Dental extraction is one of the commonest surgical procedures. Patients on oral anticoagulant treatment are at an increased risk of bleeding during and after dental extractions or oral surgery. Oral anticoagulant treatment traditionally involved the use of vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) but the use of the newer direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban) is becoming an increasingly popular. Antifibrinolytic medicine is often used in practices before, during and after minor oral surgery or dental extractions for people using oral anticoagulants.
The aim of this Cochrane review was to assess the efficacy of antifibrinolytic agents for preventing bleeding complications in people on oral anticoagulants undergoing minor oral surgery or dental extractions.
Methods
Searches were conducted in the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, PubMed, Embase, the Cochrane Library, CINHAL, ProQuest dissertation database, ClinicalTrials.gov, the International Clinical Trials Registry Platform (ICTRP), and reports from the American College of Clinical Pharmacy (ACCP) and abstract books from annual scientific conferences.
Randomised Controlled trials (RCTs) or quasi-RCTs in people on anticoagulant treatment under- going oral or dental procedures were considered. The primary outcomes were the number of patients with major postoperative bleeding episodes and side effects or other adverse events. Two reviewers independently screened and selected studies, abstracted data and assessed risk of bias using the Cochrane tool. Standard Cochrane methodological analytic process were followed.
Results
- 4 trials were included 3 RCTs, 1 quasi-RCT) involving 316 patients.
- 253 patients were included in this review’s analysis.
- No eligible trials in people on DOACs undergoing oral or dental procedures were identified.
- All 4 trials involved patients treated with VKAs having international normalised ratio (INR) values within the therapeutic range and TXA was applied locally, not systemically.
- 2 trials compared the antifibrinolytic agent Tranexamic Acid (TXA) with placebo. The other 2 trials compared TXA with gelatin sponge and sutures, and dry gauze compression, respectively.
- The 2 trials (128 participants) comparing TXA with placebo showed a statistically significant beneficial effect regarding the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) = -0.25 (95%CI; -0.36 to -0.14) (moderate-quality evidence).
- The 2 trials (125 participants) comparing TXA with either gelatin sponge and sutures or with dry gauze compression, fond no difference, RD =0.02 (95%CI -0.07 to 0.11) (moderate-quality evidence).
- The combined RD of all 4 included trials was -0.13 (95% CI -0.30 to 0.05) (moderate-quality evidence).
- There were no side effects of antifibrinolytic therapy that required treatment withdrawal (128 participants) (moderate-quality evidence).
- Overall, the risk of bias was considered to be low in the trials comparing TXA with placebo and moderate in the trials comparing TXA with alternative haemostatic measures.
Conclusions
The authors’ concluded: –
Based on the results of this Cochrane Review, there seems to be a beneficial effect of locally applied TXA in preventing oral bleeding in people on continuous treatment with VKAs undergoing minor oral surgery or dental extractions. However, the small number of identified randomised controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population.
We were unable to identify any eligible trials in people on continuous treatment with DOACs undergoing oral or dental procedures. Therefore, a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs.
Comments
This Cochrane review could only include a small number of trials but found that topical TXA was effective in reducing post-operative bleeding following dental procedures. A 2017 review by de Vasconcellos (Dental Elf -3rd Feb 2017) included 5 small RCTs and also found TXA effective. TXA has also shown to be effective at reducing bleeding during other surgical procedure (Dental Elf Tranexamic Acid blogs).
However the authors did not find any studies relevant to those patients receiving the newer DOACs and there has been a marked increase in their use so there so high quality well reported studies should be conducted to see if TXA and agents are effective in reducing post-operative bleeding for these patients.
Links
Primary paper
Engelen ET, Schutgens REG, Mauser-Bunschoten EP, van Es RJJ, van Galen KPM. Antifibrinolytic therapy for preventing oral bleeding in people on anticoagulants undergoing minor oral surgery or dental extractions. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD012293. DOI: 10.1002/14651858.CD012293.pub2.
Other references
Dental Elf Tranexamic Acid blogs
Dental Elf -3rd Feb 2017
Tranexamic acid for minor oral surgery in anticoagulated patients
