Clinical preparation and evaluation of local haemostasis effectiveness following oral surgery treatment in thrombotic patients

The oral surgery procedures in oral anticoagulated patients has always been very controversial due to the dilemma between the high risk of haemorrhage versus the possibility of embolism should the oral anticoagulated treatment be suspended.
The risk of thromboembolism depends on several factors, including the clinical indications for anticoagulation. Various protocols have been suggested for treating these patients, including substituting heparin for oral anticoagulants, decreasing the level of anticoagulation preoperatively, temporarily stopping the oral anticoagulants, and not altering the anticoagulant regimen at all.
The first goal of this doctoral thesis was to emphasize the clinical preparation (clinical and laboratory examinations) of oral anticoagulated patients before oral surgery procedures. The main objective was to demonstrate that it is possible to perform safe oral surgery on oral anticoagulated patients without having to suspend treatment beforehand. The second goal was to compare three local agents that aid haemostasis, following minor oral surgery in therapeutically anticoagulated patients.
The study was performed over a five-year period (2002-2006) and elaborated in the Clinic for oral surgery, Faculty of dentistry, Skopje. A longitudinal study was performed in oral anticoagulated treatment patients that required some type of oral surgical procedures. In order to realize the aims of the investigation, 260 subjects have been examined.
The indications for oral surgical interventions have been based on the findings of anamneses, extra-oral and intra-oral clinical examination, as well as, the findings and analyses of X-ray examinations. According to the thrombotic diagnosis, 240 patients were divided into four groups: each one of 60 subjects. The group of 20 healthy subjects served as a control group.
The patient underwent surgery after the laboratory examinations (an INR control, PT, AT III, protein C, protein S, fibrinolysis activators and inhibitors, factor XIII) which were previously controlled in the Department of haemostasis and thrombosis, Institute of blood transfusion, Faculty of Medicine, Skopje.
According to the applied various methods of local haemostasis, each group was divided in three subgroups (20 subjects): A - with compressive haemostatic gauze – Surgicel; B - with fibrin glue (TachoComb); C - with 5% tranexamic acid (Transamin).
The obtained results, their statistical analysis, and the evaluation of the coefficients of the correlation are the elaborated values of the examined parameters from the clinical and para clinical examinations.
The overall analysis included:

▫overview of subjects by gender and age, type of oral anticoagulants, elapsed therapy time, antibioprofilaxis,
▫laboratory examinations: number of thrombocytes, PT - prothrombin time, an INR control, AT III, protein C, protein S, activators and inhibitors of fibrinolysis, factor XIII,
▫patients categorizations:
▪risk of prolongated bleeding - low and high risk, and
▪potential risk for thromboembolism - low and high risk,
▫urgency of oral surgery interventions, risk factors of prolongated bleeding during and after the interventions,
▫completed oral surgery procedures (diagnosis, therapy, number of extracted teeth, number of sessions and tooth type),
▫control examinations (to confirm presence of edema, haematoma, dry socket etc., after 24 and 48 hour, seven and ten days ),
▫according to bleeding index, presence of prolonged haemorrhage after the interventions (24 and 48 hour, seven and ten days).

The results obtained lead to the following conclusions:

Dental extractions can be performed without modification of oral anticoagulant treatment.
Local haemostasis with absorbable oxidized cellulose, fibrin glue, and tranexamic acid (used as a mouthwash) are local modalities of haemostasis (methods of choice) for the treatment in oral anticoagulated patients.
It is not necessary to suspend oral anticoagulant treatment before surgery; as long as there is multidisciplinary approach for patient’s control.
Certainly, there is an evident need to make a protocol for oral surgery procedures in the patients with oral anticoagulant t therapy.

Key words: tooth extraction, oral surgery, oral anticoagulant treatment, oral anticoagulants, local haemostasis, haemostatic gauze (absorbable oxidized cellulose), fibrin glue, tranexamic acid.