Post oral

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Post oral surgery bleeding for adult patients
receiving antithrombotic therapy

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Saudi Arabia
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Background

• King Fahd Medical City is a large tertiary care
  hospital with 1095 beds.
• The American College of Chest Physicians
  guidelines recommend that routine dental
  procedures including extractions, scaling and
  restorative treatment could be done without the
  interruption of Warfarin, a Vitamin K Antagonist
  (VKA) if the International Normalized Ratio (INR)
  is within the therapeutic range and local
  hemostatic agents are used.¹
• The American Heart Association guidelines
  recommend that anticoagulant such as Clopidogrel
  do not need to be stopped for dental procedures.²
• The recommendation in the Journal of Canadian
  Dental Association is that Enoxaparin should have
  the morning dose held.³
• The American Dental Association stated it is
  generally agreed that anticoagulant including
  antiplatelet drug regimens should not be altered
  prior to dental treatment.4

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Rationale

• Little existing data in Saudi Arabia for
  antithrombotic (anticoagulant and anti-platelet)
  therapeutic doses and their effects on post-oral
  surgery bleeding.5
• There is an urgent need to standardize the
  practice for treating such patients because
  evidence from a survey we conducted showed that a
  high number of local dentists are unwilling or
  unsure how to treat patients on antithrombotic
  medications. This will lessen the delays that the
  patient faces in receiving treatment.

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Survey about perceptions of dentists in Saudi
Arabia about treating patients on anti-thrombotic
therapy
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Dentist familiarity with antithrombotic
medications
No. of dentists
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What of dentists would not treat a patient or
are unsure how to treat on antithrombotic
medications
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Objectives

• Is to assess the post oral surgery bleeding
  incidence in adult patients on antithrombotic
  once implementing the following protocol
• Warfarin Medication to be continued. Recent
  (within 24 hours) INR values to be within
  therapeutic range.
• Clopidogrel Medication to be continued.
• Enoxaparin Morning dose to be held.
• Local hemostatic agents available to be used as
  deemed necessary i.e. sutures, collagen,
  tranexamic acid.
• To reduce the interruption of antithrombotic
  medications

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Study Design

• A prospective cohort single-centre two year study
  of all patients on antithrombotic medications
  undergoing oral surgery within King Fahd Medical
  City (KFMC) Department of Dentistry.
• All patients within the inclusion criteria were
  monitored

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Inclusion and exclusion criteria

• Inclusion
• Patients for oral surgery in KFMC Department of
  Dentistry and under the care of a KFMC physician
• Patients treated under local anesthesia
• Patients 18 years old or over
• Taking the afore-mentioned antithrombotic
  medications according to the protocol described
• Exclusion
• Patients treated under general anesthesia
• Any patients stopped antithrombotic medication
  without physician approval
• Sub-therapeutic or supra-therapeutic INR values
  for patients taking Warfarin
• Patients with advanced liver disease

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Variables
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Methodology

• Protocol
• Local hemostatic agents available to be used as
  deemed necessary i.e. sutures, collagen,
  tranexamic acid.
• Warfarin Medication to be continued. Recent
  (within 24 hours) INR values to be within
  therapeutic range.
• Clopidogrel Medication to be continued.
• Enoxaparin Morning dose to be held.
• All patients who were underwent oral surgery
  procedures were monitored for post-operative
  bleeding.
• Bleeding was defined as serious post-operative
  bleeding after the patient has been discharged
  from the clinic gt 12 hours, or bleeding
  necessitating return to a medical facility and
  further measures (e.g. use of hemostatic agents).

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Results

• Out of 353 visits there were only two incidences
  of bleeding necessitating return to a medical
  facility (0.56)
• The average INR value for the patients receiving
  Warfarin was 1.9
• Treatment done
• 826 extractions
• 14 alveolectomies
• 3 bone grafts
• 2 implants
• 1 biopsy

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Antithrombotic Medications
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Antithrombotic Medications studied
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Number of teeth extracted per notation
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16
21
15
21
21
21
36
27
32
26
32
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• 28

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43
31
37
36
35
30
28
27
22
34
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21
19
19
19
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Patient Demographics - Gender
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Patient Demographics Age distribution(Average
age 50.7 years, range 18 - 88 years)
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Patient Demographics Medical Conditions
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Conclusion

• Our finding supported the following for patients
  undergoing oral surgery procedures provided local
  hemostatic agents are available to use as
  necessary
• Warfarin can safely be continued during oral
  surgery procedures as long as the INR is within
  the therapeutic range
• Clopidogrel can safely be continued during oral
  surgery procedures
• Enoxaparin the morning dose should be held

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Obstacles we faced

• Some loss of patients to follow up
• The recent introduction of Novel Oral
  Anticoagulants (NOACs) such as Dabigatran and
  Rivaroxaban mean that they should be studied for
  incidence of bleeding.
• To include dental hygiene patients.

Recommendations for further study
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References
¹ Douketis JD, Spyropoulos AC, Spencer FA, et al.
Perioperative management of antithrombotic
therapy antithrombotic therapy and prevention of
thrombosis, 9th ed American College of Chest
Physicians evidence-based clinical practice
guidelines. Chest 2012141(2) (Suppl)e326S-50S.
Available http//journal.publications.chestnet.or
g/data/Journals/CHEST/23443/112298.pdf Accessed
February 19, 2013 ² Grines CL, Bonow RO, Casey
DE et al. Prevention of premature discontinuation
of antiplatelet therapy in patients with coronary
artery stents a science advisory from the
American Heart Association, American College of
Cardiology, Society for Cardiovascular
Angiography and Interventions, American College
of Surgeons, and American Dental Association,
with representation from the American College of
Physicians. Circulation 2007115813-8.
Available http//circ.ahajournals.org/content/115
/6/813.full.pdfhtml ³ Davies C, Robertson C,
and Shivakumar S. Implications of Dabigatran, a
Direct Thrombin Inhibitor, for Oral Surgery
Practice. J Can Dent Assoc 201379d74 4
American Dental Association, Anticoagulant,
antiplatelet medications and dental procedures
http//www.ada.org/2959.aspx?currentTab1
Accessed February 27, 2013 5 Al-Mubarak, S.,
Al-Ali, N., Abou Rass, M. et al Evaluation of
dental extractions, suturing and INR on
postoperative bleeding of patients maintained on
oral anticoagulant therapy Br. Dent. J. 2007
203(7)e15 6 Nooh, N., Dental Management of
patients receiving anticoagulant therapy Saudi
Dental Journal, Volume 21, No.1, January April
2009