Hemostatic Agents for the Management of Bleeding Risk Associated
The occurrence of bleeding following dental extraction is a relatively common complication. A history of therapy with oral anticoagulants represents a major favoring factor, both in patients treated with vitamin K-antagonists (especially warfarin) and with direct oral anticoagulants (DOACs). Several local hemostatic measures can be applied to limit the bleeding risk in these patients. The aim of this systematic review is to evaluate what measures can be adopted to limit the bleeding risk following dental extractions in patients treated with oral anticoagulants. A literature search was performed, and 116 articles were retrieved. Titles and abstract analyses excluded 91 articles, and three more articles were excluded following full-text analysis. The systematic review was performed on 22 articles. Among the included articles, 20 studies reported on patients treated with warfarin, and two studies on patients treated with DOACs. The agents employed included local intra-alveolar agents, tranexamic acid, and PRF. The included studies were all at moderate/high risk of bias. Moreover, limited evidence is available on hemostasis in patients treated with DOACs. The available evidence hinders stating the superiority of one agent over the others. Further research is advised to increase the level of evidence of the application of hemostatic agents in patients treated with oral anticoagulants.To get more news about
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Dental extractions are the most common procedures performed in routine dental practice. Bleeding and oozing from the surgical wound are frequently encountered, and mostly self-limiting, complications [1]. However, in patients treated with vitamin K antagonists or direct oral anticoagulants (DOACs), additional measures may be required to manage and limit the risk of post-operative bleeding [1].
Vitamin K antagonists include coumarin and its derivatives such as warfarin. Their mechanism of action is based on the inhibition of prothrombin and clotting factors formation. Dose adjustments are often required in order to maintain the target International Normalized Ratio (INR) of 2.5 (therapeutic range 2–3) [2]. To date, warfarin is the most prescribed oral anticoagulant for the management of thromboembolic disorders, despite its narrow therapeutic index and the high variability in clinical response [3,4].
DOACs have been introduced in recent years for the management of several cardiovascular conditions, including treatment of venous thromboembolism, stroke prevention in non-valvular atrial fibrillation, and for thromboprophylaxis following orthopedic surgery [5]. The DOACs category includes four anticoagulants which directly inhibit the coagulation cascade. Dabigatran is a direct thrombin inhibitor, while apixaban, rivaroxaban, and edoxaban exert their pharmacological activity by inhibiting factor Xa [5]. DOACs are becoming increasingly used with respect to vitamin K antagonists due to their efficacy and safety [6]. It appears that a reduced risk of bleeding can be observed in patients treated with DOACs compared with warfarin as a therapeutic regimen, although in some cases monitoring is still advised [7].
Patients under oral anticoagulant therapy are more prone to bleeding complications and hematoma formation following dental procedures. Tooth extractions are the most frequently performed oral surgical procedures, and bleeding or oozing are frequently occurring complications [8,9]. The surgical trauma on both hard and soft tissues can be related to the development of post-extraction bleeding, although inflammation and/or infection of the extraction site can be concurrent factors [10]. In patients treated with oral anticoagulants, the bleeding risk is enhanced; therefore, different recommendations have been proposed, including anticoagulant therapy modulation through reduction, suspension, or bridging [11]. However, it has also been suggested that therapy discontinuation may expose the patient to a higher risk of thromboembolism against a modest risk of hemorrhage in patients with an INR within the therapeutic range [12].
At present, several hemostatic agents find application for the management of post-extractive bleeding in patients treated with oral anticoagulants. The aim of the present systematic review was to analyze the hemostatic agents employed to manage the bleeding risk associated with dental extraction procedures in patients undergoing oral anticoagulant therapy with vitamin K antagonists and DOACs.
