CDA Essentials 2017 • Volume 3 • Issue 4

S upporting Y our P ractice 35 Management of Dental Extractions in Patients taking Warfarin as Anticoagulant Treatment The following is based on a research article originally published in the “Applied Research” section of jcda.ca —CDA’s online, open access scholarly publication that features articles indexed in Medline, Journal Citation Reports and Science Citation Index. The management of patients on anticoagulation therapy is challenging. The perceived risk of bleeding in these patients (e.g., those with previous thromboembolism, atrial fibrillation, prosthetic heart valves, peripheral vascular disease) is usually weighed against the risk of thromboembolic events. 2,3 The clinical management of these patients is generally complex because they are often older, have multiple comorbidities and are taking multiple medications. A research team from the University of Toronto conducted a systematic review to establish the effectiveness of hemostatic interventions in preventing postoperative bleeding following dental extractions among patients taking warfarin. Warfarin is the most commonly prescribed oral anticoagulant for the prevention and treatment of thromboembolic events. 1,3 It has a narrow therapeutic index measured by the international normalized ratio (INR), i.e., 2.0–3.0 for most indications, 4 and can cause major and fatal bleeding if not regularly monitored. 5,6 In the past, it has been suggested that the decision to continue or withdraw warfarin among patients undergoing dental extractions be tailored to INR levels: continuing the use of warfarin with local hemostatic agents if INR is within therapeutic range 1,7 and postponing warfarin to make dose adjustments if INR exceeds 3.5 8 or 4.0. 1 A 2009 systematic review and meta-analysis concluded that continuing the regular dose of warfarin does not increase the risk of bleeding during minor dental procedures compared with altering or discontinuing the dose. 9 In contrast, the latest guideline from the American College of Chest Physicians recommends, for patients undergoing minor dental procedures, “continuing VKAs [vitamin K antagonists] with coadministration of an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies.” 10 Selection of Studies Of the 95 studies originally identified, 6 were used in this systematic review. Oral and local agents were compared in 4 studies 19-21,23 where patients continued taking warfarin before and after the procedure, and two studies 17,22 compared warfarin continuation with temporary discontinuation. Because all 6 studies compared different interventions, the heterogeneity in treatment modalities precluded from conducting a meaningful meta-analysis. Instead, authors used narrative synthesis to describe the body of evidence. Oral vs. Local Hemostatic Agents One study enrolled patients in experimental, control and negative control groups. 19 After extractions, sockets were dressed with histoacryl glue in the experimental group and with gelatin sponge in the other groups. Minor postoperative bleeding was observed in only 5 patients (33%) in the control group and was successfully stopped with local hemostatic treatment with 5% tranexamic acid. The authors concluded that patients taking warfarin can safely undergo dental extractions without any change of regimen if an effective local hemostatic agent, such as histoacryl glue, is used. 19 Research Summary Naamah Jacobs Weltman BSc Yasmeen Al-Attar MScA Johnson Cheung MSc David Philip Bruce Duncan BSc Ashley Katchky Amir Azarpazhooh DDS,PhD Lusine Abrahamyan MD,PhD lusine.abrahamyan @utoronto.ca Complete article and references available at jcda.ca/article/f20 More Online Volume 3 Issue 4 | The authors have no declared financial interests. This article has been peer reviewed.