The use of oral anticoagulants for the prevention of thromboembolic events is widespread. However, this can lead to an increased risk of bleeding following trauma or surgical procedures. A range of protocols have been suggested for varying oral anticoagulation during surgery and in recent years the topical use of tranexamic acid (TXA) or other local haemostatic agent instead of varying anticoagulant medication has been suggested.
The aim of this review was to assess the efficacy and safety of topical TXA to prevent postoperative bleeding in anticoagulated patients undergoing minor oral surgery when compared to other local haemostatic agents or placebo solutions.
Methods
Searches were carried out in the PubMed, SCOPUS, Cochrane Central Register of Controlled Trials (CENTRAL), OpenThesis ,Clinica0lTrials.gov and Google Scholar databases. Randomised controlled trials (RCTs comparing the use of topical TXA versus other topical haemostatic agents or placebo solutions for minor oral surgery were considered. Two reviewers independently selected studies abstracted data and assessed risk of bias using the Cochrane risk of bias tool. The pooled relative risk (RR) for the effect of topical application of TXA on post-surgical bleeding was calculated. The overall body of evidence was assesses using the GRADE system.
Results
- 5 RCTs involving a total of 252 patients were included.
- 3 RCTs were considered to be at low risk of bias.
- The overall quality of the evidence was considered to be high.
- All patients receiving topical TXA remained on continuous unchanged treatment with an oral anticoagulant.
- All studies used TXA for irrigation of surgical site and mouthwash (2e7 days) to prevent postoperative bleeding during the 7-day postoperative period
- The pooled data ( 5 studies) indicated a protective effect of topical TXA on bleeding after minor oral surgeries, RR = 0.13(95%CI; 0.05 – 0.36) P < 0.0001.
- Subgroup analysis suggests that topical TXA was effective in preventing postsurgical bleeding compared to placebo and epsilon-aminocaproic acid
- There were no cases of thromboembolic events in any study.
Conclusions
The authors concluded
Currently available evidence suggests that surgical site irrigation with TXA followed by mouthwash during the first postoperative week is safe and may reduce the risk of bleeding after minor oral surgeries in anticoagulated patients. However, additional trials should be conducted to compare TXA efficacy over absorbable haemostatic materials.
Comments
While this meta-analysis suggests that there is high quality evidence that TXA mouthwash may be beneficial in reducing bleeding following minor oral surgery. There are a few limitations to the review that should be considered. Although the author graded the evidence as high only 3 of the included studies were at low risk in the key assessment of bias. The studies were also relatively small range from 30 to 93 patients.
Recent guidance for the management of dental patients taking anticoagulants or antiplatelet drugs from the Scottish Dental Clinical Effectiveness Programme notes that some guidelines recommend its use but noted that it could not be prescribed by dentists on the NHS so does not recommend its use in primary care at present.
Links
Primary paper
de Vasconcellos SJ, de Santana Santos T, Reinheimer DM, Faria-E-Silva AL, de Melo MF, Martins-Filho PR. Topical application of tranexamic acid in anticoagulated patients undergoing minor oral surgery: A systematic review and meta-analysis of randomized clinical trials. J Craniomaxillofac Surg. 2017 Jan;45(1):20-26. doi: 10.1016/j.jcms.2016.10.001. PubMed PMID: 27840121.
Other references
Original review protocol on PROSPERO
SDCEP – Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs
