Predictors of oral cavity bleeding and clinical outcome after dental procedures in patients on vitamin K antagonists

Joseph S. Biedermann; Willem M. H. Rademacher; Hendrika C. A. M. Hazendonk; Denise E. van Diermen; Frank W. G. Leebeek; Frederik R. Rozema; Marieke J. H. A. Kruip

doi:10.1160/TH17-01-0040

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2017; 117(07): 1432-1439
DOI: 10.1160/TH17-01-0040

New Technologies, Diagnostic Tools and Drugs

Schattauer GmbH

Predictors of oral cavity bleeding and clinical outcome after dental procedures in patients on vitamin K antagonists

A cohort study

Authors

Joseph S. Biedermann^*

¹Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands

²Star-Medical Diagnostic Centre, Rotterdam, the Netherlands
Willem M. H. Rademacher^*

³Department of Oral Medicine, Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands
Hendrika C. A. M. Hazendonk

¹Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
Denise E. van Diermen

³Department of Oral Medicine, Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands
Frank W. G. Leebeek

¹Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
Frederik R. Rozema

³Department of Oral Medicine, Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands
Marieke J. H. A. Kruip

¹Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands

²Star-Medical Diagnostic Centre, Rotterdam, the Netherlands

Abstract

Summary

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 highrisk 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.

Keywords

Clinical studies - vitamin K antagonist - surgery - risk factors

Full Text

References

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