospective and controlled study was conducted in 36 adult patients with prosthetic valve requiring multiple tooth extractions. The first dental extraction was performed without the discontinuation of warfarin therapy, and the second procedure was performed with a discontinuation of warfarin and bridging with low-molecular weight heparin (LMWH). The two dental extraction protocols in the same patient group were compared. The total amount of bleeding was calculated as the difference between the weights of gauze swabs used before and after the tamponade; the number of gauze swabs used for bleeding control in the first 48 h was recorded.Result:The median number of used gauze swabs was 2.5 (IQR: 1–5) and 3.0 (IQR: 2–7) in the first and second dental extraction procedures, respectively. The median bleeding time was 50.0 (IQR: 20–100) in the first procedure compared with 60.0 (IQR: 40–140) min in the second procedure. The mean amounts of bleeding were 2194±1418 mg in the first dental extraction procedure and 2950±1694 mg in the second dental extraction procedure. The median number of used gauze swabs, the median bleeding time, and the mean amount of bleeding were statistically higher in the second dental extraction procedure (p<0.001).Conclusion:Continued warfarin treatment at the time of dental extractions reduces the total amount of bleeding compared with bridging therapy in patients with prosthetic valves.

Anticoagulation Use prior to Common Dental Procedures: A Systematic Review

“…Every study had its protocol to assess bleeding outcome. A statistically significant difference in bleeding among groups was only observed in 2 studies: the first showing increased bleeding when bridging with LMWH [32] the second showing an increase in mild bleeding in VKA group when compared with no anticoagulation [33]. Only 4 patients across the 10 studies were reported to need hospitalization due to bleeding.…”

“…Only 4 patients across the 10 studies were reported to need hospitalization due to bleeding. The number of teeth extracted was associated with an increased risk of bleeding in one study [32]. This relationship was not seen in two other trials [27, 29].…”

“…When maintaining oral anticoagulation, some studies found local hemostasis helpful. Bridging with LMWH [32] or giving heparin with reduced VKA dose [30] was found to increase the risk of bleeding (Table 2).…”

Antiplatelets, Anticoagulants and Its Implications in Dentistry-A Review of Literature

“…It was also found in a study that there is no association between the number of teeth extracted and postoperative bleeding status [62,68,69], except in one study [64]. In contrast to previous studies [65,66] and in line with others [61,67], a short interruption of oral anticoagulation did not seem to increase the risk of thromboembolic events in the 10 trials.…”

“…Special measures were taken in most studies to handle the risk of bleeding, like reducing soft tissue and bone injuries and minimizing the need to raise a mucoperiosteal flap during the procedures. However, it must be noted that whether a mucoperiosteal flap raise was needed or not in dental extractions [61][62][63][64][65][66], the outcome remained in favour of maintaining oral anticoagulation. Also, in implant surgery, bleeding risk was not associated with the invasiveness of the surgery [67].…”