Management of dental patients taking common hemostasis-altering medications.
OBJECTIVE
Millions of patients worldwide are taking medications that alter hemostasis and decrease the risk for thromboembolic events. This systematic review is intended to provide recommendations regarding optimal management of such patients undergoing invasive dental procedures. The primary focus of this report is on warfarin therapy, although issues related to heparin and aspirin are briefly discussed because of the frequency with which they are encountered in dental practice.


METHODS
The review of literature and development of recommendations was based on the Reference Manual for Management Recommendations for the World Workshop in Oral Medicine IV (WWOM IV). A total of 64 publications were identified for initial review. From these publications, the following types of articles were critically analyzed using WWOM standard forms: randomized controlled trials (RCT), non-RCT studies that assess effects of interventions, and studies that assess modifiable risk factors. Development of recommendations was based on the findings of these reviews as well as expert opinion.


RESULTS
The following evidence-based recommendations were developed: (1) For patients within the therapeutic range of International Normalized Ratio (INR) below or equal to 3.5, warfarin therapy need not be modified or discontinued for simple dental extractions. Nevertheless, the clinician's judgment, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision. Patients with INR greater than 3.5 should be referred to their physician for consideration for possible dose adjustment for significantly invasive procedures. (2) A 2-day regimen of postoperative 4.8% tranexamic acid mouthwash is beneficial after oral surgical procedures in patients on warfarin. (3) It is not necessary to interrupt low-dose aspirin therapy (100 mg/day or less) for simple dental extractions.


CONCLUSIONS
For most patients undergoing simple single dental extractions, the morbidity of potential thromboembolic events if anticoagulant therapy is discontinued clearly outweighs the risk of prolonged bleeding if anticoagulant therapy is continued.
Aframian
Doron J
DJ
Salivary Gland Clinic and Residency Program, The Hebrew University, Hadassah School of Dental Medicine, Jerusalem, Israel.
Lalla
Rajesh V
RV
Peterson
Douglas E
DE
D000925:Anticoagulants / Q000627:therapeutic use*; D000933:Antifibrinolytic Agents / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use*; D017742:Dental Care for Chronically Ill / Q000379:methods*; D006801:Humans; D019934:International Normalized Ratio / Q000592:standards; D009067:Mouthwashes / Q000627:therapeutic use; D011517:Prothrombin Time / Q000592:standards; D014148:Tranexamic Acid / Q000627:therapeutic use*; D014859:Warfarin / Q000627:therapeutic use*
D000925:Anticoagulants; D000933:Antifibrinolytic Agents; D009067:Mouthwashes; D014859:Warfarin; D014148:Tranexamic Acid; D001241:Aspirin