title: Predictors of oral cavity bleeding and clinical outcome after dental procedures in patients on vitamin K antagonists. A cohort study.
abstract: Patients on vitamin K antagonists (VKA) often undergo invasive dental procedures. International guidelines consider all dental procedures as low-risk procedures, while bleeding risk may differ between standard low-risk (e. g. extraction 1-3 elements) and extensive high-risk (e. g. extraction of >3 elements) procedures. Therefore current guidelines may need refinement. In this cohort study, we identified predictors of oral cavity bleeding (OCB) and evaluated clinical outcome after low-risk and high-risk dental procedures in patients on VKA. Perioperative management strategy, procedure risk, and 30-day outcomes were assessed for each procedure. We identified 1845 patients undergoing 2004 low-risk and 325 high-risk procedures between 2013 and 2015. OCB occurred after 67/2004 (3.3 %) low-risk and 21/325 (6.5 %) high-risk procedures (p=0.006). In low-risk procedures, VKA continuation with tranexamic acid mouthwash was associated with a lower OCB risk compared to continuation without mouthwash [OR=0.41, 95 %CI 0.23-0.73] or interruption with bridging [OR=0.49, 95 %CI 0.24-1.00], and a similar risk as interruption without bridging [OR=1.44, 95 %CI 0.62-3.64]. In high-risk procedures, VKA continuation was associated with an increased OCB risk compared to interruption [OR=3.08, 95 %CI 1.05-9.04]. Multivariate analyses revealed bridging, antiplatelet therapy, and a supratherapeutic or unobjectified INR before the procedure as strongest predictors of OCB. Non-oral cavity bleeding (NOCB) and thromboembolic event (TE) rates were 2.1 % and 0.2 %. Bridging therapy was associated with a two-fold increased risk of NOCB [OR=1.93, 95 %CI 1.03-3.60], but not with lower TE rates. In conclusion, predictors of OCB were mostly related to perioperative management and differed between low-risk and high-risk procedures. Perioperative management should be differentiated accordingly.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Biedermann
authors.forename: Willem M H
authors.initials: WMH
authors.lastname: Rademacher
authors.forename: Hendrika C A M
authors.initials: HCAM
authors.lastname: Hazendonk
authors.forename: Denise E
authors.initials: DE
authors.lastname: van Diermen
authors.forename: Frank W G
authors.initials: FWG
authors.lastname: Leebeek
authors.forename: Frederik R
authors.initials: FR
authors.lastname: Rozema
authors.affiliation: Dr. Marieke J. H. A. Kruip, MD, PhD, Erasmus University Medical Centre, Department of Haematology, Room Na-823, P. O. Box 2040, 3000 CA Rotterdam, the Netherlands, Tel.: +31 10 703 31 23, E-mail: m.kruip@erasmusmc.nl.
authors.forename: Marieke J H A
authors.initials: MJHA
authors.lastname: Kruip
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D000933:Antifibrinolytic Agents / Q000008:administration & dosage; D001777:Blood Coagulation / Q000187:drug effects*; D016009:Chi-Square Distribution; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009067:Mouthwashes; D015999:Multivariate Analysis; D016017:Odds Ratio; D019647:Oral Surgical Procedures / Q000009:adverse effects*; D019106:Postoperative Hemorrhage / Q000097:blood / Q000139:chemically induced* / Q000517:prevention & control; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014148:Tranexamic Acid / Q000008:administration & dosage; D016896:Treatment Outcome; D014812:Vitamin K / Q000037:antagonists & inhibitors*
chemical_list: D000925:Anticoagulants; D000933:Antifibrinolytic Agents; D009067:Mouthwashes; D014812:Vitamin K; D014148:Tranexamic Acid
keywords: Clinical studies; risk factors; surgery; vitamin K antagonist