Anticoagulated patients undergoing tooth extraction can be managed safely without altering their anticoagulation treatment by using local hemostatic measures
Hemostatic management of toothextractions in patients on oral
antithrombotic therapy. Morimoto Y, Niwa H, Minematsu K.
J Oral Maxillofac Surg 2008;66(1):51-7.
The study sample was derived from the population of patients presentingfor tooth extraction at 1 of 2 study sites between April 2002 and April
2007. The final sample was composed of 270 subjects receiving anticoagu-
lant therapy who underwent 306 episodes of dental care (extraction). Sub-jects had a mean age of 60.5 years and 61% were male.
Key Exposure/Study FactorThe primary exposure of interest was type of anticoagulant therapy There
were 3 types of anticoagulant therapy: (1) warfarin monotherapy; (2) war-
farin and an antiplatelet drug, ie, aspirin and/or ticlopidine and/or cilos-tazol; and (3) antiplatelet therapy alone, ie, aspirin and/or ticlopidine
and/or cilostazol and/or dipyridamol.
The secondary exposure of interest was preoperative (day of operation)
international normalized ratio (INR), a standard measure of therapeutic
level of anticoagulation when exposed to warfarin.
factors are associated with anincreased risk for postoperative
The primary outcome was postoperative bleeding. It was functionally clas-sified into 2 levels: (1) postoperative bleeding requiring intervention and
Main ResultsIn regard to the primary exposure variable, the frequencies of postopera-
tive bleeding after tooth extraction requiring intervention were 4.4%,
3.9%, and 2.2% for the warfarin, warfarin ’ antiplatelet therapies, and anti-platelet therapies (P > .05). Regarding the secondary exposure variable,the INR level was not associated with risk for postoperative bleeding withinthe range evaluated in the study, INR less than 3.67, and the overwhelmingnumber of patients had INRs less than 3.0.
ConclusionsThe results of this study suggest that nonsurgical and surgical tooth extrac-tions can be performed in anticoagulated patients using warfarin therapywith or without other antiplatelet medications as long as the INR is lessthan 3.0. Local hemostatic measures are generally adequate to prevent orcontrol postoperative bleeding.
This article adds to the growing body of literature suggesting that that alter-
1532-3382/$34.00Ó 2008 Elsevier Inc. All rights reserved.
ation of preoperative anticoagulant therapy before tooth extraction is not
indicated. In the context of this and other papers on the topic (cited in
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
the discussion), the weight of the findings suggests that
follow-up, clinician availability, and so forth. The treating
there should be no preoperative manipulation of antico-
clinician was not blinded to the patients’ treatment status.
agulant therapy before tooth extraction. If one does not
As such, knowing the patients were anticoagulated, the
alter the preoperative anticoagulant therapy, there is an
clinician involved may have been biased in asking patients
increased risk for ‘‘nuisance’’ postoperative bleeding. If
to return if they called about postoperative bleeding, re-
one chooses to stop warfarin preoperatively, there is
sulting an in overestimation of the frequency of postoper-
a small, but finite and measurable, risk for severe throm-
botic events ranging from peripheral to central venous
Although the differences in bleeding frequencies
among the primary interventions were statistically insig-
There are numerous indications for use of anticoagu-
nificant, the unadjusted risk for bleeding in the warfarin
lant therapy, including, but not limited to, management
monotherapy groups was twice that of antiplatelet medi-
and prevention of deep vein thromboses or pulmonary
cations only. The study was statistically underpowered
emboli, atrial fibrillation, artificial heart valves, and fol-
(power estimated to be 0.14 or beta-error = 0.86) to detect
lowing joint replacement or major orthopedic trauma.
a twofold difference in bleeding risk between patients on
For patients taking warfarin, the recommended therapeu-
warfarin versus antiplatelet medications alone. Setting ex-
tic INR level ranges between 2.0 and 3.0. This is quite for-
pectations is key to patient satisfaction. As such, it may be
tunate, as this means that for most of our patients, their
valuable to warn patients on anticoagulant therapies that
therapeutic INR coincides with the range where dental
while unlikely, they are more likely than the average pa-
extractions can be completed with minimal risk for signif-
tient to return for management of postoperative bleed-
icant postoperative bleeding. There are some circum-
ing. In addition, the postoperative bleeding will be
stances where the therapeutic INR level is greater than
a nuisance, not a life-threatening condition.
3.0, such as in patients at high risk for stroke. In these cir-cumstances, more individualized decision making may be
Although there were no specific factors associated with
1. Dodson TB. Strategies for managing anticoagulated patients requir-
an increased risk for bleeding, the frequency of postoper-
ing dental extractions: an exercise in evidenced-based clinical prac-
ative bleeding was higher (2% to 4%) when compared
2. Haug RH, Perrott DH, Gonzalez ML, Talwar MR. The American Asso-
with patients undergoing routine third-molar surgery,
ciation of Oral and Maxillofacial Surgeons age-related third molar
ie, 0.7% unexpected intraoperative hemorrhage and
study. J Oral Maxillofac Surg 2005;63:1106-14.
0.1% unexpected or prolonged postoperative bleeding.This finding suggests that there may be room for improve-
ment for minimizing the frequency and associated incon-venience of managing postoperative bleeding. An
alternative explanation for the increased frequency for
Associate Professor, Harvard School of Dental Medicine
postoperative bleeding is detection bias. Postoperative
Visiting Oral and Maxillofacial Surgeon, Massachusetts General
bleeding after tooth extraction is a notoriously difficult
variable to measure. The authors used a functional mea-
Director of Fellowship in Clinical Investigation
sure, ie, bleeding significant enough to warrant interven-
tion. This is a clinically relevant outcome measure,
although subject to the vagaries of convenience of patient
CRÍTICA DE LIBROS ses (Delumeau: 19). La formulación del primermond Jabes, «podría no ser más que la igno-rancia de un pasado por descubrir. Esta igno-rancia es el verdadero saber que, entre las es-«Plantó luego Yahvé Dios un jardín entrellas, surca en la noche sus caminos reales. Edén, al oriente, y allí puso al hombre aquien hiciera. Hizo Yahvé Dios brotar enél de la tier