ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Local Hemostatic Measures Are Enough To Control Bleeding In Implant Patients On Oral Anticoagulation Therapy
Clinical Question In a patient on oral anticoagulation therapy, are local hemostatic measures enough to prevent post-procedural bleeding after implant placement?
Clinical Bottom Line Local hemostatic measures are proven to be enough. It is not recommended for patients to be taken off of their anticoagulation therapy before a dental implant surgery.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 19663955Madrid/20092017 adult patients, 19 included studiesSystematic Review of Randomized Control Trials, Controlled Clinical Trials, and Prospective Case Series
Key resultsNineteen studies, which included five Randomized Clinical Trials (RCTs), eleven Controlled Clinical Trials (CCTs), and three Prospective Case Series, showed that patients on Oral Anticoagulation Therapy with vitamin K antagonist reported insignificant minor bleeding in a small number of patients in comparison to patients who stopped this medication before surgery. Local hemostatic measures were used in all studies to control post-operative bleeding with no major thromboembolic events. The study that reported the most significant bleeding rate was 26% in the test group (OAT patients who discontinued) versus 14% in the control group (P=0.01). The bleeding was successfully controlled with local hemostatic measures.
#2) 20946205Bacci/2011159 patients undergoing implant placementProspective Case-Control Study
Key resultsGroup A (patients receiving oral anticoagulation therapy without modification or interruption) and Group B (Patients not receiving OAT) reported 2 and 3 late bleeding complications respectively without a substantial difference in bleeding risk (RR= 1.45; P=0.06; 95% CI 0.2506-8.4271). All late bleeding complications were successfully managed with local hemostatic measures: compressive tranexamic acid soaked gauze.
#3) 26592859Clemm/ 2015564 adult patients under oral coagulation therapy receiving implantsProspective Clinical Comparative Study
Key resultsSeven of the 564 patients in the study experienced post-operative bleeding: 4 in the anticoagulant therapy (AT) group and 3 in the non- AT group (control). There was no significant effect on bleeding frequencies after the invasive surgical procedure, but patients on vitamin K inhibitors had significantly higher risk of post-operative bleeding compared to patients in the controlled group (P=0.038). Hemostatic measures were able to control all bleeding experiences.
Evidence Search Madrid and Bacci articles: "Dental Implantation, Endosseous"[Mesh] AND ("Anticoagulants/administration and dosage"[Mesh] OR "Anticoagulants/adverse effects"[Mesh]) Clemm articles: anticoagulation[All Fields] AND ("therapy"[Subheading] OR "therapy"[All Fields] OR "therapeutics"[MeSH Terms] OR "therapeutics"[All Fields]) AND ("dental implants"[MeSH Terms] OR ("dental"[All Fields] AND "implants"[All Fields]) OR "dental implants"[All Fields] OR ("dental"[All Fields] AND "implant"[All Fields]) OR "dental implant"[All Fields])
Comments on
The Evidence
Madrid presented a systematic review that included 19 studies collected during a comprehensive search through databases such as Medline and Chochrane. Each search was completed through hand assessing of individual references cited in all chosen publications. All study results had minimum risk with OAT post-operative bleeding. No meta-analysis was completed because the publications were too heterogeneous in their OAT management strategies and their protocols during and after surgery. Bacci presented a prospective case-control study in which there were two groups: Patients on Oral Anticoagulation Therapy (OAT) vs patients not on OAT. His patients started out the same, had the same testing environment, and had adequate follow-up. This study was only a single-blinded study, but in this case this was acceptable because the surgeon did not know which patient was in which group (most important factor) while the patients already knew whether they were on their normal regime or not. Lastly the trial had a high completion and compliance rate in which only 2 patients dropped out. Clemm presented with a comparative study that included 7 different groups. This was not a blinded study nor was the post-operative bleeding controlled in the same way (different local hemostatic procedures). Only the surgical procedures were calibrated and performed with the same surgical technique throughout. This approach is expected since different treatment options were being explored. These 7 studies were compared using statistical analysis and descriptive statistics to analyze if the type and invasiveness of the procedure or OAT had an effect on the frequency of post-operative bleeding. All 7 studies had a greater than 80% completion rate.
Applicability It is important to know how to treat OAT patients during minor surgical procedures such as dental implants or simple extractions. These patients should not be taken off their OAT due to the increased risk of a thromboembolic event; the risk does not outweigh the benefit especially since post- operative bleeding can be minimized through local hemostatic measures.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords Oral anticoagulation therapy, endosseous dental implants, local hemostatic measures
ID# 3023
Date of submission: 03/12/2016spacer
E-mail rodriguezm34@livemail.uthscsa.edu
Author Miranda Rodriguez
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Juanita Lozano-Pineda, DDS, MPH
Faculty mentor/Co-author e-mail pinedaj@uthscsa.edu
Basic Science Rationale
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Comments on the CAT
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