Post-operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-analysis of Observational Studies

Abstract

Background and Objective: Minor dental surgery is invasive and hemorrhagic. Thus, in patients treated with anticoagulants, the bleeding risk related to these invasive procedures is concerning. The aim of this meta-analysis is to evaluate this risk by comparing the post-operative bleeding rates of oral anticoagulation treatment (OAT) patients (without interrupted or altered anticoagulant intake) with non-OAT patients.Methods: PubMed, Embase and the Cochrane Library were searched for eligible studies that compared the post-operative (following minor dental surgery) bleeding rates of OAT patients without interrupted or altered therapy with those of non-OAT patients. Relative risk (RR) and 95% confidence interval (CI) were calculated. Subgroup analyses were used to identify the association between the bleeding rate and different dental surgeries or anticoagulants.Results: Thirty two full text articles were assessed for eligibility and 20 studies were excluded according to the selection criteria. Finally, 12 studies and a total of 2102 OAT patients and 2271 non-OAT patients were included. A pooled analysis indicated that the post-operative bleeding risk in OAT patients is higher than that of non-OAT patients (RR: 2.794, 95% CI: 1.722–4.532, P = 0.000). The pooled RRs in the dental implant surgery and dental extraction subgroups were 2.136 (95% CI: 0.825–5.531, P = 0.118) and 2.003 (95% CI: 0.987–4.063, P = 0.054), respectively. As for the different oral anticoagulants, the pooled RR in the subgroup of new oral anticoagulants (NOACs) was 1.603 (95% CI: 0.430–5.980, P = 0.482), while the pooled RR in the vitamin K antagonists subgroup was 3.067 (95% CI: 1.838–5.118, P = 0.000).Conclusion: Under current evidence, OAT patients were under a higher post-operative bleeding risk than the non-OAT patients following minor dental surgery. For the dental implant surgeries and dental extractions, our study failed to demonstrate a higher risk of bleeding in the OAT patients compared with the non-OAT patients. Besides, The NOACs might be safer than the vitamin K antagonists in dental implant surgery. However, more well-designed studies are required for future research.

Periodontitis and Cardiovascular Diseases. Consensus Report

“…In patients taking oral anticoagulant therapy (vitamin-K antagonists, VKA) and undergoing dental extraction, minor dental procedures and dental implant placement do not seem to increase the risk of bleeding compared to patients who discontinue oral anticoagulant therapy [118,139]. There may be a higher postoperative bleeding risk in patients continuing VKA and undergoing either minor dental surgery or other higher-risk procedures when compared to non-VKA patients [10,118], but local haemostatic agents appear to be effective in controlling post-operative bleeding [72].…”

Anticoagulants are dental friendly

“…The newsletter article mentions that the physician may recommend interrupting anticoagulation (either warfarin or direct anticoagulation) for dental procedures, but there is overwhelming evidence that dental surgery is safe in these patients and that interrupting anticoagulation increases the risk of a possibly fatal or permanently debilitating embolic complication. At least 10 systematic reviews [3][4][5][6][7][8][9][10][11][12] and at least 7 national medical or dental group statements from 9 national medical or dental groups (including the American Dental Association) have concluded that dental surgery can be safely performed without interrupting anticoagulation therapy. [12][13][14][15][16][17][18] Numerous prospective studies have reached the same conclusion.…”

“…24 The reason for the higher recommended therapeutic range for anticoagulation is that these patients are at higher risk of stroke compared with most other patients. There is voluminous literature, including the aforementioned 10 systematic reviews [3][4][5][6][7][8][9][10][11][12] and at least 7 national medical or dental group statements from 9 national medical or dental groups (including the American Dental Association), confirming that dental surgery can be safely performed at therapeutic levels-up to and even higher than INR 3.5. [12][13][14][15][16][17][18] By instructing not to treat if INR is above 3, dentists (in consultation with physicians) may wrongly advise their patients with the highest embolic risk (patients with mechanical mitral valves) to interrupt and/or reduce their anticoagulation for dental surgery, increasing their risk of embolic complications.…”

Avaliação do nível de conhecimento de cirurgiões-dentistas e graduandos em Odontologia quanto ao manejo de indivíduos em uso de anticoagulantes orais

“…322/327 INTRODUÇÃO Diante do envelhecimento populacional e do aumento da expectativa de vida, a incidência de doenças crônicas, como cardiopatias e desordens vasculares, é cada vez mais comum 1,2 . De modo a prevenir futuros eventos tromboembólicos, o uso de antiagregantes plaquetários e anticoagulantes orais são amplamente utilizados na profilaxia e no tratamento destas doenças [1][2][3] . Consequentemente, o número de pessoas que necessitam de tratamento odontológico e fazem uso de anticoagulantes é crescente.…”

“…No passado, muitos dentistas indicavam a suspensão de anticoagulantes previamente a procedimentos odontológicos invasivos, a fim de reduzir o risco de sangramento 3,4 . Mas, atualmente, já se entende que, caso o procedimento odontológico a ser realizado seja considerado de menor magnitude e com baixo risco de sangramento, a suspensão dos anticoagulantes previamente ao procedimento é desnecessária 2,4,[5][6][7] . Na maioria das vezes, o sangramento pós-operatório não é exclusivamente atribuído ao uso de antiagregantes plaquetários 8 ou anticoagulantes orais 2,5 , quando medidas hemostáticas locais são corretamente adotadas.…”