What influence do anticoagulants have on oral implant therapy? A systematic review.
OBJECTIVE
This systematic review aims to assess the risks (both thromboembolic and bleeding) of an oral anticoagulation therapy (OAT) patient undergoing implant therapy and to provide a management protocol to patients under OAT undergoing implant therapy.


METHODS
Medline, Cochrane Data Base of Systematic Reviews, the Cochrane Central Register of Controlled Trials and EMBASE (from 1980 to December 2008) were searched for English-language articles published between 1966 and 2008. This search was completed by a hand research accessing the references cited in all identified publications.


RESULTS
Nineteen studies were identified reporting outcomes after oral surgery procedures (mostly dental extractions in patients on OAT following different management protocols and haemostatic therapies). Five studies were randomized-controlled trials (RCTs), 11 were controlled clinical trials (CCTs) and three were prospective case series. The OAT management strategies as well as the protocols during and after surgery were different. This heterogeneity prevented any possible data aggregation and synthesis. The results from these studies are very homogeneous, reporting minor bleeding in very few patients, without a significant difference between the OAT patients who continue with the vitamin K antagonists vs. the patients who stopped this medication before surgery. These post-operative bleeding events were controlled only with local haemostatic measures: tranexamic acid mouthwashes, gelatine sponges and cellulose gauzes's application were effective. Post-operative bleeding did not correlate with the international normalised ratio (INR) status. In none of the studies was a thromboembolic event reported.


CONCLUSIONS
OAT patients (INR 2-4) who do not discontinue the AC medication do not have a significantly higher risk of post-operative bleeding than non-OAT patients and they also do not have a higher risk of post-operative bleeding than OAT patients who discontinue the medication. In patients with OAT (INR 2-4) without discontinuation, topical haemostatic agents were effective in preventing post-operative bleeding. OAT discontinuation is not recommended for minor oral surgery, such as single tooth extraction or implant placement, provided that this does not involve autogenous bone grafts, extensive flaps or osteotomy preparations extending outside the bony envelope. Evidence does not support that dental implant placement in patients on OAT is contraindicated.
Madrid
Carlos
C
Department of oral surgery, Oral Medicine and Hospital Dentistry, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland. carlos.madrid@hospvd.ch
Sanz
Mariano
M
D000284:Administration, Oral; D000287:Administration, Topical; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001281:Atrial Fibrillation; D000075202:Contraindications; D017742:Dental Care for Chronically Ill / Q000379:methods*; D003758:Dental Implantation, Endosseous; D005780:Gelatin / Q000008:administration & dosage / Q000627:therapeutic use; D006350:Heart Valve Prosthesis; D006490:Hemostatics / Q000008:administration & dosage; D006801:Humans; D019934:International Normalized Ratio; D009067:Mouthwashes / Q000627:therapeutic use; D019647:Oral Surgical Procedures / Q000009:adverse effects*; D019106:Postoperative Hemorrhage / Q000188:drug therapy / Q000209:etiology*; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control; D014148:Tranexamic Acid / Q000008:administration & dosage / Q000627:therapeutic use; D020246:Venous Thrombosis / Q000517:prevention & control; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects*
D000925:Anticoagulants; D006490:Hemostatics; D009067:Mouthwashes; D014859:Warfarin; D014148:Tranexamic Acid; D005780:Gelatin