title: Bleeding rate during oral surgery of oral anticoagulant therapy patients with associated systemic pathologic entities: a prospective study of more than 500 extractions.
abstract: OBJECTIVE
  Oral anticoagulant therapy (OAT) patients have international normalized ratio (INR) safety windows for oral surgery, the lower limit of which is determined by the thromboembolic risk, with the upper limit typically 3.0. We sought to assess whether these limits will also be true with comorbidities that favor bleeding, such as diabetes, liver disease, and chronic renal failure.
  
  
  METHODS
  The study was designed for 500 consecutive extractions. Patients with an INR greater than 3.0 were switched to heparin and used as controls. The primary outcome was the incidence of bleeding with the need for reoperation, in connection with 3 principal predictors: the INR, reasons for OAT, and comorbidity type. Continuous variables were analyzed using the Mann-Whitney U test and categorical variables using χ2 or Fisher's exact test. Statistical significance was set at P < .05. The reliability of the INR as a bleeding predictor was assessed using receiver operating characteristic (ROC) curves.
  
  
  RESULTS
  Extractions in patients receiving OAT without comorbidities had a success rate of 99.7% against severe bleeding. Despite equivalent INR values, patients with comorbidities had a significantly lower rate (81.3%, P < .001). For these patients, the ROC curve procedure indicated lower INR upper limits, 2.8 for mechanical heart prosthesis subjects and 2.3 for all others. Among the comorbidities, diabetes was associated with the greatest frequency of bleeding (31%) compared with liver disease (15%) and kidney failure (11%).
  
  
  CONCLUSIONS
  Patients with comorbidities should be advised to bring their INR within narrower safety windows (upper limit of 2.5 to 2.8 for mechanical prosthesis and 2.0 to 2.3 otherwise) or be switched to heparin. Alternatively, we propose applying to the socket, a platelet-rich growth factor preparation to foster hemostasis.
authors.affiliation: Resident, Oral Surgery Section, Dental School of the University of Torino, Azienda Ospedaliera Città della Salute e della Scienza, Torino, Italy. Electronic address: c_nadia77@libero.it.
authors.forename: Nadia
authors.initials: N
authors.lastname: Cocero
authors.affiliation: Director, SIOM Oral Surgery and Implantology Center, Torino, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Mozzati
authors.affiliation: Resident, Oral Surgery Section, Dental School of the University of Torino, Azienda Ospedaliera Città della Salute e della Scienza, Torino, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ambrogio
authors.affiliation: Resident, Department of Medical Sciences, University of Torino, Torino, Italy.
authors.forename: Marta
authors.initials: M
authors.lastname: Bisi
authors.affiliation: Professor, Department of Medical Sciences, University of Torino, Torino, Italy.
authors.forename: Mara
authors.initials: M
authors.lastname: Morello
authors.affiliation: Full Professor, Department of Surgical Sciences, University of Torino, Torino, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Bergamasco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D019540:Area Under Curve; D002908:Chronic Disease; D048909:Diabetes Complications; D005260:Female; D005337:Fibrin / Q000627:therapeutic use; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D006406:Hematoma / Q000209:etiology; D006490:Hemostatics / Q000627:therapeutic use; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D019934:International Normalized Ratio; D008107:Liver Diseases / Q000150:complications; D008297:Male; D008875:Middle Aged; D006472:Oral Hemorrhage / Q000209:etiology*; D019106:Postoperative Hemorrhage / Q000209:etiology*; D011446:Prospective Studies; D012372:ROC Curve; D051437:Renal Insufficiency / Q000150:complications; D013923:Thromboembolism / Q000517:prevention & control; D014081:Tooth Extraction; D020390:Tooth Socket / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D006490:Hemostatics; D005337:Fibrin; D006493:Heparin