Dental Implants in Venous Thromboembolism: An Insight Into New Age Anticoagulant Therapies

Introduction

Anyone thinking of getting dental implants and is on any anticoagulant therapies needs to be physically fit and consult a physician or a cardiologist before proceeding with the dental implantation and with suitable guidelines suggested by the physician for the patient. This article outlines the risks, guidelines, and preventive measures against thromboembolic events.

What Is Venous Thromboembolism and Why Do These Patients Require Anticoagulants?

Venous thromboembolism (VTE) is a condition of high morbidity characterized by thrombus or deep clot formation in veins. These patients require anticoagulant therapy to dissolve the venous clots and promote blood circulation. However, these patients are also at increased risk of bleeding (because of anticoagulant medications like Heparin, Warfarin, unfractionated Heparin, and non-vitamin K-dependent antagonists like Rivaroxaban), especially in surgical procedures related to dentistry, maxillofacial surgery, dental inflammation, and many more.

Are Dental Implants Contraindicated in Patients on Anticoagulant Therapies?

• Oral anticoagulants or coagulation therapies are the preference for all geriatric individuals with a high risk of cardiovascular stroke or thromboembolic events, for instance, deep vein thrombosis (a condition where a blood clot (thrombus) forms in a deep vein) or pulmonary embolism (a life-threatening condition that occurs when a blood clot (thrombus), usually originating from a deep vein thrombosis (DVT) in the legs).

• Some of the adverse side effects in individuals who are regularly prescribed or who intake these oral drug therapies for systemic diseases are that the risk of bleeding is greatly increased and can also predispose these individuals to fatal accidents, especially during surgeries. In the case of dental implant surgery as well, it is important to note that.

• Patient safety during dental implantation and following surgeries depends on complete preoperative assessments coupled with the general physician or cardiologist's prior consent.

• Temporary modifications in drug delivery or oral intake should be done by the physician for safe operative and post-operative management, as well as after dental implantation in individuals taking oral anticoagulants, which are commonly Warfarin therapies.

• Research shows that though dental implants are usually contraindicated in high-risk patients prone to thromboembolic events or cardiovascular stroke, the same is not true in individuals who have less operative bleeding risk as assessed by their physicians.

• If the physician or the cardiologist deems the patient is medically sound or fit to undergo the dental implantation, consent can be given in feasible conditions and with temporary anticoagulant therapy modifications.

• It is an important point to focus on, or note in oral surgery, that as patients age, especially in older individuals above the sixth decade of life, globally, there is also an increasing prevalence definitely of cardiovascular diseases.

• Interestingly, it is also in the geriatric population groups only that teeth would be commonly lost because of periodontal disease, severe systemic diseases impacting oral and periodontal tissues causing tooth mobility, or dental carious lesions that would lead up to tooth loss when left untreated.

What Are the Guidelines Suggested for Oral Surgeons/Implant Dentists to Prevent Thromboembolic Events?

According to the current guidelines in operative and implant dentistry or oral and maxillofacial surgery, oral surgical experts recommend not placing more than three dental implants in anticoagulant therapy patients in a single sitting.

1. Local hemostatic measures also need to be adopted, and the maxillofacial surgeon or dentist in charge must thoroughly cross-check them.

2. According to research by Clemm et al., implant surgery itself is not considered an invasive surgical procedure that would initiate a thromboembolic event in patients on anticoagulant therapies.

3. The physician needs to exercise precautions while giving consent and modifying the drug therapy, and the dentist needs to adopt all possible local hemostatic measures while treating such patients.

4. According to the research studies by Al Zoman et al., the flapless elective surgery procedure is considered the safest for dental implant patients undergoing anticoagulant therapies.

Can Modern Rivaroxaban Therapies Avert Thromboembolic Events for Implant Surgeries?

The common oral anticoagulants used for patients across the globe can presently be divided into vitamin K antagonists and thrombocyte aggregation inhibitors. Examples of thrombocyte aggregation inhibitors are Clopidogrel and acetylsalicylic acid, while the common examples of vitamin K antagonists are Phenprocoumon, Acenocoumarol, Warfarin, etc. This shows an excellent pharmacokinetic ability in present-day treatment strategies to prevent or manage major clotting disorders.

According to the current guidelines, patients who are advised either of these oral anticoagulant drug therapies, be it vitamin K antagonists or thrombocyte aggregation inhibitors, should still be monitored by the implant dentist and physician- that is, continuous coagulation monitoring. However, for new-age anticoagulant treatment with drugs like Rivaroxaban that have been developed by physicians to manage or inhibit only the factor Xa in the coagulation cascade directly, for individuals on rivaroxaban therapies, generally, continuous coagulation monitoring is not needed because these drugs directly inhibit factor Xa and reportedly, medical research shows that many limitations that accompany Warfarin or traditional anticoagulant drug therapies have been overcome by its use (Rivaroxaban).

Further, Rivaroxaban therapies have a short half-life only with very limited drug interactions, especially with dental antibiotics or painkillers, according to preliminary research.

Conclusion

To conclude thus, achieving hemostasis or bleeding control, though possible by modifying drug dosage, physician consent, and preoperative dental evaluation, by adopting strict local hemostatic measures in the dental or oral surgical clinical setting, is indeed possible. However, it is still noted that there needs to be an interdisciplinary collaboration between the implant surgeon and the general physician or the cardiologist when it comes to dental implant surgery in patients undergoing anticoagulant therapies.

Dental implant treatment is quite a safe and predictable surgical procedure in present-day maxillofacial and dental implant surgery fields. According to dental researchers, it can be deemed the gold standard prosthetic rehabilitation treatment strategy for patients with edentulous areas of the jaw or oral cavity to replace lost dentition or teeth with implant prosthetics. Both in terms of restoring form and function, as well as in esthetic management, it is indeed important that the dental implant specialist considers local as well as systemic risk factors of the patient before proceeding to the surgical procedure. Further, certain inclusion criteria have been developed as per current surgery guidelines to prevent unnecessary risks of long-term dental implant failure or post-operative complications. Hence, your dentist will know best if you can fit or if you are eligible for a dental implant because in several systemic diseases, in immunocompromised cases, in geriatric individuals with extensive bone resorption and less scope for sinus surgery or bone augmentation protocols, the long term stability of dental implants cannot be assured.