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J Oral Maxillofac Surg

65:1149-1154, 2007

Oral Surgery in Patients on Anticoagulant


Treatment Without Therapy Interruption
Giovanni B. Ferrieri, MD, DMD,* Stefano Castiglioni, DDS,†
Daniela Carmagnola, DDS, PhD,‡ Marco Cargnel, DDS,§
Laura Strohmenger, MD, DMD,储 and Silvio Abati, MD, DMD¶

Purpose: Conflicting opinions exist in literature concerning the management of oral surgery in patients on
oral anticoagulants because no consensus on perioperative protocols is available, including precise guidelines
regarding the need for therapy modification or withdrawal. The aim of this study was to evaluate bleeding
complications associated with oral surgery performed on patients on oral anticoagulants without therapy
modification or withdrawal but following a standardized comprehensive perioperative management protocol.
Patients and Methods: Patients on oral anticoagulant therapy with warfarin and in need of oral surgery
underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk; 255
subjects who, on the morning of surgery, had INR values ⱕ5.5 were included in the study. An atraumatic
surgical technique was carried out and all patients received postoperative careful instructions.
Results: Five cases (1.96%) of bleeding complication were observed in patients with moderate to high
thromboembolic and bleeding risk.
Conclusion: The findings from this study suggest that a comprehensive perioperative management
protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding
risk assessment, 2) an atraumatic surgical technique, and 3) postoperative careful instructions, can lead
to safe and successful results with minimal complications.
© 2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:1149-1154, 2007

Cardiovascular conditions represent a main cause of available based on randomized controlled studies.3
death in the world population and are related to an Nowadays, most authors seem to agree on the use-
increased risk for thromboembolic complications. lessness of modification or interruption of oral anti-
Patients affected by cardiovascular conditions may be coagulants when performing oral surgery because a
treated, when indicated, with warfarin (coumarin), a decreased risk for excessive bleeding might be asso-
drug that inhibits the process of hemostasis, therefore ciated with an increased risk for thromboembolic
leading to an increased tendency to bleed after trauma.1 complications.4
Conflicting opinions exist in the literature concern- Some authors consider INR (international normal-
ing the management of oral surgery in patients on oral ized ratio) values less than 4 as safe concerning bleed-
anticoagulants because general protocols have been ing complications in case of oral surgery, while they
suggested,1,2 but no specific perioperative protocol is suggest that oral surgery should be avoided with INR
values exceeding 5.5,6 Nevertheless, Blinder et al7
found no correlation between INR values and postop-
Received from the Departments of Medicine, Surgery, and Den-
tistry, Università degli Studi di Milano, Milano, Italy.
erative bleeding after teeth extractions in patients on
*Clinical Professor.
oral anticoagulants, even with INR values over 3.5.
†PhD Student.
Beirne,8 in a literature review, stated that interrupt-
‡Research Associate. ing warfarin for dentoalveolar surgery to decrease INR
§Clinical Professor. values was not supported by clinical evidence be-
储Professor and Chairman. cause the risk for life-threatening postsurgical bleed-
¶Associate Professor. ing consequences is extremely low. On the other
Address correspondence and reprint requests to Dr Ferrieri: hand, Todd9 suggested oral anticoagulants modifica-
Università degli Studi di Milano, Via Beldiletto 1/3, 20142 Milano, tion when performing oral surgery, according to the
Italy; e-mail: giovanni.ferrieri@unimi.it entity of the cardiovascular condition and the oral
© 2007 American Association of Oral and Maxillofacial Surgeons surgical intervention.
0278-2391/07/6506-0014$32.00/0 All authors agree on performing wound compres-
doi:10.1016/j.joms.2006.11.015 sion with wet gauzes and tight multiple suturing1 to

1149
1150 ORAL SURGERY AND ANTICOAGULANTS

Table 1. CHARACTERISTICS OF THE SUBJECTS


events (low, moderate, or high risk). Atrial fibrillation
INCLUDED IN THE STUDY without stroke, cardiomyopathy without atrial fibril-
lation, venous thrombosis more than 6 months ear-
Gender lier, and bileaflet aortic valve with less than 2 risk
Age Groups Male Female Total factors for stroke were considered low risk condi-
⬍40 3 1 4 tions. Bileaflet tilting disc aortic valve with ⱖ2 stroke
40-49 8 4 12 risk factors, chronic atrial fibrillation with ⱖ2 stroke
50-59 16 11 27 risk factors, and venous thrombosis less than 6
60-69 59 36 95 months earlier were considered moderate risk condi-
70-79 41 49 90 tions. Mechanical mitral valve, ball-cage valve replace-
⬎80 16 11 27
Total 143 112 255 ment, venous thrombosis less than 3 months earlier,
hypercoagulable state, atrial fibrillation with history
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007.
of stroke, acute myocardial infarction less than 3
months earlier and recent (1 month) stroke or tran-
sient ischemic attack were considered high risk con-
control intra- and postsurgical bleeding. Some proto- ditions (see Beirne8 for details).
cols recommend the use of tranexamic acid irrigation Patients were then classified in a high or low sur-
or mouth rinses after surgery, alone or with aids such gical risk group according to the type of intervention
as fibrin glue and oxidized cellulose mesh,10,11 espe- for which they were scheduled (Table 2). Namely,
cially when INR values exceed 3.5 to 4. simple single extraction and multiple (up to 4 ele-
The purpose of this study was to evaluate bleeding ments) simple extractions were considered low risk
complications associated with oral surgery performed interventions. Complicated extractions (requiring flap
in patients on oral anticoagulants without therapy elevation and/or ostectomy), multiple extractions of
modification or withdrawal but following a standard- more than 5 elements, soft tissue surgery (biopsies),
ized comprehensive perioperative management pro- and implant insertion were considered high-risk inter-
tocol including 1) thromboembolic and bleeding risk ventions.
assessment, 2) an atraumatic surgical technique, and One week before surgery, each patient received
3) postoperative careful instructions. supragingival scaling and oral hygiene instructions
and were instructed to use 0.2% chlorexidine mouth
rinses twice daily for 7 days.
Patients and Methods
Surgery was performed according to a standardized
Between November 2002 and June 2005 a total of surgical protocol including a presurgical, an intra-
255 patients (mean age, 67.8 ⫾ 9.5; range, 27-89 surgical, and a postsurgical phase, as detailed below.
years; Table 1) on anticoagulant therapy with warfarin
underwent oral surgery at the Day Hospital Unit of the PRESURGICAL PHASE
Dental Clinic, Department of Medicine, Surgery and In the early morning, patients underwent blood
Dentistry, University of Milan, Italy. sample collection for INR evaluation.
Inclusion criteria for access to this study were Patients whose INR resulted higher than 5.5 were
chronic treatment with warfarin and need for oral referred to their clinician in charge for therapy adjust-
surgery (including tooth extractions, biopsy, and im- ment before rescheduling oral surgery.
plant insertion). Patients were on anticoagulant treat- All patients with INR less than 5.5 were connected
ment because of their history of cardiovascular dis- to a multiparametric monitor (Nelicor Puritan Bennet-
ease or thromboembolic events, or because they had 3930; Anthos, Imola, Italy) for evaluation of cardiac
mechanical prosthetic heart valves and were referred
to our clinic by their private dentists or clinician in
charge.
On the first appointment, all subjects were investi- Table 2. SURGICAL RISK CLASSIFICATION
ACCORDING TO INTERVENTION TYPE
gated concerning their general medical history and
stomatologic specific history. When systemic history Low Risk High Risk
was uncertain, the patients’ clinician in charge was
Simple single extractions Complicate single extractions
interviewed to obtain complete health status informa- Simple multiple (⬍4) Simple multiple (⬎5)
tion. Further, all patients underwent clinical and ra- extractions extractions
diographic oral examination. Biopsies
According to a classification suggested by Beirne,8 Implant installation
all patients included in the study were divided into 3 Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
groups concerning the risk for thromboembolic Surg 2007.
FERRIERI ET AL 1151

frequency, blood pressure, O2 saturation, and electro- the wound for 30 minutes. Finally, gauzes soaked
cardiography activity. with saline were used to press the wound for 30
If systolic blood pressure was over 180 mmHg minutes. The wound was checked again and if a stable
and/or diastolic blood pressure was over 100 mmHg blood clot was obtained and maintained for the sub-
after 3 measurements performed at 15-minute inter- sequent 30 minutes, the patient was dismissed. If not,
vals, the patient was referred to his/her clinician in new gauze soaked with tranexamic acid was used and
charge for therapy adjustment before rescheduling the cycle was repeated until a stable clot was ob-
the oral surgery. tained. If a stable clot would not be achieved by local
According to guidelines from the American Heart measures, major bleeding was recorded and the site
Association,12 patients at risk for developing endocar- would undergo wound surgical revision.
ditis were given 2 g amoxicillin or, if allergic, 500 mg
clarithromycin, 1 hour before surgery. POSTSURGICAL PHASE
Patients were carefully instructed concerning post-
SURGICAL PHASE surgical care. For 24 hours following surgery they
Patients were asked to rinse their mouth with 10 were required to eat a liquid and cold diet and not to
mL 0.2% chlorexidine for 60 seconds. rinse their mouth. In particular, all patients were
Locoregional anesthesia was obtained using differ- warned not to create oral vortexes with water or
ent anesthetic solutions depending on the patients’ mouthwashes, not to perform any suction activity and
health status. Namely, infiltration was performed not to “push” in the wound area with their tongue.
with 3% chloridrate mepivacaine (Carbocaina 3%; Home oral hygiene care was to be suspended in the
AstraZeneca, Basiglio, Italy) in patients affected by operated region for 24 hours. In case of oozing, pa-
unstable angina, recent (less than 6 months earlier) tients were told to press the wound with gauze
myocardial infarction, recent coronary bypass (less soaked with tranexamic acid for 30 minutes. They
than 6 months earlier), poorly controlled angina, were recommended to get in contact with a doctor in
poorly controlled hypertension, and congestive car- case of bleeding that would not significantly decrease
diac failure.13 In all other cases, anesthesia was ob- or stop by compression within 1 hour.
tained with 2% mepivacaine with 1:100,000 epineph- Further, 0.2% chlorexidine mouth rinses was pre-
rine (Carbocaina) or articaine with epinephrine scribed to be used starting from the second day after
1:100,000 (Ubistesin; 3M ESPE, Segrate, Italy). When surgery twice a day for 14 days.
possible, only papillary and intraligamentous infiltra- In case of diabetes, ostectomy or large suppuration
tion were performed. of the treated sites, 1 g amoxicillin twice a day for 6
A surgical atraumatic technique aiming at soft tis- days was prescribed (clarithromycin 500 mg twice a
sue and bone tissue preservation was carried out. Soft day for 6 days in case of amoxicillin allergy).
tissues were carefully handled to minimize trauma. Postoperative pain management was achieved with
Flap elevation, when required, was performed subpe- paracetamol tablets 500 mg twice a day for 3 days or
riosteally and attention was paid to minimize flap ibuprofen tablets 300 mg twice a day for 3 days.
tension. Teeth were sectioned for removal when pos- Clinical control visits were carried out after 1, 3,
sible. When ostectomy was required, a minimal quan- and 7 days. Suture removal was performed after 7
tity of bone tissue was removed to not completely days.
destroy the bone walls and thus help blood clot sta-
bilization. Particular attention was paid to removing
Results
all granulation tissue by carefully curetting extraction
sites. A total of 334 interventions were carried out on 255
According to the extension of intraoperative hem- patients (Table 3).
orrhage, when light “regular” bleeding was observed, According to thromboembolic risk, 41 patients
the operated site was carefully sutured with non- were classified as low risk, 115 moderate risk, and 99
resorbable multiple sutures in order, whenever pos- high risk. According to bleeding risk, 127 patients
sible, to achieve primary wound repair and otherwise (189 interventions) were classified as low risk and
to bring papillae and flaps near. Further, the site was 128 (145 interventions) as high risk (Tables 4 and 5).
pressed for 30 minutes with gauze previously soaked Blood values concerning preoperative INR were
in saline. comprised between 1.3 and 5.4 (average, 2.7 ⫾ 1.2)
When large intraoperative bleeding was observed, and distributed, as illustrated in Table 6, according to
the operated site was rinsed with 5 mL tranexamic thromboembolic risk.
acid (Tranex 500 mg/5 mL; Lusofarmaco, Peschiera Out of 255 patients, 5 (1.96%) were referred for
Borromeo, Italy) and then sutured. Gauze was then bleeding complications (Table 7). Namely, 1 patient
soaked with 5 mL tranexamic acid and was pressed on was characterized by postsurgical major bleeding; 1
1152 ORAL SURGERY AND ANTICOAGULANTS

Table 3. PATIENTS’ DISTRIBUTION ACCORDING TO BLEEDING RISK AND INTERVENTION TYPE

Low Bleeding Risk High Bleeding Risk


Simple Single Simple Multiple Complicated Single Simple Multiple Implant
Extractions (⬍4) Extractions Extractions (⬎5) Extractions Biopsies Installation Total

Patients 41 86 68 44 13 3 255
Interventions 103 86 81 44 13 7 334
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Surg 2007.

patient started bleeding approximately 12 hours after Discussion


surgery; 1 about 16 hours after surgery; 1 after ap-
In the present study it was observed that by using
proximately 24 hours, and the last after 5 days. All
a standardized comprehensive perioperative manage-
subjects but the first, who underwent immediate
ment protocol including 1) thromboembolic and
wound revision, managed to control hemorrhage by
bleeding risk assessment, 2) an atraumatic surgical
pressing the wound area with gauze soaked with
technique, and 3) postoperative careful instructions,
tranexamic acid and did not need to seek help from a
oral surgery in subjects on oral anticoagulants is a safe
doctor. Nevertheless, 1 patient, namely the one who
procedure even with high INR values. In the sample
experienced bleeding 12 hours after surgery, was
population considered, only 5 (1.96%) patients
characterized at the 3-day control (but not after 24
showed bleeding complications. Such complications
hours) by the presence of submandibular, cervical,
occurred in patients who, before surgery, had been
and thoracic ecchymosis (Fig 1). Since at control visits
classified as moderate to high risk subjects for throm-
all sites showed continuous (although light) oozing,
boembolic or hemorrhagic events. Wound revision
the patients underwent new INR evaluation followed
and patient review of instructions appeared to be the
by wound revision including curettage and tight mul-
appropriate approach to the management of postsur-
tiple suturing. No further complications were ob-
gical complications.
served. When interviewed, 1 patient admitted that he
All patients were carefully investigated concerning
did not follow the instructions concerning cold and
their systemic and oral history and status, and this
soft diet and 2 subjects stated they rinsed their mouth
allowed for the identification and adjustment, when
with water on the same day of surgery.
possible and necessary, of detectable risk factors. Fur-
In 3 patients, 7 mandibular intraforaminal implants
ther, a precise classification concerning thromboem-
were inserted. No surgical or postsurgical complica-
bolic and hemorrhagic risk was possible.
tion was observed. The implants were loaded 6
In the present protocol, it was decided not to
months after placement and were functional and sur-
interrupt or replace oral anticoagulant therapy. This
rounded by healthy tissues after 18, 20, and 25
approach is supported by Dunn and Turpie3 and
months from insertion.
Beirne.8 Dunn and Turpie,3 in a systematic literature
An overall risk was calculated for each patient who
review, found 0.2% major bleeding complications fol-
reported postsurgical complications by crossing
lowing dental procedures in patients on oral antico-
thromboembolic and hemorrhagic risk (Table 8). It
agulants (4 out of 2,014). Further, evidence exists
was observed that 2 patients were characterized by
that, if INR values are within therapeutic range, oral
high thromboembolic and hemorrhagic risk, 2 by low
anticoagulation can be continued when performing
hemorrhagic and moderate or high thromboembolic
oral surgery because the risk for uncontrolled post-
risk, and 1 by high hemorrhagic and moderate throm-
surgical bleeding appears to be very low and does not
boembolic risk. No complications were observed in
justify increasing the risk for thromboembolic com-
patients who had been classified as low hemorrhagic
plications. Also, the appropriate therapeutic INR
and low thromboembolic risk subjects.

Table 5. PATIENTS’ AND INTERVENTIONS’


Table 4. PATIENTS’ DISTRIBUTION ACCORDING TO DISTRIBUTION ACCORDING TO BLEEDING RISK
THROMBOEMBOLIC RISK
Low High Total
Low Risk Moderate Risk High Risk Total
Patients 127 128 255
41 115 99 255 Interventions 189 145 334
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007. Surg 2007.
FERRIERI ET AL 1153

Table 6. AVERAGE INR VALUES ACCORDING TO


THROMBOEMBOLIC RISK GROUP

Low Risk Moderate Risk High Risk

Average INR 1.4 2.5 3.4


SD 1.1 1.3 1.2
Range 1.3-1.9 1.9-3.2 3.2-5.4
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007.

range in patients on oral anticoagulants is quite tough


to reach and maintain because it is very sensitive to
factors like diet and minor changes in tablet intake.1
Therefore, unless very invasive surgery is planned,
oral anticoagulant therapy interruption or temporary
replacement with heparin does not seem to be justi-
fied.
Various reports on oral surgery in patients on oral
anticoagulants consider INR values under 4 as safe
and recommend to not perform surgery with INR
over 5.5,6 In the present study, 14 patients with INR
values under 4 were included (up to 5.5). Such pa-
tients were classified as low risk subjects for both
thromboembolic and hemorrhagic events and did not
respond adequately to the analgesic therapy previ-
ously prescribed. Therefore, it was decided to pro- FIGURE 1. Submandibular, cervical, and thoracic eccymosis 3 days
ceed with dental extractions despite the high INR after oral surgery in a patient on anticoagulant therapy.
value. Actually, no complications were observed in Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
these patients because all subjects reporting postsur- Surg 2007.
gical bleeding had INR values ⱕ4. Blinder et al7 stud-
ied postsurgical bleeding following teeth extractions
in 249 patients on oral anticoagulants divided into 5 oral cavity. Namely, 1 week before surgery all patients
groups according to their INR values. These authors underwent oral hygiene care including gross suprag-
found no correlation between INR values and postop- ingival plaque and calculus removal. Further, all pa-
erative bleeding, even with INR values over 3.5. It tients were prescribed 2% chlorexidine mouth rinses
may be speculated that, rather than the INR value twice a day for 7 days.
alone, a thorough classification of the patient com- Concerning the specific surgical technique, an
prising the assessment of bleeding and thromboem- atraumatic approach was carried out following guide-
bolic risk can increase the predictability and safety of lines similar to those reported by Scully and Wolff1
oral surgery in subjects on oral anticoagulants. and Evans et al.14 Subperiosteal flaps were raised and
To set optimal conditions for getting limited intra- attention was paid to minimize flap tension. When
and postsurgical bleeding, in the presurgical phase an possible and indicated, teeth were sectioned for re-
effort was made to reduce the quantity of irritants and moval and if ostectomy was required, a minimal quan-
the degree of soft tissue inflammation present in the tity of bone tissue was removed. This protocol al-

Table 7. BLEEDING COMPLICATION DISTRIBUTION ACCORDING TO PATIENTS’ CHARACTERISTICS AND


INTERVENTION TYPE

Time of Complication Gender Age INR Type of Intervention Systemic Pathology

1 hour Male 60 2.8 Multiple extractions ⬎4 Mitral valve replacement


12 hours Male 57 2.9 Complicated extraction Atrial fibrillation, 4 coronary by-pass
16 hours Male 68 3.4 Multiple extractions ⬍4 Lung embolism, diabetes type I
24 hours Male 56 4.0 Multiple extractions ⬍4 Mitral valve replacement
5 days Female 77 2.6 Complicated extraction Mitral valve replacement
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Surg 2007.
1154 ORAL SURGERY AND ANTICOAGULANTS

Table 8. OVERALL RISK TREND ACCORDING TO


rhagic risk. Although particular attention was paid to
THROMBOEMBOLIC AND HEMORRHAGIC RISK conveying precise postsurgical instructions to the pa-
tients concerning home care, when interviewed 1 pa-
Thromboembolic tient indicated that he did not follow the instructions
Risk concerning cold and soft diet and 2 subjects stated they
Low Moderate High rinsed their mouth with water on the same day of
Low 0 1 1 surgery. Once the wound was re-examined and the
Hemorrhagic risk patient was reminded of postsurgical instructions, no
High 0 1 2 further complications were observed.
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Findings from the present study suggest that a com-
Surg 2007. prehensive perioperative management protocol for
oral surgery in patients on oral anticoagulants, includ-
lowed for preservation of the bone walls, thus helping ing 1) thromboembolic and bleeding risk assessment,
blood clot stabilization. Further, careful curetting of 2) an atraumatic surgical technique, and 3) postoper-
the extraction sockets to remove all inflamed and ative careful instructions, can lead to safe and success-
granulation tissue was considered a key point for ful results with minimal complications even in sub-
minimizing postsurgical bleeding. When, following jects with high INR. Preoperative risk assessment
wound compression with gauzes soaked with saline rather than the INR value alone seems to be a key
solution, simple oozing was observed, the operated factor for the safety and predictability of dental pro-
site was carefully sutured with nonresorbable multi- cedures in patients on oral anticoagulants.
ple sutures in order, whenever possible, to achieve
primary wound repair and otherwise to bring papillae References
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