ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Dental Extractions And Anti-Thrombotic Drug Therapy Management
Clinical Question Does combination anti-thrombotic therapy increase the risk of post-op bleeds versus mono-therapy in patients undergoing dental extractions?
Clinical Bottom Line Patients taking oral antit-hrombotic medications should not alter their therapeutic regimen for routine dental extractions provided their INR is in the therapeutic range (2-3) nor should the practitioner alter treatment. (See Comments on the CAT below)
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) 18083415Morimoto/2008270 patients taking oral antithrombotic medications.Retrospective Multicenter Cohort Study
Key resultsA sufficient hemostasis can be obtained in most cases of tooth extraction under anticoagulant therapy with warfarin (INR <3.0) and anti-platelet drugs. Moreover, appropriate local hemostatic methods can be successful when postoperative hemorrhage occurs. No significant differences in incidence of postoperative hemorrhage were observed between patients on warfarin monotherapy and those on warfarin with anti-platelet therapy (7/161 extractions [4.4%] vs 2/52 extractions [3.9%], respectively). Postoperative hemorrhage was thus seen in 11 of 306 occasions of extractions (3.6%) performed on patients who received warfarin and/or anti-platelet drugs.
#2) 15789328Beirne/2005Patients taking antithrombotic agents.Review
Key resultsStopping warfarin with or without bridging for dentoalveolar surgery is not supported by clinical evidence. The risk of developing life-threatening bleeding or bleeding that cannot be controlled using local measures following dental extractions, alveoloplasties, or dental implants is so low that there is no need to stop warfarin.Patients continuing to take oral anticoagulants for dentoalveolar surgery may develop postoperative bleeding that cannot be stopped with pressure alone and may require local homeostasis to control. On the day of surgery, the patient’s INR should be obtained to verify that it is within or below the therapeutic range (2.0 to 4.0). After surgery, local measures should be taken to prevent postoperative bleeding.
#3) 18305438Jimenez/2008Patients on oral anticoagulation therapyReview
Key resultsMost studies do not recommend reducing or interrupting anticoagulation, or replacing it with heparin, prior to tooth extraction - provided therapeutic international normalized ration (INR) levels are maintained, with emphasis on the application of local measures such as anti-fibrinolytic agents, for the control of hemostasia.
Evidence Search dental management, plavix, dental extractionsSearch combination antithrombotic therapy 09:21:53 908 Most Recent Queries Time Result #7 Search (#5) AND #6 09:05:29 2 #6 Search dental extractions 09:05:14 1882 #5 Search (#1) AND #2 09:04:38 12 #3 Search plavix 09:04:23 4954 #2 Search dental management 09:04:14 21483
Comments on
The Evidence
Patients who are taking oral anti-thrombotic medications and are being seen for dental extractions do not require any alteration in their medication as long as their INR is between 2-3 (or 2.5-2.5). Bleeding that occurs following dental extractions should be controlled using local hemostatic measures.
Applicability This information is useful when dealing with cardiac patients to assess whether it is safe to proceed with dental extractions, periodontal surgeries and other invasive procedures involving bleeding.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords Antithrombotic agents, Plavix, Clopidogrel, Dental extractions, Antiplatelet therapy, Anticoagulation therapy
ID# 534
Date of submission: 04/14/2010spacer
E-mail dennisl@livemail.uthscsa.edu
Author Lacie Dennis
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Charles Hermesch, DMD
Faculty mentor/Co-author e-mail HERMESCH@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
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Comments on the CAT
(FOR PRACTICING DENTISTS' and/or FACULTY COMMENTS ON PUBLISHED CATs)
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by Benjamin Vuong, Monique Garcia, Eunjin Suh, Brian Benito (San Antonio, TX) on 01/08/2013
A PubMed search on fibrinolytic agents and tooth extractions done in January 2013 resulted in a more recent study on the issue of continuing anti-thrombotic therapy during dental extraction, PubMed ID 21802823 . This RCT consisted of 63 patients with coronary artery disease, they were placed in 2 groups: one group suspended aspirin therapy and the other group did not. The clinical trial concluded that the bleeding observed after extractions were not significantly different among the two groups.
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