|Year : 2021 | Volume
| Issue : 3 | Page : 192-195
Evaluation of hemorrhage immediately after extraction and postextraction in patients on oral anticoagulant therapy for last 5 years
Deepak Kumar1, Tahir Ahmad1, Tariq Ah Bhat2, Priyadarshani Khadase3, Amandeep Kaur4
1 Oral and Maxillo Facial Surgery, Maharaja Ganga Singh Dental College and Research Centre, Sri Ganganagar, Rajasthan, India
2 Oral Medicine and Radiology, GDC, Srinagar, Rajasthan, India
3 Oral and Maxillo Facial Surgery, MGSDC, Sri Ganganagar, Rajasthan, India
4 BDS Gian Sagar Dental College, Punjab, India
|Date of Submission||07-Aug-2020|
|Date of Acceptance||13-Jan-2021|
|Date of Web Publication||12-Jul-2021|
Department of Oral and Maxillofacial Surgery, Maharaja Ganga Singh Dental College and Research Centre, 11 L.N.P Hanumangarh Road, Near Ricco, Sri Ganganagar - 335 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Aim and Objective: The aim of our study was to evaluate hemorrhage immediately after extraction and postextraction in patients on oral anticoagulant therapy for the past 5 years. Materials and Methods: A total of 100 patients, equally divided into study group and control group of 50 patients each, who were on anticoagulant therapy for the past 5 years were included in the study and were assessed for general medical status, drug dosage, indication for anticoagulant therapy, and duration of treatment before being included in the study. Before undertaking any procedure, the international normalized ratio (INR) for each of the patient under study was requested and the study was only performed if INR was within the therapeutic range of 2.0–4.0 for each patient. Any patients with INR outside the therapeutic range, patients with liver disease, patients on other drugs that affect the hemostasis (long-term use of nonsteroidal anti-inflammatory drug, chemotherapeutic and immunosuppressant drugs), and patients who refused to sign the consent for the study were excluded from the study. Results: None of the patients, in study group, had any immediate postoperative bleeding during the 30 min that they were observed after the extractions, and no patient in study group had any bleeding during the first 24 h. One patient from the study group (50-year-old female, INR 3.2) had intermittent oozing on the 3rd day postoperatively, after extractions of lower right 2nd molar. Conclusion: We conclude that hemorrhagic episodes postextraction in patients on anti-coagulant therapy is manageable following atraumatic extraction, hemostatic agents and sutures. Its also concluded that patients on anticoagulant are at high risk of thromboembolic events than postextraction hemorrhage so anticoagulant therapy should be continued without any alteration.
Keywords: Anticoagulants, extraction, international normalized ratio, warfarin
|How to cite this article:|
Kumar D, Ahmad T, Bhat TA, Khadase P, Kaur A. Evaluation of hemorrhage immediately after extraction and postextraction in patients on oral anticoagulant therapy for last 5 years. Indian J Dent Sci 2021;13:192-5
|How to cite this URL:|
Kumar D, Ahmad T, Bhat TA, Khadase P, Kaur A. Evaluation of hemorrhage immediately after extraction and postextraction in patients on oral anticoagulant therapy for last 5 years. Indian J Dent Sci [serial online] 2021 [cited 2021 Sep 20];13:192-5. Available from: http://www.ijds.in/text.asp?2021/13/3/192/321168
| Introduction|| |
The proper approach to dental extractions in patients on oral anticoagulant therapy (OAT) remains a matter of debate focused on the balance between the risk of thromboembolic events and bleeding complications. In fact, three decades of research on this issue have produced conflicting results. Some authors recommend the withdrawal of OAT for several days or prescribe heparin before the dental procedure.,
Three different treatment philosophies can be distinguished. A first group of authors recommends leaving the anticoagulant dose unaltered. They state that dental extractions are possible at therapeutic anticoagulation levels., According to these authors, the small but potentially hazardous effect of discontinuing anticoagulant therapy is not justified in patients anticoagulated within the therapeutic range. Second group of study has reported on tooth extractions in patients taking coumarin derivatives without the occurrence of severe bleeding episodes., Leaving the anticoagulant dose unaltered is a simple technique, and development of thromboembolic events is prevented. However, the fear of possible hemorrhagic complications increases stress in the cardiac patient, and this induces the release of substances that promote fibrinolytic activity.
A third philosophy is characterized by partial correction of the coagulation activity. The level should be sufficient for achieving immediate hemostasis following the intervention and at the same time, limit the risk for thromboembolic events. According to Spouge, an optimal balance is obtained when the prothrombin time (PT) is 50% above normal. Johnson and Leary adjusted the anticoagulant dose to allow for a PT 1.5 times that of the control. Mulligan and Weitzel (1988) considered the range of safety to lie between 1.5 and 2.0 times the control PT.
Warfarin, which belongs to the coumarin group of drugs, is the most commonly used oral anticoagulant. It is a competitive inhibitor of Vitamin K. Warfarin dosages are adjusted to maintain an optimum level of anticoagulation. This is done by monitoring the PT-expressed as the international normalized ratio (INR)-with the therapeutic range generally accepted as between 2.0 and 4.0, depending on the primary indication for anticoagulation. Daily maintenance doses usually range from 3 mg to 9 mg. The anticoagulant effect of the drug is delayed in onset by 2–3 days after starting treatment and likewise persists for about the same length of time on cessation, both because of the nature of drug action on protein synthesis and because coumarins are strongly bound to plasma proteins.
| Materials and Methods|| |
The aim of our study was to evaluate hemorrhage immediately after extraction and postextraction in patients on OAT for the past 5 years.
The study was carried out in the Department of Oral and Maxillofacial Surgery, Maharaja Ganga Singh Dental College, Sriganganagar, Rajasthan, after granting permission from the Ethical Committee of the college.
A total of 100 patients who were on anti-coagulant therapy for last 5 years were included in the study and were assessed for general medical status, drug dosage, type, and indication for anticoagulant therapy and duration of treatment before being included in the study.
Before undertaking any procedure, the INR for each of the patient under study was requested and the study was only performed if INR was within the therapeutic range of 2.0–4.0 for each patient. Any patients with INR outside the therapeutic range, patients with liver disease, patients on other drugs that affect the hemostasis (long-term use of nonsteroidal anti-inflammatory drug, chemotherapeutic and immunosuppressant drugs), and patients who refused to sign the consent for the study were excluded from the study.
The procedure was duly explained before being carried out and it was explained that they would be treated without withdrawal of their therapy and they were being aware of the possibility of bleeding but a lower risk of thromboembolism.
After informed consent by all the 100 patients, they were randomly allocated to either control or study group each comprising of 50 patients by using odd and even number criteria, odd numbered were included in study group while even numbered were included in the control group and all the extractions were carried out by the same surgeon.
The study group patients (n = 50) were asked not to alter their anticoagulant dose in any way before having their dental extractions and did not have their INR repeated as this was measured only within the preceding 5 days.
However, the patients in the control group with INR within the therapeutic range were instructed to stop anticoagulant 3 days before extraction and were asked to do a fresh preoperative INR again on the day of extraction to ensure that it had decreased to a value within the range of 1.5–2.0.
Under all aseptic conditions, the extractions were carried out under local anesthesia using a standard solution of 2% (20 mg/mL) lignocaine hydrochloride with 1: 80,000 adrenaline.
Regional inferior alveolar, lingual, buccal, and mental nerve blocks were given as necessary in the mandible, while local infiltrations were given in the maxilla. The teeth were extracted using forceps and elevators, with much attention being paid to a careful atraumatic technique, avoiding tearing of tissues, and excessive bone removal.
All sockets were sutured with 3–0 black braided silk and pressure pack with sterile gauze was given. The patients were asked to bite on the gauze pack, observed for 30 min for any immediate bleeding from the extraction site and asked to remove the gauze pack thereby and in the absence of any hemorrhage, were discharged and reviewed at 1, 3, and 5 days' postoperatively.
The data collected was compiled, tabulated, analyzed, and subjected to statistical tests. The data collected was evaluated using standardized statistical methods Student's t-test, which was done to compare hemorrhagic episodes between two groups and the level of significance was set at P < 0.05.
| Results|| |
Average age for all the patients was 56 years (range 30–82 years), and there were 63 male and 37 female subjects [Table 1]. The total number of extractions performed was 180 (90 extractions in the study group and 90 extractions in the control group) [Table 2].
The patients were on anticoagulant treatment for a number of reasons, and these are summarized in [Table 3]. The average duration of use of anticoagulant therapy was 6.2 years.
None of the patients, in study group, had any immediate postoperative bleeding during the 30 min that they were observed after the extractions, and no patient in study group had any bleeding during the first 24 h. One patient from the study group (50-year-old female, INR 3.2) had intermittent oozing on the 3rd day postoperatively after extractions of lower right 2nd molar and was prescribed local hemostatic agent (tranxemic acid) that was injected locally at the site of bleeding, no other patient had any evidence of delayed hemorrhage on the 3rd postoperative day. Similarly, none of the patients had any delayed bleeding as reviewed 5 days' postoperatively.
On comparison of hemorrhagic episodes between the two groups, it was found to be statistically insignificant (P ≥ 0.05) [Table 4].
None of the patients needed admission to hospital at any stage. There was no evidence of postoperative trismus due to bleeding at local anesthetic injection sites, However, there was no severe or life-threatening hemorrhage in any case, and case of postoperative bleeding were managed with local injection of tranexamic acid at site of bleeding. Local measures were sufficient, and there was no need for drug administration, alteration of anticoagulant therapy, hospitalization or transfusion nor was there any thromboembolic episode in any of the patients.
| Discussion|| |
Dental extractions in patients on anticoagulant therapy create a fear, apprehension, and dilemma in dental professionals due to hemorrhagic episodes posttooth extraction.
Thus, planning dental extractions on anticoagulant patients becomes difficult task which subject patients to high risks.
However, altering the anticoagulant treatment preoperatively, in order to reduce the risk of serious hemorrhage following extractions, puts the patient at risk of thromboembolism. A number of studies have addressed this problem of managing anticoagulated patients needing dental extractions.,
The approach of no change in anticoagulation relies on local measures to control the bleeding. In some studies, reporting few or no postoperative cases of bleeding, the majority of patients had normal PTs or PTs in the low therapeutic range.,, Patients with higher PT values may be more likely to have postoperative bleeding. In some cases, the bleeding may be intractable and Vitamin K may be needed to control it.
Another approach of change in anticoagulant intensity depends on the reduction or elimination of the anticoagulant dose for a variable period (from 2 to 6 days) before the extraction. This approach increases the risk of thromboembolism, particularly in patients with artificial heart valves. In addition, the theory of rebound hypercoagulability after withdrawal of coumarin was recently supported by a study that shows increased thrombin activity after coumarin withdrawal.
Furthermore, the replacement of coumarin by heparin before extraction is another approach, but it requires hospitalization with close monitoring of the anticoagulant treatment. Postoperatively, the patient is at risk of thromboembolism until the therapeutic level of coumarin is once again achieved, which can take several days.
In our study, there was no patient who was given low molecular weight heparin as no alteration in existing anticoagulant therapy was made and there was no severe or any life-threatening hemorrhagic episode recorded.
In our study, we divided the patients into a control group who stopped the anticoagulation therapy 3 days before extractions so that INR had decreased to a value within the mean of 1.77 and a study group who continued the drug without any alteration of the dosage provided their INR was within the therapeutic mean of 2.2.
None of the patients either in the control group or study group had any immediate postextraction hemorrhage.
However, hemorrhagic episodes were managed with local measures only which suggest that even if postoperative bleeding episodes occur in patients who continue their OAT without alteration, these episodes are not life-threatening and can be controlled easily with local measures in most cases. The recent study by Lu et al. concluded on same opinion that bleeding complications, while inconvenient, do not carry the same risks as thromboembolic complications. Sufficient hemostasis can be obtained using local measures. Whenever possible, the therapeutic levels of warfarin (INR <4) or antiplatelet therapy should not be interrupted before most dental extractions. Mingarro-de-León et al. also advocated for local hemostatic measures in case of dental extractions for patients on OAT.
Similar results have been found in many separate studies carried out by Devani et al., Blinder et al., Evans et al., Sacco et al., and Morimoto et al. There was no thromboembolic event in any of the groups.
The rationale behind the present study was to evaluate hemorrhage immediately after extraction and postextraction in patients on long term anticoagulant therapy in study and control groups and to derive a relationship between stopping of drugs and continuation of therapy.
| Conclusion|| |
Patients on anticoagulant therapy for the last 5 years with INR within therapeutic range of 2.0–4.0 can undergo extractions without stoppage of drugs, provided proper aseptic and atraumatic extraction is carried by oral surgeon.
From our study, we conclude that hemorrhagic episodes postextraction in patients on anticoagulant therapy is manageable following atraumatic extraction, hemostatic agents, and sutures. It is also concluded that patients on anticoagulant are at high risk of thromboembolic events than postextraction hemorrhage so anticoagulant therapy should be continued without any alteration.
Ethical clearance was obtained from the ethical committee of the college.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]