Introduction:
Patient compliance and local and systemic health conditions are crucial factors to be evaluated before dental treatment in patients on anticoagulant therapies. Oral anticoagulation therapies are commonly prescribed in order to prevent the occurrence of thromboembolic events such as deep vein thrombosis and pulmonary embolism. The main adverse effects of these medicines lie in the bleeding risk, which may result in invalidating sequelae, including fatal accidents.
What Are the Types of Anticoagulants?
Current anticoagulants consist of two basic drugs: thrombocyte aggregation inhibitors (such as Acetylsalicylic acid and Clopidogrel) and vitamin K antagonists (such as Warfarin, Acenocoumarol, and Phenprocoumon). The coumarin derivatives that inhibit vitamin K (vitamin K antagonist) have excellent pharmacokinetic properties and represent the standard oral anticoagulation therapy. However, their use necessitates regular dose adjustments depending on the prothrombin time, and they can have multiple drug and food interactions. Recently, new oral anticoagulants have been introduced in order to overcome these limitations.
Recently, a new drug, namely Rivaroxaban, was introduced as an alternative to Warfarin. Rivaroxaban overcomes some of the limitations of Warfarin since Rivaroxaban does not require regular coagulation monitoring or dose titration and has a rapid onset of action, a short half-life, and limited food and drug interactions.
Moreover, Rivaroxaban as a direct factor Xa inhibitor interrupts the coagulation cascade (inhibiting mainly thrombin and factor Xa). A reversal agent can be administered for immediate effect reduction, and the majority of anticoagulation effects (80%) reportedly disappear 24 hours after the last drug intake in case of normal renal function.
In contrast, vitamin K inhibitors have difficult pharmacological management, as the maximum prothrombin response occurs 2 to 4 days after drug administration, and the effect declines at a constant rate following cessation of the therapy. Several medications have been shown to influence the coagulation system. In the postoperative protocol at the dentist’s clinic provided usually, these drugs, Amoxicillin (or Clarithromycin if allergic to Penicillin) and Cephalosporins, Macrolides, and Quinolones, were avoided.
Paracetamol is usually prescribed as an analgesic, and non-steroidal anti-inflammatory drugs (NSAIDs) are avoided in order to reduce the bleeding risk and potential invalidation of the study. Vitamin K antagonists show satisfactory pharmacokinetics; however, they are not without problems, regular monitoring is required. It also has multiple food and drug interactions.
What Are the Different Types of Bleeding?
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The presence of purpura, a postoperative discoloration produced by blood extravasation under the surface of the mucosa in the oral cavity or under the skin in peri-oral facial and cervical areas.
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Petechiae is described as pinpoint, non-raised circular red spots.
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Ecchymoses, considered as areas with an extent wider than 1 cm.
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Hematomas, considered as large pools of blood resulting in a palpable mass.
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Early bleeding may be recorded after the surgery up to 24 hours in these patients on anticoagulant therapies.
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Delayed bleeding episodes are usually recorded from the second day up to the fourteenth day after the surgery.
Concerning the prevalence, to control mild bleeding in the dental office, dry gauze compression with a topical ice-pack application is sufficient to stop the bleeding. For moderate bleeding, additional local hemostatic measures are set in place, and severe bleeding is considered an episode that requires the patient’s hospitalization.
How To Handle Postoperative Bleeding In Dentistry?
All the postoperative bleeding complications can be easily handled with local hemostatic measures. Local hemostatic measures consist of bone wax, resorbable gelatin sponges placed into the alveoli before suturing, horizontal mattress technique combined with simple stitches with resorbable sutures, and wound compression with sterile tranexamic acid-soaked gauzes.
Following implant insertion in a healed site (according to the traditional protocol) allows a primary flap closure that may result in better hemostasis and a potentially lower incidence of bleeding in contrast with tooth extraction. Although bleeding post a surgical or dental procedure is easily manageable with local hemostatic measures, a statistically significantly higher frequency of postoperative bleeding was found in patients taking vitamin K inhibitors compared with non-anticoagulated patients as well as those on Rivaroxaban therapy.
Tailored anticoagulation management should be provided to patients undergoing oral surgical procedures. At present, there is evidence that anticoagulant therapy interruption generates a higher risk of suffering thromboembolic events, with more severe morbidity than that resulting from bleeding occurrence (spontaneously or perioperatively) when anticoagulation is continued.
Nevertheless, an individual risk evaluation based on the systematic health condition of the patient, the invasiveness of the surgical procedure, and the anticoagulation therapy must be performed in order to provide the safest management of the patient.
Operative And Postoperative Management:
Atraumatic extraction was performed where needed, and a mucoperiosteal flap was raised to expose the crestal bone with relieving incisions on the buccal aspects in the posterior molar areas. Bone wax is placed in fresh sockets to mechanically stop bleeding from bony surfaces where necessary, and resorbable gelatin sponges are placed into the alveoli before suturing. The horizontal mattress suturing techniques combined with simple stitches was performed with 3-0 resorbable sutures. Alternatively, compression applied on the wound through sterile gauze soaked in 500 mg/5 ml tranexamic acid for 8 minutes is also effective.
Postoperative Follow-up:
1) Paracetamol is the prescribed analgesic drug (1g immediately after surgery followed by 500 mg every six hours over five days) - The dosage commonly recommended after dental implantation.
2) Antibiotic therapy is continued for seven days after the surgery (1g Amoxicillin every 12 hours or 250 mg Clarithromycin every 12 hours if allergic to Penicillin), and two ice packs are given to the patient with the recommendation to apply them to the wound for four to seven days.
3) All patients are advised to adhere to a cold and soft diet during the first 48 hours.
4) Topical antiseptic mouth rinse (0.2% Chlorhexidine gluconate) was prescribed every eight hours for seven days starting from two days post-surgery.
The presence of bleeding and purpura is controlled by different clinicians based on the extent of dental surgical procedure (varies from mild bleeding in extractions to severe bleeding in major orofacial surgeries). Suture removal is not necessary in most cases until one week (if non-resorbable sutures are used).
Conclusion:
Bleeding complications, occurring either spontaneously or perioperatively, have been faced for a long time and can result in temporary therapy modification or interruption before oral surgeries such as dental extractions and implant treatments. Since the thromboembolic events could be more harmful than the eventual postoperative bleeding, the individual risk must be evaluated for safe management of the patient.
